Health systems are bracing for the H.R. 1’s roughly $1 trillion in Medicaid cuts to start biting harder in 2027, but the months in between will also test something harder to model: public standing. Fall 2026 will deliver two events almost guaranteed to channel public anger toward the industry and, increasingly, toward hospitals.
The mood was already sour in June. Fewer than half of Americans (49%) can consistently afford the care and medications they need, a five-year low, according to the latest West Health-Gallup Healthcare Affordability Index. The share of adults who are “cost secure” has slid from a 2022 peak of 61%, and an estimated 2.8 million more people fell out of that category between 2024 and 2025 alone. The erosion now reaches groups long considered insulated: just 61% of adults 65 and older are cost secure, down from 73% in 2021.
That financial strain is hardening into a demand for structural change. In a Century Foundation survey of 2,002 registered voters in late May, two in three said they want either new public insurance options or a complete overhaul of the system. More than half (53%) said they had cut back on care or taken on debt in the past year because of healthcare costs. The pressure is not confined to Medicaid or the ACA marketplaces: among voters with employer-sponsored coverage, nearly three-quarters reported a premium increase, higher cost-sharing or some other deterioration in the past two years.
For health system executives, the most consequential finding is where that dissatisfaction is now pointed. Asked how much of a priority various federal cost-cutting actions should be, 67% of voters called stopping hospitals from charging excessive prices a top priority — a higher share than for any other option tested, including banning surprise billing, capping insurer profits or prohibiting prior authorization. Support cut across party lines, with 66% of Republicans and 71% of Democrats in agreement.
The Century Foundation notes that hospital prices grew twice as fast as prescription drug and insurance prices between 2006 and 2023, and that hospital lobbying and market concentration have climbed in tandem. The longstanding political habit of casting drugmakers and insurers as the sole villains is, the data suggest, no longer where the public is.
Mr. Mangione’s New York state murder trial will sharpen all of the above. He has pleaded not guilty to killing UnitedHealthcare CEO Brian Thompson on a Manhattan street in December 2024 and is scheduled to stand trial in state court on Sept. 8. Proceedings are expected to last six weeks. Donations to the 28-year-old defendant’s crowdsourced defense fund top $1.5 million.
Mr. Mangione’s lawyers recently withdrew their plans to introduce psychiatric evidence. The reversal stands to return attention to the case itself, and to the strange groundswell of public sympathy it has drawn, much of it rooted in hostility toward the insurance industry. Whatever the verdict, the proceedings will likely become a spectacle, putting the rawest expression of healthcare resentment back on front pages just as midterm candidates make their closing pitch to voters.
It remains to be seen how Democrats and Republicans will address healthcare ahead of the November midterms. Only 22% of respondents in the Century Foundation poll said President Donald Trump’s changes “have improved healthcare and should be kept”; two in five Republicans (42%) defend President Trump’s healthcare record.
A growing number of candidates are centering affordability on the campaign trail, and Gallup has found healthcare reclaiming the top spot among Americans’ domestic worries. Health system leaders should expect price transparency, billing practices and consolidation to feature in midterm messaging, with hospitals named explicitly more often than in past cycles.
The disenchantment is not confined to consumers. It has reached hospitals themselves — rural ones, in particular. The $50 billion Rural Health Transformation Program, an 11th-hour addition to H.R. 1, was greeted as a lifeline, but the optimism proved largely temporary. Rural leaders have since grown skeptical that the money can rescue hospitals too financially strained to transform, and a Commonwealth Fund analysis projects that the program’s modest gains will be overshadowed by the law’s cuts: roughly $10 billion flowing into rural economies in 2026 against $31 billion stripped from ACA marketplaces, with a projection of 229,000 jobs lost this year and 1.65 million by 2029.
None of this requires a system to change its strategy overnight. But it does reframe the fall. The financial planning prompted by H.R. 1 was an exercise in absorbing a policy shock; the months ahead are a test of public standing. Executives who speak credibly about their own pricing, billing and community value — before the trial, polls and campaigns do the talking for them — will be better positioned when the pressures further mount in 2027.
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