TrustWorks On Call: Concepts of a Great Healthcare Plan

Behind the Headlines

Unpacking the forces driving healthcare's biggest stories.

1. White House releases “Great Healthcare Plan” wish list.

Last Thursday, the Trump administration unveiled its “Great Healthcare Plan,” a brief list of healthcare policy suggestions it expects Congress to further define and enact.
These policies are intended to lower drug prices and premiums, hold big insurance companies accountable, and maximize price transparency.

The plan, which is “short on specifics,” includes nine distinct proposals:

Match prescription drug prices to other countries with Most-Favored-Nation pricing
Allow more medications to be sold over the counter
Allocate money formerly spent on insurance subsidies into some version of a health savings account (HSA)
Fund the Affordable Care Act (ACA) cost-sharing reduction program
Ban “kickbacks” from pharmacy benefit managers (PBMs) to brokerage middlemen
Require insurers to publish rate and coverage comparisons “in plain English”
Require insurers to publish the percentage of their revenues paid out to claims (also known as a medical loss ratio, which the ACA already requires insurers to publish)
Require insurers to publish the percentage of insurance claims they reject and average wait times for routine care
Require providers and insurers to post pricing and fees “publicly and prominently”

TrustWorks Take: These “concepts of a plan” are more signal than substance, as the Trump administration wants to be seen as responsive to concerns about healthcare affordability with the midterm elections approaching, without having any new ideas to deliver relief. Half the items in this list are already required by law to at least some degree; the “requirement” that insurers (continue to) publish MLRs is a particularly egregious example. Restoring cost-sharing reductions would provide ACA enrollees some relief, but President Trump would only be cleaning up a mess he created when he ended them in his first term.

For months now, Congress has been trying without success to pass something that addresses healthcare affordability. The absence of details in this outline of plan only makes their jobs harder. For example, the document makes clear that they should abandon any last hope of an ACA subsidy extension, but it doesn’t begin to describe how the direct contributions to fund Americans’ healthcare purchases should work. Time and again, this White House gives the impression of having no idea how the US healthcare system functions and no interest in learning. Without better leadership, even relatively popular and bipartisan healthcare policies will struggle to pass.

2. 15K NYC nurses enter second week of strike.

On Monday, January 12, nearly 15K nurses with the New York State Nurses Association (NYSNA) walked off the job at the NewYork-Presbyterian, Mount Sinai, and Montefiore health systems in New York City, marking the largest nursing strike in state history.
In contrast to a 7K-nurse strike in 2023 that resolved in three days with the nurses winning most of their demands, this strike has proven considerably more contentious, both at the negotiating table and in the battle for public opinion.
Contract talks, which have reportedly stalled, have centered around pay and benefits, staffing levels, and workplace violence protections; meanwhile, the health systems are spending over $100M on travel nurses to maintain patient services amid the strike

TrustWorks Take: Reporting on labor negotiations is always a game of “he said, she said.” The systems claim their nurses already make over $160K annually, and would earn about $250K annually after three years under the union proposal, which NYSNA says is exaggerated. (Base salaries in their expired contracts were around $120K last year, but that excludes overtime, experience differentials, and other add-ons.) For this contract, NYSNA began negotiations asking for 10 percent annual wage increases, whereas the systems were offering a flat $4,500 annual increase per nurse to wages and benefits. Minimum staffing ratios, which resulted in significant fines for some of these hospitals after violating the previous contract, have been another point of contention.

One reason behind the bitter intensity of this strike is that the financial picture of health systems has changed since the last time these nurses’ contracts expired three years ago. Instead of enjoying a recent infusion of pandemic relief funds, hospitals are now bracing for significant Medicaid cuts and an increase in uncompensated care, without much financial breathing room. Through Q3 of 2025, Montefiore posted an operating loss, Mount Sinai barely broke even, and NewYork-Presbyterian earned a 4.5 percent margin. The striking nurses may rightly feel that their work continues to be undervalued, but their employers are finding themselves near their breaking points as well.

3. ACA enrollment down about five percent at first look.

Last week, the Centers for Medicare and Medicaid Services (CMS) released preliminary data on 2026 ACA enrollment through January 3, ahead of the open enrollment period ending for most states on January 15.
As of January 3, 2026, ACA enrollment for all exchange plans sits at 22.7M, down 1.4M from the end of open enrollment last year, or down about 800K from last year’s comparable early snapshot.

TrustWorks Take: The Congressional Budget Office estimated that a failure to extend the enhanced ACA subsidies would cause 2M people to lose insurance in 2026. These early numbers appear more favorable, especially considering that at least some of 1.4M net reduction in ACA signups may have found coverage elsewhere. However, ACA enrollment may change more than usual as the year progresses, once people start receiving invoices for higher premiums. An act of Congress to address healthcare affordability, such as funding HSAs for bronze-tier enrollees, could incentivize more people to remain on their plan, but nothing on the table is expected to replace in full the impact of the expired subsidies.

Beyond the Whiteboard

Visualizing key trends from the healthcare industry

Healthcare Growing Faster than Rest of Economy
In 2024, the US economy spent $5.3T on healthcare, an all-time high according to recently released data from CMS. Occupying 18 percent of the US economy, healthcare’s share of GDP in 2024 was only topped by 2020 and 2021, when COVID spiked our health spending and tanked the rest of our economy. According to CMS actuaries, “non-price factors were the driver” of growth, meaning that the volume and complexity of care increased more than the prices paid for that care. Relatedly, spending on care services, over 40 percent of which is hospital care, grew at more than double the rate of non-service spending. (The non-service category includes drugs and medical devices, commercial insurance overhead, and the government’s healthcare administration costs.) Moreover, across 2023-2024, personal healthcare spending grew at its fastest two-year rate since 1991-1992. There is no simple explanation for this sustained growth in the use of health services. Instead, it appears to result from some combination of temporal factors, like the uninsured rate hitting an all-time low and a post-COVID care rebound, coinciding with more systemic factors, including an aging population, the introduction of new and expensive pharmaceuticals, and the lack of effective price controls on healthcare services.

Dialing In

Sharing insights from our work with clients

Training Doctor Chatbot
I first heard about Mercor late last year at an onsite with a multispecialty group, when a physician approached me during a break. She’d received a cold message on LinkedIn asking if she was interested in a highly paid, part-time, flexible gig using her medical expertise to improve the responses of a healthcare-focused AI application. She wanted to know if I could shed any light on this company, Mercor, which seemed to me like a nice way to make some easy money, but possibly too good to be true. Now that Mercor’s been subject to a Wall Street Journal article, I’m convinced of its legitimacy, but left wondering about its implications for healthcare.

A company like Mercor sits at the intersection of two ideas I’ve been hearing a lot these days: “AI is only as good as the data that trains it," and "Horizontal AI gets the attention, but vertical AI will get the returns." Unlike a "horizontal" product like ChatGPT, which knows a good bit about everything by training on the entire internet, Mercor’s promising to help assemble training data for “vertical” AI products, which go deep on a specific skillset or industry. In healthcare, that means paying physicians, who command high salaries, a lot of money to train these algorithms.

However, the massive debts AI developers are incurring to build data centers and train their data are premised on eventually charging the end user for these tools. In the long run, the hospitals and physician groups subscribing to these tools will have to derive a value greater than the costs it took to create them, plus the returns AI investors expect for their troubles along the way, for it all to be worth it. Where will providers find that value? Under a fee-for-service system, it all depends on delivering more care using fewer resources.

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Concepts of a "Great" Healthcare Plan