WASHINGTON — When President-elect Donald Trump takes office in January, he will face a long-term care crisis marked by understaffed nursing homes, workforce shortages and care that is unaffordable and inaccessible for millions of people.

But he and the Republican-controlled Congress are likely to focus on relaxing regulations rather than imposing new mandates on nursing homes and long-term care, an approach similar to what Trump did in his first term.

For example, unless congressional Republicans manage to do so as part of negotiations over the upcoming continuing resolution, Trump is likely to roll back a Biden administration rule that requires minimum numbers of staff in nursing homes — a policy President Joe Biden said would improve care for residents but which the industry and Republicans said was an unfunded mandate that would force facilities to close.

“If you speak to the providers, those workers are not there. And there are other things that practically mean it can’t work,” said Sen. Bill Cassidy, R-La., who is slated to be the chair of the Senate Health, Education, Labor and Pensions Committee next year.

“So I’d like to see them revisit that, because I’ve opposed that rule.”

The nursing home rule

Biden made improving long-term care one of his presidency’s top missions, announcing the staffing mandate in a State of the Union address in 2023.

Access to high-quality long-term care is a pressing issue, with people 65 and older expected to make up more than 20 percent of the population by 2030. Most will stay in a nursing home at least once in their lifetime.

But the majority of nursing homes say they are short-staffed, a problem the Biden administration has tried to fix with staffing mandates which would require a minimum number of hours of care for each resident. Those staffing standards would fully take effect in 2027 for urban nursing facilities and in 2029 for rural facilities that don’t qualify for exemptions.

The rule has been universally panned by Republicans and nursing home trade organizations, who have challenged it in court. Nursing homes have argued there are not enough workers to fill those positions, and low payments from Medicaid make it difficult to compete with facilities that typically pay more like hospitals.

The rule might play a key role in negotiations over the upcoming continuing resolution. According to sources briefed on the bicameral talks, Republicans have suggested repealing the rule in order to help pay for a $30 billion, one-year package of health care provisions set to expire later this month, including community health center funding and a moratorium on Medicaid cuts to hospitals serving lower-income patients.

Still, negotiations are in their early stages and few Democrats support such a repeal, though the high likelihood of Trump rolling it back could make it more palatable.

The Centers for Medicare and Medicaid Services has estimated the increased staffing would cost nursing homes $43 billion over the next decade.

“We are quite hopeful the Trump administration would see this as one of the federal regulations that is overly burdensome and unrealistic and get repealed very early on,” said Linda Couch, senior vice president of policy and advocacy for LeadingAge, the association of nonprofit providers of aging services.

Advocate support

Advocates have said nursing homes can afford to hire more staff, and blame lack of funding on opportunistic for-profit organizations and private equity investors who siphon profits out of nursing homes.

Ending the staffing mandate would be a setback for the rights and health of 1.2 million people living in nursing homes, said Toby Edelman, senior policy attorney for the Center for Medicare Advocacy, which advocates for the rights of nursing home residents.

“It means people are going to get harmed and they’re going to die,” Edelman said. “We’ve had years of talking about how important staff is, and if they don’t have enough staff to take care of them, they don’t get their needs met.”

She also worries Trump will do what he did in his first term as president: lower fines for facilities that have been found to have endangered or injured residents. Biden reversed that policy.

Congressional proposals

While Congress has expressed interest in addressing the direct care workforce, that interest has not translated into law. And Trump and Republicans’ vow to cut health care spending will make it a difficult environment for investments in new programs.

Some bills in Congress have largely focused on easing regulations as a way to boost staffing in nursing homes.

In September, the House Energy and Commerce Committee advanced a bill that would allow nursing homes that have been required to terminate their in-house certified nursing assistance education programs because of deficiencies to resume those programs once deficiencies are corrected.

Another bill would allow temporary nurse aides to apply on-the-job training in nursing homes toward becoming certified nursing assistants.

Both bills are bipartisan, though many Democrats also supported the staffing mandates.

“There are things that we can do to relieve some of the regulations, ensuring that we have safe nursing homes but not over-regulated,” said Rep. Brett Guthrie, R-Ky., the chair of the House Energy and Commerce Subcommittee on Health. Guthrie is running to chair the full committee next year.

“Just mandating more and more people [staff] isn’t going to solve the problem, because you can’t find the workers.”

Looking forward

Trump has been mum on his plans for long-term care, although the 2024 Republican platform states the party will support an “increased focus” on long-term care and “policies that help seniors remain in their homes.”

The platform also states that “Republicans will shift resources back to at-home Senior Care,” “overturn disincentives that lead to Care Worker shortages” and support unpaid family caregivers through tax credits.

The Trump administration could impact long-term care and nursing homes in other ways.

Trump’s vow to curb immigration and conduct mass deportations could further destabilize the direct care workforce — 27 percent of which is made up of immigrants, according to estimates.

Trump’s support of Medicare Advantage also worries nursing homes, which have long complained about low reimbursement rates and denied care from those payors. Studies have shown nursing homes in counties with high levels of Medicare Advantage enrollment experience declines in revenue and profits.

Republicans’ vow to reduce Medicaid spending could impact access to care. Medicaid is the largest payor of long-term care services.

One of the ways they could do that is by moving away from Medicaid as an open-ended entitlement by shifting to a block grant system that caps federal funding to states — a proposal Republicans tried and failed to advance in 2017. Nursing homes and other health care providers fought that proposal.

“Everyone’s sort of going into their archives and making sure they remember what happened in the last Trump administration… So we definitely expect to see a reintroduction of proposals around Medicaid block grant,” said Couch of LeadingAge.

“We don’t think that that would serve older adults in the best way or the providers that serve them.”

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Ariel Cohen and Paul M. Krawzak contributed to this report.

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