Making Sense of Healthcare Policy & the Big Beautiful Bill
In this episode of Success in Chaos, Angela and Kandice sit down with Blair Childs, CEO of Childs and Associates, longtime strategist and advocate at the center of U.S. healthcare policy, to decode what’s coming next. Blair lays out a clear framework for navigating change:
- Shifting from government-designed programs to market-based, total-cost accountability models;
- Correcting fee-for-service’s perverse incentives and leveling the playing field; and
- Empowering real consumerism through data access and interoperability
They unpack the Rural Transformation Fund—why timelines matter, how states will move, and what health systems should to engage with their Medicaid offices. Blair closes with practical guidance: benchmark current performance, build a game plan across the bill’s rollout, and lean into value-based care to cut through chaos.
Episode Chapter Guide
01:42 Meet Blair Childs: A Healthcare Policy Expert
05:38 Blair’s Journey in Healthcare Policy
10:46 Transitioning to a Market-Based Healthcare System
16:45 Understanding the Big Beautiful Bill
23:19 The Future of Rural Healthcare
28:08 Accelerating Value-Based Care
To access the One Big Beautiful Bill Act, visit congress.gov.
And check out our other Success in Chaos episodes.
Full Transcript
AI-generated transcript. Accuracy may vary; please excuse any transcription errors.
Blair Childs
When you’re at an executive level, you need to step back and look at the bigger picture and understand.
that it’s really these three major areas that we’re moving toward. And we’re moving from this more government run, government design system to a market-based system. And it’s going to be really tough.
Angela Adams, RN
Welcome to Success in Chaos, a healthcare podcast where each episode is dedicated to unlocking success amid rapid change and uncertainty. I’m Angela Adams, the CEO at Inflo Health.
Kandice Garcia, RN
And I’m Kandice Garcia Tompkins, Quality Improvement Director for the ACR Learning Network and owner of Tungsten QI Partners.
Angela
We are so excited to have Blair Childs on today. Blair is the CEO of Childs & Associates, a DC-based firm that provides strategic guidance, advocacy, and communication support to leading healthcare organizations. For more than four decades, Blair has been at the center of healthcare policy in Washington, shaping legislation that impacts nearly every sector of the system.
from hospitals to insurers to medical device to pharmaceutical companies. He previously served as a member and executive team SVP at Premier Inc, leading public policy and advocacy, thought leadership, communications and government services and marketing. Blair is widely recognized for his ability to anticipate where healthcare is headed and help others prepare for it. Welcome Blair and thank you so much for being here.
Blair
Thanks Angela, great to be with you and Candice.
Angela
Perfect.
Kandice
Well Blair, to let the audience get to know you a little bit before we jump into your vast level of knowledge, we like to do something called Two Truths and a Lie. So you’re going to tell us two things that are true and one thing that’s a lie and Angela and I are going to guess which one is the lie.
Blair
Okay, so here they are. ⁓ I ran for Congress in the 1990s in my home state of Connecticut and ⁓ tried to make it work, but I did not get enough votes to win. That’s one. Second one is I met with Donald Trump in the cabinet room of the White House, along with about a dozen other healthcare leaders back in Trump number one.
first time around. And ⁓ the third one is ⁓ I’ve been involved in all of the major healthcare reform efforts ⁓ in really pretty pivotable positions, ⁓ including the Clinton healthcare reform debate, the creation of Medicare Advantage, ⁓ the drafting or the development of the provisions in the Affordable Care Act.
as well as all the interoperability legislation that’s been passing in Congress over the last decade. So what do you think?
Angela
What do think, Candice?
Kandice
a tough one. Those are all very detailed descriptions. You know, I’m going to go with, did not meet with President Trump in the first.
Angela
I’m gonna go with the first one. I don’t think you ran for office. I think you’re too smart for that.
Blair
Yeah
Kandice
Hahaha
Blair
Angela, you win. I did move back to Connecticut to run for office, but the opening I was hoping was going to appear didn’t appear. So ⁓ I was working for Aetna running their public affairs area. at that time, it was three miserable years of my life.
Angela
Yes!
