Telehealth, sometimes referred to as telemedicine, is the virtual delivery of health care, which can include virtually meeting with a care provider, checking results from labs or x-rays, physical or occupational therapy, and looking at skin problems.¹ Compared with traditional medical appointments, telehealth appointments typically have shorter wait times and can be scheduled more flexibly, making it beneficial for some patients. A 2024 survey estimated that 54% of Americans have had a telehealth visit, with 89% feeling satisfied with their experience, signaling its status as a key component of US healthcare.²

The COVID-19 pandemic led to an expansion of telehealth services in the US. A study of over 36 million individuals in the US found that, from March to June of 2019, only 0.3% of outpatient visits were conducted via telehealth, compared to 23.6% from March to June of 2020—a staggering 766% increase within a year.³ Telehealth’s increased usage has lasted beyond the pandemic: According to the American Hospital Association, the percentage of US hospitals offering telehealth services in 2022 was 86.9%, up from 78.3% in 2019 and slightly higher than 2020 and 2021 levels.⁴

Doximity, an online networking service for medical professionals that also provides telehealth services, publishes an annual “State of Telemedicine Report” that provides information on the current state of telehealth in the US based on an analysis of the service usage and physician surveys. According to the most recent report, 50% of physicians who used telehealth in 2023 are 39 years old or younger.⁵ The most common use cases were for follow-up visits and medication management, and the specialties with the highest rates of telehealth adoption were endocrinology, urology, and gastroenterology.

The COVID-19 pandemic spurred new legislation to ease and expand access to telehealth services. For instance, the CARES Act, the $2.2 trillion stimulus package signed into law at the beginning of the pandemic, included updates to Centers for Medicaid & Medicare Services telehealth regulations that lifted restrictions on the use of telehealth. With the changes, patients in all settings, not just rural ones, could receive telehealth under Medicare. Additionally, federally qualified health centers could offer telehealth, and more telehealth services became available.⁶ One change expanded Medicare coverage for audio-only services, which are important for those with limited Internet access.

Various pieces of congressional legislation extended the Medicare flexibilities beyond the pandemic, but the benefits were ultimately set to expire on September 30, 2025—the same day congressional funding expired and the government shut down. As of October 26, 2025, the government remains shut down, and until it reopens, Congress cannot vote to extend the flexibilities. Kyle Zebley, senior vice president of public policy at the American Telehealth Association, noted that older and disabled Americans will be most impacted.⁷

In a statement on the shutdown, the Association also noted that commercial insurers often model their coverage based on Medicare coverage, so in the absence of Medicare coverage for expanded telehealth, there is “growing uncertainty in the marketplace, and concern that commercial payers could soon follow suit if Congress and the Administration do not act quickly.”⁸ For the millions of Americans for whom adequate health care depends on broad insurance coverage of telehealth, these circumstances could be disastrous.

References

1. What can be treated through telehealth? | Telehealth.HHS.gov. https://telehealth.hhs.gov/patients/what-can-be-treated-through-telehealth.
2. Legere, D. 2024 National Telehealth Survey – Public Opinion Strategies. https://pos.org/2024-national-telehealth-survey/ (2024).
3. Weiner, J. P. et al. In-Person and Telehealth Ambulatory Contacts and Costs in a Large US Insured Cohort Before and During the COVID-19 Pandemic. JAMA Netw Open 4, e212618 (2021), DOI: 10.1001/jamanetworkopen.2021.2618
4. Fact Sheet: Telehealth | AHA. https://www.aha.org/fact-sheets/2025-02-07-fact-sheet-telehealth (2025).
5. Doximity. Doximity 2024 State of Telemedicine Report. https://www.doximity.com/reports/state-of-telemedicine-report/2024.
6. CARES Act: AMA COVID-19 pandemic telehealth fact sheet. American Medical Association https://www.ama-assn.org/health-care-advocacy/federal-advocacy/cares-act-ama-covid-19-pandemic-telehealth-fact-sheet (2020).
7. Cuevas, -Karina Cuevas Karina. Millions of seniors lose access to telehealth services in wake of shutdown. PBS News https://www.pbs.org/newshour/show/millions-of-seniors-lose-access-to-telehealth-services-in-wake-of-shutdown (2025).
8. Cardillo, B. DAY 14 OF THE TELEHEALTH SHUTDOWN: THE “RIPPLE EFFECT” ON TELEHEALTH REIMBURSEMENT – ATA ACTION CALLS FOR SHORT-TERM SOLUTION TO GROWING PATIENT CARE DISRUPTIONS. ATA https://www.americantelemed.org/press-releases/day-14-of-the-telehealth-shutdown-the-ripple-effect-on-telehealth-reimbursement-ata-action-calls-for-short-term-solution-to-growing-patient-care-disruptions/ (2025).

