How Trump Policies Changed Medicare and Medicaid for End-of-Life Care
This Guide provides in-depth analysis of how policies from the Trump administration (2017–2021) and the Biden administration (2021–2025) affected Medicare and Medicaid funding for end-of-life care services—specifically skilled nursing, assisted living, home health, and hospice care—and how those policies continue to influence the current healthcare landscape in the current Trump administration.
During the first Trump administration, significant structural changes were introduced in Medicare reimbursement. Payment models for skilled nursing facilities (PDPM) and home health agencies (PDGM) shifted incentives away from service volume, and toward patient characteristics and diagnoses. While these changes were aimed at aligning payments with clinical needs, they also led to reductions in therapy staffing and service intensity in many facilities. Simultaneously, a hospice benefit demonstration under Medicare Advantage began to shift hospice care from traditional fee-for-service Medicare into managed care networks, introducing negotiation-based payments and new integration challenges for providers.
On the Medicaid side, the Trump administration pursued policies that sought to reduce federal spending through waivers allowing states to implement work requirements and, in some cases, pursue block grant funding models. These efforts were largely halted by courts or the subsequent Biden administration but created uncertainty and, in some cases, led to coverage losses, particularly among low-income adults who were not yet eligible for Medicare.
At the same time, Trump-era policies supported the expansion of Medicare Advantage plans, giving them greater flexibility to offer supplemental benefits, including services that support aging in place, such as non-medical home care. Emergency funding during the COVID-19 pandemic—enacted during the Trump administration—also provided temporary relief and boosted federal Medicaid funding, shoring up care systems during the crisis.
Under the Biden administration, many Trump-era Medicaid policies were reversed. Work requirements and block grant initiatives were rescinded, and Medicaid expansion was encouraged. The American Rescue Plan Act gave a temporary but significant increase in federal funding for Home- and Community-Based Services (HCBS), which states used to improve caregiver pay, reduce waitlists, and expand access to in-home care. Biden’s policies also aimed to improve care quality through regulatory reforms, such as proposing minimum staffing standards for nursing homes and enhancing oversight of hospices and assisted living facilities.
The downloadable Guide is an in-depth outline of probable and possible future scenarios, noting that a return to Trump-era policymaking could revive attempts to limit Medicaid spending through block grants or coverage restrictions, putting strain on providers and patients alike. Conversely, continued investment in Medicaid and value-based care under the current administration could enhance access and service quality. Key challenges remain, including workforce shortages, Medicare’s long-term financial solvency, and the growing shift toward managed care.
State-level Medicaid exemptions and other alternate programs are also highlighted, showing that access to and funding for end-of-life services vary widely depending on each state's Medicaid policies, HCBS programs, and regulatory frameworks. Some states have successfully innovated improved regulations for providers and patients, while others face persistent underfunding.
Ultimately, the report concludes that end-of-life care is at a crossroads, with federal and state policy choices directly shaping the sustainability, quality, and accessibility of critical services for aging Americans and their families.
