Winter is coming. - Ned Stark
For the unaffiliated, this phrase hails from the world of Game of Thrones, and it holds a three-part meaning. First, it serves as a surface warning about the harsh and unpredictable winters in the North of Westeros and the threat of White Walkers beyond the Wall. Second, it’s a metaphorical extension for impending danger, change, and the uncertainties of life. Lastly, it remains a philosophical House Stark motto (the family who ruled Winterfell) where it is used as a symbolic and survivalist stance for the importance of honor, preparedness, resilience, and awareness of inevitable hardships. By the way, if you haven't sat down to watch this series or read the book, you are sorely missing out.
Anyway...
Lately, I’ve been thinking about this phrase while listening to healthcare policy experts speak on the anticipated Medicaid changes coming in January of 2027 and its impact on our local communities. So, what’s coming? Beginning in January, certain adults covered by Medicaid will have to demonstrate that they meet new community-engagement requirements through qualifying activities such as work, education, job training or community service, unless they qualify for an exemption. For many, that means demonstrating at least 80 hours of qualifying activity each month. Applications and renewals will also have new requirements. The American Medical Association's patient guide is a two page document that provides a good summary of these changes and more.
Also, while it is important to note that these changes will not affect every Medicaid member in the same way, this points to shifts happening in care access.
According to national projections, the Congressional Research Service's analysis of Public Law 119-21 reports that the law's health provisions are projected to reduce federal healthcare spending by about $1.1 trillion over ten years and increase the number of uninsured people by 10 million in 2034 relative to the Congressional Budget Office's previous baseline. The Congressional Budget Office estimates 7.5 million more people will be without health insurance by 2034.
For those who follow healthcare trends, something similar played out in Arkansas when the state decided to implement Medicaid work requirements in 2018. Consequently, Arkansas’s Medicaid coverage declined during the first year. There was no evidence of increased employment either. By December in the same year, nearly 17,000 adults were notified that they were removed from Medicaid. A follow-up study would later report there was no increase in employment over 18 months. In addition, among people reporting a Medicaid coverage loss, 56% reported delayed care because of cost and 64% reported delaying medication for the same reason.
The entire country isn’t Arkansas. But I think that experience gives us enough of a signal to pay attention when it comes to how changes to administrative requirements create a ripple effect in for not only coverage, but whether and when people seek care.
So what should healthcare leaders be doing now?
We don’t know exactly how all of this will play out. And honestly, I don’t think we need to before we start preparing. We know enough to get started. From a health system perspective, I’d focus on four things.
1. Don’t wait until January to understand where you’re exposed.
I’d want to know which markets and services have the greatest Medicaid exposure, where uncompensated care is already concentrated and where patients already struggle to access care. I’d also want to understand what a disruption in coverage could actually mean once it starts moving through the organization.
My line of questions would probably be along the lines of:
Where are we most exposed?
Which patients and communities are most vulnerable to coverage disruption?
Where is access already difficult?
What happens to uncompensated care?
Which services are most likely to feel this first?
What happens when someone delays care because they aren’t sure whether they’re still covered?
How do we help people who may still be eligible for coverage but face barriers proving it?
Where are people getting lost between being eligible for something, proving they’re eligible and actually getting connected to care?
2. Don’t just look at data, know what metrics you’re going to watch.
Since we are talking access, good places to start are Medicaid disenrollment, uninsured encounters, financial assistance requests, appointment cancellations and changes in utilization. Some of those signals could tell us where problems are developing before they become something bigger. Establish the baseline if you haven’t already done so. Looking at the enterprise average helps but knowing what’s happening by market and community is more critical because that’s the ground level where the signal will first show up.
3. Eliminate barriers to system access and navigation (yesterday).
The good news, according to the Healthcare Financial Management Association reports, is that states and hospitals are already preparing for additional administrative work such as automated verification and data matching. Hospitals may also have supporting roles in areas such as medical-frailty documentation (paperwork that points to one’s conditions being so significant that it impairs their ability to meet work or community‑engagement requirements) and other eligibility processes. With that in mind, I’ll shift my focus to financial counseling and eligibility assistance. Specifically, testing registration processes because I’d want to know what happens when someone shows up for care and there’s a problem with their coverage. Who helps them? Where do they go next? How many steps does it take before they get an answer? Where are we with working alongside community organizations already helping people navigate public programs? They may see problems before we do. And I’d want to know where people are getting lost between being eligible for something, proving they’re eligible and getting connected to care.
I also wouldn’t assume we know exactly what implementation will look like yet. There are still moving pieces. The October 2026 federal court decision vacated part of the federal government’s medical-frailty definition while leaving the broader Medicaid eligibility requirements in place. States may also receive implementation extensions under certain circumstances. The HFMA October 2026 update provides a useful overview of what’s still changing.
4. If you must cut costs, be careful about what you cut.
I get it. The financial pressure is real. The latest HFMA analysis of the hospital implications describes risks ranging from higher charity care and bad debt to additional pressure on hospital margins as patients lose Medicaid coverage or struggle with new reporting requirements. We know healthcare organizations are already making difficult decisions about costs, staffing and where resources go. More of those conversations are already ongoing. When I’m looking at cost reduction, I want to know which capabilities the organization may actually need more, not less, if the environment gets harder. For instance, if you cut patient navigation, you’ve reduced an expense. But if patients then have more trouble maintaining coverage or connecting with care, you’ve affected something else too. The same could be true of financial counseling, community partnerships or ambulatory access.
I’m not suggesting organizations protect every program or avoid difficult financial decisions. I’m saying we should understand what we may need more of before deciding we can afford to have less of it. So when we start talking about what needs to come out, I think there’s another question worth asking: What will we wish we had protected if the environment gets harder?
The organizations paying attention now still have something incredibly valuable: time.
The organizations paying attention now have time to understand where they’re exposed. They can look at the patient experience before problems start showing up at scale. They can figure out what they need to watch and which capabilities they need to protect. And they can start talking with the community organizations that may be dealing with the same people and the same problems.
Now that we know and understand “Winter is coming,” there is another Stark message that feels relevant for the times: “The lone wolf dies, but the pack survives.” I think there’s something in that for healthcare. It’s a reminder that while health systems can prepare for what’s coming, we can’t do it alone. We’re going to need our expanded networks from public health agencies and community organizations to local government and universities working alongside us. Considering that we are all working within a shared community and preparing for the same winter, it probably makes sense to start talking before it gets here.
Thanks for reading! I’d love to hear your thoughts on this article. Did I miss anything? Do you have personal experiences or observations to add? Let me know! As always, I hope this helps! ✌🏾 + 🫶🏾
Footnotes is a newsletter dedicated to exploring insights, trends, and strategies to help leaders navigate change and future-proof their organizations. It is also a platform where I share ideas that encourage thoughtful dialogue. Your feedback is always valued. The views expressed here are solely my own and do not represent those of any affiliated organizations. Thank you for reading and engaging with this work
