The Trump administration’s approach to regulation is creating long-sought opportunities for nursing home providers to have more say in shaping policies, but providers must do a better job of promoting the areas in which they excel.

Steve LaForte, CFO and principal​ at Cascadia Healthcare, describes the new administration’s approach as “rational regulation” – a way forward that balances necessary oversight with practical flexibility. Given this, LaForte believes skilled nursing operators need to ramp up advocacy efforts.

“In the past, when you would go in and talk to CMS, it was very sterile and it was very academic. And now you have the opportunity [that if your idea] makes sense, you might get traction,” LaForte said at the recent Skilled Nursing News RETHINK Conference in Chicago. “So there’s an opportunity that maybe we haven’t had in the last decade or so.”

Idaho-based Cascadia operates more than 58 long-term care facilities across Washington, Oregon, Montana, Idaho and Arizona.

Joel VanEaton, executive vice president of post-acute care regulatory affairs and education at Broad River Rehab, agreed with LaForte but also lamented the loss of CMS Open Door Forums. While CMS has not officially announced the end of Open Door Forums, no SNF Open Door Forum call has taken place since October 2024.

While the shifting of the Medicaid burden to states through the recently passed reconciliation bill – and a smaller-than-expected Medicare payment rate increase – has many in the sector concerned, these developments have been counterbalanced by some positive regulatory moves this year, they argue. These include a 10-year moratorium on the nursing home minimum staffing mandate, the removal of burdensome sections from the Minimum Data Set (MDS), and the elimination of complicated health equity requirements for value-based purchasing.

Regardless, many leaders feel that the industry will end up adapting to the changes, and with more change to come, providers should not only be stepping up advocacy but thinking big.

“A lot of this is like a prototype,” said Gary Blake, CEO at Creative Solutions in Healthcare. “Nothing ever is like it starts out [but] I think it’s a great opportunity to make sure you put your visionary caps on.”

Texas-based Creative Solutions’ portfolio encompasses 174 long-term care facilities in the state.

Leveraging Medicare payment rule

There are opportunities for improving reimbursement despite recent developments.

The 3.2% Medicare payment rate increase for 2026 is the lowest in recent years, reduced by sequestration, which deducts 2% from the rate, VanEaton said. 

Moreover, new value-based purchasing (VBP) adjustments and quality reporting measures could further erode the gains from the increase, he noted. The VBP system is designed to incentivize quality improvements but can also lead to financial penalties for non-compliance.

And yet, providers could use these challenges to their advantage.

Cascadia is using the lower-than-expected increase as leverage for negotiating with managed care organizations and states, particularly when it comes to discussing cost-of-living adjustments, LaForte said.

During bargaining with Medicare Advantage (MA) plans, providers need to push for rates that are at least 90% of traditional Medicare rates, Blake said. To make this case to the plans, he said that providers need to underline the modest Medicare rate hike along with the realities of inflation, while also showing evidence of how they are driving quality outcomes.

Steve LaForte (left), Joel VanEaton (center) and Gary Blake (right) at RETHINK 2025

Nursing homes “universally” do a “pretty sloppy job” in promoting what they do well, including their quality reporting related to vaccination rates, catheter usage, CMS Star Ratings and more, Blake argued. He said providers must do a better job at this, and in telling stories about how they are driving improvements where needed.

“I say, sell everything, including your Google ratings, because you can find the good in every one of the properties that you’re operating. You just have to spend more time to identify where they need training and then be ready to share with the insurance companies what you’re doing, how you’re overcoming that, how you’re going from a 3-star to a 4-star to a 5-star, and then how you’re going to maintain it,” he said.

Medicaid cuts and provider advocacy

The tax reconciliation bill and its potential impact on Medicaid, particularly the rollback of provider taxes and capped Medicaid matching funds for hospitals, will shift more Medicaid responsibility from the federal government to the states. Nursing home providers see some positives in this change.

LaForte stressed that advocacy efforts must now focus at the state level, arguing that in states such as Idaho, where his company operates 25 facilities, nursing home providers are advocating for long-term care funding to be treated as a separate line item in the state Medicaid budget. This would allow more targeted attention and funding for long-term care, which is currently part of a general Medicaid budget, he said.

That said, since the impact of OBBBA Medicaid cuts remains uncertain, operators need to be prepared to navigate financial challenges. Providers will succeed in this eventually, said VanEaton, comparing this transition to past ones, such as the introduction of the Prospective Payment System (PPS) in 1998. PPS was initially met with fear but ultimately led to success as operators figured out how to thrive under the new system. And moreover, there is a model for low hospital provider taxes that already exists in some states, which could provide valuable insights for other states facing similar challenges.

At least seven states already have their hospital provider taxes at 3.5% – the maximum cut that the reconciliation bill aims to enact federally by 2032, said VanEaton.

He also noted the shift that providers made to the Patient-Driven Payment Model (PDPM) that replaced the RUG-IV system in October 2019, and the adjustment process that CMS then went through regarding PDPM.

“Three years in, they had rebased PDPM because they overshot that. So there’s a lot of things that we’re going to learn about this. We still have two years before the first increment of this takes effect,” VanEaton said.