Signed into law by President Donald Trump on July 4, 2025, the One Big Beautiful Bill Act (OBBB) introduces major changes to the US healthcare system (1). The bill includes measures to cut federal healthcare spending, with significant implications for healthcare delivery. Officially known as H.R.1, the bill was narrowly approved by the Senate (51-50) and the House (218-214) and has been the subject of much controversy over reallocating funds, limiting federal program eligibility, and reversing Affordable Care Act (ACA or “Obamacare”) provisions (1). In the early stages of implementation, two main changes from the One Big Beautiful Bill have begun to reduce federal spending—but some critics argue that these savings come at a cost to Americans and healthcare providers.

In an attempt to cut federal spending, the first change of the bill targets the nation’s largest healthcare expenditure: public healthcare programs (1). In 2012, around 102 million Americans were enrolled in Medicare and Medicaid, which support Americans over the age of 65 and low-income or disabled adults and children, respectively (2, 3). However, due to the aging American population, ACA policies, and COVID-19 expansions, Medicaid and Medicare enrollments surged to roughly 160 million in 2023, raising total costs from about $989 billion in 2012 to $1.9 trillion in 2023 (3-6). In 2023, these programs accounted for nearly 40% of U.S. healthcare spending (5, 7).

Consequently, the OBBB targeted Medicaid, incorporating provisions for implementing employment requirements, reversing simplified Biden-era procedures, and increasing the frequency of eligibility re-determinations (8-11). Additional cost-saving measures include explicitly excluding Americans without proof of citizenship, shortening retroactive coverage periods, reducing federal health center staffing requirements, and removing federal incentives and funding for state Medicaid programs (8-11). According to the House of Representatives, these changes aim to reduce fraud and waste by disqualifying certain groups, primarily able-bodied, childless, unemployed young adults and undocumented immigrants (1, 12). However, evidence demonstrates that Medicaid fraud rarely occurs, and most Medicaid recipients work at least part-time (4, 13). Therefore, critics argue, the OBBB may cause funding issues for states, introduce administrative burdens for Medicaid management organizations, and withdraw healthcare from Americans, for minimal overall benefit (9, 13-16).

The One Big Beautiful Bill’s second change derives significant savings by reducing payments to healthcare providers (1). Historically, states utilized provider payment programs (DPPs) to reimburse Medicaid providers at above-market rates, which incentivized higher-quality, more accessible care (11). However, the OBBB sets a cap on these payments at 100% to 110% of average commercial rates (1, 10, 11). Furthermore, provider taxes—funds imposed by states to finance Medicaid and provider reimbursements—are slated to decline from a maximum of 6% in 2023 to 3.5% by 2032 (1, 10, 11). Beyond fiscal considerations, the OBBB also raises political concerns by eliminating federal funding for reproductive healthcare providers that offer abortion services (1, 16, 17). Overall, while the bill established a safety net for rural hospitals, the reduced payment rates and federal funding may lead to the closure or reduction of services in approximately 300 to 700 hospitals, as well as at least 200 reproductive healthcare clinics (11, 17, 18). Although the OBBB restricts states’ ability to waive or modify these federal adjustments, critics have urged states to counteract these changes to protect the health and livelihood of American providers and patients (8, 17).

As a consequence of these healthcare reforms, the OBBB is projected to reduce federal spending by at least $990 billion over the next decade (1, 11). Yet, these savings come at a substantial cost to American patients and providers, with estimates indicating that around 11 million Americans may lose Medicaid coverage, 839,000 may avoid necessary medical treatment, and 12,600 may suffer medically preventable deaths (11, 19). On the providers’ side, reductions in Medicaid payments, diminished hospital and state funding, and decreased patient volumes could lead to a $24 billion increase in uncompensated care, as well as the loss of 400,000 to 1.2 million healthcare jobs, over the next decade (8, 11, 20). Overall, although the bill is expected to lower income taxes for most American households, it carries profound implications for the future of the U.S. healthcare landscape (21).

References

1: One Big Beautiful Bill Act, H.R. 1, 119th Congress. 2025. https://www.congress.gov/bill/119th-congress/house-bill/1/text

2: Centers for Medicare and Medicaid Services. 2013. 2012 CMS Statistics. CMS Research, Statistics, Data, and Systems. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/cms-statistics-reference-booklet/downloads/cms_stats_2012.pdf

3: Kaiser Family Foundation. 2024. Health insurance coverage of the total population. KFF State Health Facts. https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

4: Desilver, D. 2025. What the data says about Medicaid. Pew Research Center. https://www.pewresearch.org/short-reads/2025/06/24/what-the-data-says-about-medicaid/

5: Centers for Medicare and Medicaid Services. 2024. National health expenditure data: NHE fact sheet. CMS Research, Statistics, Data, and Systems. https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/nhe-fact-sheet

6:  Kaiser Family Foundation. 2016. National health expenditures 2012 highlights. KFF. https://www.kff.org/wp-content/uploads/sites/2/2012/12/highlights.pdf

7: McGough, M., Wager, E., Winger, A., Panchal, N., and Cotter, L. 2024. How has US healthcare spending changed over time? Peterson-KFF Health Systems Tracker. https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time/#:~:text=Private%20health%20insurance%20accounted%20for,of%20all%20health%20consumption%20spending.

