Employers are using transparency data to try to slow growth of their healthcare costs.

This article was published on Friday, December 20, 2025 in KFF Health News.

By Julie Appleby

It seems simple: Require hospitals and insurers to post their negotiated prices for most healthcare services and — bingo — competition follows, yielding lower costs for consumers.

But nearly four years after the first Trump administration's regulations forced hospitals to post massive amounts of pricing information online, the effect on patients' costs is unclear. And while President Joe Biden added requirements to make pricing information more user-friendly, Donald Trump's imminent return to the White House has raised questions about what's next, even though posting prices is an area of rare bipartisan agreement.

The uncertainty of what might happen next led some proponents to lobby Congress to include hospital and insurer price transparency in must-pass legislation before Trump takes office. That would turn both his and Biden's regulations into law, making them less susceptible to being weakened or repealed by a future administration. But that effort failed.

The legislative step could also help protect against legal challenges in the wake of a Supreme Court decision that limited government agencies' regulatory authority.

Employers are using transparency data to try to slow growth of their healthcare costs, and "the last thing you want to do is start over," said James Gelfand, president and CEO of the ERISA Industry Committee, which represents large employers who finance their own health plans. His group is among the organizations pressing Congress to act.

"Congress' failure to act is deeply disappointing, but employers and other advocates will redouble our efforts," Gelfand said. "This will get done."

While there are reports that many hospitals are not fully complying, federal regulators have sent thousands of warning letters to hospitals and fined just over a dozen.

The transparency rules require hospitals to list the prices they accept from all insurers for thousands of items and services, from stitches to delivery room costs to X-rays. For consumers, hospitals must also provide a list of 300 "shoppable" services, including bundled prices accepted for common services such as having a baby or getting a hip replacement. Insurers in July 2022 were similarly required to list their negotiated prices, not only for care at hospitals, but also surgery centers, imaging facilities, laboratories, and doctors' offices.

It's a massive and often confusing amount of data that has drawn interest from researchers and commercial outlets like Turquoise Health, which has sought to organize the information to better help ordinary consumers shopping for medical services or employers overseeing workers' health plans.

The data shows a huge variation in prices, both in what hospitals charge and what insurers pay, for the same services. But the result of making those prices public is so far hard to quantify.

A recent study by Turquoise looked at negotiated rates in the nation's 10 largest metro areas for a set of common healthcare services. It found that rates in the top quarter tier — the most expensive category — declined by 6.3% from December 2021 to June 2024, during the time the transparency rules were in place. But negotiated rates for the lowest-cost tier of services rose by 3.4%.

That may indicate hospitals and insurers — who can now see what rivals are charging and paying — have either cut prices or demanded better rates, at least for the costliest services.

Even so, Gerard Anderson, who oversees research into the data as a professor at the Bloomberg School of Public Health at Johns Hopkins University, said the changes Turquoise noted were small and are not reflective of what his team has seen in their own studies.

"So far we have not detected any impact of this data on behavior, of where insurers decide to go or what hospitals do to change prices once they realize what others are charging," Anderson said.

Some health policy experts think it's unlikely the incoming Trump administration would reverse its prior commitment to price transparency.

"I don't see a world where he tanks his own regulations," said Joe Wisniewski, an associate vice president at Turquoise Health. "There is also so much broad bipartisan support on the Hill."

The current price-posting rules began with requirements in the Affordable Care Act, which the initial Trump administration more fully defined. The hospital industry failed in a legal challenge to block those rules, and the Trump-era requirements became effective in January 2021.

But even after the Biden administration made the data more user-friendly, it's still not very helpful to consumers, Anderson said.

"This data is not telling them the price they will pay. It's telling them the average price people paid last month or last quarter for a similar type of service," he said.

More useful, Anderson and other experts say, are requirements in the price transparency rules that demand insurers offer online calculators for hundreds of nonemergency services. The detailed cost estimates must take into account how much patients have paid toward annual deductibles.

For uninsured consumers or others who don't have access to online calculators, it remains difficult to piece together how much a service might cost from the information hospitals post online. For one thing, not every hospital has posted its negotiated rates.

The Department of Health and Human Services' inspector general said in November an audit of 100 hospitals found that 63 complied with the price transparency rule, while the rest failed to meet one or more requirements.

The advocacy group Patient Rights Advocate, which looked at a sample of 2,000 hospitals, says that only 21% were fully compliant, although it used broader measures for compliance than the inspector general.

