Nearly 12 million people would lose their health insurance under President Trump’s “big, beautiful bill,” an erosion of the social safety net that would lead to more unmanaged chronic illnesses, higher medical debt and overcrowding of hospital emergency departments.
Why it matters:
The changes in the Senate version of the bill could wipe out most of the health coverage gains made under the Affordable Care Act and slash state support for Medicaid and SNAP.
“We are going back to a place of a lot of uncompensated care and a lot of patchwork systems for people to get care,” said Ellen Montz, a managing director at Manatt Health who oversaw the ACA federal marketplace during the Biden administration.
The big picture:
The stakes are huge for low-income and working-class Americans who depend on Medicaid and subsidized ACA coverage.
Without health coverage, more people with diabetes, heart disease, asthma and other chronic conditions will likely go without checkups and medication to keep their ailments in check.
Those who try to keep up with care after losing insurance will pay more out of pocket, driving up medical debt and increasing the risk of eviction, food insecurity and depleted savings.
Uninsured patients have worse cancer survival outcomes and are less likely to get prenatal care. Medicaid also is a major payer of behavioral health counseling and crisis intervention.
Much of the coverage losses from the bill will come from new Medicaid work reporting requirements, congressional scorekeepers predict. Work rules generally will have to be implemented for coverage starting in 2027, but could be earlier or later depending on the state.
Past experiments with Medicaid work rules show that many eligible people fall through the cracks verifying they’ve met the requirements or navigating new state bureaucracies.
Often, people don’t find out they’ve lost coverage until they try to fill a prescription or see their doctor. States typically provide written notices, but contacts can be out of date.
Nearly 1 in 3 adults who were disenrolled from Medicaid after the COVID pandemic found out they no longer had health insurance only when they tried to access care, per a KFF survey.
Zoom out:
The Medicaid and ACA changes will also affect people who keep their coverage.
The anticipated drop-off in preventive care means the uninsured will be more likely to go to the emergency room when they get sick. That could further crowd already bursting ERs, resulting in even longer wait times.
Changes to ACA markets in the bill, along with the impending expiration of enhanced premium subsidies, may drive healthier people to drop out, Montz said, skewing the risk pool and driving up premiums for remaining enrollees.
States will likely have to make further cuts to their safety-net programs if the bill passes in order to keep state budgets functioning with less federal Medicaid funding.
The other side:
The White House and GOP proponents of the bill say the health care changes will fight fraud, waste and abuse, and argue that coverage loss projections are overblown.
Conservative health care thinkers also posit that there isn’t strong enough evidence that public health insurance improves health.
Reality check:
Not all insurance is created equally, and many people with health coverage still struggle to access care. But the bill’s impact would take the focus off ways to improve the health system, Montz said.
“This is taking us catastrophically backward, where we don’t get to think about the things that we should be thinking about how to best keep people healthy,” she said.
The bottom line:
The changes will unfold against a backdrop of Health Secretary Robert F. Kennedy Jr.’s purported focus on preventive care and ending chronic illness in the U.S.
But American health care is an insurance-based system, said Manatt Health’s Patricia Boozang. Coverage is what unlocks access.
Scrapping millions of people’s health coverage “seems inconsistent with the goal of making America healthier,” she said.
The U.S. bombing of Iran’s nuclear capability is unsettling: whether MAGA or not, hawk or dove, young or old, conservative or liberal, rich or poor—it matters.
Stability at home and abroad is utopian to some but desired by all. Pandemics, mass violence, natural disasters and even election results contribute to instability and lend to insecurity. Operation Midnight Hammer might contribute to the nation’s anxiety—time will tell.
The immediate aftermath of the bunker-bombings in Iran will involve two orchestrated campaigns by government officials:
The Campaign to Contain Middle East Tension: military, diplomatic and economic levers will be put to the test to limit escalation of the bombing and limit its consequence to the region.
The Campaign to Win Public Support: issues of consequence like military intervention ultimately depend on public opinion that support laws, funding and subsequent actions taken in response. History teaches and political leaders understand that ‘winning the hearts and minds’ of the public is necessary to success. Predictably, justification for Operation Midnight Hammer will be messaged loudly by supporters and challenged by critics.
