Still Accountable: Rules, Regs, and Bills to Track in the Newly 'Blue' DC

Like many Americans, I expected Democrats to gain seats in the House and Senate in the 2026 midterm elections but ended up stunned by the blue wave of voting, especially in states that are normally Republican strongholds.

While the pundits trade barbs and accusations about the changes, both sides realize that the Democratic majority controlling both houses of Congress is only in place until the next election. The legislative activities of both parties in the next two years will largely determine how voters see Congress and the presidency when they vote in 2028.

For now, the president is a lame duck with a permanently stalled legislative agenda unless Congress unites on legislation. Yes, he can issue presidential orders (my favorite is the latest on not allowing future presidents to change the now gold-gilded Oval Office) but these orders carry little real weight beyond his final term. What other opportunities are there for Washington, DC, to move forward?  

Rulemaking

The federal agencies still report to the president, and rulemaking and regulations can be published based on current law. For example, in 2024 the keystone nursing home activity of the Trump Administration put a 10-year moratorium on enforcing the provisions of the Minimum Staffing Rule until 2034. While this legislative action was taken through a reconciliation process in the One Big Beautiful Bill Act, it prevented CMS from enforcing the then-existing staffing requirements. The second key action was in rulemaking when CMS formally repealed the staffing provisions through an Interim Final Rule effective February 2026.

A current example of rulemaking is the CARE proposed rule – Cutting Administrative Requirements for Excellence in Patient Care published by CMS the day after the midterm elections. The CARE proposed rule is targeted at 21 provider and supplier types. The scoring of the rule estimates $320 million in annual savings and up to 3.26 million staff hours given back to provider staff for patient care through 22 distinct burden reduction actions. Eight of the 22 actions are for LTC and ICF facilities per the CMS Fact Sheet:

LTC Facilities

·       Removes the COVID-19 vaccine requirements related to educating staff about the benefits and risks, offering the vaccine, and documenting these actions.

·       Streamlines the remaining COVID-19 vaccine requirements for residents.

·       Removes the continuing respiratory illness data reporting requirement while keeping the requirement for specific reporting during a future secretary-declared public health emergency.

·       Modifies the requirement for LTC facilities to provide a state ombudsman with notice of resident transfers related to emergent care. 

·       Revises the requirements for the active involvement of representatives of direct care staff in conducting the LTC facility assessment.

·       Revises the physical environment requirements to exempt existing facilities from the room occupancy and bathroom facility standards.

ICFs/IID

·       Removes requirements related to educating staff about the COVID-19 vaccine and its benefits and risks, offering it to them, and documenting these actions.

·       Streamlines the remaining COVID-19 vaccine requirements for clients. 

Additionally, the Medicaid Transparency Reporting requirements are scaled back, the rule proposes to rescind Medicaid institutional payment transparency reporting requirements to reduce burden for states and institutional providers:

o   The percentage of Medicaid payments for nursing facility services spent on compensation for direct care workers, 

o   The percentage of Medicaid payments for nursing facility services spent on compensation for support staff, and

o   The percentage of Medicaid payments for ICFs/IID services spent on compensation for support staff.

Expanded Clinician Roles

·       The proposed rule would allow nurse practitioner and physician assistant roles to expand to perform certain physician-required visits. (This is an opportunity for greater care hours from our partners within our facilities.)

Other Regulatory Actions – Survey and Certification

CMS has made incremental changes favorable to providers but avoided significant changes to survey and enforcement that many would like to see.

In April 2026, CMS announced updates and revisions to Chapters 5 and 7 of the CMS State Operations Manual, which governs how state survey agencies investigate complaints and enforce federal regulations in nursing homes and skilled nursing facilities.

Changes included:
- Expanded guidance on immediate-jeopardy determinations.
- More detailed complaint investigation procedures.
- Clarification of survey team composition and procedures.
- Updated guidance on acceptable plans of correction.
- Revised procedures for onsite and offsite revisits.
- Updated enforcement and civil monetary penalty guidance.

In 2026, CMS also issued the first risk-based survey approach. Qualifying higher-performing facilities can receive streamlined standard recertification surveys. All facilities must still receive surveys every 15 months, and CMS may conduct traditional surveys when complaints or resident-safety concerns call for them.

Initial eligibility criteria include:

- Five-Star overall rating.
- Accurate data submissions.
- No recent citations indicating resident harm or substandard quality.
- No recent ownership changes.

This is limited progress, as only 12 percent of nursing facilities are initially expected to qualify.

Civil Monetary Penalties
In September 2025, CMS revised the CMP Reinvestment Program. This is significant because CMS is trying to connect enforcement penalties with measurable quality improvement and workforce development.

CMS also revised enforcement guidance and implemented changes involving the use of civil monetary penalties. This has emphasized greater flexibility in applying per-instance and per-day penalties where proper. They further announced that per-instance penalties would be displayed on Nursing Home Care Compare beginning June 24, 2026.

What Can We Expect Post-Election?

Could meaningful healthcare reform actually happen? Well, repeal and replacement of the ACA has not taken place, and I don’t expect Medicare-for-All to happen. That said, there are opportunities for horse-trading that could get past the 60-vote threshold in the Senate. 

The Trump Administration has had their Great Healthcare Plan on the table since January 2026. Many of the goals are consumer-friendly ways to reduce costs that may have traction with the new Congress as trade-offs for bigger goals.

I think that Prescription Drug Pricing limits, insurance premium subsidies, and provider pricing disclosures could draw new support. The Democratic Congress will look to unwind Medicaid payment limitations to rural providers and the Medicaid State Directed-Payment limits imposed in the One Big Beautiful Bill. Another goal will be to reverse and normalize the targeted enforcement of Medicare and Medicaid Fraud enforcement, which has affected predominantly blue states.

Policy development is like making sausage. You want to know how it’s done but you don’t want to see every step. We leave these to the many operational, regulatory and legal experts who represent our industry. These next two years require the full weight of our trade associations, lobbyists, and experts to get as much as we can and have it done right. We need to focus on what’s achievable in the remaining years of a Republican administration with a new Democratic majority. 

Keep the faith and avoid the name-calling to be successful. 

Martin Allen is the former senior vice president of reimbursement policy for the American Health Care Association/National Center for Assisted Living. He also served as the vice president of revenue cycle and reimbursement services for ProMedica Senior Care (formerly HCR ManorCare). A certified public accountant with a master’s in business administration, Allen has more than 35 years of extensive work in accounting, Medicare and Medicaid reimbursement, healthcare compliance, risk management, and revenue cycle processes.

Any thoughts on this article? Please contact Patrick Connole at pconnole@parkplacelive.com.