Summer of 2025 was an unusual one for health system leaders across the country that, in many ways, seemed to move both slowly and abruptly at once. Here are seven of the many questions that health system CEOs are facing as the season winds down and the effects of one massive piece of federal legislation begin to take shape.

1. What’s the real financial hit to my system? One might assume that the endless scenario planning dominating the first half of 2025 would leave executive teams with a clear sense of how the One Big Beautiful Bill Act (OBBBA) will affect their organizations. Instead, the reality — an estimated $911 billion reduction to federal Medicaid spending and an estimated 10 million more uninsured Americans by 2034 — is less clear.

Three truths stand out. First, no system is looking at a financial lift from OBBBA. Second, the severity of the headwinds — ranging from challenging to devastating — depends on state policy and payment models, market dynamics, population needs, specialty mix, payer relationships, timelines and other local factors. Third, OBBBA is only one piece of the puzzle. NIH funding cuts, tariffs and inflation threaten to compound its costs, pushing some CEOs to draft “doomsday” plans or “nuclear options,” while leaving others effectively paralyzed with little room to plan at all.

2. How much influence do health systems have? Leading up to July 4, hospital leaders were outspoken about the damage OBBBA’s healthcare spending reductions and coverage changes would inflict. CEOs traveled to Washington and their state capitals, warning lawmakers of the downstream effects: hospital closures, service cuts, care deserts and reduced access for patients. Did those efforts move the needle? It’s hard to see evidence they did. For many leaders, this moment feels like less familiar terrain, where ideology outweighs policy and the traditional levers of lobbying, advocacy and coalition-building no longer carry the influence they once did. What does it look like now for health systems not only to be heard by lawmakers, but to inform the outcomes they need?

3. What’s an OBBBA reaction versus a change I’d need to make anyway? Just as COVID-19 gave cover for businesses in many industries to push through unpopular decisions, OBBBA may serve as a convenient rationale for moves health systems were already considering. It could become a justification for some overdue changes, whether that’s consolidating low-volume service lines, outsourcing select functions to AI, or trimming administrative headcount and layers of management. CEOs will face the question of what’s truly an OBBBA-driven response versus what’s a necessary change regardless? For some decisions, the answer may be both. The sharper test for CEOs may be how transparently they communicate these dual drivers, and whether they use the moment to reshape their organizations in ways that endure beyond the political cycle.

4. How do CEOs lead when decline comes drip by drip? Ironically, the most significant rollback of health insurance coverage ever driven by federal policy changes may feel less like a flood than a drip. The impact of OBBBA is expected to unfold unevenly — what one CEO described as the slow degradation of services year over year. This pace complicates both planning and leadership. In some ways, leading through an acute crisis is easier: urgency is clear, all hands mobilize, collaboration is expected and stakes are understood. But a crisis that crawls demands different muscles — sustaining urgency when pressure is uneven, rallying teams without a single inflection point, and making hard choices long before the pain is fully felt.

5. In the near-term, what happens when ACA enhanced premium tax credits expire? While OBBBA’s impact may unfold gradually, the imminent lapse of enhanced ACA premium tax credits poses a more immediate challenge. Health systems have been warning that the looming expiration of the credits at the end of 2025 is a critical concern. Since their introduction, the credits have led to a boom in marketplace coverage, with enrollment rising from 11.4 million in 2020 to 23.4 million in 2025, with 93% of those enrollees receiving enhanced credits. As insurers submit rate filings with median increases of 15% for 2026, even the largest insurers have signaled they will scale back to avoid the market instability.

The American Hospital Association has warned that the loss of the credits will upend emergency departments and worsen provider burnout. More uninsured individuals or those facing higher premiums would likely delay or forgo care, exacerbating health disparities and increasing uncompensated care. That shift could result in a $28 billion reduction in hospital spending over the next decade.

Local and state leaders have been voicing their alarm for months, with governors calling insurer rate hikes “insane” and healthcare trade groups shouting that the cost of health insurance will “explode.” The deadline presents another stark, and more timely challenge: how to plan for a potential surge in uninsured patients and a growing financial burden, all while continuing to address the systemic issues of cost, access, and workforce burnout that dominate the priorities outlined above.

6. What do physician and labor shortages look like now? For all the new headwinds health system leaders face in 2025, one challenge remains stubbornly familiar: the bad math between healthcare supply and demand. Regardless of political party or administration, the U.S. population keeps growing while the healthcare workforce lags behind. Today, 340 million Americans rely on roughly 840,000 direct patient care physicians and 5.3 million nurses, with shortages extending across allied health providers and critical support staff as well. The question is not whether shortages persist, but how much more destabilizing they will become.

7. What costs are hidden or harder to see? In healthcare, an entire category of system performance remains difficult to quantify: the number of people who forego or delay care. This issue resurfaced with urgency during the COVID-19 pandemic and now commands CEOs’ attention once again. Already, 36% of adults said in July 2025 that they skipped or postponed needed healthcare in the last 12 months because of the cost.

If the ranks of those delaying care expand whether due to costs, loss of coverage, long wait times or other barriers, the consequences ripple outward. Communities see worse health outcomes. Systems face more intensive and expensive interventions as untreated conditions worsen. EDs may experience higher volumes and higher levels of acuity, with the majority of ED visits already qualifying as “emergent.” And systems’ long-term cost curves can bend upward in ways that challenge the forecasts. As one CEO put it when bookending a conversation about OBBBA’s ripple effects: “We aren’t even talking yet about the people who won’t seek care.”

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