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I'd disagree that they aren't accounted for - there's a reason that skilled nursing assets trade so differently than seniors housing (independent living, assisted living, etc.) and it's mostly due to the higher degree of operational risk at skilled nursing assets as well as the exposure to public payor sources and everything that comes with that (basically what you describe above). Some assisted living facilities will participate in "Medicaid Waiver" programs where the resident pays a portion of rent and state pays a portion, but the majority of seniors housing assets are 100% private pay. Seniors housing cap rates are typically in the 6-8 range that someone mentioned above, but skilled nursing facilities generally trade in the low to mid teens (call it 11%-14%). Your points are valid, especially that there are a lot of new entrants that don't understand the space, I'd just argue that the risks you mentioned are accounted for through cap rates that can be twice as a high as a traditional seniors housing asset. People not as familiar with the space sometimes lump seniors housing and skilled nursing together (which I understand), but it's really two distinctly different asset classes within the same vertical that price very differently due at least in part to those political risk factors.
I think what can cause a little confusion is that real estate buyers (like a REIT or PE firm) will report their lease yield (rent/price) as opposed to the true effective cap rate (NOI/price), and in seniors housing/skilled nursing those figures can be materially different. Not 100% sure how it works in other asset classes, but in this space the real estate buyer will derive its lease payment off of NOI using two levers, lease yield (described above) and lease coverage (NOI/Lease Payment), which is just the amount of cash flow in excess of lease payment. Seniors housing lease yields are typically a little lower than the cap rates I described above (call it 100bps lower so 5%-7%) with lease coverage ratios of 1.15x-1.20x, whereas skilled nursing yields are usually 8.50%-9.50% with coverage ratios of 1.40x-1.50x. The way the math works is if you multiply your lease yield by the coverage, you get your typical cap rate that translates to NOI/Price, so if you did the math on the ranges I laid out above you'd get in the same 6-8 range for seniors and 11-14 for skilled that i noted in previous comment. So my guess is you're seeing real estate buyers report their skilled lease yields in the 8s and 9s, but there is considerable NOI cushion to account for the operational risk. On the surface you're right that those yields are a little tighter than the cap rate ranges I quoted, but I'd revert back to the point that the operational/political risk is still being accounted for via a larger cash flow cushion through the underwritten coverage ratio. I've been in the space for ~4 years and cap rates for skilled nursing facilities have been extremely consistent, while seniors housing cap rates have ticked down a little bit because of the influx of institutional capital into that sub-sector (a lot of institutional players still will not touch skilled). Deal size obviously has a pretty wide range, but on the whole deals tend to be on the smaller side. Would guess that median transaction is somewhere between 15 and 30 mill, probably 70%-80% debt and 20%-30% equity,