With a new Congress and Administration, navigating the current healthcare policy landscape is like taking a mountain road late at night — full of swerves, turns and constant switchbacks. The good news is you don’t have to go it alone.

Here are five “guideposts” to help you navigate potential changes and opportunities coming in healthcare policy.

Five Guideposts to Navigating U.S. Healthcare Policy

1. Solid Foundation of Federal Healthcare Policy and Programs

Despite anticipated changes in clinical healthcare, the administration of healthcare billing and payments remains stable. Key programs like Medicare, Medicare Advantage, Medicaid, and the ACA Exchanges are not being significantly challenged by either party or Congress. .

In recent years, both political parties have championed consumer-centric policies across many industries, including healthcare. This rise in populism has strengthened core administrative healthcare policies including:

Putting it plainly, there’s no substantial threat to the basic infrastructure of U.S. healthcare.

However, there could be implications for two core healthcare programs. Read more about what 2025 means for programs and policies.

2. Pushing Policy vs. Regulatory Restraint

The Trump administration has signaled changes to regulation, aiming for fewer regulations and fewer regulators (although CMS is looking at only about 4% in personnel cuts). This balance between pushing healthcare priorities while also maintaining regulatory restraint is something to keep an eye on.

3. Not Chaos, Decentralization

The Trump administration’s approach to decentralization allows agency leaders to prioritize and pursue policies independently. You can gain insight into where healthcare policies are headed by checking out CMS’ leaders and advisors.

4. The Expanding Role of States and Courts in U.S. Healthcare Policy

As the administration steps back on regulations, states and courts are taking a more active role in healthcare policy. In the area of out-of-network ground ambulance, you might have heard how some state plans to set reimbursement rates on a city-by-city basis. Talk about complexity! That’s just one (extreme) example of how payers need to track what’s going on in the states and courts.

5. Rising Medical Costs

Medical cost pressures are increasing. We’ll probably see restrictions placed on Medicaid and ACA Exchanges , more uninsured individuals and other impacts like inflation and supply chain issues. If healthcare costs become too great, political reactions may follow. Payers should see where innovation could improve experiences and efficiencies.

Where’s the Opportunity?

Keep in mind – we’re not starting from scratch. The core programs and policies around healthcare billing and payments are solid. There’s also some breathing room on the regulatory front, which gives the industry some space to innovate and lower costs for members.

Transparency and AI open up big opportunities, too. We can go beyond the minimum requirements for Transparency in Coverage to show members we’re truly on their side.

And with the government stepping back a bit on regulating AI in healthcare, now’s the time to explore what’s possible—and find new ways to bring costs down.

As Zelis CEO Amanda Eisel has said, progress is possible. We must keep moving forward. Let’s strive to do one percent better each day on the spaces where we can push.

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