Following the Tuesday, November 5, 2024 elections, former President Donald Trump handily won the White House and is now President-elect Trump. The Senate’s composition shifted from a very slim Democrat majority to a not-quite-as-slim 52 to 47 Republican majority, with one recount underway in Pennsylvania. Republicans will retain House control.

As for chamber leadership, Senators the week of November 11 elected John Thune (R-SD) as Majority Leader while in the House, Representatives stayed the course, keeping House Speaker Mike Johnson (R-LA) as theirs.

As with every incoming administration, a substantial transition team serving incoming President Trump is now hard at work, establishing the personnel structure and the initial policy moves of his Administration. From our Washington D.C. headquarters, LeadingAge’s policy team is  connecting with the White House’s transition team and making plans to engage with landing teams at each agency as the incoming Administration completes necessary vetting and paperwork to begin their work within the agencies themselves.

Analysis: Incoming Administration’s Focus: 

Based on insights gleaned from a range of sources, including: 

• The Republican National Convention’s platform,  which focuses on reining in wasteful federal spending, cutting costly and burdensome regulations, supporting active and healthy living, protecting Social Security, protecting care at home for the elderly, and reining in an ideologically driven federal workforce;
• The Heritage Foundation’s Project 2025’s Mandate for Leadership: The Conservative Promise;
• Insights taken from experiences during the first Trump administration;
• Trump team statements in press statements and media coverage

ELECTION IMPACT ISSUE: Early 2025 Congressional Actions

ELECTION IMPACT ISSUE: Expected Direction on Medicare and MA Under New President and Congress 

ELECTION IMPACT: Workforce 

ELECTION IMPACT: Employment and Labor: How the Trump Administration May Shape Federal Policy Impacting Aging Services Provider Employers

ELECTION IMPACT Congressional Health Committees Outlook 

ELECTION IMPACT Care in the Home and Community Outlook 

ELECTION IMPACT Affordable Housing

ELECTION IMPACT Nursing Home Outlook 

Early 2025 Congressional Actions

The opportunity of holding both chambers of Congress as well as the White House will be taken advantage of, in part, through the use of budget reconciliation, a tool often used to achieve big impact on federal funding–without requiring 60 votes in the Senate to do so. Passage of both the Tax Cuts and Jobs Act of 2017 and the Inflation Reduction Act was achieved through the use of budget reconciliation; it is expected to be the vehicle of choice for a tax package and other changes next year.

Very early in 2025, Congress is expected to pass a budget resolution with instructions to committees to reauthorize expiring tax cuts, create or change others and to change mandatory programs in ways that impact federal mandatory spending. Generally anything but Social Security and funding for discretionary programs is on the table in budget reconciliation. Very basically, the budget resolution tells authorizing committees to impact federal spending by “X” amount and then the authorizing committees have to recommend ways to change or cut or add to programs to achieve that amount of impact. Authorizing committees are instructed by the budget resolution to achieve certain savings or spending.

Since Congress does not have a final budget resolution yet for fiscal year 2025 (FY25), they’ll have two opportunities for budget reconciliation next year: one for FY25 and one for FY26.

ELECTION IMPACT ISSUE: Expected Direction on Medicare and MA Under New President and Congress 

Medicare Advantage (MA) has long enjoyed bipartisan and bicameral support. However, in recent years, as MA enrollment has reached nearly 55% of eligible Medicare beneficiaries, some lawmakers have begun to suggest there are opportunities for “improvements.”  

With this in mind, we are hoping that Congress will opt to pass the bipartisan  Improving Seniors Timely Access to Care Act as part of the 2024 lame duck session. The bill has received a budget neutral score from the Congressional Budget Office, which we hope will help get it across the finish line this time. We are advocating for its passage, as it would move us toward electronic prior authorizations and standardization; and also lead to greater transparency related to these practices.  

What can we expect in the 4 years ahead for Medicare and MA?  Little is known currently about Health and Human Services (HHS) Secretary-Nominee Robert F Kennedy Jr’s (RFK Jr.) positions on Medicare or MA programs but President -Elect Trump has said RFK Jr. will essentially have free reign in directing HHS policy. Some pundits, however, suggest RFK Jr’s interests lie elsewhere and therefore  the Centers for Medicare and Medicaid Services (CMS) nominee will hold more sway on policy direction in these areas.

President-elect Trump nominated Dr. Mehmet Oz to head CMS on November 19. When Dr. Oz  ran to represent Pennsylvania in the U.S. Senate in 2022, he  expressed support for privatization of Medicare that he called, “Medicare Advantage for All.”  It is unknown whether this is still his view but it does align with proposals from other Republican think tanks. The Heritage Foundation in the Project 2025 document, for example, calls for making MA the default enrollment option for Medicare beneficiaries. While other conservative think tanks have describe this idea as requiring Medicare beneficiaries to choose between traditional Medicare and MA, default enrollment could also mean automatically enrolling beneficiaries into MA instead of Medicare Part A if no other option is actively selected. This could significantly increase MA enrollment, which has been of great concern to LeadingAge members due to the inadequate provider rates paid by the plans and impacts on beneficiaries’ access to needed services under these plans. Such a measure would likely require Congressional action and could not take effect before 2026 even if passed early in 2025. In addition, such a shift of all beneficiaries to MA would give plans even more leverage over what they pay providers unless Congress takes action to protect providers. The latter action may be less likely given Republican support for a health care system that is market-based and embraces competition.  

While we’ve seen no views expressed by RFK Jr or Dr. Oz on other issues within the MA program, it is possible that how MA plans are paid by CMS will get some reform attention from the Administration. Since MedPAC reported plans being overpaid by 22%, several ideas for reforming MA plan payments are being floated. These proposed reforms could include changing how MA benchmarks are calculated, which would cost money, to ideas that would create considerable savings such as eliminating MA plan quality bonuses, and changes to risk adjustment. Any savings would help extend the life of the Medicare Trust Fund aligning with Republican goals to sustain Medicare.  

