The absence of meaningful healthcare policy through the 2024 election marks a lost opportunity and even more lost time for health system leaders.
Republican Donald Trump will be the 47th U.S. president after securing a second term in the White House. The outcome brings to an end an election cycle in which healthcare bobbed up and down in attention and air time before ultimately sinking in priority to the economy.
In August, it was unclear if the Affordable Care Act was a central issue in Vice President Kamala Harris and Mr. Trump's campaigns or not. Candidates spent a lot of time in semantic debate, namely the meaning of verbs repeal v. replace. By September, Gallup polling revealed a striking consensus: 67% of Americans across party lines believed healthcare wasn't receiving adequate attention in the campaign. This diminished focus marked a shift from previous election cycles, where healthcare reform — particularly the fate of the Affordable Care Act — weighed more heavily in political discourse.
As economic anxiety dominated voter concerns, both candidates missed a big opportunity by failing to frame healthcare as an economic issue.
The Medicare Hospital Insurance trust fund, out of which Medicare Part A benefits are paid, is projected to be depleted in 2036 — just 12 years from now. In the meantime, physicians are facing a 2.8% cut in pay under the 2025 Medicare physician payment rule — a move the American Medical Association has described as "death by a thousand cuts."
As Medicare payments shrink in effort to shore up a few more years of trust fund solvency (the idiom of arranging deck chairs on the Titanic comes to mind), hospitals and health systems are watching governmental payers continuously eclipse commercial reimbursement in their payer mixes.
Consider the numbers out of world-renowned University of Pennsylvania Health System in Philadelphia. When CEO Kevin Mahoney began his time with the organization in 1996, its payer mix was approximately 60% commercial and 40% governmental reimbursement. It has completely flipped today. The six-hospital system with hundreds of outpatient locations is now nearly 63% government paid. ("You could also say 'government underpaid,'" as he put it.)
Particularly troubling is the rapid expansion of Medicare Advantage, which has grown from covering 19% of Medicare beneficiaries in 2007 to 54% in 2024. This privatized version of Medicare, while increasingly popular, faces serious scrutiny for waste and questionable practices. Recent investigations revealed an estimated $7.5 billion in questionable risk-adjustments for 2023, while Senate findings indicate major insurers prioritized profits over patient care through aggressive prior authorization practices, often denying necessary post-acute care services to seniors.
Mr. Trump has put forward that he "will not cut one penny from Medicare." Project 2025, a political vision from the conservative Heritage Foundation for the 47th presidency, calls for making Medicare Advantage plans the default enrollment option for Medicare. Ms. Harris had proposed expanding Medicare to include home care, vision and hearing benefits, which could have made the traditional option more competitive to its MA counterparts.
Meanwhile, hospitals, health systems and urban and rural communities bear the brunt of healthcare's unaddressed systemic pressures. The ongoing closure of rural hospitals and reduction of essential services, especially maternity care, reflects the unsustainability of reimbursement models amid an aging population with approximately 10,000 Americans becoming Medicare-eligible per day.
"While I do think we need to push back on the insurers, I believe the more fundamental issue is that politicians aren't addressing the core problem: the fact that Medicare isn't profitable, and it covers a huge portion of the population," Jim Molloy, executive vice president, CFO and treasurer of 46-hospital Ochsner Health in Baton Rouge, La., said at Becker's CEO + CFO Roundtable Nov. 11. "No one is tackling this problem head-on."
And these challenges are just the financial side of healthcare. As Kevin Smith, CFO of St. Louis-based SSM Health, warns, even more fundamental problems loom: workforce shortages and limited care capacity.
"We have to understand, do we first have the assets to be able to take care of these patients? The resources from a workforce perspective to take care of these patients? Substantial reimbursement to ensure that we're covering the cost of these patients?" Mr. Smith said at Becker's CEO + CFO Roundtable.
"When you start to meld all those things together, we have a problem in the future. How do we start to really think big about that? From our perspective, we need to ensure that we're giving some light and national attention to ensure that we can mitigate some of those issues that are coming on to us like an onset train," Mr. Smith said.
Both presidential candidates missed a crucial opportunity to frame healthcare as the fundamental economic issue it represents. As government payments increasingly dominate hospital revenue streams while failing to cover costs, the sustainability of America's healthcare system hangs in the balance.
The absence of substantive healthcare policy discussion during this election cycle doesn't just represent a failure to address current challenges — it may well compound them in the years ahead.