How did that go? Honestly, ⁓ that’s a perfect segue for me. Blair and I have been friends for a few years now, met him through a CEO advisory group and was just blown away. I’m going to brag about Blair for a few minutes here. ⁓ Was just blown away. I think it takes a very special skill set to sit in Washington, understand everything that’s going on.
Blair
Yeah.
Angela
and be able to make application and kind of predictions even on how this is going to impact healthcare, ⁓ especially in the current climate and landscape. There’s been a lot of bouncing back and forth in DC for a few years. Not that that has ever not happened, but I think it’s become a little bit more, let’s say chaotic over the last couple of years. ⁓ We have this wonderful podcast here called Success in Chaos, and we have…
people on Blair that are really trying to drive success through the chaos of the healthcare system. You know, from the 1990s to today, there’s never been a moment that healthcare has not been in some kind of state of chaos, whether it’s coming from government or regulations, or whether it’s coming from something like COVID-19. ⁓ But I think we are in this kind of period where it feels like another swirl of chaos, ⁓ especially even coming from Washington, DC.
So my first question for you is really like, how did you pick to be in this industry? ⁓ You’re so phenomenal at it, but how did you end up where you are today?
Blair
⁓ Yeah, it’s really strange, but it says something about my strengths and weaknesses, I guess. But since I was a little kid, I literally was always interested in public policy, believe it or not. Like I was five years old, six years old, and I was thinking about this stuff, believe it or not. Yeah, I just have always been very interested in sort of history and how things came to be. And then I’ve
Angela
Really?
Blair
And because I’m very entrepreneurial, when I went to Washington, I just went to Washington ⁓ in the early 80s ⁓ without a job or anything like that. I just started working ⁓ in, I was thinking I work on Capitol Hill, but I didn’t. I ended up working in an association and I just started ⁓ starting and running associations and.
⁓ different organizations and advocacy efforts. ⁓ I founded and ran the American Tort Reform Association back in the late 80s. ⁓ And we got legislation passed in 41 states. ⁓ I then went to Connecticut where I was thinking of running for Congress, but that didn’t work. And I was working for Aetna and I then went back to DC ⁓ and
started working for the Health Insurance Association of America and I ran its ⁓ program that was opposing the Clinton healthcare reform debate. It was very famous, the program that I ran, ⁓ which was, it was a national advertising program and everything in it. It was a major ⁓ first of its kind kind of a campaign.
But there were a lot of concerns with the Clinton healthcare reform debate. It wasn’t just that program, but that program was very pivotal in changing that. Then I started my own business. And ⁓ one of the things I was doing was working with the Healthcare Leadership Council, which works with all the different sectors in the healthcare community. So pharmaceuticals, insurance, device manufacturers. ⁓
You name it, all hospitals, everybody was involved in that organization. It all the CEOs of these organizations. It’s like the business roundtable, but it was across healthcare. And, you know, we ended up working very closely with Newt Gingrich and the Republican Congress to create Medicare Advantage. It was at that point Medicare plus choice, but I ran the national campaign on that. ⁓ So that was that led to the creation of that program. ⁓
Angela
No.
Blair
But I have to say, I’ve always ⁓ really tried hard not to be partisan. This sounds partisan when you talk about Newt Gingrich. ⁓ I also then, after that, I was the number two person in ⁓ the device industry association, AdvaMed, and really created a lot of what AdvaMed is today. ⁓ And then I went to Premierer.
and worked with Premier for a number of years, which again is a health system organization that’s working with 4,800 hospitals, but some of the largest health systems in the country. And I was running their public policy area, their marketing communications thought leadership, government services, a number of different programs for them. And we were really at the forefront of the movement to value-based care.
I ended up writing a number of the provisions in the ACA related to value-based care and trying to move to ⁓ solving the problems within the healthcare system through the providers, a provider-led transformation of our healthcare system was what I was trying to achieve. And it’s very similar in many ways to Medicare Advantage because Medicare Advantage, at least the concept was
total cost of care models where basically somebody is accountable for the total cost of care. So, and I was hoping more health systems would move that way, but they, some have, some haven’t. That’s really what’s going on in healthcare. And the thing is when you say how chaotic the system is. So when I was with Premier, I did a number of things, but we were very much a leader in Washington ⁓ in terms of value-based care.
