Hospital emergency departments are crowded and specialist wait times are growing. The care patients need most — in cancer, cardiovascular disease and neurology — is increasingly hard to reach in time. Access to care has become the dominant operational challenge of 2026 and the pressure point around which nearly every other strategic decision is developed.
At the same time, commercial payers owe hospitals billions in unpaid Medicare Advantage claims. Renton, Wash.-based Providence alone reports more than $1 billion outstanding, with nearly $600 million in the past five months. Medicaid work requirements take effect in 2027, threatening coverage for millions of enrolled patients. Operating margins at safety net hospitals are thin or negative and the federal funding designed to help rural hospitals transform comes with requirements that the hospitals most in need of it often cannot meet.
The result is a sector trying to move forward on multiple fronts at once. The priorities that emerged from Becker’s conversations with 60 C-suite executives ahead of the 14th Annual CEO + CFO Roundtable in November span expansion and austerity, AI deployment and workforce strain, rapid acquisition and the painstaking work of integration. The 10 themes below are shaping the financial future of hospitals and health systems across the U.S., according to the executives who lead them.
1. Expanding access to care
Access to care is often cited among the top issues for hospital and health system CEOs and CFOs. The underlying pressure is structural: an aging population, specialist shortages in key service lines and care backlogs have pushed patient demand to levels that outstrip current delivery infrastructure at many organizations. The challenge is no longer building brand or driving referrals, but how to have the physical and operational capacity to absorb patients once they arrive.
“Access is not just the No. 1 priority for the 2nd half of 2026,” said Peter Banko, president and CEO of Baystate Health in Springfield, Mass. “It is our top three priorities.”
Baystate Health is working to reduce friction between patients and providers, address workforce challenges and expand digital and virtual care options. Shane Strum, president and CEO of Broward Health in Fort Lauderdale, Fla., has a similar outlook.
“My number one priority heading into the second half of the year is to continue expanding access to care through growth, collaboration and workforce development,” he said. “In the first half of the year, Broward Health achieved exceptional financial performance, recognized with upgrades from S&P, Moody’s and Fitch, positioning us to continue investing in the future of healthcare in Broward County. That momentum provides a strong foundation for what comes next.”
Broward aims to add freestanding emergency rooms, medical office buildings, clinics and more as well as invest in technology and infrastructure for more access points and a sustainable organization.
2. Financial sustainability and margin recovery
The financial picture heading into the second half of the year varies sharply by organization type. For large systems with strong credit ratings and growing volumes, access expansion is funded. For smaller safety net hospitals and rural providers, daily cash management is the most immediate strategic reality. For both, thin margins leave little room for the unexpected and unexpected things keep happening. Tom Conklin, executive vice president and CFO of Care New England Health System in Providence, R.I., is focused on margin recovery in the near term.
“The first half of 2026 was impacted by soft regional and national patient volumes and acuity,” he said. “Achieving ‘recovered’ volumes and revenue, as well as achieving greater expense efficiency, are critical for goal achievement in 2026 as well as for strategic planning/sustainability reasons as healthcare organizations prepare for probable, unprecedented decreases in government reimbursement in 2027 and beyond.”
The concern is not only this year’s performance but what comes after: the reimbursement environment in 2027 and beyond is widely expected to worsen as government payment reductions take effect. Building reserves and improving efficiency now, before those pressures arrive is essential, especially since health systems can’t depend on the same funding they did in the past.
“While Congress did not approve the deepest cuts proposed last year, government research support remains flat and cannot be counted on as a growth engine,” said Boris Pasche, MD, PhD, president and CEO of Barbara Ann Karmanos Cancer Institute and oncology department chair at Wayne State University in Detroit. “As a result, our focus is on expanding other revenue streams, particularly through continued growth in patient volume and selective opportunities in industry-sponsored clinical research, while also improving operational efficiency. We are implementing AI and other process improvements in areas such as insurance verification and billing collections to help reduce costs and improve performance. Taken together, these efforts are aimed at offsetting pressure on research funding and maintaining the organization on a strong growth trajectory.”
3. Medicaid cuts and policy advocacy
The Medicaid reductions embedded in HR-1 have moved from policy debate to operational planning across care settings. Work requirements for Medicaid expansion beneficiaries are set to take effect in 2027, with projected impacts including 5 million people losing coverage and nearly $1 trillion in Medicaid funding reductions over the next decade. Health systems serving high Medicaid populations are responding now, before the changes arrive, with enrollment protection campaigns and advocacy efforts aimed at state and federal lawmakers.
The urgency is partly a communication problem. Erik Mikaitis, MD, CEO of Cook County Health in Chicago, cited survey data showing nearly half of Medicaid enrollees are unaware of upcoming changes.
“That’s why Cook County Health and our partners launched Get Medicaid Facts, a free, open-source communications toolkit,” he said. “The need is clear: a recent survey shows that nearly half of Medicaid enrollees are unaware of the upcoming changes. By working together now, we can help eligible individuals stay covered to protect not only their own health, but the health and sustainability of our healthcare delivery ecosystem.”