MA Rules and Regulation A lot remains unclear about the regulatory direction CMS may take in the next four years. However, based upon the first Trump Administration’s practices and what is available on Republican’s thinking on these issues, we expect CMS to: propose fewer regulations that constrain MA plans and how they administer Medicare benefits, pursue efforts to reduce administrative burden and rollback or reinterpret some of the Biden Administration MA regulations.  

LeadingAge along with its Post-Acute Care (PAC) Coalition partners have made significant strides in the past couple of years on MA policy culminating in the CY2024 MA Policy and Technical rule related to prior authorizations and plan use of artificial intelligence and similar tools. Under the incoming administration, our focus will remain on enforcement of these rules. It is unclear if aspects of this rule will be rolled back, reinterpreted, or limitedly enforced nor whether we can expect CMS to issue additional FAQs providing further guidance on their implementation. Past Republican support on similar issues would suggest we should be able to expect continued support for these regulations especially as consumers face more denials. However, reducing administrative burden is a thread throughout several of the Republican platforms and was a tenet of the first Trump Administration so we also expect CMS to balance any regulatory requirements with the corresponding administrative burden they may impose. Therefore, it is possible to see certain provisions scaled back.  

The administrative burden reduction goals might also create opportunities for us to pursue our own interests around burden reduction by standardizing certain processes like prior authorizations or credentialing.  

Finally, as is common for all Presidential transitions, we expect the incoming Trump Administration to carefully review the numerous rules finalized by the Biden CMS Administration in 2024 to determine if they align with Trump Administration goals. These rules include: the CY2024 and CY2025 MA policy and technical rules, the Advancing Interoperability and Improving Prior Authorization rule, and the risk adjustment data validation rule, which allows CMS to claw back funds following audit findings where an MA plan’s where medical diagnoses submitted for payment were not supported in the beneficiary’s medical record.    

Medicare and CMMI Although Speaker of the House Mike Johnson has discussed reforming the Affordable Care Act (ACA) in the coming years, we do not anticipate an outright repeal of the entire ACA, and we also believe the Center for Medicare and Medicaid Innovation (CMMI) will remain. CMMI allows for rapid testing of alternative payment and care delivery models that are expected to generate savings.  

This doesn’t mean existing models will automatically remain in place and there is precedence of prior administrations repealing their predecessor’s programs. The GUIDE dementia model is expected to continue under the Trump Administration given its bipartisan support. However, the fate of Transforming Episode Accountability Model (TEAM) – the new mandatory bundled payment program scheduled to begin in 2026 — is less certain. Hospitals have voiced their displeasure with the mandatory nature of the program, but it is this feature that could generate savings, which could be used to fund other Republican priorities. In addition, some Republicans have expressed interest in rolling back aspects of the Medicare Shared Savings Program, which is the primary Accountable Care Organization (ACO) vehicle.  

 The Heritage Foundation in its Project 2025 materials highlighted some CMMI initiatives from the first Trump Administration that were repealed or revised by the Biden Administration that it would expect to return under a second Trump Administration. One of these models was the precursor to the ACO REACH program, called the Global and Professional Direct Contracting model.  While there were aspects of this model that LeadingAge supported, we were concerned about its geographic direct contracting model that had the potential to expand managed care dominance of markets in both MA and Medicare FFS in certain markets.  

Providers should continue to develop their contract negotiation skills and focus on improving their quality, as all indications are that the next Trump Administration will continue to shift Medicare payments away from FFS to accountable or value-based arrangements. Whether they will retain the Biden Administration goal to shift all Medicare FFS beneficiaries and most Medicaid recipients to an accountable care relationship by 2030, remains to be seen. As reported at the Health Care Payment and Learning Action Network Summit on November 14, the Biden Administration is just shy of 50% of Medicare beneficiaries and 29% of Medicaid recipients being in an accountable relationship as of 2023.  The Trump Administration may opt for an alternative goal or measure related to value-based care participation the encompasses all Medicare beneficiaries including those in MA given Republican interest in increasing MA enrollment.   

ELECTION IMPACT: Workforce 

Senate 

The Health Education Labor and Pensions committee (HELP) is responsible for shaping the healthcare, workforce, education and social safety net landscape.  Senator Bill Cassidy (R-LA.), the current Ranking Member, is set to take over as chair. Senator Bill Cassidy(R-LA) said he is “excited to work closely with President Trump and his Republican colleagues to implement a pro-America agenda and deliver real solutions for Louisiana and American families”. The incoming chair has expressed his intention to advance the Workforce Innovation and Opportunity Act (WIOA), a federal job training program. Interestingly Senator Rand Paul (R-KY) was next in line to chair Senate HELP but chose instead to lead the Senate Homeland Security and Government Affairs Committee.

The Homeland Security and Government Affairs Committee holds wide-ranging responsibility and oversight, including overseeing the efficient operation of federal agencies and homeland security including immigration and trade. Sen Paul(R-KY) is known for his strong perspectives and has advocated for securing the U.S. border and implementing stricter enforcement mechanisms but has also supported reforms to streamline legal immigration including work visas and a pathway to legal status (not necessarily citizenship) for undocumented immigrants already in the country. Senator Rand Paul has long emphasized the importance of reforming immigration laws to benefit the economy while maintaining border security. In recent comments Senator Rand Paul has indicated that the committee will consider reinstating the “Remain in Mexico” policy, that required immigrants seeking asylum in the U.S. to remain in Mexico while awaiting a court hearing. Senator Rand Paul also stated that he intends for the committee to “expeditiously advance” several of President Elect Trump’s nominees for key positions in his upcoming administration, including South Dakota Gov. Kristi Noem(R-SD), who has been nominated to serve as Secretary of Homeland Security.

The Senate Judiciary Committee holds broad jurisdictions, encompassing a wide range of legal, constitutional, and judicial matters including confirming cabinet nominees. Key areas of its oversight and legislative responsibility include immigration policy as well as border security and enforcement. Senator Lindsey Graham (R-S.C.), the current ranking member, is set to return as chair a role he previously held between 2019-2021. We don’t know exactly what Senator Lindsey Graham will do, but we can look to some of his recent actions, earlier this year he introduced the Birthright Citizenship Act of 2024 that would stop the practice of granting citizenship to the children of undocumented immigrants and the children of non-immigrants in the U.S. on temporary visas.