"By keeping their prices hidden, hospitals continue to block American consumers from their right to compare prices and protect themselves from overcharges," said Cynthia Fisher, founder and chairman of the group, which has called for stricter rules and enforcement.

Julie Appleby: jappleby@kff.org, @Julie_appleby

Experts describe the narrow escape from Unicoi County Hospital as a cautionary tale.

This article was published on Monday, December 16, 2024 in KFF Health News.

By Lauren Sausser and Holly K. Hacker

ERWIN, Tenn. — April Boyd texted her husband before she boarded the helicopter.

"So, I don't want to be dramatic," she wrote on Sept. 27, "but we are gonna fly and rescue patients from the rooftop of Unicoi hospital."

Earlier that day, Hurricane Helene roared into the Southern Appalachian Mountains after moving north through Florida and Georgia. The storm prompted a deadly flash flood that tore through Unicoi County in eastern Tennessee, trapping dozens of people on the rooftop of the county hospital.

The fast-moving floodwaters had made earlier rescue attempts by ambulance and boat impossible. Trees, trailers, buildings, caskets, and cars swept past the hospital in murky, brown rapids that overwhelmed the one-story structure with 12 feet of water on all sides.

No one knew how long the hospital's frame would hold or if the rising water would breach the top of the 20-foot-tall building. Little more than a mile downstream, six people at a plastics plant in Erwin's industrial park died in the flood.

"I do not feel good about this," Boyd, a flight nurse for Ballad Health, texted her husband at 1:41 p.m., just before takeoff.

She wrote that she loved him. "If anything goes wrong," she wanted him to tell her daughters "how much I love them," too.

Her fears were well-founded.

In 2018, Unicoi County Hospital relocated from higher ground in the heart of Erwin to the southern edge of town, between Interstate 26 and the Nolichucky River. The new hospital was built in a known flood plain, but the facility wasn't designed to accommodate helicopter landings on its roof. Boyd and her team weren't sure the roof could bear the weight of their 7,200-pound Eurocopter in good weather, let alone during a flash flood.

"I had a horrible feeling about it," she said.

By many accounts, the evacuation of 70 people, including 11 patients, by helicopter that day was a stunning success. The hospital was destroyed, but no one died. No one was even physically injured by the ordeal.

Yet, earth scientists, emergency management officials, and others who spoke to KFF Health News describe the narrow escape from Unicoi County Hospital as a cautionary tale. As climate change forces healthcare leaders and public officials to prepare for severe storms in landlocked parts of the country — where residents haven't historically paid much attention to hurricane warnings — they must be strategic about both the infrastructure design and the locations selected for new projects, like hospitals.

The Biden administration finalized a rule this year designed to make the construction of such projects that receive funding from the Federal Emergency Management Agency more resilient to flooding. But a review by KFF Health News identified about 20 other Tennessee hospitals already built in, or near, flood plains.

Patrick Sheehan, director of the Tennessee Emergency Management Agency, said past weather patterns can lull people into a false sense of security. But, he added, "past is not always prologue. We're going to experience novel, new ways of having disasters."

Historically, the Southern Appalachian Mountains have been the place "where hurricanes go to die," said Ryan Thigpen, an earth and environmental sciences professor at the University of Kentucky whose research focuses on flooding in the region. But as the Gulf of Mexico becomes warmer and storms, like Helene, that move northward into the mountains carry more moisture, weather events will become more severe.

"It's apocalyptic," said Thigpen, of the damage in Erwin. "The next storm may come before they are finished recovering from this. And that's kind of scary."

Hospitals in Flood Plains

All week, Michelle Matson had been worried about Unicoi County Hospital in the oncoming storm.

As a district coordinator for the Tennessee Emergency Management Agency, Matson works with local officials to plan for worst-case scenarios.

Leading up to Hurricane Helene, she'd been in regular communication with the county's emergency management director. The hospital's vulnerability next to the river kept coming up.

"That was the only place we were worried about," Matson said.

But concern over the hospital's location wasn't new.

In November 2013, Unicoi County Memorial Hospital, which opened in 1953, was acquired by Mountain States Health Alliance on the condition that Mountain States would construct a hospital in Erwin to replace the old one.

