Back in May, I wrote this blog post to share a white paper I had written on the quiet dismantling of America’s healthcare safety net—Medicare, Medicaid, and the VA.

At the time, I knew it was serious. I didn’t expect it to start moving this fast.

Since then, the “Big Beautiful Bill” passed, triggering new waves of cuts, privatization, and eligibility rollbacks—some hidden in plain sight, others buried in legislation that few people outside of Washington noticed. Even fringe healthcare proposals have started creeping into the mainstream.

So I’ve written a follow-up.

This new essay is far more than an update—it’s a deep dive into the accelerated erosion of Medicare, Medicaid, and VA healthcare, the growing risks for millions of Americans, and what we can still do to push back before it’s too late.

You can read it here on my Substack:
👉 Hollowed Out: How America’s Healthcare Safety Net Is Quietly Being Dismantled

I’m keeping this blog as a running record of these shifts—not because I think anyone’s sitting around reading my archives, but because these fights over healthcare are going to define the next few years in ways that many people won’t see coming.

If you’ve followed my writing before, you know this isn’t just a political exercise for me. This is personal. These policies affect veterans, working families, seniors, and anyone who depends on the healthcare safety net to survive.

I’ll keep tracking it.

I work in the digital healthcare business — helping healthcare organizations build systems that talk to each other, share data, and ideally reduce friction for both patients and care teams. I’ve also spent time working on digital front doors—the slick, app-like experiences many hospitals and other providers now use to engage patients. These solutions are effective, but they’re not too cheap, both in licensing costs and the services required to put them together.

Recently, I’ve been thinking about what happens to all of this infrastructure—the APIs, middleware, and patient portals—when the funding starts to disappear.

The signals are there: pressure on Medicaid, Medicare, VA services, and public health agencies is rising. In previous posts, I’ve explored the downstream risks (The Big Beautiful Bill, Can We Automate Our Way Out, The Cost of Early Death). But it’s clear that interoperability itself may also be in the crosshairs.

What Interoperability Meant—And Why It Might Be Changing
Interoperability has been around for a while, but was supercharged about 15 years ago with the HITECH Act (Health Information Technology for Economic and Clinical Health). The Office of the National Coordinator for Health Information Technology (ONC) define interoperability across four levels:

• Foundational: Data exchange between IT systems
• Structural: Standard formats and syntax (e.g., HL7, FHIR, CCD)
• Semantic: Shared meaning of data between systems
• Organizational: Consent, governance, legal agreements, workflows

(HealthIT.gov, 2023)

These definitions assume continued growth and investment—backed by Meaningful Use, Cures Act mandates, and adoption of EHRs. However, if federal reimbursement begin to shrink, this framework may no longer hold up.

Digital Front Doors—What Happens When the Budget Gets Tight?
Digital front doors, including mobile apps, chatbots, appointment engines, and patient access APIs, are not free. In fact, a 2023 Chilmark Research report noted that digital front door initiatives often exceed $500K in upfront investment for midsize systems—not including maintenance and integration costs (Chilmark Research, 2023).

If funding goes away, some possible outcomes may be:

• Front-end features dropped in favor of bare-bones portals
• Shifts toward payer-controlled ecosystems
• ​Use of white-labeled third-party tools that sacrifice customization for cost

This is not theoretical--state-level Medicaid agencies have already pulled back on HIE access in some cases (KFF, 2024).

Have We Engineered Ourselves Into a Privacy Trap?
Modern interoperability assumes real-time, cross-entity data sharing. The Trusted Exchange Framework and Common Agreement (TEFCA) is supposed to enable this while protecting consent and governance (ONC TEFCA Overview, 2024). But things have gotten messier.

• Weak HIPAA enforcement at the federal level has left state-level agencies scrambling with inconsistent protections
• Growing use of third-party apps under the 21st Century Cures Act creates new privacy risks—especially when developers fall outside HIPAA’s scope (GAO, 2023)
• Centralized architectures, like some cloud data lakes, create single points of failure—convenient but exposed

Interoperability doesn’t inherently weaken privacy, poor implementation and deregulation can.

