The nursing home sector hopes to move away from outdated, punitive oversight and toward a more constructive, modern regulatory model in 2026 and beyond – an approach Clif Porter, president and CEO of the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), has been tirelessly working to achieve and refers to as “rationalized regulation.”

The current system, largely unchanged since 1989, fails to reflect today’s skilled nursing landscape, where facilities are caring for increasingly complex patients, he told Skilled Nursing News.

“We’ve gone from largely being a custodial model to now really being an interventionist type model where you’re really dealing with very, very sick and complex patients who have some pretty complicated needs,” said Porter. “To think that the regulatory construct should not change with that is ridiculous.”

And so, rationalized regulation is about fairness and proportionality – ensuring that providers operating in good faith aren’t treated the same as bad actors, Porter said. To that end, AHCA has submitted over 75 pages of detailed recommendations to agencies like Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (HHS), advocating for reforms such as eliminating Obama-era strict liability standards, which currently penalize providers for issues often beyond their control, he noted.

In terms of compliance, Porter cited burdensome reporting requirements like Payroll-Based Journal (PBJ), particularly for small facilities where staffing flexibility is necessary but not adequately recognized. He also criticized the one-size-fits-all survey process, calling for a more tailored, supportive approach.

Porter also addressed Medicare Advantage, calling it a major challenge for older beneficiaries. He noted that delays and denials linked to the pre-authorization process disproportionately affect the “old-old” population. AHCA is pushing for policy changes to hold Medicare Advantage plans accountable and ensure equitable access to care.

On the staffing front, Porter highlighted recent wins, including a 10-year pause on the federal minimum staffing mandate and a significant reduction in agency labor use. However, workforce turnover remains a major concern, he said.

Ahead of the upcoming AHCA/NCAL 2025 Convention taking place in Las Vegas next week, Porter sat down with SNN to discuss these and other major areas of focus for AHCA/NCAL.

Editor’s note: The comments below cover a portion of Porter’s interview. A second story will address the potential impacts of the One Big Beautiful Bill Act (OBBBA) and the government shutdown, as well as some major wins for AHCA/NCAL under his leadership.

The following interview has been edited for length and clarity.

SNN: This is your first official AHCA/NCAL convention as president and CEO, because last year it was cancelled due to hurricanes in Florida. There must be a lot to catch up on?

Porter: There’s a lot of value in bringing our members together in person. It’s just always good to see each other’s faces in such a virtual world now. We’ll be covering a lot of ground during the convention. The programming is always top tier, in my view, as it relates to the opportunities for our members to get not only CEUs, but just to learn from thought leaders.

SNN: Let’s turn to some of the main policy areas for the convention, starting with your approach of ‘rational regulation.’ Tell us about this concept.

Porter: So rationalized regulation is a passion for a lot of us here at AHCA/NCAL. And, the main reason is because we fundamentally recognize that no one is satisfied with the existing model. Families aren’t, patients aren’t, advocates aren’t, providers are not and the government’s not. I mean, no one is. So we continue with a system that was crafted in 1965 and modernized – for lack of a better term – in 1989, and effectively, it has not been fundamentally redesigned since. So when you think about how much the industry has changed and how we’ve gone from largely being a custodial model to now really being an interventionist type model where you’re really dealing with very, very sick and complex patients who have some pretty complicated needs, to think that the regulatory construct should not change with that is ridiculous. And so, we’re committed in our Better Way package, and that term is just as descriptive as any.

We’ve submitted dozens of pages of recommendations to 40-plus government agencies about ways to improve the regulatory system, and it’s not about making it easier. We deal with very vulnerable people, and there must be regulation. But should we deal with every provider in the same way, with the same consequences? That’s kind of what we have now. There are very, very heavy-handed consequences with no real consultative support at all. It’s about, “We’re just here to catch you if you fail. We’re here to close you.” That’s kind of how the system currently works. And that just doesn’t make sense because communities around America really do depend on these facilities being healthy and thriving.

So I envision an environment where one day we get to where we treat and operate and regulate facilities to operate in good faith differently than we do those that don’t. Those that operate in bad faith should be addressed in a more aggressive way.

SNN: Are there examples of rational regulation that has already taken place?

Porter: It is a broader theme, and the reason it’s so broad is because the current system is so broad – the one-size-fits-all approach. It’s the one hard, punitive approach for everybody. So we have to change the mindset as it relates to how we regulate. So that starts there.

In terms of specific [regulation], we submitted 75 pages of recommendations to HHS, CMS, the White House, and the Department of Labor and every agency that asked for some suggestions on how we can do better on the regulatory front.

And so as an example, one important [issue] to us that’s very high priority is this issue of strict liability. And we operate under a strict liability standard today. My last nursing home I ran in 1998 we did not operate under a strict liability standard, and that standard was created during the latter months of the Obama administration. And that’s sort of, since 2016, been our existence. Effectively, you’re just punished for a lot of bad things that are completely outside of our control. If a facility has a system in place, and you still get an immediate jeopardy [from a one-time event], your five star is affected, it has a cascading effect and a lot of it [is] just completely unnecessarily. It’s just kind of an overreaction. So strict liability is just one example of something specific we’d like changed.

SNN: What are some compliance changes that you would like to see changed?

Porter: It’s a long list, but PBJ is an example. I still struggle with [the nursing home industry] being the only health care entity in America that has to report its payroll hours to a centralized federal government source monitoring. For example, the current rules don’t allow you to count hours put in by an off-duty director of nursing to pass meds. There are times in a pinch where if a nurse calls out, the DON has to come in and actually work the cart and pass the meds, right? So when he comes in and does that, you can’t count the hours, because they’re the DON, even though they’re functioning as an RN.

That’s just one example, something that needs to change from a compliance perspective. There are others in a variety of different areas. 

One is just the survey process writ large. There ought to be an approach that’s more constructive for operators and providers who work in good faith, where they have good systems, consistent systems, and that should be treated differently than those who don’t. We have great facilities doing wonderful work, and we ought to be in a position to have good systems that monitor what they do, but are not oppressive, and put them in a situation where they’re out of business.

SNN: What are your thoughts on Medicare Advantage for 2026?

Porter: Medicare Advantage is a big challenge, and the most impacted cohort of folks is the beneficiary, and particularly the old-old beneficiary. And our goal is to address the disparate treatment that the old-old within Medicare Advantage gets from what I call the young-old. And the reality is that there are challenges from pre-authorizations … with the hope of [MA plans] that folks will quit. Those that don’t quit normally get the decisions overturned, but most don’t, because they’re exhausted. That’s got to stop, because patients lose.

I’m going to need that care when I’m 85, and we’ve got to make sure the Medicare Advantage keeps its promise. So we’re going to hold them to that, and we’re going to be advancing policies.

SNN: And then turning to staffing, things are starting to look up and agency labor is down. On the flip side, turnover rates remain high. Can you discuss any initiatives on that front?

Porter: Turnover has been an issue for our sector, and it’s remained an issue because it’s just tough, tough work. I don’t think any operator out there would be satisfied with their turnover rates, and many operators are laser focused on that metric. But when it comes to the workforce, the power is in the hands of the operator. I can’t solve workforce problems from D.C. The situation is just too unique to different markets. But, as far as what’s possible, [operators] have got to be innovative. You’ve got to pay market rates, think about different benefit packages and different ways to make your employees feel important.

There’s a lot of innovation going on out there right now, and that’s one of the reasons agency staff has been virtually eliminated. It’s not gone, but it’s way down from what it was at the height of the pandemic. So we’ve gotten our act together there. We’ve been able to replace them with permanent people and create an environment that people want to work in.