House of Representatives
The House Committee on Education and the Workforce has jurisdiction over federal education policies, labor laws, workforce development, and job training programs. The current Chair, Virginia Foxx(R-NC) is a stalwart of the committee with a wealth of historical knowledge having served as the ranking member and chair, but due to term limits she must relinquish her role in the next 1119th Congress. The race for her replacement is competitive with Reps. Tim Walberg (R-MI.) and Burgess Owens (R-UT) contending to take on the role. During her tenure Chair Foxx(R-N.C) has worked closely with Ranking Member “Bobby” Scott(D-VA) to move legislation related to short term training and apprenticeship programs.

The House Judiciary Committee that oversees a variety of issues including immigration will be led by Rep. Jim Jordan(R-OH) who has served on the committee since 2020 and is the current chair. Congressman Jordan has strong views on immigration and naturalization and has said he adheres to a threefold approach to addressing these issues: border security, robustly enforcing our immigration laws and fixing the system so that it works for those who want to come to the U.S. through legal pathways.

Administration
The Department of Education has significant impact governing both K-12 and higher education, where it oversees around $1.5 trillion in student loan debt for more than 40 million borrowers, making it one of the largest holders of consumer debt in the United States. This is significant to aging services as nearly 70% of nursing students report using student loans to fund their education.

Health and Human Services – The Public Health Service Act (PHSA) a comprehensive piece of U.S. legislation enacted in 1944, aimed at enhancing public health infrastructure and addressing various health needs across the country. It provides the legal foundation for many federal health agencies and public health programs, including efforts to improve health services, research, workforce training, and disease prevention. There are two key titles up for reauthorization in the next Congress: Title VII and Title VIII

Title VII provides support for health professions education and training by offering grants and entering into contracts with educational institutions, as well as providing direct financial assistance to trainees.

Title VIII focuses exclusively on nursing education and workforce. Through five core funding areas: Advanced Nursing Education & Advanced Nursing Education Workforce, Nursing Workforce Diversity, Nurse Education, Practice Quality and Retention Program, Nurse Corp Scholarship and Repayment Programs and the Nurse Faculty Loan Program. These programs collectively provide millions of dollars to support tuition, research and strengthen healthcare delivery enticing nurses to work in underserved areas or to become a nursing educator. The most recent reauthorization of Title VIII occurred in March 2020 as part of the CARES Act

The Department of Labor covers a wide range of issues aimed at protecting and enhancing the U.S. workforce. In recent years the department has been led by Acting Secretary Julie Su who has served since March 2023, but her official confirmation has languished in the Senate. While President Trump has yet to name a nominee, a few names have emerged as likely contenders. They include Patrick Pizzella, the current mayor of Pinehurst, North Carolina. Pizzella previously served as Deputy Labor Secretary and later as Acting Labor Secretary following Alex Acosta’s resignation in 2017. Keith Sonderling, a former Commissioner at the Equal Employment Opportunity Commission (EEOC). Sonderling, who left the EEOC in August, is considered a less contentious choice given his work with employers on preventing discrimination, including the use of artificial intelligence in hiring processes.  Andrew Puzder, Trump’s initial pick for Labor Secretary in his first term, may be under consideration despite his previous nomination being withdrawn. Rep. Brandon Williams (R-N.Y.) is another potential nominee. Williams, who recently lost his reelection bid, has served on the House Education and the Workforce Committee.

The State Department is broadly responsible for overseeing U.S. foreign policy, managing diplomatic relations, and promoting American interests abroad. Its jurisdiction includes negotiating treaties, managing international conflicts, coordinating foreign aid, overseeing the U.S. diplomatic corps, handling passport and most important to aging service providers, visa services. President elect Trump has nominated Senator Marco Rubio(R-FL) as his Secretary of State.  Senator Marco Rubio (R-FL) has held various positions on immigration throughout his political career, often balancing reform efforts and conservative policies. In 2013, he was part of the bipartisan “Gang of Eight” that proposed comprehensive immigration reform that aimed to increase border security while providing a pathway to citizenship for undocumented immigrants. In recent years, Rubio has supported stricter immigration enforcement indicating support for some of President Trump’s statements about immigration, emphasizing concerns over national security and illegal border crossings. Despite this, Rubio has continued to advocate for resolving issues surrounding Deferred Action for Childhood Arrivals (DACA), urging bipartisan solutions to protect Dreamers.

The Department of Homeland Security (DHS) is responsible for safeguarding the United States from a wide range of threats, including terrorism, natural disasters, and other emergencies. Its jurisdiction covers national security, border security, immigration enforcement, cybersecurity, emergency management, and the protection of critical infrastructure. DHS oversees the U.S. Citizenship and Immigration Services (USCIS) that implements the immigration and naturalization process. President Trump has nominated Governor Kristi Noem(R-SD) to lead the Department. The governor has been vocal about the need for tighter border security.

ELECTION IMPACT: Employment and Labor: How the Trump Administration May Shape Federal Policy Impacting Aging Services Provider Employers  

The 2024 presidential election will have a significant impact on employment and labor policies implemented by federal agencies, affecting both employers and employees, as we expect the incoming Trump Administration to consider a variety of options for reducing regulatory burdens and creating flexibility for employers over the next four years.

President-elect Trump has not yet announced his choices for Labor Secretary or deputy secretaries in key roles, or for key National Labor Relations Board positions, and we will know more about the potential agenda to come when these nominations and appointments occur.

Selected examples of potential focus for President-elect Trump and his Administration: 

Department of Labor: Wage & Hour Requirements

Independent Contractor Classification We believe the new Administration will likely seek to roll back the current standard for classification of individuals as independent contractors under the Fair Labor Standards Act (FLSA).In the final month of President Trump’s first term, the Department of Labor (DOL) finalized a rule establishing standards to govern the determination of whether a worker should be considered an employee or an independent contractor. The rule identified five factors that drive the classification decision and designated two of those factors as having the most weight – the nature and degree of control over the work and the worker’s opportunity for profit or loss – and it was set to take effect in May 2021.

