This blog has been around since 2009. There are 600 plus posts on it not to mention presentations, pod casts I’ve done, etc. Suffice to say, it hosts lots of content and that content is still growing.
About mid-year, I made the decision to memorialize the work I’ve been doing on Reg’s Blog (https://rhislop3.com) into a book. That book is almost complete. The title: Who Absorbs the Risk: Forty years inside the collision between Washington and the senior care balance sheet. The forty years? My career in and around healthcare. Folks with interest can get previews and the book itself on release at the website https://whoabsorbstherisk.com .
At least weekly, I will be posting segments from the book like chapter summaries here and via links on the who absorbs the risk website. To start, below is the Introduction chapter in the book. Enjoy!
Introduction: Forty Years, One Throughline
I have spent more than four decades in senior living, post-acute care, and healthcare economics — as an operator, an executive, an M&A advisor, a litigation consultant, and for the past decade and a half, as a writer tracking this industry in close to real time. Reg’s Blog began as a way to think out loud about a sector that almost nobody outside of it understands well, and that almost everybody inside of it experiences as a series of disconnected shocks: a payment rule changes, a lawsuit lands, a lender pulls back, a state attorney general intervenes in a case that started as a routine wrongful-death claim. Five hundred-plus posts and sixteen years later, what started as scattered commentary on individual events has revealed something more useful: a pattern. This book is my attempt to write that pattern down properly, in one place, for the operators, investors, boards, and legal teams who have to navigate it whether or not anyone in Washington ever bothers to name it.
The pattern
Here is the throughline, stated as plainly as I can state it: risk in this industry does not disappear, it transfers. It moves from the federal government to insurers, from insurers to operators, from operators to residents and families, and increasingly, from all of the above to whichever party in a given transaction has the least leverage to resist absorbing it. Medicare Advantage plans are paid more by CMS for documenting higher acuity, then deny post-acute coverage at rates that, when appealed, get overturned the overwhelming majority of the time — which means the risk CMS thought it was transferring to a private insurer is, in practice, often landing back on patients and providers instead. PDPM was designed to remove a volume-based incentive from skilled nursing reimbursement, overshot its own budget-neutral target within months, and has spent every year since being recalibrated back toward a stability it has never quite achieved. Medicaid financing reform protects nursing facilities from its most direct cuts while quietly squeezing the state-level revenue infrastructure those facilities depend on indirectly. A federal staffing mandate, motivated by a genuine and well-documented quality problem, died three separate deaths — in court, in Congress, and at the agency that wrote it — without the underlying labor shortage it was meant to address improving by even a fraction as much.
None of this is conspiratorial, and very little of it is anyone’s fault in any simple sense. It is what happens when a trillion-dollar sector is financed primarily by a government trying to control its own costs, delivered primarily by private operators trying to remain solvent, and consumed primarily by people who are old, often cognitively or physically vulnerable, and rarely in a position to advocate forcefully for themselves. Risk has to land somewhere. The purpose of this book is to help you see, chapter by chapter, exactly where it is landing right now, and why the next place it lands is rarely a surprise to anyone who has been paying close attention.
Why this book, and why now
I am writing this in 2026, which is not a neutral moment to be writing it. In the past two years alone, this industry has absorbed a Supreme Court decision that upended forty years of administrative law deference, the largest Medicaid spending reduction in the program’s sixty-year history, the complete death — by three independent mechanisms — of a federal nursing home staffing mandate, a private equity enforcement landscape that has shifted meaningfully with a change in presidential administration, and a state attorney general’s direct legal assault on the arbitration-confidentiality architecture that has quietly protected operators from public accountability for a generation. Any one of these developments would have justified a chapter on its own merits in a quieter year. Having all of them compress into this short a window is, frankly, unusual even by this industry’s standards — and it is exactly the kind of compressed, consequential period that rewards having a framework for understanding it, rather than processing each development as an isolated news item.
I should be direct about something else: I have occasionally been right early. Writing in February 2020, four months after PDPM’s launch, I flagged a specific documentation risk — cognitive-status coding tied to Speech-Language Pathology billing — that I suspected would eventually trigger CMS audit scrutiny once auditing began in earnest. It did, years later, as part of the broader case-mix-creep pattern CMS itself now openly studies. More meaningfully, when I wrote a three-part series analyzing Medicare hospice and home health fraud, a subsequent congressional letter to HHS’s Office of Inspector General — investigating suspected systemic fraud among home health agencies and hospices in Los Angeles County — cited my analysis directly as a reference point. I mention both not to claim any special prescience, but because I think they say something true about this industry: the patterns are visible in advance, in the public record, to anyone willing to look closely and consistently over time. That is the entire premise of this book. I am not claiming to predict the future. I am claiming that the future in this industry rhymes with its past more reliably than most people in it want to believe, and that the rhyme is worth learning to hear.
How this book is organized
The chapters that follow are grouped into four parts, each addressing a different layer of where risk currently concentrates.
**Part I** examines the federal payment and policy mechanisms that determine who absorbs financial risk first — Medicare Advantage’s risk-adjustment and denial economics, the recurring overshoot-and-recalibration cycle in skilled nursing payment models, the 2025 Medicaid financing overhaul and what it actually protects versus what it leaves exposed, and the strange, three-part death of the federal staffing mandate.
**Part II** turns to the demand side — the occupancy and capital market dynamics shaping who gets served and at what price, and the particular structural vulnerability of Continuing Care Retirement Communities, which sit at the intersection of nearly every pressure described elsewhere in this book.
**Part III** addresses capital, ownership, and enforcement — the genuine, if often overstated, role of private equity in this industry’s consolidation; the False Claims Act’s evolution from a billing-accuracy statute into a tool for scrutinizing entire business models; and the simultaneous boom in merger activity and bust in bankruptcy filings that are, properly understood, two faces of the identical underlying pressure.
**Part IV** closes with defense — how litigation theory is evolving to target the secrecy mechanisms operators have relied on for a generation, and, in the final body chapter, what separates the boards and governance structures that navigate disruption successfully from those that are blindsided by exactly the risks this book describes.
A closing chapter pulls these threads together and offers my best, necessarily provisional, view of where this is all heading next.
Who this book is for
I wrote this for the people I have spent my career working alongside: senior operators making capital allocation decisions under genuine uncertainty, investors trying to underwrite risk in a sector that resists conventional financial modeling, board members trying to exercise real fiduciary oversight over organizations operating in one of the most regulated corners of the American economy, and the legal and compliance professionals defending all of the above when the inevitable dispute arrives. If you are looking for a sentimental account of caregiving or a policy advocacy tract arguing for a specific legislative fix, this is not that book — plenty of others exist, and I’d point you toward them happily. This is a translation layer: an attempt to render the collision between Washington policy and the healthcare balance sheet legible to the people who have to manage that collision for a living, written by someone who has spent forty years standing at exactly that intersection.
