Dying Well: A Forgotten Sacred Passage

Congress’s “Big Beautiful Bill” set off a political fireworks show, but the quieter fallout is the one that will hit health systems the hardest. Millions of Americans will lose coverage, Medicaid enrollment will churn, and uncompensated care will rise. For health systems, the economics of Medicaid and the uninsured are being rewritten in real time, and the implications will ripple across operations, planning, and financial performance. We’re entering a new era of health system finance. The organizations that adapt now will be the ones still standing when the dust settles. The Coverage Landscape Is About to Shift Hard The new law introduces a challenging combination: Nearly $900 billion in Medicaid cuts over ten years Work requirements that push millions off the rolls Administrative coverage churn that drops eligible patients out of Medicaid DSH and supplemental payment reductions delayed for years Rate normalization rules lowering hospital-directed payments toward Medicare levels Medicaid payments to health systems will decrease and uninsured patients will increase. As coverage shrinks and eligibility rules tighten, the uninsured population becomes more unpredictable and clinically complex. This shift affects every part of a health system. How to Approach the Decrease in Medicaid and Increase in Uninsured 1. Rebuild the Medicaid P&L Most health systems understand that Medicaid margins are thin, but far fewer have a clear, unblended view of how the program performs on its own. With new pressures ahead, that level of clarity is no longer optional. It’s foundational. This is the time to rebuild the Medicaid P&L with discipline and accuracy. Separate Medicaid from the blended payer mix and create a standalone P&L by service line, site of care, and acuity. This gives leaders an honest, detailed picture of where losses are concentrated and where opportunities for improvement exist. It becomes the roadmap for more informed decision-making. 2. Negotiate Managed-care Contracts for Predictability Not Just Rates Rate increases matter, but stability matters more. Systems should prioritize: Encounter-level predictability Clear carve-outs for high-cost services Protection against state budget volatility Reduced administrative friction (denials, prior auth, appeals) Create a contracting environment that reduces risk and stabilizes performance. 3. Build Accurate Unit-cost Models for Medicaid Services Many systems still rely on Medicare proxies or blended averages to estimate Medicaid cost. Medicaid patients often have different utilization patterns and require more coordination and administrative effort, meaning blended assumptions miss the mark. A Medicaid-specific unit-cost model should include: Cost per ED visit by acuity Cost per inpatient day by DRG/severity Cost per behavioral-health visit NICU and maternal-child costs Care coordination and social-needs support Administrative cost of denials and prior auth This level of precision usually reveals that a meaningful share of Medicaid losses stem from operational gap and not just reimbursement. When those gaps are addressed, performance improves in measurable, durable ways. 5. Build Clear Uninsured Pathways The uninsured population is about to grow, and without a defined pathway, these patients bounce through the most expensive parts of the system such as the ED, avoidable inpatient stays, and unresolved behavioral-health crises. A clear, standardized pathway preserves resources, protects capacity, and improves care. Pathways should ensure: ED to primary-care handoff within 72 hours Behavioral-health triage and fast-track routing Social-needs screening and referral workflow Real-time scheduling assistance Embedded financial counseling in clinics 6. Partner Deeply With FQHCs and Community Health Centers No health system can absorb the coming uninsured surge alone. FQHCs and CHCs already specialize in serving low-income and uninsured patients, but the relationships are often inconsistent or purely referral-based. The next era requires integrated, operational partnerships that redirect care to the right setting. This can include: Shared “rapid access” scheduling blocks Warm handoffs from ED and primary care Co-located or virtual behavioral-health support Joint care-plan development for high-need patients Data-sharing agreements that support continuity and follow-up 7. Build a Behavioral-Health Stabilization Loop Behavioral health is where the coverage losses will hit hardest. Without a closed-loop stabilization model, patients will continually churn through EDs, inpatient units, and law enforcement encounters. A stabilization loop creates faster connection to care and reduced avoidable utilization. This can include: Embedded behavioral-health clinicians in EDs Urgent behavioral-health access points (same-day/next-day) Guaranteed rapid follow-up after crisis encounters Full SUD navigation integrated into the pathway The Bottom Line Medicaid is entering a period of maximum volatility. Coverage will fall, complexity will rise, and financial pressure will sharpen. Community health expectations will increase even as funding sources shrink. But health systems can treat this as an opportunity for a strategic pivot. Systems that strengthen Medicaid strategy, redesign uninsured pathways, and modernize operations now will emerge strongest in the new economics of Medicaid.