In the early weeks of President Biden’s administration, however, DOL delayed the implementation date of the rule, then withdrew it altogether before it took effect. The Department later conducted a separate rulemaking process that culminated in March 2024, when it finalized a new regulation that created a longer list of factors applicable to the classification determination, all of which have equal weight, and expanded the definitions and descriptions of those factors. The result was to create a higher bar for businesses to clear in terms of classifying workers as independent contractors.

If the past is prologue, it seems likely that the DOL under President Trump will seek to reverse the current Administration’s policy and install a standard similar to the one issued in 2021.  If a reversal does occur, a new rulemaking process will be required, because the 2024 rule is already in effect. Rulemaking is a time-consuming process, so no regulatory change will occur immediately.

Federal Salary Threshold for Overtime Exemption The Trump Administration’s approach to overtime eligibility will likely be narrower than the Biden Administration’s policy. Earlier this year, DOL finalized new regulations concerning the “white collar” overtime exemptions under FLSA, effective July 1.  The rule established a significant two-step increase (from roughly $35,000 to roughly $58,000 per year) in the minimum annual salary that must be paid in order for executive, administrative and professional employees to be classified as exempt from overtime. The rule also established a requirement for DOL to update the salary level every three years, without a notice and comment rulemaking process. On November 15, however, a Texas federal court struck down the 2024 rule, saying the Department had exceeded its authority.

As with the independent contractor issue, we can look to the past to predict what may lie ahead, because this will be the second time President Trump takes office after an administration has tried to expand overtime coverage, only to be blocked by a federal court.  In 2016 President Obama’s DOL finalized a rule that would have raised the overtime salary threshold from roughly $23,000 per year to roughly $47,000. A federal court blocked that rule and in 2019, during the first Trump Administration, DOL replaced the 2016 rule with one that raised the threshold by a smaller amount, from $23,000 to roughly $35,000. The incoming Administration faces a similar situation now, because, as noted, a federal court has just vacated the Biden Administration’s overtime rule, with nationwide effect.

An issue to watch is whether the incoming Administration will continue to defend the 2024 rule in court. The Biden administration naturally did so in the Texas case, as its own rule was being challenged, and a big question is whether the current Administration will appeal the district court’s decision to the Fifth Circuit Court of Appeals.  If it does, the question becomes whether the incoming Labor Secretary will cause the Department of Justice to change course and drop its defense of the rule at the appellate level.

If the new Administration does not seek to defend the Biden rule, a second question is whether President Trump’s DOL would revisit the issue and propose a new rule that raises the overtime salary threshold from its current level but by a smaller amount, covering fewer workers, than the Biden rule would have done. We’ll have to stay tuned to see how this plays out over the next few months.

As part of our efforts to forecast possible policy changes, we have also reviewed the Heritage Foundation’s 2025 Presidential Transition Project.  While the president-elect distanced himself from Project 2025, policy priorities expressed there may find footing in the new Administration.  Among other issues concerning DOL, Project 2025 calls for Congress to take certain actions relating to overtime, such as providing flexibility for the overtime calculation period to occur over two or four weeks, instead of one. We will monitor developments in this area.

DOL: Occupational Safety & Health Given messaging from the Republican national party platform and from the President-elect about the general importance of reducing regulatory requirements – and considering President Trump’s track record during his first term in office – we can expect that the new Administration will issue fewer rules, and possibly roll some back, relating to workplace safety and health.

For example, the Obama Administration launched new requirements for electronic reporting to OSHA of certain employer injury and illness data. President Trump pulled this back during his first term in office. Under the Biden Administration, however, DOL has restored and expanded the practice, including new reporting requirements that took effect January 1.  Given the President-elect’s prior position, this is an issue where the pendulum may swing back again, with less reporting required.

Observers also expect the new Administration will conduct rulemaking to roll back a final OSHA regulation that took effect in May, permitting third parties – including union representatives – to accompany inspectors during facility walkarounds.

Regulations in process but not yet finalized: We will also watch closely to see how the new Administration chooses to handle these. For example:

OSHA has proposed a national standard designed to protect workers from heat related hazards, but, with a comment period open through December 30, this rule could not become effective prior to Inauguration Day. This means the new Administration will have discretion and latitude to pause the rule, scale it back or drop it altogether.

Federal infectious disease standard. OSHA has submitted a proposed rule for review by the Office of Management and Budget, but it has not yet been formally released for public review.  Here again, because the rule will not be effective prior to the change of Administration, the new Deputy Secretary for OSHA will have discretion to advance, change, pause or drop the rule.

National Labor Relations Board The National Labor Relations Board (NLRB)  interprets, implements and enforces the National Labor Relations Act (NLRA), which protects the rights of workers to unionize and to collectively bargain with their employers, and it works to prevent and remedy unfair labor practices committed by employers or unions.

The NLRB primarily establishes labor law requirements by deciding individual cases relating to what the NLRA does or does not require or allow. The current Board has issued many precedent setting decisions during the Biden Administration that are broadly supportive of workers’ rights. The Trump Administration will pursue new policy and priorities at the NLRB.  

The Board can also engage in rulemaking. Though it does not issue rules often, the impact can be significant when it does, such as the Board’s 2023 revision to the “joint employer” standard (which a federal court ultimately struck down).

The NLRB is a bifurcated agency, governed on one side by a five-person Board and on the other side by a General Counsel.  What happens at the NLRB depends significantly on who holds these positions, and this is a key issue we will be watching in the next few months.

The Board has five members. They are appointed by the President to 5-year terms, with Senate consent, and the term of one member expires each year.  The Board currently has a 3-1 Democratic majority, and one seat is empty.  Board members do not always take positions strictly along party lines, but it does often happen, and the incoming President will seek to establish a Republican majority on the Board.