For the moment, the news cycle will shift to foreign policy and away from tariffs, inflation, household prices and the “Big Beautiful Budget Bill” which the Senate Republicans hope to bring to the floor this week. News media will speculate about the after-effects of the Israeli-Iran bombing and what role the U.S. plays in an increasingly complicated geopolitical landscape marked by marked by armed conflicts Gaza, Ukraine, Myanmar, Yemen and 26 and other countries.
The attention these get in traditional media and social media channels will exacerbate public anxiety that’s already high: 19% U.S. adults and 40% of the country’s adolescents suffer from anxiety disorder: “a persistent, excessive fear or worry that interferes with daily life and functioning”. But, per the National Institute of Mental Health, fewer than a third suffering from severe anxiety receive professional treatment.
In the public health community, much is known about anxiety: it’s more prevalent among women than men, in minority populations, lower income populations and in the Southeast. It’s significant across all age groups, and at an alarming level among young working-class adults facing unique issues like affordability and job insecurity. And it is stigmatized in certain communities (i.e. certain fundamentalist religious sects, certain ethnic communities) lending to silent suffering and unattended consequences.
My take:
Operation Midnight Hammer came at a time of widespread public anxiety about the economy, tariffs, inflation, costs of living and political division. I will let pundits debate the advisability and timing of the bunker-bombing but I know one thing for sure: mental health issues—including anxiety, mood and substance abuse disorders– deserve more support from policymakers and more attention by the healthcare community.
The former requires local, state and federal lawmakers to revisit and enforce mental health parity laws already on the books but rarely enforced.
The latter requires the healthcare community to elevate behavioral health to a national priority alongside obesity, heart disease, cancer and aging to secure the public’s health and avoid unintended consequences of neglect.
Regrettably, the issue is not new. Employers, school systems, religious organizations and local public health agencies have been mental health default safety values to date; extreme have been temporarily shuffled to in hospital emergency rooms most ill-equipped to manage them. But systematic, community-wide, evidence-based help for those in need of mental health remains beyond their reach.
The Trump administration’s healthcare leaders under HHS’ Kennedy and CMS’ Oz espouse the U.S. healthcare system should prioritize chronic disease and preventive health. They believe its proficiency in specialty care is, in part, the result of lucrative incentives that reward providers and their financial backers handsomely in these areas.
In the President’s February 13 Executive Order establishing the Make America Healthy Again Commission, its goal was laid out:
“To fully address the growing health crisis in America, we must re-direct our national focus, in the public and private sectors, toward understanding and drastically lowering chronic disease rates and ending childhood chronic disease. This includes fresh thinking on nutrition, physical activity, healthy lifestyles, over-reliance on medication and treatments, the effects of new technological habits, environmental impacts, and food and drug quality and safety… We must ensure our healthcare system promotes health rather than just managing disease.”
Nothing could be more timely and necessary to the Commission’s work than addressing mass anxiety and mental health as a national priority. And nothing is more urgently needed in communities than mainstreaming anxiety and mental health into the systems of health that accept full risk for whole person health.
PS: Before Operation Midnight Hammer over the weekend, I had prepared today’s report focused on two government reports about the long-term solvency of the Medicaid and Medicare programs. Given the gravity of events in Israel and Iran and other hot spots, and after discussions with my family and friends this weekend, it became clear public anxiety is high.
I am concerned about the future and worry about the health system’s response. It’s composed of good people doing worthwhile work who are worried about the future. I recently spoke to a group on the theme (link below): ‘the future for healthcare is not a repeat of its past.’ That lends to anxiety unless accompanied by a vision for a better future. That’s what all hope for those in Iran, Gaza, Israel and beyond, and for all who serve in our industry.
The U.S. health care industry is approaching a critical inflection point, according to veteran health care strategist Paul Keckley. In a candid and thought-provoking keynote at the 2025 Healthcare Marketing & Physician Strategies Summit (HMPS) in Orlando, Keckley outlined the challenges and potential opportunities health care leaders must navigate in an era of unprecedented economic uncertainty, regulatory disruption, and consumer discontent.
Drawing on decades of policy experience and his signature candid style, Keckley delivered a sobering yet actionable assessment of where the industry stands and what lies ahead.