Commercial payer disputes are running in parallel. Erik Wexler, president and CEO of Providence in Renton, Wash., has made the Medicare Advantage Prompt Pay Act a top advocacy priority, characterizing the backlog of unpaid claims as a systemic failure with direct implications for rural hospital viability.
“Our organization alone is owed more than $1 billion from commercial payers for Medicare patients, with nearly $600 million outstanding for more than five months,” Mr. Wexler said. “When payments are delayed or denied, it is financially destabilizing for hospitals, clinics and physicians with the potential to limit access to the care patients need.”
Mr. Wexler spent time on Capitol Hill earlier this year alongside other hospital and rural healthcare leaders to emphasize the bill, which now has 19 co-sponsors.
4. AI and clinical technology deployment
AI deployment has moved from strategy to implementation and the most consequential shift is from AI as a back-office efficiency tool to AI embedded directly in clinical workflows. Ambient documentation is deployed widely and imaging AI is going live. Clinical decision support linked to those systems is expanding. The operational question is now how to sequence and govern the tools without compounding the change burden already falling on clinical teams.
“We’re focused on moving beyond simply adding appointments and instead redesigning how care is delivered. That means scaling proven models such as virtual care, advanced triage and same-day resolution of many patient needs, often without requiring an in-person visit,” said Megan Remark, executive vice president and COO of HealthPartners Care Group in Bloomington, Minn. “We’re also accelerating the use of AI to identify risk earlier and proactively connect patients with care, and we’re reducing barriers that can delay treatment.”
The health system was able to develop a second-level triage program connecting nurses with clinicians to help patients find appropriate care settings before the visit the ED. Sixty-five percent of the patients have avoided unnecessary ED visits through the program and instead leveraged urgent care, primary care and virtual visits.
The risk of moving too fast is real. Chief clinical officers across multiple systems identified protecting their teams from tool overload as an explicit priority, ensuring that what is being deployed augments clinician judgment rather than adding friction to an already demanding workflow. Roberta Schwartz, PhD, executive vice president of Houston Methodist Hospital and chief innovation officer of Houston Methodist, said her team is advancing solutions from point-based capabilities into scalable, integrated platforms.
“We are challenging both ourselves and our partners to expand beyond single-use applications and identify adjacent opportunities where existing capabilities can drive additional value,” she said. “For example, our OR visualization partner is exploring ways to support surgical block utilization through ‘time boost’ offerings that help fill gaps in the schedule.”
The system also has a predictive analytics partner that is charting data to identify present-on-admission conditions to extend the value of the technology beyond the traditional use case.
5. Workforce stability, development and engagement
The workforce framing has shifted. The acute labor shortage that defined the pandemic years forced reactive, expensive responses such as travel nurses, signing bonuses, rapid hiring at any cost. The key priority for many organizations now is replacing those reactive strategies with proactively redesigning staffing structures flexible enough to match volume fluctuations. They are also incorporating AI tools that reduce administrative burden and engagement strategies that actually keep people once they are hired.
Emily Moorhead, president of Macomb Market at Henry Ford Health in Detroit, named leadership development as her top priority, arguing that transformation cannot happen with existing mental models.
“Healthcare cannot achieve transformational results with the same thinking and operating models that produced today’s outcomes,” Ms. Moorhead said. “Ambitious goals require new ways of working, not simply more people, bricks and mortar or resources. As leaders, our responsibility is to set goals that change behavior, not just measure performance.”
Acute care nursing is a specific pressure point. Sentara’s enterprise chief nursing officer, Amber Price, is scaling virtual nursing and AI-enabled workflows in Norfolk, Va., with a stated goal of returning hours to frontline nurses — measuring success not by initiatives launched but by time given back.
“We are also strengthening shared governance so our nurses have a direct voice in shaping the future of care delivery,” she said. “Our goal is simple but powerful: remove friction from the system, re-engage our teams, and give nurses the time, support and influence they need to do what they do best – care for patients.”
6. System integration and acquisition execution
For several large systems, the second half of 2026 will be defined by the integration work that follows rapid expansion. The strategic rationale for consolidation — scale, capital access, clinical program alignment — is well established. The operational reality is that bringing acquired organizations into a unified system requires sustained attention across EHR platforms, care pathways, physician relationships and culture. That work, more than the transactions themselves, is what determines whether growth creates value or complexity.
West Virginia University Health System in Morgantown is executing one of the most ambitious integration agendas in the country. The system is managing the pending acquisition of Independence Health System, a five-hospital network in southwest Pennsylvania, while simultaneously expecting two additional hospitals by year-end and executing a board-approved capital improvement package exceeding $350 million.
7. Rural healthcare sustainability
Rural systems are navigating a distinct version of nearly every pressure on this list, with fewer resources and less room for error than their urban counterparts. The Rural Health Transformation Program has generated cautious interest, but the funding is designed to support transformation and most of the hospitals that need it most are too financially distressed to build for transformation. Keeping the doors open is the first requirement.