Two years later, Mountain States purchased a 45-acre tract of land next to a bend in the Nolichucky River, just off Interstate 26. A hospital system press release at the time explained that due diligence had been conducted to ensure, among other things, that the hospital building would not be in a flood plain. It also presented the location as desirable because it was near the interstate and the landscape would provide "a healing environment by taking advantage of the natural beauty of Unicoi County, with the river running along the east side of the property."

Dating back decades, though, flood maps published by FEMA put the entire property in a flood plain. The building itself was in a 500-year flood plain (meaning a 0.2% chance of flooding in any given year), while the only road on and off the property was in a 100-year flood plain (meaning a 1% annual risk).

But it wasn't only FEMA maps that forecast this possibility. In 2001, a report published by Unicoi County marked this land as being in a "flood hazard" area. The report warned of "considerable pressure" to develop flood hazard areas across the county "due to population increase and the need for vacant land."

The same report acknowledged a history of destructive flooding in the county and the risks it faced being situated along "three major streams," including the Nolichucky River, which flows northward out of the Blue Ridge Mountains of western North Carolina straight through Erwin.

"If you start looking at the river's history, there are a number of these notable flood events, and quite a few in the 20th century. They just did not reach this magnitude," said Philip Prince, a geologist with Appalachian Landslide Consultants. His YouTube videos about mountain flooding during Helene have been viewed hundreds of thousands of times. "People should have been expecting more than they did. But again, we have not seen anything like this."

Matthew Rice, a former Unicoi County commissioner, served as chair of the Hospital Visioning Committee for the new hospital in 2015. He said some committee members raised questions during the planning process about the location, but he conceded there weren't many large, flat places to build a hospital in Erwin.

Amid a wave of rural hospital closures across the United States, Erwin residents celebrated when the new hospital opened in 2018. One lawmaker told the Johnson City Press it was "the most modern facility on the planet."

Alan Levine was CEO of Mountain States Health Alliance during that time and later became the head of Ballad Health, when Mountain States merged with a competing hospital system in 2018 to form the largest state-sanctioned hospital monopoly in the country.

Levine said Mountain States was aware the property carried flood risk but noted that the hospital system added levees to protect the building from river flooding at the recommendation of outside consultants. One levee already existed along the river's edge. And the hospital itself was deliberately constructed on a high point of the land, at the same elevation as the interstate, Levine said.

"I feel like everything we did when we built it was done the right way," said Levine, a former healthcare leader in Louisiana and Florida.

Even so, Matson, who lives in Kingsport, about 45 minutes northwest of Erwin, said some residents were quietly critical of the new hospital's location.

"We all thought that it was a stupid idea to build a hospital in a flood plain. It's like, who does that?" Matson said. She said her opinion doesn't represent an official position of the Tennessee Emergency Management Agency.

But Unicoi isn't the only Tennessee hospital built in a flood plain. Eight others across the state were built in moderate- or high-risk flood zones, and a dozen other hospitals are situated just outside them, KFF Health News found.

The hospitals at risk span the length of the state, from Memphis on the western edge to Knoxville in the east, and include big-city general hospitals, smaller rural hospitals, and behavioral health facilities.

Some of the hospitals are decades old. Parkridge East Hospital in Chattanooga, for example, was built in the 1970s inside a high-risk flood zone. Others are more recent — like Creekside Behavioral Health in Kingsport. That building, which opened in 2018, straddles high- and moderate-risk flood zones.

Then there are facilities like Pinewood Springs in Columbia. The 60-bed mental health facility, which opened in 2020, is in a low-risk area, but the main road leading in and out of the hospital lies in a high-risk flood area.

To identify these hospitals, KFF Health News looked for licensed facilities in or near areas that, according to FEMA, have either a high flood risk (with a 1-in-100 chance of flooding in any given year) or moderate risk (a 1-in-500 chance in any given year).

But FEMA's maps likely underestimate the true flood risk, researchers and government watchdogs agree, because they're largely outdated and don't account for current or future conditions, including more frequent and more intense storms and flooding associated with climate change.

Those maps are updated on an ongoing but slow and piecemeal basis. Meanwhile, the federal regulation finalized this year to expand areas considered at risk for current and future flooding also sets more stringent building standards for critical infrastructure projects located in 100-year flood plains and funded by federal taxpayers.

The rule became effective on Sept. 9, less than three weeks before Hurricane Helene ravaged the Southern Appalachians, but it is unclear whether the incoming Trump administration will preserve it.

