The Future of Healthcare: What Upcoming Legislative Changes Mean for the Industry

As 2025 unfolds, healthcare leaders stand at a critical juncture - one defined by a fast-changing regulatory landscape, new legislative requirements, and a renewed push for greater efficiency, equity, and digital transformation.

Understanding these shifts is not just an exercise in compliance - it’s a strategic imperative. Healthcare organizations that fail to adapt will face financial strain, operational inefficiencies, and potential penalties. Meanwhile, those who proactively align with these regulations will not only safeguard their organizations but also unlock new opportunities for innovation, competitive advantage, and patient-centered care.

The Legislative Landscape: What’s Changing?

Several legislative developments are shaping the future of healthcare. The following four policy areas stand out as transformative forces:

1. Interoperability & Patient Data Sharing

The promise of seamless, real-time patient data exchange has long been an elusive goal in U.S. healthcare. With the 21st Century Cures Act and Trusted Exchange Framework and Common Agreement (TEFCA) gaining traction, the industry is moving toward true interoperability.

✅ The Immediate Impact:

• Increased scrutiny on compliance with federal interoperability mandates.

• Fines and penalties for organizations that fail to provide patients with timely access to their health data.

• Accelerated adoption of FHIR-based APIs and AI-driven automation for data integration.

  
  

💡 Strategic Recommendations:

• Audit existing data-sharing practices and prepare for TEFCA alignment.

• Invest in interoperable infrastructure that meets compliance needs while enhancing operational efficiency.

• Explore AI-driven analytics to extract meaningful insights from disparate data sources.

  
  

⏳ What Happens Next? By 2026, expect mandatory compliance enforcement for TEFCA adoption, reshaping how payers, providers, and health tech companies operate.

2. Medicaid Redeterminations & Coverage Shifts

With the end of the COVID-19 Public Health Emergency, Medicaid eligibility redeterminations have resumed, leading to coverage losses for millions of patients. The complexity of re-enrollment processes has left many at risk of losing access to care.

✅ The Immediate Impact:

• Up to 15 million Americans may lose Medicaid coverage, increasing uninsured rates.

• Hospitals and providers are bracing for a rise in uncompensated care costs.

• The shift is placing a greater burden on eligibility verification systems and administrative workflows.

  
  

💡 Strategic Recommendations:

• Automate eligibility verification to mitigate revenue loss and prevent claim denials.

• Develop targeted patient outreach programs to assist with Medicaid re-enrollment.

• Train front-line staff on new payer mix complexities to ensure proper billing and reimbursement.

  
  

⏳ What Happens Next? State-level policies on Medicaid expansion will continue to shift, making adaptability key for providers and payers alike.

3. Drug Pricing Transparency & PBM Reform

The role of pharmacy benefit managers (PBMs) is under greater scrutiny than ever before. Policymakers are introducing new regulations to promote pricing transparency, reduce out-of-pocket drug costs, and curb PBM middlemen’s influence.

Notable initiatives include:🔹 California’s push to regulate PBMs and increase drug pricing oversight (source)🔹 Federal legislation that may limit PBM rebate structures🔹 Stricter reporting requirements for drug price negotiations

✅ The Immediate Impact:

• Greater transparency in drug pricing and formulary structures.

• New compliance burdens on health plans, payers, and PBMs.

• Growing market competition among pharmaceutical manufacturers seeking direct-to-consumer pricing models.

  
  

💡 Strategic Recommendations:

• Develop clear and compliant drug pricing structures ahead of anticipated policy shifts.

• Leverage predictive analytics to anticipate future price fluctuations.

• Establish direct manufacturer-provider relationships to reduce reliance on PBMs.

  
  

⏳ What Happens Next? By 2025, expect legislation requiring real-time transparency on drug pricing, rebates, and PBM practices to take effect.

4. Telehealth & Remote Patient Monitoring (RPM) Policy Adjustments

While telehealth utilization surged during COVID-19, many of the reimbursement flexibilities that enabled its expansion are now at risk of being scaled back. The federal government is reviewing policies on reimbursement rates, interstate licensing, and RPM device integration.

✅ The Immediate Impact:

• CMS is reevaluating payment parity between in-person and virtual care.

• State licensure laws may limit cross-border telehealth consultations.

• Reimbursement for remote monitoring technologies remains uncertain in some states.

  
  

💡 Strategic Recommendations:

• Advocate for permanent telehealth parity legislation at the state and federal level.

• Enhance RPM adoption strategies, ensuring compliance with evolving reimbursement models.

• Build hybrid care delivery models that integrate in-person and virtual services seamlessly.

  
  

⏳ What Happens Next? By 2025, CMS will finalize telehealth reimbursement models—organizations that adapt early will have a competitive edge.

What This Means for the Future of Healthcare

As these legislative changes unfold, healthcare organizations that take a proactive, strategic approach will be positioned for long-term success. The winners of this new era will be those who:

✅ Prioritize compliance readiness—avoiding penalties and securing sustainable reimbursement models.

✅ Leverage AI & automation—to streamline processes, improve patient outcomes, and reduce administrative burden

✅ Adopt patient-centric strategies—ensuring that policy shifts don’t lead to gaps in care access or quality.

At Cooper River Advising, we specialize in helping healthcare organizations navigate regulatory complexity, modernize systems, and harness AI for sustainable growth.

📢 The future of healthcare is being rewritten in real time. The question is - are you prepared?