This process will take time, however, and there are some near term unknowns.  President Biden has nominated current Board Chair Lauren McFerran (whose term expires in mid-December) to a third term and nominated Joshua Ditelberg to fill the Board’s vacant Republican seat. The Senate, however, has not yet confirmed these nominations. If Chair McFerran is confirmed for a third term, the Board would maintain a Democratic majority until 2026, when another Democratic member’s term expires.  If the Senate does not confirm Biden’s nominees before Inauguration Day, President-elect Trump will nominate individuals to fill those two seats, returning the Board to a Republican majority.

The General Counsel, who is also appointed by the President, is independent from the Board and is responsible for the investigation and prosecution of unfair labor practice cases and for the general supervision of the NLRB field offices in the processing of cases. As such, the General Counsel plays a significant role in setting priorities, providing legal guidance to staff, and bringing cases forward to the Board.

When President Biden took office, one of his first actions was to terminate the NLRB’s General Counsel and appoint a replacement. President-elect Trump will almost certainly do the same in the early days of his Administration, dismissing the current General Counsel, Jennifer Abruzzo, and replacing her with someone new.  Making this change is one lever that the new Administration will pull in order to begin affecting policy changes.

In short, we expect a paradigm shift under the new Trump Administration with a newly appointed Republican General Counsel shaping the internal agenda and, eventually, a Board composition with a Republican majority.

Federal Trade Commission: Non-Competition Agreements Another federal workplace policy issue is the status of non-compete agreements.  President-elect Trump and Republican lawmakers will oppose certain regulations considered to be anti-business, and federal noncompete restrictions are likely to be viewed this way.

A Federal Trade Commission (FTC) Non-Compete Rule, which was set to take effect on September 4, would have prohibited employers from entering into new non-compete agreements and from enforcing most existing non-compete agreements entered into before that effective date, and it would have required employers to notify workers subject to a non-compete clause that the employer will not enforce it.

Just before the rule was to take effect, however, a federal court in Texas struck it down, saying that the FTC had exceeded its statutory authority. As such, the court held the rule to be unlawful and set it aside with nationwide effect.

In mid-October the FTC filed notice of appealing that decision to the Fifth Circuit Court of Appeals, and this raises questions about what action the new Administration might take.  It is possible that the FTC, under new leadership, will choose not to continue defending the rule in court, leaving the nationwide ban in place.  Another possibility is that the FTC will seek to repeal the non-compete rule, or to amend it in a way that establishes few restrictions on a narrower scope of agreements.  As with the other issues outlined above, time will tell.

ELECTION IMPACT Congressional Health Committees Outlook 

Given the expiration of many of the tax changes authorized by the Tax Cuts and Jobs Act of 2017 (TCJA) at the end of 2025, taxes will be at the forefront of the 119th Congress. Health care spending, particularly in Medicaid, is likely on the table for a dual purpose: to provide savings to offset the tax cut extensions and to reform Medicaid to align with the Republican party’s vision of a more limited program.

General Issues

• Enhanced Subsidies for Marketplace Plans (ACA Enhanced Subsidies): The American Rescue Plan Act in 2021 and the Inflation Reduction Act of 2022 created funding for enhanced cost sharing subsidies that help people afford their insurance through the Marketplaces. These subsidies expire at the end of 2025. It is generally thought that Republicans will not be interested in extending the subsidies but health plans who offer Marketplace coverage will lose enrollees and the money subsidizing existing enrollees – so they, along with consumer advocates, will be pushing for their extension. Staff at LeadingAge member organizations may be receiving health care through the Marketplaces.
• Medicaid: Republicans have already indicated that Medicaid reform is top of mind. No specifics have been released as of yet but reports indicate that they will look at spending caps.  Currently, states receive federal Medicaid funding based on what it actually costs to provide services to Medicaid enrollees. Republicans would likely look at block grants (which allocates to states a fixed amount of money to administer Medicaid based on a pre-determined formula) or per capita caps (under which states would get an initial allotment of funds that would be increased every year by a certain growth rate). In both cases, the amount of dollars allocated would not be tied to the actual costs of providing Medicaid services to enrollees. The expected result: huge cost shifts to states trying to maintain current services and/or enrollment numbers. Work requirements in Medicaid are also likely to be a focus – both Congressionally and administratively–based on the last Trump Administration’s Medicaid agenda. LeadingAge opposed work requirements and changes to the Medicaid financing structures in the past because they would reduce access to our care and services and have a detrimental impact on our providers’ sustainability and access for those who they serve.

Changes in the leadership of the health care committees of jurisdiction in Congress for the 119th Congress:

Senate Finance Committee Senator Mike Crapo, R-ID, will take over as Chair of the Senate Finance Committee; Senator Ron Wyden, D-OR, will be ranking member. Mr. Crapo and Mr. Wyden worked in a bipartisan fashion in the 118th Congress on pharmacy benefit manager reform, prescription drug shortages, Part B payment reform, mental health, telehealth, and other issues. The Finance Committee has jurisdiction over, among other issues, Medicare, Medicaid, Social Security, and taxes. Given the expiration of many of the tax changes authorized by the Tax Cuts and Jobs Act of 2017 (TCJA), Chair Crapo will be leading on issues related to taxes in the 119th Congress and on any changes to the Medicaid program that may ride along with a reconciliation package. Any work on continuing the enhanced subsidies for Marketplace coverage will also run through the Finance Committee. Finally, any and all Medicare policy work is done in the Finance Committee; it is not clear yet when in the year Medicare policy will be prioritized. With the departure of John Thune (R-SD) from the Senate Finance Committee, one potential seat is open for a new Republican to join the Finance Committee. 

Currently, the ratio is 13 majority members and 12 minority members. The Republicans could choose to reduce the number of seats  and keep their number at 12 or to add another Republican Senator. Given the anticipated focus on tax policy, a seat on the Committee will be even more coveted than usual.