After he took office in 2017, President Donald Trump revoked federal flood protection standards set up under the Obama administration. Karoline Leavitt, a spokesperson for the incoming Trump administration, did not respond to emailed questions for this article.

An ‘Antiquated and Broken' System

On Sept. 24, three days before the hospital evacuation, the National Hurricane Center issued the first of several warnings predicting significant river flooding and landslides in the Southern Appalachians. Two days before the flood in Erwin, a satellite office of the National Weather Service in Morristown, Tennessee, predicted "life-threatening flash flooding" near the Tennessee-North Carolina state line.

The warnings kept coming. The National Weather Service in upstate South Carolina forecast on Sept. 26, a Thursday, that Helene would amount to one of the region's most significant weather events "in the modern era."

"I don't think people knew what that meant," said Prince, the geologist. "We just didn't have a precedent."

Ballad Health didn't anticipate that Unicoi would flood during the storm, Levine said, even though a hazard vulnerability assessment conducted annually for the hospital identifies external flooding as the second-highest risk facing Unicoi County Hospital, behind only a civil disturbance. The same 2024 assessment rated the hospital's preparedness for a flood as a "3" or "low," the worst possible score.

But a document outlining the hospital's emergency alert procedures makes no mention of flood risk. If anything, hospital leaders said they were anticipating a surge of patients during Hurricane Helene if Erwin and the surrounding area experienced widespread power outages.

"There was no conversation I had with anybody, anywhere about the risk of flooding before Friday morning," Levine said.

The day before, Jennifer Harrah, the hospital's administrator, had called a meeting to discuss the storm. Sean Ochsenbein, an emergency medicine physician and the hospital's chief medical officer, recalled that the group gathered "just to kind of circle the wagons, make sure everybody was on the same page."

Later that day, Harrah spoke to Unicoi County's emergency management director. But "let me be very clear," Ochsenbein said. "Nobody gave us — as Ballad or our hospital — any kind of indication that we would have floodwaters."

And yet little more than 24 hours after their planning meeting, both Harrah and Ochsenbein were stranded on the hospital roof, literally praying to God for their rescue.

"I called my husband, and I called my sons," Harrah said. "I told them that I loved them."

Dozens of hospital patients, staffers, and first responders were rescued by helicopter after floodwaters from the nearby river overwhelmed the building.(Maddy Alewine for KFF Health News)

One reason the impact of the storm seemed to catch people off guard was a disconnect between the strong warnings issued by the federal agencies and the low expectations that many people in the region, including Ballad Health leaders, had of the potential flood risk.

It was sunny outside when people were evacuated from the hospital roof, Thigpen pointed out. It had rained about 5 inches in Erwin over several days, but that was nothing compared with places in the North Carolina mountains that received more than 20 inches over the same period. Rainfall at those higher altitudes eventually drained into the rivers and streams that ultimately destroyed places like Erwin.

But residents in Unicoi County had no clue what was coming their way, Thigpen said, because there weren't river gauges upstream to sound alarms about dangerous water levels.

"I think that our warning systems are antiquated and broken," he said. "These people in Erwin have seen floods — and a lot of big floods — and it's never been anywhere close to this."

Tennessee state climatologist Andrew Joyner is one of several experts now calling for more river gauges to monitor water levels and a network of weather stations in every county designed to collect live precipitation data.

Thirty-eight states already operate similar systems, he said, estimating that setting up and staffing weather stations across Tennessee would cost less than $4 million in the first year.

But the state has failed to act before. Following a catastrophic flood in Waverly, Tennessee, that killed 20 people and destroyed hundreds of homes and businesses in 2021, the Tennessee General Assembly denied a $200 million request to relocate 14 public schools across the state that had been deemed vulnerable to future flooding.

‘Might Not Make It Back'

On the morning of the flood, Matson had stood with the county's emergency management director behind Unicoi County Hospital and watched the rising river. "We both had this, like, sick feeling in our stomach that said we've got to evacuate," she remembered. "I said to him, worse comes to worst, we evacuate, nothing happens. Just blame it on me."

They made the call to start moving patients out of the hospital just before 9:45 a.m. Less than 30 minutes later, the river had breached its banks, cutting a new channel in front of the hospital and eliminating access to the only road on or off the property.

