Howard Gleckman, a senior fellow at the Urban Institute and Forbes columnist, provided a comprehensive overview of recent public policy changes affecting older adults. Drawing from his expertise in aging and tax policy—stemmed from personal caregiving experiences—Gleckman analyzed the implications of the Trump administration's "big beautiful bill" and related executive actions as of August 2025. The focus was on Medicaid and Medicare reforms, which could reshape long-term care, costs, and access for millions of seniors and people with disabilities.

Medicaid, which supports about 7.2 million seniors and 4.8 million younger disabled individuals (dual eligibles), faces a $1 trillion reduction in federal spending over the next decade. Key changes include:

• Work Requirements and Paperwork: Starting potentially in December 2026, states must impose work mandates, though older adults and those with disabilities are exempt. Family caregivers' status remains unclear, risking benefit loss for those quitting jobs to provide care. Recertification is now required at least twice yearly, increasing administrative burdens and potentially deterring eligible recipients.
• Funding Reductions: Limits on state provider taxes (e.g., on nursing homes) will cut federal contributions by about $120 billion starting in 2028. Expansion states under the Affordable Care Act lose extra funding from January 2026, forcing tough choices: cut benefits, limit eligibility, or raise taxes. Gleckman warned that optional home and community-based services (HCBS) are most vulnerable, as nursing home care remains mandatory. While the bill allows states to expand HCBS for less needy individuals without lengthening waitlists, funding cuts make this unlikely.
• Staffing and Workforce Impacts: The bill repeals Biden-era minimum staffing rules for nursing homes until 2034. Combined with mass deportations, this exacerbates shortages of direct care workers, driving up costs for facilities and families.

Gleckman emphasized that states may prioritize institutional care over community-based options, potentially worsening outcomes for older adults preferring to age at home.

Despite campaign promises to protect Medicare, changes aim to curb fraud, boost efficiency, and emphasize prevention—but at the risk of higher costs and reduced access:

• Prior Authorization Expansion: For the first time, traditional fee-for-service Medicare will require prior approval for 17 procedures (e.g., back surgeries, pain injections) in a six-state demo (New Jersey, Ohio, Oklahoma, Texas, Arizona, Washington). CMS plans to use AI for reviews, with human oversight.
• Payment Adjustments: Skilled nursing facilities see a 2.8% payment increase for 2026, deemed insufficient by the industry. Home health agencies face a 6.4% cut ($1 billion+), sparking bipartisan opposition. The Labor Department repealed Obama-era rules, allowing home care workers to earn below federal minimum wage ($7.25/hour) and exempting them from overtime, per state laws.
• Enrollment and Programs: Easier enrollment in Medicare Savings Programs (for low-income beneficiaries) is delayed until 2034. The GUIDE program for dementia care navigation continues but with penalties if it fails to improve outcomes or save money. Value-based care is expanding, rewarding providers for quality over volume.
• Drug Pricing and Hospice: Trump favors "most favored nation" pricing to align U.S. drug costs with foreign markets, potentially supplementing Biden's negotiations. Hospice faces crackdowns on alleged fraud, though details are pending.

Gleckman noted deregulation of nursing homes (e.g., rolling back transparency rules) and potential reductions in Medicare Advantage supplemental benefits like gym memberships due to insurer financial pressures.