Angela
Yeah.
of course. And this is the premiere out
of Valentine, right? Yeah. Okay.
Blair
Yeah.
But we really, we were sort of known as a very, very influential organization at that time. ⁓ So it was great. the thing that when you talk about the chaos in healthcare, and I think the way I would describe what’s going on is we are moving from what was really designed as a government, really a more government run healthcare system.
And that was with Medicare and Medicaid in the 1960s. ⁓ that system, government can’t run things very well in our system, the way our Republic works. have states that are very involved in all government. Then you have the federal government, which really is very weak in many, many ways. And so it was given all this authority to run Medicare and Medicaid. And initially that’s the way it worked. Medicare was run entirely by government.
So we had CMS, we had the states running Medicaid. And now how does it work? It’s not that way at all. You have Medicare Advantage, which is more than 50 % of the Medicare lives. And you have states that have basically contracted out the private plans, all the Medicaid program. So we’re going through this massive change from a government designed system to a more market-based system.
which is what really our Republic was designed to encourage was a market-based solution in the way things work in our economy. And it’s very hard. It’s just been the change has been dramatic. And then what’s made it even tougher now is things have become so partisan and so much you hit one person and they hit you back. So everybody’s doing this kind of an approach.
because there’s not this sense of we’re all in this together. There’s big ideological differences, although I would say in healthcare, there’s a lot of common ground. And that’s what people need to focus on is the common ground.
Kandice
Yeah.
Angela
I think
more so than anything, just you’ve been in this since the nineties, right? Or maybe the eighties, I think you said at one point, so we don’t want to give away your age or anything, but ⁓ you’ve been in this from the eighties, there’s a lot more back and forth punching and hitting. I agree with you. I think people are closer in their thought process and how they think about healthcare than they are farther away, but it feels like from a distance, like everybody is like in a punching mat.
Blair
Ladies.
Kandice
You
Blair
You’re already dead.
Kandice
You
Angela
Like, what do you see kind of feet on the street in Washington? Are people closer than we think or are they truly that far apart?
Blair
⁓ There’s a lot of common ground. And this is how I try to help people think about this. There’s three major areas where you need to just, that’s the framework you should be thinking about what policy is being done in. And they are very clear where we are moving, I think. One is, the three are, one is moving from ⁓ government design to a market-based system where
Angela
What are the three?
Blair
somebody is accountable for the total cost of care. So when I say the total cost of care, it means somebody is really responsible for the financial ⁓ costs of the care, the outcomes for the patient, and really making it all work together in some way. I still think providers should be the ones doing that, ⁓ but there’s insurers.
Angela
think they’ve had their opportunity
and they haven’t taken it.
Blair
I think some have. There are clearly some health systems who have, and I think they’re the leaders and they’re going to be the winners in the end.
Kandice
Yeah.
Angela
still about
30 % that have taken up the value-based care kind of model and about 70 % that are still fee for service. Okay.
Blair
That’s correct. Although
I wouldn’t say there’s still fee for service because fee for service is never going to go away. You still have to pay for people doing services. It’s more a question of how you organize yourself. Are you going to have the total cost of care? And that’s really a capitated total cost of care payment. That’s how Medicare Advantage pays for care is they pay a capitated payment. That’s what ACOs do. They pay a capitated payment. that
Angela
Yeah.
Blair
That’s one thing. Second thing is fixing a lot of the perverse incentives in fee for service today. Because as I said, fee for service isn’t going to go away. It’s just that it has a lot of very perverse incentives. And that’s everything from the way 340B has been, you could say, used by health systems to their advantage, because you’re going to, you’re more smart business people and you’re going to take advantage of a system. But in the same thing, in the same way, you could say Medicaid.
Angela
Good point.