On the Democratic side, there are 6 members not returning. Senators Ben Cardin (D-MD), Debbie Stabenow (D-MI), and Tom Carper (D-DE) are retiring. Senator Bob Menendez (D-NJ) resigned in August; his seat was taken by Senator George Helmy, the temporary NJ senator but that seat on the Committee will be open in the new Congress. Senator Sherrod Brown (D-OH) lost his re-election and at this time, it is expected that Senator Bob Casey (D-PA) will also be lose his seat. Therefore, depending on what decisions the Republicans make about the number of seats, the Democrats could have 4-5 vacancies to fill.

The new Senate Majority Leader is Senator John Thune (R-SD). A current member of the Senate Finance Committee, he’s active on rural health and telehealth as well as currently being in bipartisan workgroups on 340B reform and Medicare Part B Payment reform. He will no longer be on the Finance Committee but knowing his interests is helpful since he will be majority leader.

Senate Health, Education, Labor and Pensions Committee (HELP) Senator Bill Cassidy (R-LA) will chair the HELP Committee in the 119th Congress. It is not known yet if Senator Bernie Sanders will seek to be a ranking member. Senator Cassidy is very active on health care having released requests for information on diverse topics like clinical lab tests, primary care payment, health data privacy, gene therapy, CDC reform, NIH reform, artificial intelligence, and dual eligibles in the 118th congress. He has released white papers on health data privacy and NIH reform. Senator Cassidy led a bipartisan working group that led to the development of the Delivering Unified Access to Lifesaving Services (DUALS) Act, a bill LeadingAge supports which includes expansions of the PACE program. His focus on reforming the NIH and CDC are similar priorities to HHS Secretary Nominee RFK Jr – while all of their ideas may not align, it would not be surprising if these were areas of focus. Senator Cassidy is also on the Senate Finance Committee and has been supportive of efforts to increase transparency in Medicare Advantage. Senator Cassidy will be a key player in anything health care related given his positions on both Committees of jurisdiction and his personal interest in the issues – he is a doctor. There will likely be a couple of new Republicans on the Committee.

This Committee has jurisdiction over labor issues and workforce – more on that can be found in ELECTION IMPACT: Workforce 

Senate Special Committee on Aging This Committee will likely have completely new leadership. If Senator Casey’s race (which is in a recount) ends with a loss for him, Senator Kirsten Gillibrand is next in line to take over as Ranking Member of the Committee. On the Republican side, Senator Rick Scott (R-FL) is in line to be the Chair. He has not indicated whether he will seek the Chairmanship. Senators Marco Rubio (R-FL) and Vice President Elect JD Vance (R-OH) as well as Ranking Member Mike Braun (R-IN) will not be serving in the Senate in the new Congress (assuming Senator Rubio is confirmed as Secretary of State). It remains to be seen if they choose to keep the same ratio or shrink the size of the Committee, but regardless, we will be seeing some new faces on this Committee on the Republican side.

House Ways and Means The House remains in republican control. Rep Jason Smith, R-MO, will maintain his chairmanship and Ranking Member Richard Neal (D-MA) will remain as the ranking member. This Committee has jurisdiction over the Medicare program, particularly Part A (SNF, hospice, home health), some Part B and Medicare Advantage, private insurance, and Part D issues. Mr. Smith is from a rural district and has been very interested in rural issues along with kidney care and telehealth. He has been more active on tax policy than health care and given that 2025 is shaping up to be a tax heavy year, we anticipate that much of the focus in the first part of 2025 will be on tax policy. Mr. Neal will likely be focused in a more defensive posture on priorities like the ACA enhanced subsidies and Medicare expansion and oversight. The Committee will have at least two Republican open seats, possibly three (Rep Steel’s (R-CA) seat remains uncalled). In the minority, Reps Blumenauer (D-OR) and Kildee (D-NJ) both are retiring, leaving openings.

House Energy and Commerce The Energy and Commerce committee has shared jurisdiction over Medicare Part B, Medicare Advantage, and Medicare Part D with the Ways and Means Committee. It has sole jurisdiction over Medicaid and over agencies like FDA, CDC, and NIH. Rep Cathy McMorris Rodgers, the current chair, chose not to run for re-election. Representatives Brett Guthrie (R-KY) and Bob Latta (R-OH) are running to be chair. Mr. Guthrie is the current chair of the Subcommittee on Health and  has been more engaged on the health care portfolio in the Committee than Mr. Latta. Ranking Member Frank Pallone (D-NJ) will remain as ranking member of this committee.

ELECTION IMPACT Care in the Home and Community Outlook 

Generally speaking, care in the home and community is a bipartisan issue. The Republican platform says “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 and reduced red tape.” President-elect Trump reiterated this commitment to supporting caregivers through a tax credit at a rally in Madison Square garden in October. Project 2025 also talks about basing payments in FFS Medicare on the intensity of the service or the health status rather than site of service which suggest a Medicare advantage style payment model – which, with guardrails, could help members taking care of complex patients.

Issues and topics

Medicaid The Biden Administration finalized a number of rules related to the Medicaid program. The streamlining eligibility and enrollment rule is one that will probably see major changes in the new Administration since there is fundamental disagreement between Republicans and Democrats on policies that facilitate access to the Medicaid program. The new Administration will want to, in various forms, shrink the size of the Medicaid program and that includes imposing more stringent eligibility requirements or determinations. It is also likely that the 80/20 provision of the Medicaid access rule will be undone, either administratively or by congressional action. There is a bipartisan bill, H.R. 8107, Ensuring Access to Medicaid Buy In Programs, that would codify some of the reporting requirements in the Access Rule and also lower the clinical eligibility threshold for 1915c waivers. Bipartisan work on Medicaid like this bill could continue in the new Congress or might be put on hold if work on changing the financing begins in earnest.

Home Health Looking toward the end of the year, LeadingAge is still working on and hoping to get some relief on the persistent Medicare fee for service payment cuts. This has been a bipartisan effort. In a new Congress and Administration, LeadingAge will continue to work on sustainable access to home health care including thinking about more holistic changes to the benefit as well as targeted policies like specific add-ons that might provide some more immediate relief.