Primary care was meant to be the front door to health. Instead, it’s become a crowded hallway where everyone, from the perfectly healthy to the chronically ill, waits in the same line for a 15-minute visit. Patients feel unseen. Clinicians feel overwhelmed. And the system keeps asking both sides to do more with less. If healthcare truly wanted to serve people better, it would start by understanding them. Every other industry uses customer segmentation to meet people where they are. Healthcare should do the same. It’s time to redesign primary care around the needs and goals of the people it serves, not the limitations of the system that delivers it. A Personal Observation: When the Insiders Opt Out At one health system where I worked, the irony was hard to ignore. Nearly my entire department, the same people tasked with improving access, experience, and outcomes, went to the same clinic. It wasn’t one of ours. It wasn’t even in-network. It was a small, cash-pay concierge practice. The difference was immediate. The lead provider was trained in both Western and Eastern medicine. For a monthly fee, patients could meet with him once a month to talk about wellness, get personalized recommendations, and receive acupuncture. You could text him anytime. The experience felt personal, thoughtful, and deeply human. Meanwhile, in our own clinics, we were surrounded by sterile walls, packed schedules, and rigid workflows. The preventative care services offered didn't appeal to us as consumers. That contrast stuck with me. If the people designing the system are opting out of it, that tells you something fundamental: patients want connection and true wellness services, not complexity with a diagnose and treat mindset. 1. The Healthy and the Well: Prevention as a Service One of the biggest opportunities lies in getting healthy patients out of overburdened MD offices. Physicians are facing real burnout, stretched thin by the pressure to see more patients in less time. Let’s reserve their expertise for people who truly need it. For everyone else, we can build a better experience. Imagine healthy patients engaging directly with nutritionists, wellness coaches, trainers, acupuncturists, and therapists, the people best equipped to keep them well. Many of these services can be delivered virtually, through partnerships with trusted digital platforms and experts in nutrition, fitness, and behavioral health. Done right, this model keeps people engaged, lowers unnecessary utilization, and creates space for physicians to focus where they’re needed most. It’s a smarter use of resources and a more satisfying experience for everyone involved. 2. The Complex and the Chronic: Coordination, Not Chaos People managing multiple chronic conditions need something entirely different: consistent, coordinated support. They don’t need another specialist referral; they need someone who helps connect the dots. Dedicated complex care clinics can anchor this model, staffed by nurse practitioners, pharmacists, social workers, and care navigators who work as a team. Technology ties it all together, tracking medications, labs, and social factors so patients aren’t left managing it alone. The measure of success here isn’t visit volume. It’s stability, quality of life, and fewer avoidable hospital stays. 3. Everyone in Between: Smart Triage and Seamless Access For those who fall somewhere in the middle, smarter triage can make all the difference. AI-assisted intake, same-day nurse visits, and virtual follow-ups can ensure people get the right care at the right moment, without clogging up waiting rooms or defaulting to the ER. It’s not futuristic; it’s just organized. 4. How Employers Can Help Make It Real Employers can drive this transformation faster than health systems alone. By rethinking benefit design through a segmentation lens, they can align incentives with wellbeing: - For healthy employees: invest in virtual wellness programs, lifestyle coaching, and preventive memberships. - For complex cases: cover access to high-touch, coordinated care teams. - For everyone else: offer navigation tools that simplify decision-making and direct people to the right setting. The result? Healthier people, less clinician burnout, and lower costs that actually mean something. The Future of Primary Care Primary care doesn’t need to be reinvented from scratch, just rebalanced. We can preserve what’s best about medicine, expertise, compassion, trust, while building a structure that reflects how people actually live and what they really need. Because at its core, good care is still personal. It listens. It teaches. It helps people stay well, not just get well. And that’s the kind of system worth building.

