What Medicaid Reforms in H.R. 1 Mean for Nurses

  

As Americans were celebrating our nation’s birthday with BBQ and fireworks, President Donald Trump signed the One Big Beautiful Bill (OBBBA; H.R. 1) into law. This new law:

  • permanently extended the 2017 tax cuts,
  • adopted additional tax reforms, and
  • provided funding for other Trump Administration priorities.

One tax reform includes tax deductions on overtime pay for nurses, first responders, and others. To partially offset the law’s $3.3 trillion price tag, OBBBA includes almost $1 trillion in cuts to Medicaid spending and will make health insurance coverage inaccessible to 10 million individuals by 2034, according to estimates from the Congressional Budget Office.

Here is an overview of Medicaid and other health reforms that will impact the nursing workforce and the patients whom they serve.

Medicaid Finance Reforms

OBBBA makes several reforms that lower federal and state government spending on Medicaid and have a trickledown effect on healthcare facilities and the nursing workforce in these settings. For example, one provision restricts states’ use of provider taxes to finance their share of Medicaid spending with exceptions for nursing homes and intermediate care facilities. Another section in the bill related to state-directed payments changes how much states can direct Medicaid managed care plans to pay providers. Finally, OBBBA eliminates the temporary 5% increase to the traditional federal medical assistance percentage (FMAP) that the federal government provided to new expansion states under the American Rescue Plan.

Finally, OBBBA eliminates the temporary 5% increase to the traditional federal medical assistance percentage (FMAP) that the federal government provided to new expansion states under the American Rescue Plan.

Restrictions on Medicaid financing will force states to limit eligibility, coverage, and payments to meet statutory budget constraints.

Consequently, healthcare facilities that are heavily reliant on Medicaid funding will be forced to either cut critical services or close their doors altogether. This could:

  • jeopardize nursing jobs,
  • aggravate nursing workforce challenges, and
  • reduce reimbursement for advance practice registered nurses (APRNs).

Patients will ultimately see less access to care, particularly in rural and medically underserved communities.

Changes to Medicaid Eligibility and Access Policies

H.R. 1 also makes several policy changes that restrict Medicaid eligibility and access. Starting in 2027, the law requires adults between the ages of 19 and 64 to work or participate in a qualifying activity for at least 80 hours a month. Thanks to ANA’s advocacy, the law provides an exemption for adults who are enrolled in nursing school or other academic settings.

OBBBA will require states to conduct eligibility checks every six months beginning next year and restrict their ability to provide retroactive coverage starting in 2027. The law also delays implementation of the Eligibility and Enrollment Rule, a pair of Biden-era rules that aim to reduce barriers to enrollment in Medicaid and other programs, until 2035. One bright spot for patients in the law is its expansion of home and community-based services to individuals who do not need an institutional level of care beginning in July 2028.

Most of these policy changes will make it difficult for Medicaid beneficiaries to retain coverage and disincentivize other patients from enrolling in the program. Patients who no longer have access to Medicaid coverage will delay care and experience worse patient outcomes when they finally do receive care. Healthcare providers will also experience an increase in uncompensated care. While it is heartening to see H.R. 1 expand home and community-based services to patients who do not need an institutional level of care, the jury is out on whether these patients will have adequate access to nurses and other healthcare personnel.

Rural Health Transformation Program

H.R. 1 is projected to result in a $155 billion reduction in Medicaid spending in rural communities over the next decade, resulting in hospital closures and reduced access to care for rural patients. To blunt the impact on Rural America, the law establishes a Rural Health Transformation Program that will support efforts to address challenges facing rural health systems. Initiatives that aim to strengthen the rural health workforce, improve access to rural providers, and/or promote technology-driven solutions like robotics and artificial intelligence are perfect candidates for support from this program. OBBBA authorizes $50 billion in funding to the program with $25 billion equitably distributed among the states and $25 billion given out at the discretion of the CMS Administrator. More information from CMS is expected in September.

While well-intentioned, the reality is that this program does not fully offset the cuts that rural facilities will face because of the law. Additionally, the language in the section creating this program is written in a manner that makes non-rural facilities eligible for funding.

Delayed Implementation of Nursing Home Staffing Rule

Last year, the Centers for Medicare and Medicaid Services (CMS) finalized the Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting Final Rule (CMS 3442-F). This rule:

  • sets minimum staffing standards,
  • requires a registered nurse (RN) to be onsite 24 hours a day, 7 days a week in long-term care facilities that participate in the Medicare and Medicaid programs, and
  • requires facilities to engage nurses in identifying staffing needs through facility assessments.

To help defray the cost of OBBBA, the law delays HHS from implementing the final rule through September 30, 2034. However, the facility assessment and Medicaid transparency provisions in the rule were excluded from the final text because they were subject to the Byrd Rule in the Senate. The Byrd Rule requires that provisions included in budget reconciliation measures focus on fiscal matters. This delay in implementation of the staffing rule only exacerbates staffing challenges in long-term care facilities that lead to nurse burnout and attrition from the profession. This moratorium also delays patient care and results in worse patient outcomes for nursing home residents.