Hospice Hospice program integrity reforms have been a bipartisan effort to date so we may see more work on that in the 119th congress. LeadingAge is advocating for a two-year delay of the special focus program and an expansion of hospice face to face telehealth flexibilities – along with pushing for broader telehealth extensions for two years – in an end-of-the-year package. Telehealth has been broadly bipartisan as have programs like hospital-at-home that expand access to care at home. Project 2025 also indirectly references carving hospice into Medicare advantage. Hospice remains the only benefit carved out of the MA program. We will closely monitor any policy discussions in this space. Palliative care has also received bipartisan support and is mentioned in Project 2025 noting that palliative care education is vital.

ELECTION IMPACT Affordable Housing 

Oversight and policy jurisdiction for the Department of Housing and Urban Development (HUD) and United States Department of Agriculture (USDA) Rural Housing Service programs is within the House Committee on Financial Services and the Senate Committee on Banking, Housing, and Urban Affairs. The next chair of the House Committee on Financial Services is still unclear after current Chair Patrick McHenry’s (R-NC) retirement at the end of this session. 

Representatives Andy Barr (R-KY) and French Hill (R-AR) are making their cases to be the next chair for early December votes. Rep. Barr has focused on ending the housing first approach in homelessness and says he will reform HUD and improve housing affordability. Mr. Hill’s main housing goals are showcased in his Renewing Opportunity in the American Dream (ROAD) to Housing Act, which includes increased access to small dollar mortgages, expanded broad regulatory flexibility to all public housing agencies, and studying work requirements’ impact in affordable housing. Representative Maxine Waters (D-CA) will continue as Committee Ranking Member.

On the Senate side, the election loss of Senate Banking, Housing, and Urban Affairs Chair Sherrod Brown (D-OH) coupled with the Senate’s flip to Republican-control leaves the new Committee leadership to be determined. Many think Senator Tim Scott (R-SC) will take the gavel and it is likely that either Senator Elizabeth Warren (D-MA) or maybe Mark Warner (D-VA) will be the lead Committee Democrat. In addition to being a longtime member of the Banking Committee, Senator Scott has been the lead Republican on the Senate Special Committee on Aging. Senator Scott’s goals in housing are spelled out in his Renewing Opportunity in the American Dream (ROAD) to Housing Act, the Senate companion to Representative Hill’s bill referenced above, and in his 2022 report, Housing for the Golden Years: Trends, Gaps, and Solutions for Older Americans, which discusses the need for affordable and accessible housing for older adults while also calling for reduced federal intervention in housing markets.

The Senate’s long time champion for Section 202 funding, Senator Robert Menendez (D-NJ), resigned earlier this year after being convicted on 16 counts in a political corruption case and we’re on the hunt for new champions.

In the House, at least nine appropriators aren’t returning to Congress next year. Representative Tom Cole (R-OK) will retain his House Committee on Appropriations chairmanship and has expressed a desire to work from President-elect Trump’s priorities, which include deep spending cuts.

President-elect Trump has said he will support homeownership by restoring state and local tax deductions, sell federal land to make way for home construction, provide homeownership tax incentives, and has pledged to compassionately address homelessness and to completely eradicate homelessness among veterans. In Project 2025, former HUD Secretary Ben Carson outlines support for single family housing, including tax credits in rural areas for the repair and renovation of single family housing, and repeal of HUD’s climate-related efforts.

We expect the incoming Administration will seek similar policy changes attempted in President-elect Trump’s first term. Of course, there could be a much smoother path to enactment of changes with the same party in control in Congress and the White House for at least the next two years.

Expected repeated proposals to HUD programs from the Trump administration include:

• An increase in the tenant contribution toward rent from 30% of adjusted income to up to 35% of gross income (with income adjusted by exclusions but not deductions).
• For Section 8 Project-Based Rental Assistance and Section 202 Project Rental Assistance Contracts, imposing a one-year freeze on annual rent adjustment increases.
• And, allowing HUD to transfer of up to 30% between the Housing for the Elderly and Housing for Persons with Disabilities accounts as the agency sees fit.

With the 2017 Tax Cuts and Jobs Act’s provisions expiring in 2025, next year is sure to be a big tax year in Congress, including, we hope, expansion and improvements to the Low Income Housing Tax Credit. It is likely that tax work will be wrapped into one of the budget reconciliation packages.

The next HUD will take over implementation of the Housing Opportunity Through Modernization Act (HOTMA). We’ll have to work to ensure that the next Administration continues to interpret HOTMA to say that owners have an option whether to impose asset limits on currently assisted residents, which the current HUD came around to understanding and is still in the process of implementing.

HUD still has much it could do this year including publishing a final Affirmatively Furthering Fair Housing rule and issuing a final rule on criminal background screening in multifamily housing, both of which we’d expect to be reversed by the next Administration.

Also in 2024, the current continuing resolution is set to expire on December 20. If the lame duck session has any hope to complete spending bills this year, they’d need to agree on a new topline spending cap by close to Thanksgiving, a hard task since the respective House and Senate bills are a combined $90 billion apart. Right now, there’s a good chance that finalizing the fiscal year 2025 bills will get punted into next year, perhaps until March. Funding HUD programs at last year’s levels for six months into the new fiscal year could be insufficient to fully renew rental assistance contracts with owners and LeadingAge is urging Congress to include anomalies for these accounts should the bills be pushed into next year.

ELECTION IMPACT Nursing Home Outlook 

As we anticipate the priorities of the new Administration, it’s useful to reflect on the past four years under the current one. The Biden Administration brought heightened focus and scrutiny to nursing homes, particularly as the sector grappled with its central role in the COVID-19 pandemic. This marked a shift from the widespread praise healthcare workers initially received to a more critical examination of nursing home operations and outcomes.