Schools Are the Front Line But They Can’t Do It Alone Every parent and teacher knows that mental-health needs among students are rising. Anxiety, depression, and trauma have become common language in schools, yet access to qualified care remains uneven at best. Nearly every U.S. public school now offers some form of mental-health support, but the quality and capacity vary widely. Counselors are overextended. Funding is fragmented. Wait times for external therapy can stretch for months. Schools are the natural front door to care, trusted, accessible, and embedded in daily life, but they’re not designed to operate as full-service clinics. To meet today’s demand, they need new partners and new funding models. A Scalable Solution: Public-Private Partnership for Student Mental Health Imagine if every school had a trusted on-site counselor, backed by a network of licensed clinicians accessible through a secure digital platform. That’s where a partnership with companies like Lyra Health comes in. Lyra already connects millions of employees to high-quality mental-health care through telehealth, AI-assisted triage, and measurable outcomes tracking. Translating that model into the education sector could fill one of the largest gaps in U.S. healthcare: early, equitable access to youth mental-health services. A public-private partnership model could look like this: - Schools provide the setting, local trust, and basic staff infrastructure. - Digital partners like Lyra provide the therapist network, tele-mental-health platform, and data analytics. - Health systems and foundations supply blended funding to sustain operations and evaluate outcomes. The result: a networked system that combines the empathy of local care with the scale of modern technology. The Sustainable Triangle: Health Systems, Foundations, and Schools To make this work, funding must be as innovative as the delivery model. Instead of relying on short-term grants, this approach would draw from three stable, complementary sources: 1. Community Benefit Contributions from Local Health Systems Nonprofit hospitals are required to reinvest in their communities, typically through health education or chronic-disease initiatives. Youth mental health is squarely aligned with those objectives—and investing in prevention reduces future emergency-department visits and behavioral-health crises. By directing Community Benefit dollars to school-based programs, hospitals could fulfill their IRS obligations and generate measurable improvements in community health. Outcomes such as reduced absenteeism or lower behavioral-health ER use provide tangible reporting metrics. 2. Private and Corporate Foundation Support Local and national foundations can match hospital contributions, funding the digital backbone—technology, telehealth licensing, and data analytics. Corporate donors could participate through ESG or workforce initiatives, framing youth mental health as essential to long-term community resilience. 3. Public Education and Medicaid Matching Funds Federal education programs (ESSA, Title I) and state behavioral-health budgets could fund on-site coordination. In states that allow school-based Medicaid billing, districts could recover part of the costs, making the model sustainable beyond philanthropy. Together, these three forces create a sustainable triangle: - Hospitals bring dollars and population-health accountability. - Foundations bring innovation and flexibility. - Schools bring reach, trust, and daily access to students. Why It’s a Smarter Investment This model shifts mental-health care from reactive to preventive, from fragmented to integrated. Instead of treating crises, we build resilience early. It’s also fiscally sound: - Hospitals meet Community Benefit goals with measurable outcomes. - Foundations amplify their impact through scalable digital infrastructure. - Schools gain sustainable support without overwhelming local budgets. The returns show up not only in reduced ER visits or absenteeism, but in healthier adults decades later. A Call to Lead Schools are already the front line of mental health. What they need now isn’t more disconnected programs, it’s partners. By aligning the missions of education, healthcare, and philanthropy, we can create a system where mental-health care is accessible, data-driven, and sustainable. A public-private partnership model combining Community Benefit dollars, foundation grants, and technology partners like Lyra Health could make that vision real. This isn’t just a new funding model. It’s a new social contract: one where every school becomes a doorway to lifelong wellbeing.

Back in 2015, I had the opportunity to work on my first Accountable Care Organization (ACO) model with CMS. It was an exciting time filled with energy, collaboration, and the hope that we could finally bend the cost curve and make care more affordable for everyone. Although the ACO was considered a success, it did little to change the true cost of care to consumers. Today, that message feels more urgent than ever. Healthcare premiums continue to climb. Family coverage through employers now averages nearly $27,000 per year, a 6% increase from 2024. Employers expect costs to rise another 6.5% or more in 2026, and much of that increase will be passed along to employees through higher premiums, deductibles, and out-of-pocket expenses. With costs shifting more heavily to consumers, it’s no longer optional for patients to think like buyers, it’s essential. We keep trying to lower healthcare costs by pressuring hospitals, insurers, and pharmaceutical companies. Yet after decades of attempts, costs continue to rise. The most powerful lever isn’t going to come from healthcare delivery, it’s going to be someone with real incentive to change, and that’s employers. Employers Hold the Untapped Power Employers account for nearly half of all healthcare spending in the United States. Yet for too long, healthcare strategy has been treated as a benefits issue rather than a business one. It sits within HR departments, disconnected from finance, supply chain, or operations, functions where cost control and performance management are part of the daily language. Forward-thinking companies are starting to change this. They are recognizing that healthcare is a trillion-dollar business expense and should be managed with the same discipline as any other major investment. That means analyzing healthcare data, benchmarking costs, and negotiating based on value and performance, not just access. It means bringing finance and operations leaders into benefit design, creating dashboards, measuring ROI, and asking the same questions they ask of any other vendor: Are we getting what we pay for? Are our dollars driving measurable outcomes? When companies start to apply that level of rigor, they begin to see results. Walmart and Disney have both experimented with direct contracting models, partnering with high-performing health systems to negotiate bundled pricing for specific procedures. Other large employers are forming regional coalitions to negotiate as a group, using data, scale, and shared accountability to demand better pricing and transparency. Imagine if every Fortune 500 company treated healthcare the same way they manage supplier contracts, negotiating based on cost, quality, and service levels. The industry would have no choice but to evolve. Hospitals and payors would need to compete for employer business, innovate faster, and deliver measurable value. The Bottom Line Healthcare reform will not be led by hospitals, insurers, or policymakers alone. It will be driven by employers who decide to treat healthcare as a strategic investment rather than a sunk cost. If large employers begin to measure, negotiate, and design benefits based on value, performance, and prevention, the market will follow. Costs will fall, transparency will rise, and innovation will accelerate. We’ve built endless programs to reform healthcare from the top down. Maybe it’s time to rebuild it from the inside out, starting with the organizations that pay for most of it.

