The nursing home industry was on a roll last summer.
It had just won a 10-year moratorium on a rule initiated during President Joseph R. Biden Jr.’s administration to require increased staffing levels in an effort to reduce neglect among residents, which had led to injuries and deadly infections.
Nonetheless, some in the industry, warning that the rule would have substantially increased costs, wanted to make it go away permanently.
So nursing home executives turned to a tool that has proved successful in getting President Trump’s attention: money.
Starting in early August, the industry began making donations that over the course of weeks would eventually total nearly $4.8 million to MAGA Inc., a super PAC devoted to Mr. Trump and run by his allies.
Later that same month, a handful of nursing home executives who had given the biggest donations joined industry lobbyists at Mr. Trump’s golf club in suburban Washington to plead their case, according to campaign finance filings and people familiar with the meeting.
Over light lunch fare, the contingent “urged the president to formally repeal the harmful minimum staffing mandate, which would have surely forced providers throughout the country to close their doors to new residents — or possibly close their doors altogether,” Bill Weisberg, the founder and chief executive of Saber Healthcare Group, recounted in a text message to The New York Times.
Less than one month after the lunch meeting, Trump administration lawyers quietly stopped defending the pending staffing rule in court against challenges from the industry.
Complete victory came a couple of months after that, when the White House approved a full revocation. The Department of Health and Human Services announced the repeal in a statement that echoed industry talking points, which have emphasized the industry’s difficulty in hiring enough staff, especially in rural areas.
The moves outraged groups representing patients. They argued that the rule was necessary to protect millions of American seniors — a demographic that helped power Mr. Trump’s return to the White House last year.
“Residents are not getting the care they need,” said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care. “They’re dying from a lack of care.”
By one estimate, the staffing rule could have saved 13,000 lives of nursing home residents per year. It set off a tense debate over whether the industry, still recovering from the Covid-19 pandemic, could have found the funds to attract the staff needed to meet the new requirements. Research has suggested that the industry relies on a warren of corporations to conceal profits — profits that could have been used to improve care.
Because the rule was never enacted, it is impossible to say who is right. But even nonpartisan government analysts expected that state and federal governments would have kicked in an additional $22 billion over 10 years to help the industry boost staffing.
In written statements to The Times, the White House and H.H.S. defended the repeal. Kush Desai, a White House spokesman, called the move a “common-sense, anti-red tape policy decision,” and said it had nothing to do with any special interest influence campaign.
“The only special interest guiding President Trump’s decision-making is the best interest of the American people,” Mr. Desai said.
There is no evidence linking the decision to scrap the rule to the nursing home industry’s donations or its lobbying of Mr. Trump. And the rule was already facing uncertain prospects before the August meeting. Mr. Trump had signed a bill in July that included the 10-year delay; behind the scenes, other parts of his administration were preparing to back away from the rule in the days before the lunch meeting.
But the industry’s fund-raising for MAGA Inc. highlights the eagerness of corporate America to curry favor with a president who has repeatedly used the levers of government to reward donors and allies — and to punish critics. Mr. Trump has remained keenly interested in fund-raising, keeping close tabs on who has donated.
Companies that are heavily regulated by the government or reliant on it for contracts have donated millions to groups and causes favored by Mr. Trump since his return to the White House, while hiring lobbyists and consultants in his orbit. Corporate donors have received remarkable access to plead their cases directly to the president of the United States, to a degree seldom seen with other modern administrations.
Fund-raising for super PACs is something of a departure for well-established national trade groups that seek support from both parties, like the American Health Care Association, which has represented the nursing home industry’s interests in Washington for more than 75 years.
The association’s president and chief executive attended the lunch meeting alongside Brian Ballard, a top Trump fund-raiser whose lobbying firm represents the association and also registered to lobby for Mr. Weisberg’s company six weeks after the meeting.
Rachel Reeves, a spokeswoman for the American Health Care Association, said in a statement that the group “appreciated the opportunity to speak with the president directly and foster an open dialogue with the administration.” But she emphasized the association’s nonpartisanship and denied that the lunch focused on either the staffing rule or possible Medicaid cuts — another threat that Mr. Weisberg, who is on the association’s board, said was discussed at the meeting.