8: Galace, A. 2025. State impacts of the One Big Beautiful Bill. National Association of Community Health Centers (NACHC) Newsroom. https://www.nachc.org/state-impacts-of-the-one-big-beautiful-bill/

9: Ortaliza, J., McGough, M., Cox, C., Pestaina, K., Rudowitz, R., and Burns, A. 2025. How will the One Big Beautiful Bill Act affect the ACA, Medicaid, and the uninsured rate? KFF Policy Watch. https://www.kff.org/policy-watch/how-will-the-2025-budget-reconciliation-affect-the-aca-medicaid-and-the-uninsured-rate/

10: Association of State and Territorial Health Officials (ASTHO). 2025. One Big Beautiful Bill Law Summary. ASTHO Legislative Alerts. https://www.astho.org/advocacy/federal-government-affairs/leg-alerts/2025/one-big-beautiful-bill-law-summary/

11: Heuer, T. 2025. The One Big Beautiful Bill: what every PA needs to know. American Academy of Physician Assistants (AAPA) News Central. https://www.aapa.org/news-central/2025/07/the-one-big-beautiful-bill-act-h-r-1-what-every-pa-needs-to-know/

12: The White House. 2025. Myth vs. fact: the One Big Beautiful bill. The White House Articles. https://www.whitehouse.gov/articles/2025/06/myth-vs-fact-the-one-big-beautiful-bill/

13: Hinton, E. and Rudowitz, R. 2025. 5 key facts about Medicaid work requirements. KFF Medicaid issue briefs.

https://www.kff.org/medicaid/issue-brief/5-key-facts-about-medicaid-work-requirements/

14: National Academy for State Health Policy (NASHP). 2025. What health care provisions of the One Big Beautiful Bill Act mean for states. NASHP Health Coverage. https://nashp.org/what-health-care-provisions-of-the-one-big-beautiful-bill-act-mean-for-states/

15: Galewitz, P., Appleby, J., Rayasam, R., and Wolfson, B. 2025. 5 ways Trump’s megabill will limit healthcare access. Shots: Health News, National Public Radio. https://www.npr.org/sections/shots-health-news/2025/07/02/nx-s1-5453870/senate-republicans-tax-bill-medicaid-health-care

16: Lee, C. 2025. Abortion is legal in Maine, but Trump’s Big Beautiful Bill could gut much of the state’s reproductive health care access. Reproductive Health, TIME. https://time.com/7299743/trump-big-beautiful-bill-reproductive-health-care-maine/

17: Goldman, R. 2025. What is the One Big Beautiful Bill and its impact? League of Women Voters. https://www.lwv.org/blog/what-one-big-beautiful-bill-and-its-impact#:~:text=Federal%20funding%2C%20including%20Medicaid%2C%20is,filed%20lawsuits%20challenging%20the%20law.

18: Cruz-Martinez, G. 2025. What to know about new Medicaid cuts: is your local hospital closing soon? Kiplinger Today. https://www.kiplinger.com/taxes/medicaid-cuts-and-your-local-hospital

19: Gaffney, A., Himmelstein, D. and Woolhandler, S. 2025. Projected effects of proposed cuts in federal Medicaid expenditures on Medicaid enrollment, uninsurance, health care, and health. Annals of Internal Medicine, vol. 25. https://doi.org/10.7326/ANNALS-25-00716

20: Ku, L., Kwon, K., Krips, M., Gorak, T. and Cordes, J. 2025. How Medicaid and SNAP cutbacks in the One Big Beautiful Bill would trigger big and bigger job losses across states. The Commonwealth Fund Issue Briefs.

https://www.commonwealthfund.org/publications/issue-briefs/2025/jun/how-medicaid-snap-cutbacks-one-big-beautiful-bill-trigger-job-losses-states

21: Watson, G., Li, H., York, E., Muresianu, A., Cole, A., Van Ness, P. and Durante. A. 2025. One Big Beautiful Bill Act tax policies: details and analysis. Tax Foundation. https://taxfoundation.org/research/all/federal/big-beautiful-bill-senate-gop-tax-plan/

The increasing preference for outpatient surgery over inpatient procedures reflects advancements in medical technology, anesthesia, and postoperative care. Over the past two decades, the number of surgeries performed on an outpatient basis has risen substantially, with healthcare systems seeking to reduce costs and accommodate patient preferences for a faster discharge and more comfortable recovery at home. While most outpatient surgery is safe and associated with lower overall morbidity, the issue of at-home mortality deserves close attention. The period immediately following discharge represents a vulnerable time, and in certain patient populations, seemingly minor complications can lead to significant, even fatal, outcomes.