Paul Keckley, PhD, health care research and policy expert and managing editor of The Keckley Report
Health care now accounts for a staggering 28 percent of the federal budget, with Medicaid expenditures alone ranging from the low 20s to 34 percent of individual state budgets. Despite its fiscal significance, Keckley points out that health care remains “not really a system, but a collection of independent sectors that cohabit the economy.”
In the article that follows, Keckley warns of a reckoning for those who remain entrenched in legacy assumptions. On the flip side, he notes, “The future is going to be built by those who understand the consumer, embrace transparency, and adapt to the realities of a post-institutional world.”
A Fractured System in a Fractured Economy
Fragmentation complicates any effort to meaningfully address rising costs or care quality. It also heightens the stakes in a political climate marked by what Keckley termed “MAGA, DOGE, and MAHA” factions, shorthand for various ideological forces shaping health care policy under the Trump 2.0 administration.
Meanwhile, macroeconomic conditions are only adding to the strain. At the time of Keckley’s address, the S&P 500 was down 8 percent, the Dow down 10 percent, and inflationary pressures were squeezing both provider margins and household budgets.
“Economic uncertainty is not just about Wall Street,” Keckley warns. “It’s about kitchen-table economics — how households decide between paying for care or paying the cable bill.”
Traditional Forecasting Is Failing
One of Keckley’s key messages was that conventional methods of strategic planning in health care, based on lagging indicators like utilization rates and demographics, are no longer sufficient. Instead, leaders must increasingly look to external forces such as capital markets, regulatory volatility, and consumer behavior.
“Think outside-in,” he urges. “Forces outside health care are shaping its future more than forces within.”
He encourages health systems to go beyond isolated market studies and adopt holistic scenario planning that considers clinical innovation, workforce shifts, AI and tech disruption, and capital availability as interconnected variables.
Affordability and Accountability: The Hospital Reckoning
Keckley pulls no punches in addressing the mounting criticism of hospitals on Capitol Hill, particularly not-for-profit health systems. Public perception is faltering, with hospital pricing increasing faster than other categories in health care and only a third of providers in full compliance with price transparency rules.
“Economic uncertainty is not just about Wall Street. It’s about kitchen-table economics — how households decide between paying for care or paying the cable bill.”
“We have to get honest about trust, transparency, and affordability,” he says. “I’ve been in 11 system strategy sessions this year. Only one even mentioned affordability on their website, and none defined it.”
Keckley also predicts that popular regulatory targets like site-neutral payments, the 340B program, and nonprofit tax exemptions will face intensified scrutiny.
“Hospitals are no longer viewed as sacred institutions,” he says. “They’re being seen as part of the problem, especially by younger, more educated, and more skeptical Americans.”
The Consumer Awakens
Perhaps the most urgent shift Keckley outlines is the redefinition of the health care consumer. “We call them patients,” he says, “but they are consumers. And they are not happy.”
Keckley cites polling data showing that two out of three Americans believe the health care system needs to be rebuilt from the ground up. Roughly 40 percent of U.S. households have at least one unpaid medical bill, with many choosing intentionally not to pay. Among Gen Y and younger households, dissatisfaction is particularly acute.
“[Consumers] expect digital, personalized, seamless experiences — and they don’t understand why health care can’t deliver.”
These consumers aren’t just passive recipients of care; they’re voters, payers, and critics. With 14 percent of health care spending now coming directly from households, Keckley argues, health systems must engage consumers with the same sophistication that retail and tech companies use.
“They expect digital, personalized, seamless experiences — and they don’t understand why health care can’t deliver.”
Tech Disruption Is Real
Keckley underscores the transformative potential of AI and emerging clinical technologies, noting that in the next five years, more than 60 GLP-1-like therapeutic innovations could come to market. But the deeper disruption, he warns, is likely to come from outside the traditional industry.
Citing his own son’s work at Microsoft, Keckley envisions a future where a consumer’s smartphone, not a provider or insurer, is the true hub of health information. “Health care data will be consumer-controlled. That’s where this is headed.”
The takeaway for providers: Embrace data interoperability and consumer-centric technology now, or risk irrelevance. “The Amazons and Apples of the world are not waiting for CMS to set the rules,” Keckley says.
