[ESSAY] The Big Beautiful Restructuring

Notes from the other side of policy

Somewhere between a cheerful login screen and a softly brutal memo titled “FY26 Staffing Realignment: Administrative Efficiencies,” the consequences of the Big Beautiful Bill began to seep into The Health System Formerly Known as a Merger: slow, quiet, and almost polite.

This is how a law, officially titled the One Big Beautiful Bill Act, moves from televised politics to hallway conversation. You read the summary on Becker’s over a lukewarm lunch break, and it sounds somewhat theoretical. Medicaid work requirements? Six-month eligibility reviews? A $35 copay for people without housing?

But now it’s a law and in one Michigan system—the product of a high-profile merger, with more than 60,000 employees, 21 hospitals, and a footprint sprawling from rural outposts to urban towers—the effects aren’t theoretical anymore. They’re logistical. Operational. Emotional. The bill isn’t reshaping healthcare in broad ideological strokes; it’s doing it in Outlook invitations, redeployment requests, and quiet role eliminations.

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Clinical Staff: Restructured, Reassigned, Retained (For Now)

Doctors, nurses, techs—the roles most visible to patients—haven’t been laid off en masse. But they have been redirected. Staff who once worked in Medicaid-heavy units now find themselves reassigned to service lines with more stable reimbursement. OB nurses rotate into med-surg. Primary care physicians adjust panels. Behavioral health teams are consolidated.

This is called maximizing service line efficiency, and it’s not unique to one system. Across the country, hospital administrators are facing projected losses in Medicaid reimbursement and adjusting service delivery accordingly.

There is exhaustion. Staff are asked to float, to flex, to adapt. Burnout was already a systemic issue. Now it’s a spreadsheet column.

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Non-Clinical Staff: A Quiet Rebalancing

The bill’s ripple effects are sharpest in roles that aren’t directly patient-facing. In early 2025, The Health System Formerly Known as a Merger announced the elimination of roughly 190 administrative positions, largely in remote coding and billing, and moved those services overseas.

This was, in the words of internal communications, a “strategic realignment to ensure long-term viability.” With the passage of the bill, that strategy appears to have become the national norm.

Across U.S. systems, non-clinical departments—finance, HR, marketing, IT—are being asked to consolidate or automate. Roles that once supported care delivery are now being reviewed for redundancy, as evidenced by the numbers—the numbers that never laid anyone off, they suggest it mathematically.

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The Policy Behind the Pressure

The One Big Beautiful Bill Act isn’t merely about Medicaid work requirements. It contains structural shifts that, according to KFF and the Congressional Budget Office, will lead to 11–13 million people losing coverage over the next decade. That coverage loss translates directly into a rise in uncompensated care, projected by some analyses to exceed $42 billion annually.

Hospitals in rural and high-Medicaid areas, many of them already financially fragile, are expected to close units or entire facilities. Urban systems may absorb more patients, but with fewer resources and a more complex payer mix. All will be forced to rethink how they allocate limited funding, especially when state Medicaid matching rates are reduced and provider taxes are capped.

For employees, this shows up not in legislation, but in restructuring: fewer new hires, reassigned duties, paused expansions. For patients, it may show up as longer wait times, narrower networks, and limited access to specialized care.

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System at Speed: A Timeline Inside The Health System Formerly Known as a Merger.

The One Big Beautiful Bill Act is already reshaping healthcare. Health policy experts, hospital associations, and internal moves all point in the same direction: this is structural.

When the bill passed, hospital leaders warned that cuts of this scale could lead to closures and widespread service reductions. Those warnings are now turning into operational plans. Recently, the CEO of The Health System Formerly Known as a Merger told staff to “brace for Medicaid impacts,” not just for patients, but within the organization itself.

With an operating margin of just 2% in mid-2024, there wasn’t much cushion. Even a modest drop in Medicaid payments can ripple outward quickly, affecting clinics, units, and departments. Executives likely mapped out best- and worst-case scenarios months ago, knowing that a few hundred million in lost revenue doesn’t get absorbed quietly.

The timeline below outlines how these shifts are likely to take shape, based on patterns already in motion.

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2025

The One Big Beautiful Bill Act passes.

• Medicaid work requirements become law.

• Affordable Care Act subsidies begin their wind-down.

• Leadership at The Health System Formerly Known as a Merger assures staff that “we are monitoring developments closely.”

Behind the scenes:

• Remote coding and billing roles are eliminated.

• Departments are told to “tighten discretionary spending.”

• A hiring pause begins—unannounced, but noticeable.

Staff sense the shift before it’s ever acknowledged.

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2026

The first wave of Medicaid redeterminations begins.

• Enrollment drops.

• Clinics operating on thin margins begin to lose money.

Internal memos circulate:

“Cost containment strategies.”
“Clinical realignments.”

• High-Medicaid service lines reviewed for “viability.”

• Staff are reassigned, floated, and merged.

• Units are “temporarily consolidated” with no clear timeline to reopen.

Leadership frames it as a commitment to “operational flexibility.”

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2027–2028

The pressure deepens.

• Patient volume rises.

• So does uncompensated care.

• Some facilities show negative margins quarter after quarter.

