A resiliency lens on Medicaid policy disruptions: Insights from rural nursing home leaders

BACKGROUND: Because Medicaid is the dominant payer of U.S. nursing home (NH) care, Medicaid policy changes can have wide-reaching effects, especially for NHs in rural communities. H.R. 1, or the "One Big Beautiful Bill Act," passed in July 2025, enacted reforms projected to reduce Medicaid funding over the next decade. PURPOSE: This study examined (NH) leaders' perceived impact of these Medicaid changes through the lens of organizational resilience theory, a framework that explores how an organization anticipates threats, copes with adversity, and adapts to changes. METHODS: This qualitative descriptive study involved semistructured interviews (n = 15) with NH leaders in rural and suburban locations. Data were analyzed using directed content analysis, with a priori codes established before analysis, iteratively refined throughout, and supplemented with codes that emerged inductively to form the final codebook. DISCUSSION: Analysis yielded 15 codes organized into four thematic antecedents of organizational resiliency: power and responsibility, social resources, resource availability, and knowledge base. Each antecedent functioned on a continuum, such that its presence served as a protective factor that helped NHs prepare for and adapt to change, while its absence represented a vulnerability that challenged adaptive capacity. CONCLUSION: These findings illuminate the high burden rural NHs confront amid Medicaid funding reductions and underscore the need for equitable policy that accounts for the unique challenges facing rural long-term care. By identifying the antecedents of organizational resiliency, this study contributes to a growing evidence base for supporting resilient, sustainable long-term care systems, particularly in communities where access to care is already fragile.