The fight over the federal nursing home staffing mandate isn’t over yet – it might be entering its next phase, according to Jonathan Blum, former COO and principal deputy administrator at the Centers for Medicare and Medicaid Services (CMS), who said the idea of having such requirements is certainly still circulating among federal officials.

While the Biden-era minimum staffing regulations may be in the rear-view mirror for now, providers could risk seeing a version of such staffing regulations return come November, unless they propose credible alternatives to improve care quality, Blum said at the LTC 100 Leadership conference this week. Providers need to be ready with clear solutions.

“If Democrats take the House, that staffing rule will come back. The Dem Chairman of the Finance Committee pushed that rule hard,” said Blum. “But I think the question is, if not the staffing mandate, then what is the alternative?”

In the meantime, more constructive dialogue between policymakers and providers is needed to develop flexible, effective staffing approaches to raise care standards, he said. And more importantly, to avoid another stringent mandate.

Demand policymakers get in the field

Blum mentioned a disconnect between policymakers and on-the-ground realities for nursing homes – agency staff are so focused heavily on statutory and regulatory requirements that it can limit their understanding of operational challenges in facilities. For operators, this could be an opportunity to change the narrative, he said.

“I think policymakers need to see, need to hear and need to really understand what the challenges are,” said Blum. “Whether it’s members of Congress or staff or their CMS policy leaders, CMS policy staff need to get out into the field … not just simply ask, ‘what does the law tell me to do? How do I calculate the market basket? How do I calculate various quality measures?’”

Instead, questions around why some facilities, despite pushing for higher quality care after being surveyed, continue to have low star status. In other words, providers should be asking what exactly it will take to raise all boats.

“Demand policymakers to get out in the field, talk to residents, talk to staff, talk to operators, talk to investors … that’s when the government works best, when it really builds not just the kind of legal foundation, but also the understanding of what it takes to provide better quality care,” said Blum.

Policymakers need more direct exposure to care settings, visiting facilities and talking with staff and residents to understand why quality varies. But better storytelling from nursing homes could help bridge the gap too, Blum said, influencing more practical and effective policy decisions.

Medicaid balance reset

As for Medicaid, Blum expects that recent federal policy changes, including the One Big Beautiful Bill Act (OBBBA), will act as a balance “reset,” shifting more responsibility back to the states. Budget pressures and potential provider cuts at the state level are due to come down the pike, regardless of sector carveouts in the federal reconciliation process.

“The federal government is paying more for the Medicaid program today, on a per capita basis, than ever before,” said Blum. “Congress now is saying they’re going to balance that going forward. [They] are going to take away some of the tools that states use to shift more of the financing back from the federal government to the states … we can debate whether that’s good policy or not.”

Political dynamics, especially with upcoming midterm elections in November, are likely to shape whether these policies are implemented, delayed or revised in some way, Blum said.

“If Congress does shift this fall, and if health care becomes one of the key themes, I think we’re going to see members of Congress begin to realize that we have gone too far, that we do need to worry about preserving coverage,” said Blum. “To me, it’s less about the shift of seats and more about what the themes are.”

Medicare Advantage (MA), meanwhile, is equal parts promising and challenging. MA organizations have shifted toward competing on supplemental benefits and lower premiums instead of quality, despite having the tools to better coordinate care and improve outcomes.

“I think we’ve lost track of the ultimate purpose of the MA program,” said Blum. “To me, the ultimate purpose is that incentive to manage the care. We pay plans well and they don’t compete on this notion … they compete on how they can maximize supplemental benefits for the beneficiaries.”

This likely comes as no surprise to nursing homes, but this shift has created inefficiencies and disparities especially as lower-income beneficiaries start to rely more on MA. Reforms need to refocus the program on delivering better patient outcomes and aligning payments with value, he said.

There are some reform bills out there, with the Medicare Advantage Improvement Act of 2026 on the national stage, put forth with the help of the American Health Care Association, and another at the state level in California.

CMS is currently in a major transition overall, he said, shifting away from paying for individual services and toward models centered on total cost of care, cost covering entire episodes or populations.

There’s more alignment between Medicare and accountable care organization (ACO) models too, he said, and nursing homes are seen as part of the broader continuum in this way – CMS is putting on the pressure on operators to demonstrate value through quality outcomes instead of a volume of services.

“In order for those strategies to work, we have to have thoughtful policy for how we think about promoting care in the highest quality, lowest cost setting. If you look over time, there has been a lot of success and thinking through how we shift the focus, shift the priorities, shift how we think about paying for care,” said Blum.