When an ambulance evacuation became untenable, the Tennessee Emergency Management Agency called in swift-water teams, specially designed to rescue people in turbulent waters. But the flash flood had become so violent and the river was so full of debris that the boats couldn't safely carry patients away. Meanwhile, dangerous wind conditions prevented helicopters located to the east or west from immediately flying that morning to rescue everyone by air.

"To be honest, I really thought we may not make it back" from the rescue mission, Boyd, the flight nurse, said.

When the wind started to die down that afternoon, Virginia State Police deployed two helicopters to rescue patients. Eventually, three Black Hawk helicopters from the Tennessee National Guard assisted in the effort. Pilots were required to make multiple round trips between the hospital and the local high school to evacuate four or five people at a time who had been stranded by the flood. Some patients stranded in boats near the hospital were hoisted into helicopters, while those who were stranded on the roof were either carried onto the aircraft or climbed aboard while the helicopters lightly touched down on their skids.

As the afternoon wore on and the evacuation was nearing its completion, pilot Jeff Bush with the Virginia State Police said he learned that the hospital building was weakening. They weren't sure how much longer it would hold.

"It was intense," he said. "The fact that the building is still standing is, I think, kind of amazing."

Ballad Health evacuated two other hospitals and one nursing home by ambulance within 24 hours of the flood in Erwin, but none of those sustained damage. Meanwhile, what's left of Unicoi County Hospital stands next to the Nolichucky in a field of mud and displaced river rocks.

For now, Ballad Health has opened a temporary urgent care center and plans to establish an emergency department at the site of the former Unicoi County Memorial Hospital in downtown Erwin.

Levine said Ballad Health will eventually rebuild a full-service hospital, but he estimated the project would cost $50 million, roughly twice as much as it did in 2018. It remains unclear where it would be built.

Probably not in a flood plain, Levine said. "I would avoid it if I could."

Lauren Sausser: lsausser@kff.org, @laurenmsausser

Holly K. Hacker: hhacker@kff.org, @hollyhacker

The states have trigger laws that would swiftly end their Medicaid expansions if federal funding falls.

This article was published on Wednesday, December 4, 2024 in KFF Health News.

By Phil Galewitz

With Donald Trump's return to the White House and Republicans taking full control of Congress in 2025, the Affordable Care Act's Medicaid expansion is back on the chopping block.

More than 3 million adults in nine states would be at immediate risk of losing their health coverage should the GOP reduce the extra federal Medicaid funding that's enabled states to widen eligibility, according to KFF, a health information nonprofit that includes KFF Health News, and the Georgetown University Center for Children and Families. That's because the states have trigger laws that would swiftly end their Medicaid expansions if federal funding falls.

The states are Arizona, Arkansas, Illinois, Indiana, Montana, New Hampshire, North Carolina, Utah, and Virginia.

The 2010 Affordable Care Act encouraged states to expand Medicaid programs to cover more low-income Americans who didn't get health insurance through their jobs. Forty states and the District of Columbia agreed, extending health insurance since 2014 to an estimated 21 million people and helping drive the U.S. uninsured rate to record lows.

In exchange, the federal government pays 90% of the cost to cover the expanded population. That's far higher than the federal match for other Medicaid beneficiaries, which averages about 57% nationwide.

Conservative policy groups, which generally have opposed the ACA, say the program costs too much and covers too many people. Democrats say the Medicaid expansion has saved lives and helped communities by widening coverage to people who could not afford private insurance.

If Congress cuts federal funding, Medicaid expansion would be at risk in all states that have opted into it — even those without trigger laws — because state legislatures would be forced to make up the difference, said Renuka Tipirneni, an associate professor at the University of Michigan's School of Public Health.

Decisions to keep or roll back the expansion "would depend on the politics at the state level," Tipirneni said.

For instance, Michigan approved a trigger as part of its Medicaid expansion in 2013, when it was controlled by a Republican governor and legislature. Last year, with the government controlled by Democrats, the state eliminated its funding trigger.

Six of the nine states with trigger laws — Arizona, Arkansas, Indiana, Montana, North Carolina, and Utah — went for Trump in the 2024 election.

Most of the nine states' triggers kick in if federal funding falls below the 90% threshold. Arizona's trigger would eliminate its expansion if funding falls below 80%.

Montana's law rolls back expansion below 90% funding but allows it to continue if lawmakers identify additional funding. Under state law, Montana lawmakers must reauthorize its Medicaid expansion in 2025 or the expansion will end.