Blair
And this is why the big beautiful bill attacked Medicaid because you have this huge variation across the states with provider taxes and state-directed payments that cause real differences in an uneven playing field. And you can’t have a competitive system if you have an uneven playing field. So fixing these fee-for-service perverse incentives, getting rid of these advantages for one provider group over another,
Kandice
Hmmmm
Blair
That is a major thing that is going to happen and it’s happening. And this legislation actually accelerated it in some areas, but there’ll be more coming. There’s just more that’s going to happen. The last thing is, is consumerism and that’s access to data. It’s access to ⁓ your, your personal health record. It’s ⁓ access by insurers as well as providers. It’s really the free flow of information and ⁓ to help consumers make better choices.
and ⁓ really vote with their feet much more than they are today. So those are the three major trends. And that’s the framework I encourage people to think in terms of what’s going on. And that’s where we’re going. It’s just a question of how fast it’s going to happen because health care is very delicate. It’s politically fought over. It’s always going to be politically fought over because people care about it. They vote based on it. They’re scared if they think that they’re going to lose their health care.
And so it can be used as a scare tactic. It’s been used as a scare tactic going back forever. And let’s face it, elections are about scaring people. They really are. So.
Kandice
Yeah. know,
Blair, I think that is the clearest, most visual understanding of the complexity of this transition that I think I’ve ever heard. From the front line, which is where a lot of the work that I’m doing with the front line staff and management and leadership, it is so hard to understand how those things are shifting and moving.
when we are feeling kind of the effects of the tiniest little bit from an exam code to a CPT code to rescheduling exams and interacting with patients and each other in an effective way, that framework actually provided a ton of clarity for me to say, ⁓ OK, those are like large models that are shifting. And this disconnection at the front line is actually because the model shifts.
Can you help me understand, you know, we’ve been talking about the big, beautiful bill and like all this legislation that’s gonna be affecting the payment structure. I’m kind of understanding now that that is part of that shift, but what can we expect? There’s so much information out there. Like you said, scare tactics and fear mongering and like, you know, propaganda. And it’s so hard from like the population level to kind of understand what is even happening.
Is this something that we want? Is this something that we don’t want? What would be the effects? Can you kind of help us understand a little bit about what are the downstream effects from this shift and what are the things, if we’re going to be voting for our future, what are the things we need to be considering?
Blair
⁓ boy. So Candice, you just asked a huge question. I guess the thing I would say is there’s different levels, obviously, of detail you need to know. And my point to executives is you need to understand that larger context. And this is where reforms are bucketed. And believe it or not, this is bipartisan. This is happening. The Democrats, all the Democrat states,
have moved to managed care organizations running their Medicaid programs in a capitated program.
So the Democrats have moved in that direction just as much as the Republicans have. And in fact, many of the Democrats are some of the biggest advocates for Medicare Advantage today because Medicare Advantage is attracting more ⁓ poorer segment of our population. Actually, the largest number of people going into Medicare Advantage programs are poor people. And they tend to be more of a constituency and more
urban areas that where the Democrats are. So it’s things have changed a lot, but you need to understand the details. Like you were saying, Candice at the, if you’re working on coding and payment and revenue cycle and all those kinds of things, which are just a nuts and bolts of the system, you need to really understand how those work, those mechanics work. But
when you’re at an executive level, you need to step back and look at the bigger picture and understand.
that it’s really these three major areas that we’re moving toward. And we’re moving from this more government run, government design system to a market-based system. And it’s going to be really tough.
And it’s going to change. It’s constant change. And based on the way you structure your organization. So if you’re an organization that is what I call a pay-vider,
where you’re both a provider as well as managing payments. So you’ve got a payment side. You may have an insurance plan. Like look at Intermountain. They have Select Health. They’ve also got one of the finest medical ⁓ care systems in the country. You could look at Banner. They’re the same way. There’s a number of organizations that have this. Kaiser is the foremost of these, which is a…
pay VITR. But even HCA, a for-profit entity, they in so many ways are preparing themselves to be in position to succeed in a new value-based accountable system. And they are building their structure to do that. They see this coming. They’re still operating in fee-for-service, but they’ve said they’re not going to try to be a pay VITR.
They’re going to instead be the top performer in the provider delivery side. We’re going to be more accountable with higher outcomes at a lower cost than anybody else. And, the thing is in the system, and this gets back to the perverse incentives, you’ve got for profits and not for profits. That’s an uneven playing field. So what Donald Trump is trying to do and the Republicans are trying to do and the Democrats too.