Capital, Consolidation, and Private Equity
Capital constraints and the shifting role of private equity also featured prominently in Keckley’s remarks. With declining non-operating revenue and shrinking federal dollars, some health systems increasingly rely on investor-backed funding.
But this comes with reputational and operational risks. While PE investments have been beneficial to shareholders, Keckley says, they’ve also produced “some pretty dire results for consumers” — particularly in post-acute care and physician practice consolidation.
“Policymakers are watching,” he says. “Expect legislation that will limit or redefine what private equity can do in health care.”
Politics and Optics: Navigating the Policy Minefield
In the regulatory arena, Keckley emphasizes that perception often matters more than substance. “Optics matter often more than the policy itself,” he says.
He cautions health leaders not to expect sweeping policy reform but to brace for “de jure chaos” as the current administration focuses on symbolic populist moves — cutting executive compensation, promoting price transparency, and attacking nonprofit tax exemptions.
With the 2026 midterm elections looming large, Keckley predicts a wave of executive orders and rhetorical grandstanding. But substantive policy change will be incremental and unpredictable.
“Don’t wait for a rescue from Washington. The future is going to be built by those who understand the consumer, embrace transparency, and adapt to the realities of a post-institutional world.”
The Workforce Crisis That Wasn’t Solved
Keckley also addresses the persistent shortage of health care workers and the failure of Title V of the ACA, which had promised to modernize the workforce through new team-based models. “Our guilds didn’t want it,” Keckley notes, bluntly. “So nothing happened.”
He argues that states, not the federal government, will drive the next chapter of workforce reform, expanding the scope of practice for pharmacists, nurse practitioners, and even lay caregivers, particularly in behavioral health and primary care.
What Should Leaders Do Now?
Keckley closed his keynote with a challenge for marketers and strategists: Get serious about defining affordability, understand capital markets, and stop defaulting to legacy assumptions.
“Don’t wait for a rescue from Washington,” he says. “The future is going to be built by those who understand the consumer, embrace transparency, and adapt to the realities of a post-institutional world.”
He encouraged leaders to monitor shifting federal org charts, track state-level policy moves, and scenario-plan for a future where trust, access, and consumer empowerment define success.
Conclusion: A Health Care Reckoning in the Making
Keckley’s keynote was more than a policy forecast; it was a wake-up call. In a landscape shaped by economic headwinds, political volatility, and consumer rebellion, health care leaders can no longer afford to stay in their lane. They must engage, adapt, and transform, or risk becoming casualties of a system under siege.
“Health care is not just one of 11 big industries,” Keckley says. “It’s the one that touches everyone. And right now, no one is giving us a standing ovation.”
The growth in denials can be partially explained by the increasing popularity of managed Medicare and Medicaid plans, but evolving payer practices, including the adoption of AI for algorithmic denials, have also contributed. Claims denials have emerged as one of the key points of payer-provider tension, and an effective claims denials management and prevention program is a powerful way for health systems to rebalance their payer relationships.
Denied claims result in reduced reimbursement, added administrative burdens, and patient and provider frustrations. Even when denials are successfully appealed and reversed—the KFF report found that in 2023, 82% of Medicare Advantage denials were partially or fully overturned—the time and resources devoted to the appeals process add to the costs of providing healthcare services. Optimizing pre-billing activities to reduce avoidable denials and improve and streamline the patient experience of care is as essential for health systems as a robust appeals strategy. This article addresses critical success factors for both preventing and appealing denials.
Preventing Claims Denials During Pre-Bill Period
Successfully preventing denials requires a centralized program across the workforce, from frontline providers to clinical and revenue cycle staff, to manage pre-bill activities by focusing on identifying the correct patient insurance information, obtaining accurate authorizations, and preventing concurrent denials while the patient is still in the facility. Utilization review nurses, attending providers, and Physician Advisors should be attentive to documenting the full state of patient acuity, while collaborating with the revenue cycle team. This team should focus on the collection and reporting of medically necessary data and documentation, which serves as the evidence payers use to evaluate prior authorization requests. When information about a patient’s condition isn’t recorded, or acknowledged in an authorization request, unnecessary denials can result.