Although the overall mortality rate at home after outpatient surgery is low, it is not negligible. Data collected from Medicare populations have shown that mortality within the first seven days after outpatient procedures can range from 25 to 50 per 100,000 cases, depending on the setting in which the surgery was performed. For example, among elderly Medicare beneficiaries, outpatient surgeries performed in ASCs had a seven-day mortality rate of 25 per 100,000, while those conducted in physician offices had slightly higher rates around 35 per 100,000. While these figures are low compared to inpatient surgery, they reveal a persistent risk, particularly within the first 30 days following discharge. Furthermore, data shows that mortality tends to cluster within the first 7 to 30 days post-discharge, underscoring the importance of close monitoring during this period.

Patient-specific factors strongly influence the risk of at-home mortality following outpatient surgery. Frailty—characterized by diminished physiological reserve—is among the most powerful predictors. A meta-analysis involving over 1.1 million surgical patients found that frail individuals had a 3.7-fold higher risk of 30-day mortality compared with non-frail patients. In a large retrospective cohort study, frail patients undergoing major noncardiac surgery had a 13.6% one-year mortality rate versus 4.8% in non-frail patients, corresponding to a hazard ratio of 2.23. Even in lower-risk outpatient procedures, frailty significantly worsens outcomes: very frail patients experienced over 10% 30-day mortality after low-stress procedures and nearly 30% mortality at 180 days. Comorbidity burden further compounds these risks; for example, higher Charlson Comorbidity Index scores were associated with increased mortality and inability to return home postoperatively. Advanced age, cognitive impairment, and limited social support also correlate with poorer outcomes and delayed recognition of complications. Collectively, these data emphasize that frailty and comorbidity drive vulnerability, even in procedures deemed low risk, underscoring the importance of robust preoperative screening and individualized perioperative planning.

To reduce the risk of at-home mortality after outpatient surgery, several strategies can be implemented. Careful patient selection is paramount; not all patients are ideal candidates for outpatient procedures, especially those with significant frailty or poorly controlled chronic illnesses. Pre-habilitation programs, which focus on improving physical and medical fitness before surgery, have shown promise in lowering complication rates. Additionally, closer monitoring of patients who experience minor complications before discharge could help identify those who need more intensive follow-up. Finally, improved postoperative care protocols—including patient education, remote monitoring tools, and structured check-ins—may provide the safety net necessary to prevent avoidable deaths after discharge.

While outpatient surgery is a cornerstone of modern surgical care and is generally associated with favorable outcomes, the rare occurrence of at-home mortality remains a serious concern. Recognizing the risk factors that contribute to such outcomes—frailty, predischarge complications, and insufficient post-discharge support—can help healthcare providers better identify vulnerable patients and design interventions to protect them during this critical recovery period.

References

1. Madsen HJ, Henderson WG, Dyas AR, Bronsert MR, Colborn KL, Lambert-Kerzner A, Meguid RA. Inpatient Versus Outpatient Surgery: A Comparison of Postoperative Mortality and Morbidity in Elective Operations. World J Surg. 2023 Mar;47(3):627-639. doi: 10.1007/s00268-022-06819-z.
2. Fleisher LA, Pasternak LR, Herbert R, Anderson GF. Inpatient hospital admission and death after outpatient surgery in elderly patients: importance of patient and system characteristics and location of care. Arch Surg. 2004 Jan;139(1):67-72. doi: 10.1001/archsurg.139.1.67.
3. Roshanov PS, Chan MTV, Borges FK, et al. One-year Outcomes after Discharge from Noncardiac Surgery and Association between Predischarge Complications and Death after Discharge: Analysis of the VISION Prospective Cohort Study. Anesthesiology. 2024 Jan 1;140(1):8-24. doi: 10.1097/ALN.0000000000004763.
4. Rothenberg KA, Stern JR, George EL, Trickey AW, Morris AM, Hall DE, Johanning JM, Hawn MT, Arya S. Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery. JAMA Netw Open. 2019 May 3;2(5):e194330. doi: 10.1001/jamanetworkopen.2019.4330.
5. Sun X, Shen Y, Ji M, Feng S, Gao Y, Yang J, Shen J. Frailty is an independent risk factor of one-year mortality after elective orthopedic surgery: a prospective cohort study. Aging (Albany NY). 2021 Feb 26;13(5):7190-7198. doi: 10.18632/aging.202576.