I am trapped in a circadian rhythm that I cannot escape from. I think it started when I finished my residency. And to make matters worse, this week it felt like I was also trapped in the series Squid Game. I awake about an hour before first light (sometimes as early as 4:30 a.m.) and almost instantly fall asleep about an hour after dusk if I am laying down. No matter the time zone.

On Thursday morning, May 22, I awoke as usual, but instead of some yoga, some reflective meditation, and my typical sunrise walk, I turned on C-SPAN. What a Squid Game moment. Who would be eliminated? How intense would it be? Who gets to take home the prize money? And at what cost?

I couldn’t help myself. Parts of me just couldn’t look away (you know, like when your parents were arguing in the living room and told you to go to your room, but you peeked from the top of the staircase anyway?)

I had to watch a few minutes of Rep. Hakeem Jeffries (D – New York) call out the perceived shortcomings of the Big Ugly Bill, only to then hear Speaker Pro Tempore Rep. Steve Womack (R – Arkansas) interrupt Mr. Jeffries and ask him to direct his comments to the chair rather than referring to Republicans as “you.” To which Mr. Jeffries responded, “Every time I come on this floor … [and] … use sharp language, you choose to admonish me. I don’t work for you, sir. I work for the American people.”

This type of exchange is not particularly new to the floor of the House and, in earlier eras, was even more contentious. What was different in this instance was the extended session of the House in preparation to vote on HR1, the Big Beautiful Ugly Bill (depending on your perspective). A reconciliation bill exceeding 1,000 pages, most members on either side likely had not read it in full or fully understood its implications.

Nevertheless, each political party was firmly committed to its position on the bill. One side argued it fulfilled a campaign mandate; the other viewed it as the embodiment of Project 2025. At the center of the debate was the future of Medicaid and possibly Medicare. This, too, is not unprecedented. The Affordable Care Act has been both praised and criticized since its inception 15 years ago. But that debate focused on expanding access to insurance.

Today, the concern is about potentially removing access.

And, for what it is worth, much of what appears in the public sphere—particularly on C-SPAN and in corporate media—can resemble performative commentary. The passage of the bill by the House seemed inevitable. So what? Was it a waste of time for viewers?

Not if you are a chief medical officer. This poses a real challenge.

Although the full impact of the proposed legislation remains unknown, the concern is legitimate. It may be two to three years before the effects are visible within your organization. By the time the bill is enacted and implemented through the administrative apparatus of government—and if people lose Medicaid coverage or disenroll from ACA plans due to cost—you might have transitioned to another role. However, if you remain or are newly in the role, preparation must begin immediately.

Becker’s reported, on the same day Congress began its late-night session on HR1, that four of the nation’s largest Catholic health systems described the potential impact of Medicaid enrollment reductions as “catastrophic.” They warned it could exacerbate the “polycrisis” affecting U.S. health care, which they say is approaching an inflection point, suggesting these systems are nearing their limits.

This was reported just one day before Speaker Johnson planned to bring the bill to the floor. At that stage, public protest may have seemed too late. Most observers understood the bill was likely to pass, perhaps by a narrow margin.

Is this a sign of improved performance or preparation for future challenges? Possibly.

Regardless, if you are a physician leader in a facility—whether rural or urban, hospital or FQHC—where Medicaid plays a major role, it is time to conduct planning exercises.

Five years ago, I led similar planning efforts, imagining our 900-bed hospital system needing to accommodate a census of 1,800–2,000 COVID-19 cases. We did not know if those figures were accurate, but we did our best to apply projections and operationalize resources for a potential surge.

We even planned for field hospitals—in Florida, during the summer, in hurricane season.

Fortunately, I worked with a COO and an emergency management director who had experience establishing field hospitals during SuperStorm Sandy in 2012. They had logistical expertise, but not necessarily clinical insight for a pandemic. We considered how many emergency visits, ventilators, respiratory units, ICU beds, respiratory therapists, and what level of throughput would be needed.

At what point would the system collapse? When would we call the governor for National Guard medical support? The military? Could we convert a cruise ship at Port Canaveral into a hospital for non-COVID patients?

Does this resemble the health care environment you know? The one you trained for?

Or does it sound like a contingency plan for an ongoing crisis?

The U.S. health care system is indeed facing a significant challenge. Originally expanded in response to the Spanish flu and formalized through the Hill-Burton Act of 1945, hospitals grew to meet social and medical needs. Insurance models developed to protect consumers from high costs, and federal funding increased accordingly. Thus, the modern health care system—complex and burdened—took shape.

Today’s tensions center on both funding and ideology. One issue is the societal obligation to support vulnerable populations. Another concerns the management and distribution of financial resources.

Regardless of political affiliation, it is evident that health care is increasingly used as a tool in broader ideological disputes. One approach raises public concern by highlighting potential threats to access and affordability. The other focuses on restructuring institutions and reallocating funding to influence systems of education, research, and service delivery.

• Which approach serves vulnerable populations more effectively?
• How should financial priorities be determined?
• Which actions are driven by public interest and which by political strategy?
• Who benefits from the current structure, and who is harmed?

These questions may not have straightforward answers. They reflect the broader conditions shaping our health care system. The debates continue. The system faces ongoing strain. Reform remains elusive. External assistance may not arrive.

As military analysts note, conflicts are often resolved when one side’s political will diminishes. Today, that will is being tested—at every level.

Perhaps upcoming legislative negotiations will moderate the current bill. The Senate has voiced concerns about its cost. The president may also influence the outcome when it reaches the Oval Office. Notably, he avoided harm during a recent event in Butler, PA, suggesting he is not easily caught off guard.

As a CMO, ensure your participation in executive discussions regarding the human, operational, and financial impact of the proposed changes. Join in planning exercises. Use data and analytical tools to estimate how many uninsured patients your organization might serve. Consider how their care and rehabilitation will be managed without funding, and how repeated emergency visits will affect length of stay and resource allocation. Evaluate how staff and patient well-being will be influenced. This is the core of your professional responsibility.

This is why you entered medicine and chose leadership: to make an impact under challenging conditions. You were trained to treat illness, heal injuries, alleviate distress, and provide safety in vulnerable moments. The mission has not changed. The context has.

In a future discussion, I will explore the power dynamics and financial forces shaping the direction of health care. I will also offer strategies to respond effectively.

In crisis training, individuals are taught to run, hide, and fight—in that order. If you are a leader in health care, retreat is not an option. Now is the time to advocate for patients and communities. Contribute to decision-making processes. Help design the solutions. This is the purpose for which you are prepared. You are ready.

Lee Scheinbart is a medical oncologist.