Ms. Reeves said “our meeting with the president was primarily about how we could focus on more meaningful ways to advance quality and prepare for the care needs of our nation’s aging population.”
‘Patients are suffering’
For decades, studies have linked insufficient staffing levels to poor care in the nation’s 15,000 nursing homes.
Inspection reports have repeatedly faulted facilities for leaving residents lying in their own feces, suffering severe bedsores and falls, contracting infections or ending up 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.
Tinamarie Scicchitano said she saw the effects of understaffing firsthand when her mother, Madeline Tardiolo, developed a pressure wound in 2022 while living her final days at an Arizona nursing home, a scenario that experts say is often the result of having too few staff members to regularly reposition immobilized patients.
Ms. Scicchitano said it was an indignity for her mother, who had filled their home with warm cookies and family friends, but never lost the sharp wit she got growing up in prewar Brooklyn. The family has sued over Ms. Tardiolo’s 2022 death in the nursing home, appending a gruesome photo of the black wound that spread across her back and claiming that neglect and insufficient staffing levels contributed to her death.
The lawsuit, filed in 2023, is ongoing. The Ensign Group, the publicly traded nursing home chain that owns the facility, did not respond to requests for comment.
Ms. Scicchitano said the repeal of the staffing rule boded poorly for other families.
“I’m deeply concerned that they will not staff these facilities appropriately because the patients are suffering, and my mom is living proof of what had happened,” Ms. Scicchitano said.
The Ensign Group reported $3 billion in revenue in 2022 — an increase of more than 15 percent from the previous year. Barry Port, the company’s chief executive, emerged as a leading opponent of the staffing rule.
In his State of the Union address in 2022, Mr. Biden criticized declining quality and increasing costs at nursing homes. “That ends on my watch,” Mr. Biden said, promising to “make sure your loved ones get the care they deserve and that they expect.”
In 2023, Medicare officials unveiled a proposal requiring facilities to have enough staff members to provide at least three and a half hours of care to each patient each day. There was also a new requirement for a registered nurse to be on-site at all times.
Patients’ rights groups pushed to raise the staffing minimum, eventually citing a 2024 government report that found that more than 60 percent of nursing home profits were hidden in a maze of transactions among related corporations. The report, by the National Bureau of Economic Research, showed that if those funds were spent on staff, nearly 76 percent of facilities could meet the new standard for 24-hour registered nurse coverage.
Senator Elizabeth Warren, Democrat of Massachusetts, wrote a letter pressing the Ensign Group on its opposition to the rule even as it offered multimillion-dollar executive pay and dividends to shareholders. She cited the government report as “evidence that nursing homes can afford to meet higher staffing standards, but are simply unwilling to do so.”
Even so, R. Tamara Konetzka, a University of Chicago economist who studies long-term care, said pressing the staffing rule would have been a high-stakes way to test the notion that nursing homes could find the money, if it resulted in facilities accepting fewer patients or closing.
“To me, that’s a really dangerous game,” said Dr. Konetzka, whose research has been supported by government grants under Democratic and Republican administrations.
The American Health Care Association, which counts Mr. Port and Mr. Weisberg among the members on its board of governors, claimed that the proposal established “impossible standards” that 95 percent of nursing homes did not meet. The association warned that the cost of complying could put some nursing homes out of business and estimated that it could displace as many as 290,000 residents.
After the Biden administration finalized the rule in April 2024, the association sued to block its implementation.
Some in the industry came to see Mr. Trump’s campaign as their best hope. His first administration had pushed to remove what he described as burdensome regulations on health care providers.
Within six weeks of the Biden administration’s finalizing the staffing rule, Mr. Weisberg and several other nursing home executives donated as much as $250,000 each to Mr. Trump’s campaign, according to campaign finance filings.
Mr. Weisberg told The Times this month that “the Biden administration spent four years doing its best to attack us, vilify us and regulate us into nonexistence.”
The industry had reason for optimism when, during his confirmation hearing to be health secretary last January, Robert F. Kennedy Jr. echoed the industry’s claim that the rule was not feasible given the industry’s challenges finding enough staff. Though its intent was “noble,” he said, in practice it would be a “disaster.”
But the administration continued defending the proposed rule in court, including taking steps to appeal rulings that were going in favor of the industry.