Angela
Yeah.
Yeah.
Kandice
you
Blair
are trying to level the playing field. so, reverse incentives is really about leveling the playing field. And there’s a whole lot of different areas that you could talk about that in, from site neutral payment to total cost of care models and where they’re structured.
Angela
I think one thing that I’ve learned from you, I’ve watched your presentations for years now, ⁓ is that there’s really pros and cons in every legislation that goes through. think Big Beautiful Bill definitely has some pros and cons. In your last edit, of course, I’m not sure, I feel like very fortunate to be on your ⁓ list of people that gets your edits, but you bullet pointed ⁓ several really key things that are coming out of the bill.
One thing that I think that we’ve heard a lot of like fear around is the rural health transformation program. I would love to know from your perspective, obviously like I have a near and dear place in my heart for rural hospitals and health systems. I would like to understand like you’ve got a whole paragraph here that I won’t like steal the thunder on, but what do you think is going to happen with rural based health in the next two, three years?
Blair
Well, this is something where again, everything has got its strengths and weaknesses, its opportunities and risks. The Rural Transformation Fund, is $40 billion, it’s half of that, so 20 billion of that is going to go, sorry, $50 billion. What am I saying? Half of that is going to go to the states and the states are going to have to get a plan done. The thing that’s interesting is that
Angela
Yeah.
Blair
They’re already saying they want to get the plans in fast so that people start planning and doing things with this money. I think it’s an incredible opportunity, but it really needs to be focused on key things that are long term, which are like, how do we build an infrastructure with telehealth and other kinds of…
ways of delivering care, which increases access and increases the care that’s delivered in these rural communities. And the Republicans are very focused on the rural side, much more so than the Democrats, just by political constituency. So they really want to do something here. This is an incredible opportunity. People should be stepping up right now. And the thing that I have found is so many health systems, they’re sort of like,
Kandice
Hmm.
Blair
their head is spinning because of this bill that just passed and they’re trying to figure it out. They need to understand the bill. They need to understand all the details in the bill. They need to have somebody really strong who is helping them put together a game plan, a game plan to figure out how they’re going to work within this, the confines of this bill. Cause it rolls out over different timelines and
The Rural Transformation ⁓ Fund is the first thing up. You ought to be on this like today. ⁓
Angela
Yeah, it says that
the funds start in January 1st, 2026.
Blair
I think they’re going to start sending money out to states after the start of the fiscal year, is October 1. I think states can get money that early, and I think they’re going to make it available. So people should be busting their butts right now, putting their plans together. And that’s what I’ve been telling people.
Kandice
my gosh.
Angela
Yeah, I think that’s an important,
that’s a really important kind of it, though the shift has been that much of this is moving to a state level to decide. It’s like, are the state levels ready? And I think that’s a very good point that you’re making. So people getting in touch with their state representatives and making sure that they’re active in that, I think is a very important part of this. One other bullet.
Blair
Yeah, and making sure
you’re in the governor’s office. You’re making the point. I was just speaking to a health system last week and ⁓ their board and their senior management. And these are the points I was making to them. And they’re right in the middle of the rural ⁓ community. I mean, one of the most impacted areas in the country. And they should be all over this.
Kandice
Yeah.
Angela
There’s,
yeah, so there’s money that’s there, that’s available, that’s ready for action plans is what you’re saying. I think your first question on here was exactly that. Who will be working with your state’s Medicaid office to protect against the impact of all of these reforms and model different policy responses? And that’s a great question to bring up. ⁓
Kandice
Yeah.
Blair
And I also
think, you know, because public policy is always changing. this bill that was passed is going to be the center of the 2026 election. So it will be a referendum on the bill and we’ll see what happens. ⁓ Right now, you know, if the Democrats take the House or it’s harder for them to take the Senate, but if they take the Senate and the House,
That is going to send a very clear message and you’re going to see adjustments to the law. If they don’t, you know, anyway, we we could game out all these different eventualities. My point in saying that, though, is people should be benchmarking where they are today in terms of access, in terms of care, in terms of other services they’re providing and making sure that they’re tracking how the law rolls out.