• Overtime is capped.

• Vacancies go unfilled.

Transitions begin:

• Nurses moved laterally to procedural areas with better reimbursement.

• New operations teams measure “cost-per-patient-contact.”

Downstream effects appear:

• Fewer mental health visits.

• Longer wait times in rural clinics.

• Team morale is stretched thin.

Morale surveys come back with high participation and increasingly vague comments.

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2029

Language shifts.

From “short-term adjustments” to “long-term optimization.”

• Service lines quietly phased out in areas hit by Medicaid disenrollment.

• Outpatient volumes shift toward privately insured populations.

• Care becomes narrower, faster, and more segmented.

Additional changes:

• Community outreach “transitioned to strategic partners.”

• Roles collapsed into hybrid positions.

• Staff are told that their input is vital, but decision-making becomes opaque.

At town halls, “resilience” replaces “resources.”

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2030 and Beyond

The system stabilizes, but not around the mission.
It stabilizes around the margin.

• The landscape now includes fewer insured patients and stricter reimbursement.

• The system becomes leaner. More digital. Less predictable.

• Institutional knowledge remains. Institutional security does not.

Hiring resumes, but only in revenue-positive domains.
Public messaging celebrates innovation.
Internal projections reflect:

• Higher charity care

• Lower state funding

• A narrow definition of what qualifies as care

The system hasn’t collapsed.
But it has changed.
And it will take years to understand how much.

Could Something Like This Have Been Avoided?

Of course.

Had Medicaid expansion been made permanent, had public health infrastructure been framed as something other than a budget line, had a broader coalition demanded long-term investment over short-term savings, then yes. Something like this could have been stopped.

But the public’s attention was captured, diverted, and redirected. People cared, but they were pulled in too many directions. That’s how modern media fragments urgency.

In early 2025, national focus was splintered across what felt like a thousand more urgent screens.

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What were we paying attention to instead as healthcare policy quietly shifted?

AI regulation dominated headlines in early 2025, with Congressional hearings on job displacement, synthetic media, and algorithmic labor—while hospitals outsourced coding and billing without public scrutiny.

Climate failures drew sustained focus: the Pacific Northwest grid collapse and Gulf hurricanes redirected national attention toward infrastructure—while public health systems quietly began closing high-Medicaid units.

Immigration crackdowns like Operation Border Legacy, led news cycles with biometric checkpoints and mass detentions—as Medicaid eligibility for immigrants was quietly restricted in the bill.

Culture-war distractions consumed digital space: TikTok bans, book removals, and DEI rollbacks drowned out healthcare reform in the algorithm.

Collective fatigue set in after the elections; the sense that the real fights had already happened, when in fact, one of the biggest changes passed with little resistance.

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The One Big Beautiful Bill Act wasn’t introduced as a sweeping healthcare overhaul. It was framed as a “budget bill,” a matter of numbers and efficiencies. It didn’t sound like the kind of thing that would determine who got dialysis.

So systems will need to adapt, and in this case, that means reshaping how care is delivered. It means rethinking priorities, finding strength in smaller teams, and doing more with less.

You’ll be asked to stretch.

You’ll be asked to listen, to hold space, to speak up when something doesn’t sit right.

You’ll be asked to care for one another.

This is how a big beautiful bill becomes your daily workflow, and how, despite everything, people continue to show up and still make the work matter.

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The views expressed are my own and do not represent the opinions of any employer. All examples are based on publicly available reporting and aggregated system trends.

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Sources

• Becker’s Hospital Review – One Big Beautiful Bill Act fallout: Health system CEOs brace for change

• Becker’s Hospital Review – GOP bill would increase hospital uncompensated care costs by $42B in 2034: AEH

• WIRED – ‘Big Beautiful Bill’ Would Leave Millions Without Health Insurance

• Advisory Board Daily Briefing – $1T in healthcare cuts: What 'One Big Beautiful Bill Act' means for the industry

• American Hospital Association – AHA Statement on Senate Passage of One Big Beautiful Bill Act

• Michigan Health & Hospital Association – MHA Provides Powerful Testimony on Federal Threats to Medicaid

• Becker’s Hospital Review (via LinkedIn) – The Health System Formerly Known as a Merger cuts administrative jobs

• Becker’s Hospital Review – Providence to cut 600 positions in restructuring

• AP News – How millions will lose health insurance if tax bill becomes law

• Becker’s Hospital Review – GOP bill would uninsure 11 million: CBO

• Becker’s Hospital Review – Proposed Medicaid cuts, quantified

• American Progress – The Big, 'Beautiful' Bill's Health Care Cuts Would Drive Up Uncompensated Care and Threaten Vulnerable Hospitals

• WZZM13 - The Health System Formerly Known as a Merger’s CEO tells staff to brace for Medicaid impacts following spending bill

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You’ll see three types of posts in this space, twice a week:

• Essays: Quiet reflections and sharp critiques from inside the system.

• Flash fiction: Brief, surreal vignettes that bend the rules of healthcare, memory, and paperwork.

• Serial: Working Terms, a novella that mistakes survival for success, told one chapter at a time.

They rotate weekly. You don’t need to read everything, but you’re welcome to.