What Happens When the Money Dries Up?
If proposed federal cuts materialize, the interoperability ecosystem will feel it in three key ways:

• Stalled Modernization: Small and rural providers may halt FHIR upgrades or delay EHR replacement cycles (CMS, 2024)
• Shrinking HIE Participation: Public health departments and Medicaid MCOs may exit expensive exchange networks
• Vendor Consolidation: Fewer dollars may push smaller integration vendors out, consolidating the market around major players

We should expect increased demand for cloud-native integration platforms, Pay-as-you-go API solutions, and simplified FHIR middleware that minimizes custom development.

How We As Consultants, Product Teams, and Strategists Can Respond

For Consultants & Integrators:

• Push modular architectures—ditch "all-in-one".
• Help clients develop interoperability tiers based on urgency and budget.
• Prioritize data governance and privacy early in the design phase.
• Create exit strategies for fragile HIEs and legacy networks.

For Vendors & Product Developers:

• Build tools that can scale down gracefully—not just up
• Make FHIR-native functionality the default, not a premium
• Explore federated data models and zero-trust architectures
• Data isn't always going to be great. Deliver value using imperfect, incomplete, or disconnected data—perfection will be rare

Where the Market Is Shifting
This took some research on my part, but it looks like a number companies are well-positioned for what’s next:

• Redox, Health Gorilla, Particle Health: - API-based  vendors with national reach (Redox, Health Gorilla, Particle Health).
• Skyflow, TripleBlind: Startups focused on privacy-preserving data exchange and federated AI (Skyflow, TripleBlind).
• AWS HealthLake, Google Cloud Healthcare API, and Microsoft Cloud for Healthcare offer elastic infrastructure for payers and providers trying to do more with less.

Final Thought: Strategy Over Nostalgia
Interoperability isn’t collapsing—but it looks like it is evolving. Consultants, technologists, and product leaders will need to adjust expectations, revise architectures, and help clients prioritize privacy and value over perfection.

This new era we are in is marked by constrained budgets, decentralization, and (not always strategic) tradeoffs. We are going to have to build things differently.

Sources & Citations

• ONC – What is Interoperability?
• ONC TEFCA Overview (2024)
• Chilmark Research – Digital Front Door Trends (2023)
• CMS – Strategic Vision 2024 (Not sure how much this vision will evolve)
• KFF – Medicaid & HIE Participation Trends
• GAO – Privacy Gaps in App Ecosystems (2023)
• Redox
• Health Gorilla
• Particle Health
• Skyflow
• TripleBlind

In earlier posts--“Can We Automate Our Way Out of Healthcare Cuts?” and “Why It Feels Like We’re Being Left Behind”—I looked at how federal retreat from public health investment erodes trust and destabilizes care. Now, with the true scope of Trump’s so-called “Big, Beautiful Bill” in view, it is easier to assess its cumulative toll: sweeping cuts to Medicaid, Medicare, SNAP, veterans’ health, tribal care, research infrastructure, and environmental protections. The result? A nation that will get sicker.

A Nation Made Sicker
Recent research in the Journal of General Internal Medicine finds that people who lose public coverage due to redetermination suffer higher mortality and avoidable ER use. This is already underway: over 20 million people have been removed from Medicaid since post-pandemic eligibility reviews resumed (KFF, 2025).

This is denial by design—and it’s expanding.

A Fragile Safety Net: Veterans, Tribes, the Working Poor
The VA system, historically excellent at delivering veteran-specific care (PTSD, MST, toxic exposure), is being hollowed out. Under the MISSION Act, funding is redirected to civilian providers who lack military cultural competency. That leads to misdiagnoses, disengagement, and preventable deterioration (RAND Corporation, 2022).

Tribal health programs are equally vulnerable. With IHS underfunded and reliant on Medicaid reimbursements, coverage losses hit Native communities hardest—compounding already stark health disparities.

Medicare Advantage is a Costly Illusion
Despite its popularity, Medicare Advantage (MA) costs taxpayers 6–9% more per enrollee than traditional Medicare—and comes with higher denial rates and narrower networks (MedPAC, 2024). A 2022 HHS OIG report found that 13% of MA denials were for services that would have been approved under traditional Medicare.

More money, less care.

Environmental Rollbacks: The Invisible Health Threat
While rarely discussed in healthcare briefings, environmental deregulation—air quality standards, water protections, pesticide safety—affects everything from asthma rates to cancer prevalence. The Lancet Commission on Pollution and Health estimates over 200,000 premature U.S. deaths per year due to pollution alone. That number will rise as oversight shrinks.