Mr. Port called the trade group’s lobbying “enormously efficient and effective” during an earnings call in April. “I personally met with leadership in both the House and the Senate,” he said.
In June, the association mobilized about 750 nursing home staff members to converge on Washington and attend about 450 meetings with lawmakers to tell them about the importance of Medicaid funding for long-term care.
The advocacy seemed to pay dividends in July, when Mr. Trump signed into law the spending bill that included the 10-year moratorium on the staffing rule and exempted nursing homes from a Medicaid cut.
A moment with the president
After the victory, the industry continued courting Mr. Trump.
About 40 corporate entities associated with nursing homes across the country gave to MAGA Inc. in August through mid-September.
As the donations were arriving and the lunch meeting approached, the Trump administration was taking steps to scrap the rule.
Five days before the meeting, a Trump appointee at the Justice Department recommended the administration drop its legal defense of the rule in an internal email that was described to The Times. The day before the meeting, Medicare officials inside of H.H.S., who were also lobbied by the industry, sent a request to the White House to formally repeal the rule.
The lunch meeting was attended by the executives whose companies made the largest donations to MAGA Inc., including $750,000 each from a subsidiary of the Ensign Group (on whose behalf Mr. Port attended), a company associated with Saber Healthcare (Mr. Weisberg attended) and PruittHealth Corporation, which owns nursing homes in the Southeast and sent an executive to the meeting. Another $600,000 came from entities associated with the Alabama-based nursing home company NHS Management; its chief executive, Norman Estes, also attended the meeting.
Mr. Estes declined to comment. Mr. Port and his company did not respond to requests for comment.
PruittHealth said in a statement that “we fully support the Trump administration and all policymakers who advocate for the well-being of our patients and caregivers.” It added that it has highlighted “work force shortages and rising patient acuity” to policymakers, and said that one meeting “does not determine federal policy, nor does it reflect the full scope of our longstanding advocacy.”
At the meeting, Mr. Trump was accompanied by his lead fund-raiser, Meredith O’Rourke, who raises money for MAGA Inc. and who regularly briefs the president about who has donated to the various groups and projects he favors.
Mr. Weisberg said they were eager to lobby the president against cuts to Medicaid reimbursements and the staffing rule, indicating that the combination could have “crippled our ability to provide care to the country’s aging population.”
They thanked Mr. Trump for the Medicaid carve-out in the tax and spending bill signed into law the month before, according to Mr. Weisberg, and urged him to repeal the staffing rule.
Mr. Trump left the group with the impression that he understood and was sympathetic to their concerns, Mr. Weisberg suggested.
“He wants to see our industry survive as he values the population we serve,” Mr. Weisberg said, indicating that Mr. Trump was more knowledgeable and thoughtful than he might appear from afar.
About a month after the lunch meeting, the Justice Department dropped its effort to appeal rulings favoring the industry.
Chad Gilmartin, a Justice Department spokesman, said in a statement that the decision came after consultation with Medicare officials and “had absolutely nothing to do with the fund-raiser.”
Emily G. Hilliard, a spokeswoman for the health department, said in a statement that the rule “disproportionally burdened facilities, especially those serving rural and tribal communities and jeopardized patient’s access to care.”
The next month, Clifton J. Porter II, the industry association’s president and chief executive, took a victory lap when the nursing home industry convened in Las Vegas for an annual convention.
“I forget the artist, but I like the song, ‘All we do is win, win, win no matter what,’” he said on a podcast during the convention.
A month later, the White House finalized the repeal, putting the old rules back in place. These require a registered nurse to be on-site for at least eight hours per day and for staffing to be sufficient to meet patients’ needs without requiring minimum numbers.
When Mr. Kennedy announced the move at a cabinet meeting in early December, he claimed that the rule was going to “destroy the nursing home industry” in rural and Native American communities. By revoking it, he boasted, the Trump administration had saved the federal government $25 billion, though a spokeswoman from a federal budget office told The Times that the figure was $22 billion.
“Those are some of the things that we’re doing because of your leadership, President Trump,” Mr. Kennedy said. “Thank you so much, and Merry Christmas to you.”
Kenneth P. Vogel is based in Washington and investigates the intersection of money, politics and influence.
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