Across the states with triggers, between 3.1 million and 3.7 million people would swiftly lose their coverage, researchers at KFF and the Georgetown center estimate. The difference depends on how states treat people who were added to Medicaid before the ACA expansion; they may continue to qualify even if the expansion ends.

Three other states — Iowa, Idaho, and New Mexico— have laws that require their governments to mitigate the financial impact of losing federal Medicaid expansion funding but would not automatically end expansions. With those three states included, about 4.3 million Medicaid expansion enrollees would be at risk of losing coverage, according to KFF.

The ACA allowed Medicaid expansions to adults with incomes up to 138% of the federal poverty level, or about $20,783 for an individual in 2024.

Nearly a quarter of the 81 million people enrolled in Medicaid nationally are in the program due to expansions.

"With a reduction in the expansion match rate, it is likely that all states would need to evaluate whether to continue expansion coverage because it would require a significant increase in state spending," said Robin Rudowitz, vice president and director of the Program on Medicaid and the Uninsured at KFF. "If states drop coverage, it is likely that there would be an increase in the number of uninsured, and that would limit access to care across red and blue states that have adopted expansion."

States rarely cut eligibility for social programs such as Medicaid once it's been granted.

The triggers make it politically easier for state lawmakers to end Medicaid expansion because they would not have to take any new action to cut coverage, said Edwin Park, a research professor at the Georgetown University Center for Children and Families.

To see the impact of trigger laws, consider what happened after the Supreme Court in 2022 struck down Roe v. Wade and, with it, the constitutional right to an abortion. Conservative lawmakers in 13 states had crafted trigger laws that would automatically implement bans in the event a national right to abortion were struck down. Those state laws resulted in restrictions taking effect immediately after the court ruling, or shortly thereafter.

States adopted triggers as part of Medicaid expansion to win over lawmakers skeptical of putting state dollars on the hook for a federal program unpopular with most Republicans.

It's unclear what Trump and congressional Republicans will do with Medicaid after he takes office in January, but one indicator could be a recent recommendation from the Paragon Health Institute, a leading conservative policy organization led by former Trump health adviser Brian Blase.

Paragon has proposed that starting in 2026 the federal government would phase down the 90% federal match for expansion until 2034, when it would reach parity with each state's federal match for its traditional enrollees. Under that plan, states could still get ACA Medicaid expansion funding but restrict coverage to enrollees with incomes up to the federal poverty level. Currently, to receive expansion funding, states must offer coverage to everyone up to 138% of the poverty level.

Daniel Derksen, director of the Center for Rural Health at the University of Arizona, said it's unlikely Arizona would move to eliminate its trigger and make up for lost federal funds. "It would be a tough sell right now as it would put a big strain on the budget," he said.

Medicaid has been in the crosshairs of Republicans in Washington before. Republican congressional leaders in 2017 proposed legislation to cut federal expansion funding, a move that would have shifted billions in costs to states. That plan, part of a strategy to repeal Obamacare, ultimately failed.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

The industry is trying to kill the mandate before it takes effect, leaving thousands of residents in homes too short-staffed.

This article was published on Tuesday, December 3, 3034 in KFF Health News.

By Jordan Rau

COVID's rampage through the country's nursing homes killed more than 172,000 residents and spurred the biggest industry reform in decades: a mandate that homes employ a minimum number of nurses.

But with President-elect Donald Trump's return to the White House, the industry is ramping up pressure to kill that requirement before it takes effect, leaving thousands of residents in homes too short-staffed to provide proper care.

The nursing home industry has been marshaling opposition for months among congressional Republicans — and some Democrats — to overrule the Biden administration's mandate. Two industry groups, the American Health Care Association and LeadingAge, have sued to overturn the regulation, and 20 Republican state attorneys general have filed their own challenge.

Consumer advocates, industry officials and independent researchers agree that the incoming administration is likely to rescind the rule, given the first Trump administration's "patients over paperwork" campaign to remove "unnecessary, obsolete, or excessively burdensome health regulations on hospitals and other healthcare providers." Among other things, Trump aided the industry by easing fines against homes that had been cited for poor care.

"The Trump administration has proven itself really eager to reverse overreaching regulations," said Linda Couch, senior vice president for policy and advocacy at LeadingAge, which represents nonprofit elder care providers. "We think it's got a pretty good chance of being repealed, and hope so."