From the outset, including in President Biden’s State of the Union addresses, nursing home reform emerged as a key priority. Proposed initiatives sought to raise standards and ensure that residents receive the care and respect they deserve. These reforms included establishing a minimum staffing requirement, reducing overcrowding, enhancing the value-based purchasing program, and reinforcing protections against unnecessary medications and treatments. Additionally, the Administration emphasized increasing accountability and oversight, introducing detailed plans to improve transparency and quality across the industry. There were also heightened requirements for reporting in quality and value-based programs, mandates for COVID-19 education and vaccination, and an unfunded, one-size-fits-all staffing mandate—despite the absence of a steady workforce pipeline. Coupled with a generally negative outlook toward nursing homes, these measures have forced the sector to confront difficult choices about its ability to sustain operations and remain viable in the future.

The next four years under a Trump Administration could signal a significant shift for nursing homes. If history serves as any indication or if guidance is drawn from Project 2025 and the Republican Party Platform, the regulatory and legislative framework governing nursing homes could undergo dramatic changes.  We also are gleaning information on the HHS nominee Robert F. Kennedy Jr., who was tapped last week to run the agency.  We can say there is a clear focus on making sweeping changes to NIH and CDC.

The previous Trump Administration was known for scaling back regulations and reducing healthcare administrative costs, aiming to provide relief to America’s healthcare providers and refocus efforts on patient care. In 2017, LeadingAge participated in discussions with CMS Administrator Seema Verma to launch the Patients Over Paperwork initiative, addressing regulatory reform. During these discussions, we highlighted the specific regulatory burdens faced by nursing homes. Through this initiative, the Trump Administration repealed, rolled back, and relaxed various nursing home regulations. As we review and analyze the proposals outlined in Project 2025 and the Republican Party Platform, we anticipate similar actions in the years ahead.

Let’s begin with the federal staffing mandate. This unfunded mandate from the current Administration seems poised for potential reversal under a Trump Administration. Our ongoing advocacy and legal efforts continue to push for the rule to be overturned, repealed, or discarded entirely. We are optimistic that a new Administration will recognize that this mandate, as currently structured, does not address workforce shortages and could force some nursing homes to close, leaving residents without care and staff without jobs. The Republican Platform emphasizes protecting seniors as a priority, pledging to safeguard vital programs and promote economic stability. Their commitment focuses on working alongside seniors to support active, healthy lifestyles and ensuring a secure future for seniors and American families alike.  Reading between the lines, we believe the new Administration will reverse the staffing mandate. However, it must be said that there could be a spilt in that move.

Remember the staffing mandate rule has two other parts, the facility assessment which is now in survey compliance and the Medicaid transparency reporting focused on state reporting.

Nursing homes must continue to be compliant in the facility assessment enhancements and updates and there is a chance that would these requirements of the rule would continue. LeadingAge will immediately ask the Trump Administration to make repealing the staffing mandate a priority, first through the transition team and then directly to the new Administration.

LeadingAge is taking every avenue to fight the staffing mandate. We are plaintiffs in a lawsuit seeking to strike down the rule and prevent it from taking effect. We’ll continue our legal advocacy unless and until the new Administration acts to repeal the staffing requirements. There is a lot at stake and we are hoping for a strong outcome.

Beyond the staffing mandate, other regulations and requirements are causing significant concern and adding to the administrative burden on nursing homes. Among these is the required off-cycle revalidation using the 855A CMS Medicare Reenrollment Application Form—a cumbersome rule that could easily align with the Patients Over Paperwork initiative for reconsideration.

The current Administration has placed a strong emphasis on increasing transparency in nursing homes, including scrutiny of private equity and ownership structures. A Trump Administration might prioritize reversing or scaling back some of these transparency requirements under the guise of reducing administrative burdens.

Looking into Project 2025, its outlined goal of preparing for the next health emergency highlights structural reform at the CDC, with an emphasis on streamlining vaccine education and mandates, as well as risk mitigation strategies. The plan also calls for significant changes to current reporting requirements, which it identifies as overly burdensome for frontline workers. Fragmented data collection processes would need updating to reduce the workload on clinicians, reflecting a broader effort to minimize administrative strain and enhance efficiency.

Let’s turn to Congress, the end of the year and the next Congress:

Despite our success in advocating for the introduction of resolutions in the House and Senate to overturn the federal staffing mandate through the Congressional Review Act Resolution of Disapproval on the Staffing mandate, the threat of a veto by President Biden rendered passing these measures impractical. Additionally, the Congressional Review Act allows a new Congress to overturn regulations only within a 60-day lookback period, making it unlikely that this tool will be utilized in the next session. However, alternative pathways remain available, including legislative, regulatory, and legal remedies, to pursue the repeal of the staffing mandate.  There could be an appetite in the new Congress with for an option to overturn the staffing mandate.

The Ensuring Seniors’ Access to Quality Care Act (H.R. 3227 / S. 1749) is a bipartisan, bicameral bill introduced by Representatives Ron Estes (R-KS) and Gerald Connolly (D-VA) in the House, and Senators Mark Warner (D-VA) and Tim Scott (R-SC) in the Senate. The bill has gained significant momentum in the Republican-led House of Representatives, passing the House Ways and Means Committee on May 8 and the House Energy and Commerce Committee on September 18, with support from LeadingAge. Discussions with congressional and committee leaders suggest the bill is well-positioned for a vote in the full House and possible inclusion in a legislative package before the year’s end. If that does not occur, the bill will remain strategically positioned for consideration and potential passage in the next Congress under a Republican-led House, Senate, and administration.

The Building America’s Health Care Workforce Act (H.R. 9067) known as the TNA bill is also a bipartisan bill introduced by Representatives Brett Guthrie (R-KY) and Madeleine Dean (D-PA).  The amended bill is another priority of House Republicans for possible inclusion in a year-end legislative package.

The Improving Access to Medicare Coverage Act (H.R. 5138 / S. 4137) is the primary bill in Congress to address the 3-Day qualifying hospital stay requirement for skilled nursing coverage under Medicare.  LeadingAge engaged in the rulemaking process and views the appeals process as an important step forward. However, we will also continue advocating for a legislative fix to address the 3-day stay requirement — although the prospects of legislative action in the next Congress are a bit murky for this particular bill.