Kandice
You
Blair
and how it’s impacting care in their communities. And they should be trying to impact it right now at every step in the equation. We talked about the rural health transformation program, but there’s a lot of other elements.
Angela
Yeah, I agree. want to land on this question right here and kind of end with this. If you could wave a magic wand, so you have one, right, Blair? You’ve got a magic wand. Change one regulation or policy to reduce chaos and improve health care delivery. What would it be and why? Magic wand, one whist.
Blair
⁓
Kandice
Hahaha
Blair
I would really accelerate the movement to value-based care and accountability, total cost of care models. But the challenge is you can’t do that because it’s too disruptive, but it’s happening slowly and it’s going to continue to happen.
Angela
soon.
That’s right.
Blair
That’s what, if I could accelerate that, that’s what I would do.
Angela
Yeah, that’s
Kandice
I mean, I feel like I could do this for another two hours. Thank you, Blair, for sharing just like what you have. I mean, I’ve learned so much over this little bit of time ⁓ that helps us, I think, understand, like you said, like from the nuts and bolts, the operational levels, the ground floor, what shifts do we need to make? And what I’m hearing is that it is actually a shift in identity of who we are and how we show up in our communities. And then redefining the funding sources or re-
connecting with the funding sources in a way that actually serves the mission of the administration, the vision of the funding and the shift, but also the vision of the healthcare organization, the patients and the staff. I’m gonna take so much away. Yeah, thank you. I’m gonna take so much away from this. Now, you are so smart in so many ways. Do you have any recommendations for books?
Blair
But I really like that, Candice. I like what you just said. Yeah.
Kandice
or things that we can make ourselves more knowledgeable or that would help us become better experts in this arena.
Blair
Yeah, it’s, you know, I was thinking about that because you warned me you’d be asking someone like this. I read biographies and so I like history and I like biographies and stuff like that. you know, ⁓ I Walter Isaacson, you know, books and Stephen Ambrose and John Meacham are people I I’ve read their different books on different historic figures. But I guess what I feel like is.
Kandice
You
Angela
level.
Blair
Because we’re living in such a dynamic changing time, you really have to just dig into the primary sources and understand what’s going on right now. So the big beautiful bill, understanding that and making sure you get people to help you understand that and what the timelines are, what you should be planning for, what are the things that you’ve got that you should have in place now. So to me, it’s
Yeah, there’s, I like to read about, you know, the history of our country and who the great leaders have been, and I’m always interested by that. But I’m, I’m encouraging people right now to be very focused on.
on the here and now and really understanding it and making sure you’ve got people assigned to address the different parts of it that of the bill and what’s going on in health care so that you’ve got a game plan in place to manage all the different changes that are going to be coming because they’re not going to stop.
Angela
anybody out there doing a good job breaking down big beautiful bill for like healthcare impact that you feel like you guide people to a lot of times is there like
Blair
Now,
it’s really, you know, I, that’s what I try to do. That’s really what I try to do because I, but you know, the problem in healthcare is that everybody is a partisan and they’re either advocating for their particular constituency in DC because that’s what you do and you’re defending the status quo effectively. And that goes for all the different interest groups in healthcare.
Angela
Yeah.
Yeah.
Blair
There aren’t many people who can step back with experience to know how the policy process will unfold and what’s going on. I just encourage people to be very ⁓ level-headed about it.
Angela
Yeah, well you’re
about to get real busy because we’re about to send all these people to you then. So are you ready? Everybody who hasn’t talked to Blair, think you need to be on the phone. ⁓ Blair’s phone is going to be ringing off the hook.
Kandice
Hahaha
Blair
Yeah.
Thank you.
Angela
Thank you so
much, Blair. Candice?
Blair
Thank you.
Great to chat with you guys. Really fun.
Kandice
Yes. ⁓
This was such a great discussion. Thank you, Blair. And thank you to our audience for joining us on Success in Chaos. Please be sure to like, follow, and share today’s episode on Spotify, Apple Podcasts, YouTube, or wherever you get your podcasts. And a special thanks to the Inflo Health team for their production support.