Issued in April, the staffing regulation requires nursing homes to have registered nurses on-site around the clock — something that the industry has endorsed — and to maintain minimum numbers of nurses and aides. Four in 5 homes would have to increase staffing. The requirements would be phased in, starting in May 2026.

Even before the election, many experts and activists had doubts that the rule would be effectively enforced, given the poor results in states that have imposed their own minimums. In New York, California, Rhode Island, and Massachusetts — states with the most robust requirements — many homes remain below the legal staffing levels. Governors have given many homes reprieves, and other homes have found that paying penalties costs less than the increase in payroll for additional staff.

The federal government estimates the average annual cost over a decade to meet the Biden mandate would be $4.3 billion a year, a 2% increase in expenses, though the changes do not include increases in federal Medicare or Medicaid payments.

"Staffing is everything in terms of nursing-home quality," said R. Tamara Konetzka, a professor of public health sciences at the University of Chicago.

While the rule's effectiveness was uncertain, she worried that repealing it would send the wrong message. "We would be losing that signal that nursing homes should try really hard to improve their staffing," she said.

Advocate groups for nursing home residents, who had criticized the Biden administration rule for not requiring even higher staffing levels, have since pivoted and are trying to protect it.

"We're hoping the president-elect will come in and take a look at the science and data behind it and see this really is a modest reform," said Sam Brooks, the director for public policy for the National Consumer Voice for Quality Long-Term Care, a Washington, D.C.-based nonprofit. "We'd be devastated to see it fall."

The Trump transition team did not respond to a request for comment. The Department of Health and Human Services did not respond to requests for comment, but in a court filing it argued that nursing homes should be able to reach the required staffing levels.

"There is more than enough time to identify, train and hire additional staff," the Biden administration wrote.

The quality of care in the nation's 15,000 nursing homes and the lack of adequate staffing for their 1.2 million residents has been a concern for decades. Inspection reports continue to find homes leaving residents lying in their own feces, suffering severe bedsores and falls, contracting infections, choking on food while unattended, or ending up back in a hospital for preventable reasons. Some nursing homes overuse psychotropic medications to pacify residents because they do not have enough workers to attend to them.

Leslie Frane, executive vice president of the SEIU, the Service Employees International Union, which represents health care workers, said in a statement that "far too many nursing home owners will not do the right thing and invest in workers without oversight and binding regulation."

The nursing home industry says many homes cannot afford to increase their workforces, and that, even if they could, there is a scarcity of trained nurses, and not enough people willing to work as aides for an average $19 an hour. A registered nurse earns $40 an hour on average in a nursing home, less than what they could make at a hospital, according to the Bureau of Labor Statistics.

The Biden administration noted in its court filing it was planning to spend $75 million to recruit and train more workers, and that there were more than 100,000 workers who left nursing homes during the pandemic and could be lured back if salaries and working conditions were better.

How many nursing homes could afford the increased cost remains a mystery because of weaknesses in the government's requirements for financial transparency. About half of homes lose money, according to their reports to Medicare, but some nursing home owners grow rich through clandestine maneuvers to siphon profits into their own pockets.

Last month, owners of Centers Health Care, one of New York state's largest nursing home chains, agreed to pay $45 million to settle allegations by Attorney General Letitia James that they diverted $83 million intended for resident care to themselves during the pandemic.

Maryellen Mooney, a spokesperson for the Centers Health Care chain, which denied the allegations, said in a statement that Centers was "committed to fully implementing the settlement terms, including a significant investment in resident care."

About three-quarters of nursing homes are for-profit. The industry, though, highlights the most sympathetic examples: rural nonprofit nursing homes like Kimball County Manor & Assisted Living in Kimball, Nebraska. Its staffing levels for registered nurses are 40% below what the new rule would require, federal data shows.

Sarah Stull, Kimball's administrator, said recruitment had always been challenging and that temporary nursing staffing agencies charged more than double what she paid her own staff.

"We had to pay $65 for a nurse aide during COVID, and that's insane," she said.

The government estimated that about a fourth of the nation's nursing homes would be eligible to apply for hardship exemptions if there were a documented shortage of nurses and aides in their communities compared with the national average.

But Nate Schema, the chief executive of the Good Samaritan Society, which runs 133 nonprofit homes mainly in the rural Midwest, estimated that only seven would be likely to qualify for a hardship waiver.

"Philosophically, they sound great," he said. "But in practicality and how they're put together, they won't do much for us."

Jordan Rau: jrau@kff.org