As federal policymakers address issues including drug pricing, insurance subsidies and Medicaid eligibility, health system executives say any meaningful national plan — from either party — must address reimbursement stability, administrative burden and workforce sustainability.
President Donald Trump released a healthcare policy framework Jan. 15 outlining proposals related to drug pricing, direct payments tied to ACA subsidies and expanded transparency requirements. The document does not detail how several provisions would be implemented. Since then, the administration has launched TrumpRx, a direct-to-consumer prescription drug discount platform, and continued to call on Congress to codify most-favored-nation drug pricing.
Against that backdrop, Becker’s asked three health system leaders what they would include in a one-page national policy both parties could support, what action Washington could take in the next year to support healthcare delivery and what details they would need to judge whether a federal plan could work in practice.
Becker’s spoke with Dan Pickett III, president and CEO of Albany (N.Y.) Med Health System, a regional system anchored by a 766-bed academic medical center and serving communities across Northeastern New York; Kerry Heinrich, president and CEO of Roseville, Calif.-based Adventist Health; and Kristen Roy, senior vice president, chief public affairs officer and general counsel of Medford, Ore.-based Asante. Ms. Roy spoke in alignment with Asante President and CEO Tom Gessel and leads the system’s advocacy work.
Two themes emerged:
Reimbursement stability and payment reform must come first.
Leaders said any meaningful healthcare policy must address reimbursement adequacy and insurance accountability, particularly in light of Medicaid-related changes under HR 1.
Changes under HR 1 to premium subsidies and Medicaid eligibility are projected to reduce hospital revenue nationwide by $68.5 billion in 2026 and 2027, according to a Dec. 15 analysis from Premier. Texas and Florida are projected to see the largest total losses at $11.5 billion and $8.8 billion, respectively, followed by California at $4.9 billion and New York at $4.3 billion. Asante in Oregon has separately projected a nearly $186 million five-year impact from Medicaid cuts and provider tax changes.
Mr. Heinrich, CEO of Adventist Health, which operates more than 440 sites of care across the West Coast and Hawaii, noted that financial stability varies based on geography, payer mix and the circumstances of individual hospitals. While organizations with 35% to 40% commercial insurance are generally stable, he said those with disproportionately high Medicaid and Medicare populations are increasingly strained and stand to be hit hardest under HR 1.
“In our East Los Angeles hospitals, it is 90% government payer,” he said. “That means I have roughly 9% of my patient mix that has to pay for the underfunding of the Medicaid program and the break-even funding on the Medicare program.”
He argued that safety-net hospitals, disproportionately located in inner-city and rural communities, have been underfunded for years, leaving them capital-starved and unable to recruit and retain staff.
Mr. Heinrich also said provisions tied to eligibility, work requirements and redetermination may push more individuals out of coverage, leading them to seek care in emergency departments and further straining hospitals that already operate on thin margins.
To alleviate those pressures, he said policymakers should create a protected funding track for safety-net hospitals. In practice, he suggested building on existing programs such as Disproportionate Share Hospital payments and California’s Hospital Quality Assurance Fee program, with a defined additive reimbursement amount specifically for hospitals that disproportionately serve Medicaid and dual-eligible populations.
“If I could write one page of federal policy, it would be this: Let’s have transparency into those areas of the healthcare system that treat and care for the underserved, and let’s create a safety-net financial mechanism to stabilize those systems,” Mr. Heinrich said.
He acknowledged that a key political challenge would be defining which hospitals qualify as safety-net providers — a designation that varies significantly depending on methodology and can affect funding distribution.
Mr. Pickett emphasized that coverage continuity is critical for systems such as Albany Med, which serves rural and urban communities across Northeastern New York.
“Coverage in general is a big concern,” he told Becker’s in mid-February. “The more we can keep the people who need our care covered, and not end up with a swelling uninsured population, the better.”
