At a recent health care conference, a panel of leaders gathered to talk about financial resilience. The framing was intentionally designed. The question wasn’t “How do we save money?” It was “how to deliver the right care, at the right time, in the way that is most meaningful, so that outcomes change, health improves, and the total cost of care comes down.”
When the audience asked how social and structural drivers of health (SSDOH) are built into these models, every panelist had a real example of their teams bringing culturally congruent care into communities and honoring people’s lived experience. A few years ago, SSDOH rarely made it onto panels like this one. That is meaningful progress.
Three words that stopped the room
Then an audience member raised a hand: “With H.R. 1 on the horizon, how are you thinking about caring for those who will be losing access to insurance?”
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The answer: “I don’t know.”
One panelist continued: “I don’t know. But I do know that people will be coming to my emergency department more frequently for things they could previously get care for outside of the hospital. People will be delaying care. People will be sicker. And that will continue to put financial pressure on our already fragile systems. I don’t know, but if any of you know, please tell us.” It may have been the most honest moment of the entire conference.
“I don’t know” is not the same as inaction
It would be easy to hear those three words as a lack of preparation. And that is simply not the case.
Behind an answer like that, planning is almost always underway. Leaders are modeling the financial impact, forecasting utilization, strengthening charity care and financial counseling, and preparing their teams. They are thinking this through and taking action.
“I don’t know” isn’t a confession of inaction. It’s a recognition that no single organization, however well-resourced or well-led, can answer this question alone. And that is exactly the point.
Weeks, not years
The country is weeks away from one of the most significant shifts health (not just health care) has seen. Between H.R. 1 and the expiration of the Affordable Care Act enhanced premium tax credits, it is estimated that an additional 14 million Americans will lose insurance coverage by 2034, above the roughly 30 million who experience lack of coverage today.
When systems are designed around coverage as the primary way of describing people, something essential gets lost. Insured, uninsured, Medicaid, commercial, self-pay: Those labels help finance care, but they say nothing about who someone is. Worse, they often carry stereotypes, and those stereotypes are harmful. They shape how people are greeted at the front desk, whether their concerns are believed, and whether they come back at all.
The nuance matters to the person receiving care. It matters to the family and community caring for them outside the four walls of a clinic. Their need for care, their story, and their humanity don’t change when their eligibility does.
People are not their coverage type. And coverage should not dictate dignity.
A system problem, not a leadership problem
This is not a leadership problem. It is a health ecosystem problem.
The deepest flaw this moment reveals is that true cross-sector collaboration isn’t the default. Health systems, health plans, public health, community-based organizations, employers, and local governments each plan within their own walls, with their own data, timelines, and funding.
Collaboration happens, but as the exception: a grant-funded pilot, a time-limited coalition, or a partnership held together by a few committed people. When those people move on or the funding ends, the connective tissue goes with them.
So even thoughtful, well-prepared leaders end up saying “I don’t know.” They’re being asked to solve, alone, a problem that can only be solved together.
H.R. 1 didn’t create these cracks. It’s revealing them. Some are the result of decades of neglect. Others were designed into the system on purpose: coverage tied to employment, eligibility that has to be proven again and again, and care organized around who pays rather than who needs it. These weren’t accidents. They were choices. And what was designed can be redesigned.
An opportunity, if leaders choose it
Moments like this create an opening. When the cracks are this visible, there’s a chance to build something different, not by solving everything at once, but by starting with what matters most: How do we design a space where people can receive basic care with dignity, no matter their coverage status this month?
Basic care with dignity might look like:
- A place to go before the ED, where people are greeted as people, not by payer
- A consistent relationship with a care team that doesn’t disappear when coverage does
- Access to primary and preventive care, essential medications, and help navigating what’s next
- A front door free of shame, where no one has to prove they belong before someone asks how they’re doing
None of this is radical. Much of it already exists in community health centers, free clinics, direct primary care practices, faith communities, and community-based organizations. What’s missing is the infrastructure to design together across them as the default, not the exception.
“If any of you know, please tell us”
The panelist’s closing words weren’t a shrug. They were an invitation, and it’s worth accepting.
Start by asking who isn’t at the table. Solutions designed only by the people who run systems will serve the systems first. The people most affected by coverage loss, along with the community health workers, doulas, faith leaders, and neighborhood organizations who know them, belong in the design process from the beginning, not as a focus group at the end.
Bring those partners in before January 1, not after demand spikes. And continue to bring them to the table to co-design as the plans inevitably will evolve.
Design for churn. Someone may be covered in March, uncovered in May, and covered again in September. Their care team, their medications, and their sense of belonging shouldn’t disappear every time their coverage does.
Resource the organizations already catching people when coverage drops. They don’t need to be reinvented. They need to be invested in. And build shared planning tables that outlast any single grant, pilot, or champion, so that cross-ecosystem collaboration becomes the default way the work gets done.
The answer may still be “I don’t know.” But it won’t stay that way if it’s worked out together.
The panel opened with a vision of the right care, at the right time, in the way that is most meaningful. The work now is making sure that vision holds no matter what coverage someone has.
Katie Abbott is the founder and chief operating officer of MitoKhon and a third-generation, heart-centered entrepreneur on a mission to inspire more joy, health, and well-being in the world. A Fellow of the American College of Healthcare Executives, she is a visionary upstreamist thinker dedicated to identifying and healing the root causes of broken processes and systems in health care.
With expertise in complex matrixed health care operations, strategic business planning, and multimillion-dollar program development and implementation, Katie creates holistic solutions that drive meaningful and sustainable change. Her career reflects a relentless drive to simplify complexity, empower teams, and transform health care systems to better serve all people, especially the most vulnerable.
Katie was a key leader in designing and operating Stanford Health Care’s South Bay Cancer Center, which integrated academic medicine with community oncology. As the founding co-chair of the center’s Patient and Family Advisory Council, she helped create a center recognized globally as the “cancer center designed by patients, for patients.” Her career spans the health care continuum, with progressive leadership roles at Blue Shield of California Promise Health Plan and Indiana University Health.
A certified yoga teacher and Integrative Nutrition Health Coach, Katie teaches women leaders to build an empowered relationship with their stress so they can achieve (and be present for) what matters most without sacrificing their health, well-being, and authenticity. Rooted in a commitment to equity, innovation, and holistic care, she leads with a heart-centered approach focused on creating systems that work with and for the people they serve, and she holds a deep belief that health care can one day become a true sanctuary of healing.
Katie serves on the alumni board of Indiana University’s Fairbanks School of Public Health and is a past president of Women Health Care Executives and a past board member of the California Association of Healthcare Leaders. She also volunteers with Kara Grief as a group facilitator for children and young adults who have experienced the death of someone special, giving them the opportunity to grieve in a supportive environment.