SNAP, Nutrition, and the Health-Hunger Feedback Loop
SNAP isn’t just an anti-poverty program; it’s a public health policy. Undernourished people are more prone to chronic conditions like diabetes and hypertension. Cuts to nutrition assistance will silently raise disease burdens, especially for children and the elderly.

The Economic Impact: A Sicker, Less Productive Workforce
According to the Brookings Institution, chronic disease now erodes U.S. GDP by hundreds of billions annually. With more people uninsured or underinsured, hospitals absorb rising uncompensated care costs—and many rural hospitals are forced to close. This feeds a downward spiral of health deterioration, labor force dropouts, and medical bankruptcies.

Can This Be Reversed?
Yes—but not passively. The safety net is a legislative construct. That means it can be restored.

• Reform Medicare Advantage: Require transparency in denials and cap risk scores.
• Preserve the VA: Freeze downsizing and ensure veteran-specific training for community providers.
• Protect Medicaid Access: Ban work requirements, streamline eligibility, and enforce nondiscrimination.
• Invest in Modern Infrastructure: Interoperable EHRs, cross-agency coordination, and integrated care models
• Reduce Costs Ethically: Expand drug price negotiations and outcome-based payment models.

These and other ideas are outlined in my white paper, Undermining the Safety Net (PDF) .

What Can We Do—Even When Leadership Won’t
It is a fact that many of the people with the power to fix this lack the moral courage and incentive to act. They defer, deflect, or distract. But that doesn’t mean we’re powerless. Here’s how ordinary people are already pushing back—and how you can join them:

🧠 Get Loud Locally

• Your city council, school board, and county health office may seem small—but they have direct influence on Medicaid enrollment, hospital funding, and public health rules.
• Attend meetings. Ask questions. Demand public discussion on how federal cuts are affecting your community.

📣 Tell Real Stories

• Data is easy to ignore. Human stories aren’t. Share how healthcare policy has affected you or someone you know.
• Contact local media. Post on social platforms. Join campaigns like Advocates for Community Health that amplify patient and provider voices.

🧭 Support People Doing the Work

• Donate to or volunteer with Federally Qualified Health Centers (FQHCs), free clinics, and advocacy groups who are holding the line where policy has failed.
• Encourage your local providers—nurses, therapists, case managers—to share what they’re seeing. Front-line stories cut through political spin.

📜 Watchdog and Report

• Work with organizations like the Center for Medicare Advocacy to track denied claims, inaccessible services, or unlawful eligibility purges.
• File complaints. Join public comment periods. Bureaucracies change when they are flooded with documented, on-the-record pushback.

🗳️ Vote—but Don’t Wait for an Election

• Voting matters. But elections are the bare minimum. Pressure representatives between elections. Call. Email. Show up. Make it known that these policies aren’t just abstract budget items—they’re life and death for your neighbors.

This isn’t about partisan slogans or “resistance.” It’s about reclaiming the public systems that made us healthier, safer, and more just.

Even if it feels like a drop in the bucket, action matters. Enough drops? That becomes a tide.

Final Thoughts
America’s public health institutions aren’t perfect—but they’ve helped us live longer, live better, and recover faster. If we let them wither, we will pay not only in dollars but in lives.

Let’s not look back in ten years and ask how we let this happen. 

Let’s be real: this was supposed to be a blog post.
​
I sat down thinking I’d write a few hundred words about some proposed changes to the VA, Medicare, and Medicaid systems—just a quick post to highlight a few concerns. But the deeper I dug, the more it became clear: this isn’t a blog entry. It’s a white paper.

Why? Because what’s happening isn’t simple. What’s being sold as “streamlining” or “cost efficiency” is, in practice, a restructuring of how care is delivered to veterans, seniors, and low-income Americans. These systems aren’t perfect, but they’re foundational—and when you start chipping away at them without a plan that puts outcomes first, people suffer.

Medicare Advantage plans are costing more while denying more. Medicaid redetermination is booting millions off coverage for paperwork reasons. And VA services are being diverted to private providers who aren’t always equipped to treat veteran-specific trauma. These aren’t abstract issues—they have real human consequences.

So yeah, the blog became a paper. It’s detailed, sourced, and longer than your average lunch-break read. But if you work in healthcare, policy, or even just vote, this affects you too.