“Innovation isn’t optional in rural America; it’s how we preserve access,” said Martha Henley, CEO of Unity Medical Center in Manchester, Tenn., whose organization has used telecardiology programs to bring specialty care into the community and reduce unnecessary patient transfers. “The next frontier–remote monitoring, smarter triage and the right partnerships will only deepen that impact.”
For other rural organizations, the second half is explicitly about stability following a period of rapid change, allowing newly implemented systems and service lines to mature before adding more. Several rural leaders described absorbing implementation burden at the administrative level so frontline staff can operate at a sustainable pace and build confidence in recently adopted tools. Strategic planning work, including positioning for Rural Health Transformation Program funding, is being sequenced into the fall once that foundation is set.
“We must also invest in the next generation of healthcare professionals,” said Ms. Henley. “That means increasing our presence in local schools and giving students real exposure to the many rewarding careers healthcare offers, from clinical roles to operations. If rural healthcare is going to thrive in the future, we must start building that workforce today.”
8. Operational efficiency and care delivery redesign
For a number of organizations, the second half priority is not expansion but throughput. They are improving how patients move through existing systems so capacity is not consumed by bottlenecks. The most commonly cited constraint is post-acute discharge options. When patients who are medically ready to leave an inpatient bed cannot move to a nursing facility, rehabilitation center or home care program, the bed stays occupied, emergency departments back up and access for new patients is blocked upstream. The problem is not isolated; it is systemic, and it cascades.
Kathy Parrinello, who leads Strong Memorial Hospital and Highland Hospital at University of Rochester Medicine in N.Y., named capacity management as her top priority — specifically building partnerships with post-acute providers and expanding hospital-at-home capacity to open discharge pathways that do not currently exist.
“Strengthening those parts of the healthcare system is essential to improving patient flow and ensuring patients receive the care they need in the most appropriate setting,” she said. “Ultimately, improving discharge options and out-of-hospital capacity improves access for everyone. When patients cannot move efficiently to the next level of care, it creates bottlenecks throughout the healthcare system, contributing to emergency department crowding and delays in access to inpatient beds. A priority for URochester Medicine is the ongoing work developing partnerships with post-acute partners such as long term care, home care, assisted living organizations as well as continuing to develop our hospital at home program.”
9. Value-based care at scale
A meaningful cluster of leaders is using the second half of the year to move value-based care from pilot to proof. The argument is partly philosophical and partly economic, as volume-based reimbursement creates misaligned incentives that reward treatment over prevention, and as payer mix shifts and government reimbursement tightens, organizations that have built the infrastructure for value-based care are better positioned for what comes next. The challenge has always been demonstrating that the model works, not in a controlled pilot but at the scale of a real health system serving a real population.
At Banner University Medicine in Phoenix, where the system covers approximately 1 million members and operates as a fully integrated nonprofit, that demonstration is underway. Targeted outreach programs have more than doubled colorectal screenings and tripled preventive care engagement in underserved populations.
“Our top priority is proving that value-based care works at scale,” said Benjamin M. Schwartz, MD, president of academic delivery, framing the work as a model American healthcare needs. The health system works with the University of Arizona to bring new research and advanced medicine to the broader community, and Banner has a prevention-focused health plan that has produced results like doubling colorectal cancer screenings and tripling preventive care engagement in underserved populations.
In Hawaii, Hawaʻi Pacific Health is advancing One Health Hawaʻi, an integrated, value-based approach to care coordination, delivery and payment designed to reduce fragmentation, lower costs for families and support a primary care infrastructure strong enough to serve rural and neighbor island communities.
“When we reduce fragmentation, eliminate the administrative burden, strengthen care coordination and invest in primary care, outcomes improve and care teams will spend more time caring for their patients,” said Ray Vara, president and CEO of Hawai’i Pacific Health in Honolulu. “This must happen in an open system, with real safeguards, regulatory oversight, and a healthcare market that stays competitive and collaborative.”
10. Leadership development and organizational culture
Every priority on this list requires not just a strategy but people capable of executing it under conditions of sustained uncertainty. The leaders who named organizational culture and leadership development as their top second half priority are arguing that the variable most likely to determine whether any of the other nine priorities succeed is not the plan itself but the capacity of the organization’s people to carry it out.
The specific challenge of the moment is focus. The volume of regulatory change, payer pressure and technological disruption competing for leadership attention in 2026 creates a real risk of reactive management, responding to each new development rather than executing a coherent strategy.
“There is simply too much noise,” said Mark Moseley, MD, president of USF Tampa General Physicians and executive vice president of Tampa (Fla.) General Hospital. “This often leads us, as leaders, to react emotionally rather than pausing to consider a more reasoned response to things that are frequently beyond our individual control.”
The most successful leaders are able to put on “noise canceling headphones,” he said, and focus on the most important initiatives to move the organization and care delivery forward.
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