The next administration could transform healthcare—shifting focus from treatment to prevention, slashing federal budgets and peeling back regulations in a bid to fuel innovation.
It’s a vision that requires a dedicated urgency from President-elect Donald Trump, Make America Healthy Again (MAHA) leader Robert F. Kennedy Jr. and Department of Government Efficiency commission heads Elon Musk and Vivek Ramaswamy. Legal challenges will likely follow.
This month, RFK Jr. is meeting with lawmakers to convince them to approve his nomination as Department of Health and Human Services (HHS) secretary. If successful, he’s likely to push a bold path, putting a new spotlight on vaccines and food regulation.
But norms, lawmakers and bureaucracy stand in the way. What objectives will the new administration actually prioritize, and will they be successful? RFK Jr.’s stance on vaccines and food captures the headlines, but Trump’s approach toward federal programs through the Centers for Medicare & Medicaid Services (CMS) is critically important, if lower-profile.

Fierce Healthcare spoke with Paul Mango, former deputy chief of staff for policy for the HHS during Trump’s first term from 2019 to 2021, to learn more about how the new Trump coalition may go after the entrenched healthcare system. Mango is working on the Trump transition team but has not yet been named to a role within the new administration. He reportedly was in consideration for CMS administrator.
The role of technology and how MAHA squares with deregulation
Trumpworld wants to rescind regulations, pull back power from federal agencies and cut costs. That could sound contradictory, considering more rules and requirements may be necessary to transform the nation’s food system in RFK Jr.’s vision.
His allies say the mission of rooting out waste and abuse fits within the broad MAHA coalition.
Republican lawmakers and conservative think tanks are concerned brokers improperly enroll individuals in Affordable Care Act (ACA) plans, with nine states deemed the biggest culprits.
The Paragon Health Institute estimates fraudulent enrollment accounts for more than 4 million people at a cost of at least $15 billion each year.
“If I’m Elon and Vivek, that’s the first place I go,” said Mango. The Paragon report also supports ending the ACA enhanced subsidies, limiting automatic reenrollment and better oversight of HealthCare.gov.
He believes technology is the key to achieving the scale of deregulation and efficiency Republicans are craving. In a Wall Street Journal op-ed penned by Musk and Ramaswamy, the two say legal experts and the use of “advanced technology” within government agencies should pinpoint regulations that should be paused, and eventually rescinded, through executive action.
“The government, at least when I was there, was probably 15 years behind in the application of technologies that could detect fraud, waste and abuse,” said Mango. “I think AI and large language models have advanced to an inflection point in the last three or four years. If we introduce those to the claims processes, those big programs, I think we’re going to find a hell of a lot.”
Mango believes there are many areas where technology is sorely needed and can lead to creative solutions.
Republicans also oppose a Biden-era rule mandating minimum staffing requirements at nursing homes, at one point trying to reverse this rule in a spending bill due this week. Democrats say the requirements are necessary to ensure quality of care, while critics and industry interests say the mandate is unrealistic and will push nursing homes out of business.
Mango’s solution? “What if we could use technology to help monitor patients differently than the way nurses did it 20 years ago, and we only needed half the number of nurses?” he offered.
Maybe, he suggests, nurse practitioners can take on additional responsibility to alleviate burden on physicians. Or AI could be deployed for diagnostic purposes through Medicare Coverage of Innovative Technologies to innovate faster and more effectively. Perhaps there will be a “liberalization” of telehealth (coupled with program integrity requirements) to help rural communities, he notes, though efforts in Congress to extend key telehealth flexibilities could be in peril long-term after Musk, and then Trump, thwarted the stopgap bill.
Another example Mango gave is the Transformed Medicaid Statistical Information System (T-MSIS), a program aggregating Medicaid claims. A CMS spokesperson told Fierce Healthcare T-MSIS is intended to be the "most trusted" resource for Medicaid and Children's Health Insurance Program data for policy and oversight. Mango wants to train AI models on this data to detect suspicious claims, something he believes the CMS currently fails to do.
“There’s a number of models on the market that do this,” he said. “I would invite vendors in—maybe have a bake-off—give them 100 million claims and say, ‘Tell me what you find.’”
The other problem, as he sees it, is that the federal government, not states, pays for the majority of an ever-escalating Medicaid budget, disincentivizing states from prioritizing waste and abuse. Other times, they exploit loopholes with supplemental payments and direct provider payments to get more money, he argued.
States undergo Medicaid payment error rate measurement audits every three years, but states often get warned for high error rates before penalties are dealt out. This means the problems, either through fraud or administrative inefficiency, last for years.
“To me, that’s egregious, and there could be immediate intervention to see what’s going on,” he said.
RFK Jr. has warned he will eliminate departments within the Food and Drug Administration and lay off 600 people at the National Institutes of Health. That will be tricky legally, but there has been less discussion over how RFK Jr. will approach the CMS.
The agency—or the regulatory factory, as Mango refers to it—is responsible for 80% of HHS spending yet employs less than 10% of the HHS’ workforce. He thinks technology is critical here, too, because rulemaking is a painstaking, cumbersome process. The process consists of information gathering from prior rules and legislation, statutory authority checks, proposals, comments on proposals and, finally, the final rule. Rinse and repeat.
“You could just imagine something like a ChatGPT could cut that process down by 50%, right?” he posed.
That recommendation may be necessary if Trump and his allies are able to close or consolidate federal agencies and mass fire federal employees through Schedule F, leaving the employees left at agencies flooded, at least temporarily, with more work.
CMS strategic pivot under MAHA
The Centers for Disease Control and Prevention estimates 129 million Americans have at least one chronic disease.
RFK Jr. blames the food system, environmental toxins and vaccines for the rise of chronic diseases in modern society. Those issues largely fall outside the scope of the CMS, but Mango says there are ways for the CMS to tackle chronic disease.
For example, Mango thinks HEDIS measures, and star ratings broadly, should be reimagined to focus more on outcomes, not inputs. HEDIS measures include breast cancer screenings, immunization status, medication adherence and other similar factors. Health plans are judged on how effectively they measure these results.
“If you measure hemoglobin A1c, okay, you’re measuring it, but there’s no reward for improving it,” he said.
He also suggested changing requirements within the inpatient prospective payment system, an annual Medicare rule. Hospitals are financially dinged when patients have to readmit to the facility within 30 days of a discharge, but Mango advocates for rewarding positive outcomes—like evaluating whether a discharged patient is fully functional six weeks after a major operation such as a hip replacement.
Each administration can also utilize state Section 1115 and 1332 waivers to further its ideological goals, said Mango.
“The current administration put a lot of emphasis on access and health equity,” he explained. “They did the same thing with CMMI models. You could imagine this one being focused on waivers that demonstrate better health outcomes.”
Mango envisions an administration that will try to meet members of the public where they are to encourage healthier behaviors, similar to public health campaigns of the past advocating against smoking and drugs.
“Let’s help people become more healthy, not in a paternalistic way, but in a more conservative way, which is through some of these change levers that about building awareness and transparency,” he said, giving the examples of healthy eating campaigns, food labeling and reevaluating the food pyramid as examples of this approach in action.
“What I’m saying is there needs to be a part that is focused on modifying human behavior as well, not just changing the context for good health,” he added. Simply removing harmful elements in foods, while important, is not enough, Mango said.