Every year, thousands of ambitious graduate students apply for Administrative Fellowships at top healthcare systems like Cleveland Clinic, Corewell Health, and Kaiser Permanente. These programs are the launchpad for future healthcare leaders, offering hands-on experience working directly with executives on real strategic initiatives. But landing one isn’t easy. Administrative Fellowships are among the most competitive opportunities in healthcare leadership. The candidates who stand out don’t start preparing a few months before the deadline, they start years earlier. Step 1: Start Early and Choose the Right Fellowship If you’re pursuing an MHA, MBA, or MPH, begin planning your fellowship as soon as you start graduate school. Most applications close in September, and programs begin the following summer or fall, meaning you’ll apply at the beginning of your final year of your master’s program. The strongest candidates use their entire graduate experience to build a cohesive story, aligning their coursework, thesis, and internships around the type of organization they hope to join. Every fellowship is different. Some emphasize operations and performance improvement, while others focus on strategy, population health, or system transformation. The first step is identifying which programs align with your interests and leadership style. Step 2: Research Deeply and Create Alignment Before you apply, immerse yourself in the organizations you admire. I like to joke that I became a bit of a professional stalker, learning everything I could about each organization’s priorities and leadership. Read annual reports, strategic plans, and community benefit tax submissions. Follow executives on LinkedIn. Attend ACHE panels or webinars where they speak. This level of research helps you tailor your academic and professional work to what matters most to them. If your target system focuses on value-based care, consider aligning your thesis in that space. If they emphasize digital transformation or workforce resilience, shape your coursework and internships to match. Step 3: Build Relationships Early This step is non-negotiable. When I was applying, I reached out to every fellow at the organizations I was interested in. It wasn’t about asking for favors, it was about learning what the experience was really like and establishing a personal connection. Those conversations shaped my essays and interviews and gave me perspective no amount of research could. Later, when I served as an interviewer for fellowship candidates, I saw how critical this was. Some organizations won’t even interview candidates that didn’t reach out to the current fellow. Step 4: Position Yourself as Top National Talent Not only are you competing for a coveted fellowship placement, but health systems across the country are also competing for top talent. They want to select the best of the best for their program. Position yourself as someone with a national perspective on the healthcare landscape. Many universities and professional organizations offer funding to help students attend national conferences, and taking advantage of those opportunities can set you apart. For example, HIMSS offers $5,000 scholarships for graduate students to attend its annual conference. Even better, apply to be a speaker or to showcase your research. Presenting your work at a national conference is one of the strongest ways to distinguish yourself early in your career. Start positioning yourself not just as a graduate student, but as a nationally recognized emerging leader and expert in your area of research or interest. Step 5: Approach the Interview as a Person, Not Just a Candidate Once you’re invited to interview, remember, the goal isn’t just to answer questions well, it’s to connect. Behind every question is an executive wondering what it will be like to work with you every day. Don’t just show that you’re qualified, show that you’re someone they’ll enjoy having on the team. When I was preparing, I researched every executive I’d meet. I read their bios, articles, and interviews, and even checked LinkedIn to see their interests. Before each interview, I’d find a genuine point of connection, whether it was a shared sports affiliation, alma mater, or professional focus. Be professional, but be human. Bring authenticity and curiosity into the room. That combination is what makes great leaders, and great fellows. Final Thought Landing a top Administrative Fellowship takes more than ambition, it takes planning, focus, and consistency. The best candidates don’t stumble into these roles; they design their graduate experience around them. Start early. Study deeply. Build relationships. And by the time September comes, you won’t just be another applicant, you’ll be the candidate they’ve been hoping for.