In follow-up comments, Mr. Pickett said policymakers should focus on reducing churn — keeping eligible individuals from losing coverage because of paperwork or administrative barriers. He pointed to 12-month continuous eligibility, simpler renewal processes, better coordination between Medicaid and marketplace plans, and adequate state support to manage redeterminations smoothly as practical levers.
“At the end of the day, stability in coverage is better for patients and for the overall health system,” he said.
Ms. Roy echoed those concerns, noting that neither Medicare nor Medicaid cover Asante’s operating costs — a significant challenge for a system in which roughly 80% of patients are insured through those programs. Asante employs more than 6,000 people and serves approximately 600,000 residents across Southern Oregon and Northern California.
“It’s just not sustainable,” Ms. Roy said. “How can you continue to operate when your primary funding sources don’t cover your costs?”
According to data from the American Hospital Association, Medicare paid 82 cents for every dollar hospitals spent caring for Medicare patients in 2022, resulting in $99.2 billion in underpayments that year.
Ms. Roy said any meaningful federal plan must ensure payment stability and improve accountability across insurers, pharmaceutical companies and suppliers so providers are adequately paid for the care they deliver. She said that begins with modernizing the Medicare reimbursement structure so payments better reflect the actual cost of delivering care, particularly for systems serving a high proportion of government-insured patients.
She added that Medicare Advantage plan behavior also contributes to reimbursement pressure, saying some plans are not consistently paying for services already delivered. Medicare Advantage now covers roughly 55% of eligible beneficiaries nationwide. She said stronger federal oversight of Medicare Advantage plans — including monitoring plan solvency and enforcing timely payment requirements — would help protect providers and patients.
More broadly, Ms. Roy cautioned that national conversations about affordability must not come at the expense of providers’ financial viability — including their ability to cover operating costs, recruit and retain clinicians, and continue offering essential services.
“We need to make sure affordability doesn’t mean underpaying providers,” she said. “Primary care and behavioral health are not adequately reimbursed. We’ve seen a huge increase in demand for behavioral health, and we’re still underpaid for that service. We have to look at the entire ecosystem and improve accountability around insurance carriers, pharmaceutical pricing and supply costs. That’s how we ensure both sustainability and affordability.”
Administrative simplification is a bipartisan opportunity.
Executives also identified prior authorization, denial management and regulatory burden as areas in which policy reform could redirect resources from administration to patient care.
Ms. Roy said administrative and regulatory simplification would be one of her top policy priorities. She pointed to prior authorizations and denial management as examples of requirements that divert staff time and financial resources away from patient care.
A survey of 1,000 practicing physicians conducted by the American Medical Association in December 2024 found prior authorizations are increasingly straining the industry. On average, physicians and their staff spend 13 hours per week on prior authorization requirements, and 40% of physicians report having staff who work exclusively on prior authorizations.
“Every dollar we spend on administrative or regulatory burden is a dollar we can’t spend recruiting physicians or nurses into our community,” she said.
She added that because Oregon’s regulatory environment is more heavily regulated than many other states, hospitals such as Asante face an added layer of administrative and financial pressure. In supplemental materials provided after the interview, the system cited state-level regulatory requirements and new oversight programs that it said increase administrative workload and strain hospitals already operating on narrow margins.
In that context, Ms. Roy said federal policymakers should prioritize administrative and regulatory simplification as part of any bipartisan healthcare framework, allowing providers to redirect resources from compliance functions to patient care and workforce investment.
Mr. Heinrich similarly described administrative simplification as important but secondary to revenue stability, saying that while billing reform and regulatory streamlining matter, they do not solve the underlying funding imbalance facing safety-net systems.
Leaders said reimbursement policy directly affects workforce sustainability and access to care, particularly in rural and underserved communities.
Ms. Roy said inadequate reimbursement in primary care and behavioral health makes it difficult to recruit and retain providers, especially in rural areas where systems already operate on thin margins.
“If we want to create a sustainable pipeline of providers, we have to reconsider the entire reimbursement structure,” she said, pointing specifically to primary care and behavioral health services that she said are essential to communities but not adequately reimbursed.
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