A successful denials prevention program expands beyond the utilization management (UM) team and includes revenue cycle, and provider collaboration. Revenue cycle pre-service procedures should focus on confirming insurance benefits and securing payer authorization for planned services while collaborating with UM and referral sources. A comprehensive and proactive denials prevention program helps conveys to payers the full extent of inpatient clinical work, thanks to a collaborative effort to improve documentation.
The following list can help organize denials prevention programs across all locations, clinics and practices:
Establish an enterprise-wide denials prevention strategy which includes a multi-disciplinary denials management committee focused on identifying denials trends, conducting root cause analyses, developing proactive denials mitigation plans, creating enhanced reporting, monitoring improvement, and communicating risk
Establish proactive revenue cycle, UM, pre-certification, and peer-to peer workflows procedures to confirm completion of payer requirements prior to scheduled services and discharge
Ensure patients are financially cleared through implementation of pre-service protocols, including enhanced medical necessity process for outpatient services, authorization defer and delay procedures to reduce rework and avoidable denials
Identify pre-bill edits to increase “clean claim” efficiency, reducing initial denials and expediting reimbursement
Deliver education to providers, care management, and nursing teams on key observation concepts, such as clinical documentation improvement, patient status documentation, medical necessity documentation and orders for the Two Midnights rule, and payer reimbursement methodologies
Pursuing Post-Bill Appeals, Reversals and Payer Escalation
A strong denials management and prevention program should include a robust post-bill appeals program with skilled coding, clinical and technical resources. A targeted and strategic appeal process can result in improved overturn rates and increased reimbursement. Appeal letters which are supported by clinical facts, payer policies, and a summary of key components relevant to each case and the associated denial increase the likelihood of success.
Components of the appeal program should include the following:
Guidelines for when to appeal based on potential success by payer and appeal level
Reviews of upheld appeals for second and third level appeals based on strategy by payer
Trends for all upheld appeals by reason and by payer
Dashboard for tracking denials activities
Appeal letter writing guidelines and tips to support
Evaluation process for existing payer escalation workflows, tools and payer communication strategies with consideration for payer
Process to measure and monitor overturn rates and improvement opportunities
The collaboration with managed care is vital to the success of the denials management/prevention program. A formal payer escalation process which facilitates transparency between the payer and provider can result in improved relations and a reduction in initial denials. Successful denials management/prevention payer escalation programs are strategic and focus on addressing unfair/incorrect denials and establishing clear bi-directional reporting and communications. These programs can result in improved contract negotiations and reduce incorrect denials.
Artificial Intelligence (AI) can support the post-bill appeals process and can be especially relevant when developing a strategy to combat denials. Not only are payers increasingly using AI to trigger denials, but health systems can also deploy AI to write appeal letters, analyze denial trends, and summarize medically necessary documentation. Although algorithmic denials have become a source of frustration for providers and patients, health systems can also deploy AI to their defense. While payers are often better positioned to devote AI resources to claims, a little bit of investment from health systems, deployed effectively, can go a long way toward evening the playing field.
Closing Thoughts and Seven Questions to Consider
A formal denials management and prevention program is essential to obtaining proper reimbursement for the care provided and reducing rework across the enterprise. A strong program should also improve the patient’s experience of care: ideally, a patient should not need to interact with or hear from their provider between scheduling an appointment and checking in.
Denials management and prevention programs should be led by multi-disciplinary committees and focus on reducing avoidable denials and rework. Reducing denials requires the implementation of a multi-disciplinary program and collaboration between UM, revenue cycle, clinical documentation improvement, managed care, clinical operation and providers.
Health systems reassessing their claims denials program should consider these questions:
Do you have a reactive or proactive denials management strategy in place?
Does your denials strategy include multi-disciplinary team representation?
What reporting/tools are currently being used to track and manage denials?
What are your top five denial categories and what is being done to address the root cause of these denials?
How are avoidable denial risks managed, communicated and monitored?
Have you implemented a comprehensive denials management strategy with a multi-disciplinary committee?
Are the system’s internal resources and expertise sufficient for addressing identified challenges, or should the system seek external partners to implement changes?
HENRY KOTULA 