Temporary Payment Increase for Healthcare Providers

Since Calendar Year (CY) 2000, the reimbursement rate that healthcare providers receive has been declining due to statutory budget neutrality requirements. This gradual reduction is especially challenging for APRNs who receive 15% lower reimbursement than physicians in Medicare for doing the same work. In CY 2025, CMS finalized a 2.8% cut to the conversion factor after a temporary increase in payments for CY 2024 expired.

H.R. 1 temporarily increases the conversion rate by 2.5% for 2026. While this increase does not resolve reimbursement challenges facing APRNs, it is a step in the right direction to ensuring that patients have access to APRN care.

Future Opportunities to Shape Medicaid Policy

The fight to save Medicaid is far from over. Through the Partnership for Medicaid, ANA recently endorsed a pair of bills to roll back provisions in H.R. 1:

  • Senator Josh Hawley’s (R-MO) Protect Medicaid and Rural Hospitals Act (S.2279) would repeal the law’s restrictions on provider taxes and state directed payments. It would also double the duration and funding for the Rural Health Transformation Program.
  • Senate Minority Leader Chuck Schumer (D-NY) and Senate Finance Committee Chair Ron Wyden (D-OR) introduced the Protecting Health Care and Lowering Costs Act (S.2556) to repeal the entire health section of H.R. 1. The measure also permanently extends the ACA premium tax credits that are set to expire at the end of this year and result in an additional 5 million individuals losing healthcare coverage.

ANA will also have ample opportunity to weigh in on implementation of H.R. 1 by the federal government and the states. It is also quite possible that the Administration issues regulations that adopt Medicaid reforms that did not make it into OBBBA. Similarly, House Speaker Mike Johnson and other Republican lawmakers have mentioned the possibility of additional budget reconciliation measures. While it’s not clear what these bills would cover, it’s quite possible that they may address policies that didn’t make it into H.R. 1. ANA and its allies in the nursing and broader healthcare community stand ready to play defense yet again if the need arises.

Check out our report on H.R. 1 for more information about what is in the bill that is relevant to nurses. Let us know how the reforms will impact your practice and patients, share your story today.

New Year, New Congress and Administration, Same Mission.

  

The American Nurses Association (ANA) continues to advocate on behalf of the nation’s nearly 5 million registered nurses (RNs) to federal policymakers. With a new Congress and Administration comes change and a level of uncertainty. However, our priorities remain centered around the following goals: building and preserving a robust nursing workforce; improving health care outcomes and access; removing practice barriers for advanced practice registered nurses (APRNs); shaping payment strategies to account for the direct impact of nursing care; preserving the relationship between nursing and public health; and utilizing health care technology appropriately. 

We detailed these priorities and positions in a letter to Congress, sent to both Senate and House leadership. For our regulatory advocacy, ANA’s Policy Team has crafted a priorities document to share with internal and external stakeholders and policymakers and recently sent a letter to Secretary Kennedy.

Building and Preserving a Robust Nursing Workforce 

We believe that federal policymakers must take action to address current workforce challenges and ensure the health care workforce is able to meet future challenges by protecting our nurses and creating healthy work environments. We continue to call on Congress to address workplace violence for nurses, as well as limit mandatory overtime. Congress must take action to improve nurse staffing and reduce burnout, such as investing in mental health and substance use dependence support for nurses. Additionally, we encourage HHS to engage with nurses to implement measures that will protect a robust nursing workforce, address the current nursing shortage, and make the workplace safer for nurses.  

Ensuring a robust nursing workforce requires new, well-trained nurses. We urge Congress to invest in nursing education to ensure that a new generation of nurses are ready to work in the changing health care landscape. Investments in nursing education and recruitment will attract more nurses, nurse faculty, and nurse preceptors.  

Improving Health Care Outcomes and Access 

ANA believes that all people in America deserve access to high quality health care and care options. One area where ANA is working to improve health care outcomes and access is in the field of maternal health—working with Congress to enact legislation to expand the perinatal nursing workforce to ensure that women have access to the perinatal care they need and recommending that HHS keep nurses central to addressing maternal health challenges. Additionally, we are currently working with allies in the health care community to defend Medicaid to ensure that our most vulnerable patient populations have access to health care providers, such as trusted nurses.  

Removing Practice Barriers for APRNs 

We believe that removing practice barriers for advanced practice registered nurses (APRNs) will promote quality care and help provide proper payment for nurses. We encourage HHS to issue rulemaking to implement provider nondiscrimination protections, while urging the Centers for Medicare & Medicaid Services (CMS) to use its administrative authority to remove regulatory barriers to APRN practice in Medicare. Bolstering access to APRNs only serves to increase health care access, especially for our most vulnerable patient populations.  

