The sometimes wretched state of American nursing home care grabbed the national spotlight in 2020 when COVID-19 swept through facilities across the country, starting with the Seattle nursing home where nearly 40 people died and many more became seriously ill.

Now President Joe Biden is proposing to act. And hes not waiting for Congress to give its approval.

During Tuesday nights State of the Union address, Biden formally announced a new initiative to regulate nursing homes more aggressively. The main goals are to make sure all facilities have enough staff and to shore up the care workforce while publicizing more information about nursing home operations and finances something that, Biden says, is essential at a time when investors are acquiring so many facilities.

As Wall Street firms take over more nursing homes, quality in those homes has gone down and costs have gone up, Biden said Tuesday. That ends on my watch.

The initiative hasnt gotten a ton of attention outside of the trade media for health care, which isnt surprising given everything else in the news and the fact that discussion of Bidens domestic agenda continues to focus mostly on Democratic efforts to pass components of their Build Back Better agenda.

But with those initiatives languishing, as leaders negotiate with holdout Sen. Joe Manchin (D-W.Va.) over a possible deal, regulatory action offers a surer way forward. And though there is only so much that Biden can accomplish on his own, experts and advocates who follow the nursing home industry say his initiative could offer the most far-reaching reforms of nursing homes in decades, going back to a landmark Ronald Reagan-era law that created the first national standards for care.

It is, without question, the most important set of changes proposed in nursing home care since the 1987 nursing home law, Toby Edelman , senior attorney at the Center for Medicare Advocacy , told HuffPost.

Why Advocates Are Thrilled

Its not hard to see why these advocates are so enthusiastic. The pandemic exposed problems they have been screaming about for decades, such as high rates of bed sores and infections, not to mention reports of neglect and abuse.

Sometimes those calls led to action as they did in 2015, when the Obama administration announced it would be stepping up oversight of nursing homes through a combination of stricter safety requirements, more frequent inspections and more training for workers. But the Trump administration reversed many of those changes and cut back on penalties as part of its broader agenda to reduce regulations affecting the health care industry.

One provision of Bidens agenda seeks to restore the Obama-era enforcement reforms. Another swath of Bidens proposals would require the gathering and publication of more information about exactly who owns and manages nursing homes and how they manage their finances.

A primary target of these transparency efforts are the private equity firms whose stake in the nursing home business increased from $5 billion in 2000 to $100 billion in 2018, according to an analysis from the Center for Economic and Policy Research .

Advocates worry that the equity firms and other for-profit owners are underfunding care in order to line their pockets, given academic studies linking for-profit status to poor quality and investigative articles spotlighting poor care and safety lapses at such facilities.

But proving the relationship between profits and care is difficult without detailed financial information, and that information is hard to get because owners have gotten adept at disguising their transactions and management through layers of corporate intermediaries. Simply making that information more widely available could make a big difference, according to advocates like Richard Mollot , executive director of the Long-Term Care Community Coalition .

You have a much more sophisticated corporate environment than you did 35 years ago, Mollot told HuffPost. There are forensic accountants and attorneys who have spent a lot of time connecting the dots here and there, but we dont have a national system in place to really know whats going on.

Why Advocates Are Especially Happy About Staff Ratios

A promise to improve staffing levels may be the most concrete and consequential part of Bidens plan.

Research has repeatedly linked lower staffing levels to substandard care, although all it takes to grasp the relationship is a visit to a facility where harried workers are shuttling among needy residents. Under those conditions, its difficult if not impossible for staff to keep up with recommended routines including hand washing, which, in a nursing home environment, can dramatically increase the spread of disease.