Additionally, we are actively engaging members and other stakeholders to urge Congress to pass the bipartisan Improving Care and Access to Nurses (ICAN) Act to permanently remove longstanding Medicare and Medicaid restrictions that limit Advanced Practice Registered Nurses (APRNs) from practicing to the full extent of their education and clinical training. By addressing these barriers, the ICAN Act will enhance access to essential health care services, particularly in rural and underserved communities. We encourage our members to take action and show support for the ICAN Act

Shaping Payment Strategies to Account for the Direct Impacts of Nursing Care 

At ANA, we understand just how essential APRNs and RNs are to the provision of patient care and how they deserve fair compensation for the services they provide. We call on HHS to support CMS in taking regulatory and administrative steps to account for nursing care under Medicare and Medicaid payment methodologies and to align reimbursement and quality rewards with the provision of high-value nursing care. Additionally, ANA is ready and willing to engage with Congress on future efforts or roundtables to reform parts of the Medicare payment system. 

Preserving the Relationship Between Nursing and Public Health 

The COVID-19 pandemic demonstrated how intertwined the fields of nursing and public health are. We stand firm in our position that HHS must continue to promote vaccinations, in order to protect nurses and their patients, as well as to relieve overburdened health systems. ANA knows how important federal medical research and its impacts are for nurses leading research, the provision of health care, and the nursing profession. Additionally, we continue to underscore to HHS the importance of international relationships and partnerships in public health preparedness and have stressed the need to keep federal government public health datasets accessible.  

Utilizing Health Care Technology Appropriately 

New technologies can be used to improve health care outcomes and access, but they must be used ethically. ANA believes that HHS must investigate how artificial intelligence (AI) can best be used in the medical and health spaces, while underscoring how critical it is that AI should neither substitute licensed practitioners, nor should it be the only diagnostic tool that practitioners use. At the same time, we want to see HHS promote the use of telehealth to increase access to health care, especially to increase access to care in rural areas. Currently, there is a proposed rule on special telehealth registration from the Drug Enforcement Agency (DEA), and ANA has advocated for HHS to lead efforts to encourage the DEA to revisit their proposed rule and to issue a new rule that better reflects the needs of APRN practice. Additionally, we are working with allies to advocate for the permanent extension of telehealth flexibilities.

Looking at the Year Ahead 

A new Congress and Administration provides ANA with new opportunities and challenges to advance our priorities and to advocate for our members. ANA is ready to work with the 119th Congress on improving health care delivery and advancing the nursing perspective. We will seek common ground with the new Administration, so that we can continue to advance the nursing profession and the wellbeing of America’s nurses. As always, ANA stands ready to respond to emerging policy issues that impact nurses and their patients, while remaining steadfast in our mission to lead the profession to shape the future of nursing and health care. 

HIMSS 2022: When Nurses Reimagine Health Care

  

ANA staff attended the 2022 Health Information and Management Systems Society (HIMSS) conference last week where reimagining health and the health care delivery system were top of mind. The week started by reimagining health with a NursePitchTM Innovation event. ANA’s Innovation Department collaborates with HIMSS by setting the stage for nurses to share their creative business ideas and programs to a team of judges, who are health innovation, business, and industry leaders. ANA knows that nurses have important ideas and approaches that can positively change the health delivery system and we encourage them to learn more and be ready to present at an event in the future!

It would be an understatement to say that the nursing workforce was top of mind in discussions around reimagining health. Attendees at HIMSS22 represent a microcosm of the health sector and have been living during the seismic shift that the delivery system has done over the past two years. The COVID-19 pandemic has triggered the need to adapt to new treatments, delivery options, and other environmental factors. Another key focus for the health care industry is developing new ways to support providers facing the challenges of today and the hope of the health system of the future. Digital tools can help with flexible scheduling, reduce duplications in workflow, and assist in charting. However, ANA continues the drumbeat about the importance of health systems valuing nurses through reimbursement, safe work environments, and ensuring each and every nurse achieve health equity in order to meaningfully solve the staffing crisis.

Over the course of the pandemic, we have also seen reports of the increase in digital technologies to deliver health services. The increased use happened seemingly overnight and is unlikely to return to pre-February 2020 levels ever again. At the same time, we must reflect and address the existing digital divide. Investments in our workforce must reflect the patient population in every community is vital, but we also need to make sure that the digital tools that are being used to assist in clinical decision making are free from unintentional biases. Just as important for patients, we must also ensure that nurses have access to the same opportunities to reach their own health equity—the nation cannot have a workforce that is shut off from the same system they provide care in.

Attending the HIMSS 2022 conference provided a great opportunity to learn, connect, and share ideas with others working to better the health care delivery system. The one thing missing was nurses on the big stage. ANA knows that nurses have stories, research, and ideas to share and together, we must be bold, step forward, and ensure our voices are heard in front of industry leaders as we all work to shape the health delivery system of the future.