Your Levers Have a Lead Time. The Coverage Cliff Doesn't.
By Jill Steeley, former FQHC CEO and host of the Community Health Collective podcast
I've gotten the same question three different ways in the last couple of weeks, always at the end of a call.
"Okay, I hear you on the four levers. But if I can only focus on one right now - which one should I pull first?"
I've been answering it wrong. Not wrong exactly - I've been answering the question people asked. But it's the wrong question, and if you're building a 2027 budget right now, the right one matters more than almost anything else on your desk.
Highlights of this post:
Why "which lever first?" is the wrong question for a health center facing the coverage cliff
The correction on January 1st that makes your timeline tighter, not easier
All four levers ranked by lead time, with the real numbers behind each one
Why the slowest lever is the urgent one, and how the fast lever shortens it
Five problems this creates, and five things to do about them this week
When does the Medicaid coverage cliff actually hit my revenue?
Not on January 1st.
I want to correct this clearly, because I've said it wrong myself and I hear it repeated constantly.
Starting January 1, 2027, Medicaid expansion adults ages 19 to 64 move from annual redeterminations to every six months, for renewals scheduled on or after that date. Work requirements get verified at both application and renewal - 80 hours a month. (There's also a separate change coming October 1, 2026, affecting immigrant patient populations.)
But the redetermination clock runs from each patient's own original application date.
Steve Weinman and I get asked constantly what "the redetermination date" is. There isn't one. There is no Tuesday in January where your revenue drops off a cliff. What actually happens is that beginning January 1st, your patients start rolling through renewals a few hundred at a time, continuously, and the coverage losses accumulate across all of 2027.
That sounds like relief. It isn't.
Because it means your replacement revenue needs to be arriving in 2027 - not sitting in a strategic plan waiting for a calmer quarter. And as I'm writing this, we are 108 days from January 1st.
How long does it take for a new revenue strategy to actually pay off?
This is the question nobody answers, and it's why so many well-intentioned plans fail.
Every lever has a lead time: the gap between the day you pull it and the day a dollar shows up. Here are all four, fastest to slowest. Not most important to least - fastest to slowest. Those are completely different rankings, and that's the whole point.
Lever: Reduce costs and increase productivity: 30 to 90 days.
Your fastest lever, and the one I'd start with if you're reading this in a panic. It's fast because the money is already yours. You're not earning it - you're stopping it from leaking out of your health center.
Go look at no-shows. Run 20,000 Medicaid visits a year with a 20% no-show rate and that's 4,000 visits that didn't happen. At a $200 reimbursement rate, that's $800,000 out the door in one year.
Or go one provider at a time. One full-time physician with three no-shows a day - that's a 20% no-show rate if they're seeing 17 patients a day - is about $70,000 a year in lost revenue from one schedule, and almost 800 appointment slots other patients could have used. So it isn't only a revenue problem. It's an access problem, and it hits your bottom line and your patient outcomes at the same time.
Same with your staffing model. Same with the vendor contracts nobody's looked at in four years. You can start Monday and see the needle move inside the quarter.
Lever: Retain patients through exceptional care: 6 to 9 months.
Second fastest, sometimes faster, and probably the most underrated of the four.
It costs $425 to $750 to acquire a new patient. It costs $100 to $200 to keep one you already have - less than half. And the lifetime value of a retained patient runs between $5,500 and $8,000.
We worked with a COO I'll call Gina. Her health center had 29% of its patients never coming back. High staff turnover, inconsistent hours, no marketing, and a reputation around the city as the clinic for people with no other options.
She did not add a single new service. She fixed the hours so they were consistent and open when patients actually needed to be seen. She got turnover down so patients saw the same person twice. And she changed what her community believed about who was welcome there, who they served, and what insurance they accepted.
88% patient retention. $700,000 recovered in eight months. She just stopped losing what she already had.
Lever: Increase and diversify revenue: 6 to 18 months.
Now we're into the levers that need a running start.
Take payer contracts. When I was CEO, I spent my whole first year convinced our problem was that we didn't have enough funding - and in that entire year I never picked up the phone to a single payer. Not one.
I found out later, because I went to work for Blue Cross Blue Shield of Montana after I left my health center, that no one in Montana had renegotiated a commercial contract with Blue Cross in about 15 years. We had all just been accepting the rate they gave us. When I became director of the provider network there, I started calling health center CEOs to tell them they could negotiate with me - and more or less handed them the script.
So I've sat on both sides of that table, and I'll tell you plainly: you can absolutely have that conversation, and you matter more to that health plan than you think. They're selling a product. You're the one delivering the service that sells it.
But it is not a fast lever. You request the meeting, you prepare, you submit negotiations, and the new rate takes effect at your next contract cycle. Realistically that's six to twelve months before a different number hits a remittance.
Attracting insured patients has the same shape. One insured primary care patient at a $200 reimbursement, coming in four times a year - which is what a primary care patient averages - is $800. A thousand new insured patients is $800,000 in a year. If half of them use your 340B pharmacy at a $2,000 average annual spend, that's another million. If a quarter use more than one service, that's another $200,000.
That's $2 million a year from one lever. And it takes 12 to 18 months to build, because you have to have the providers to see those patients before you go get them. You have to recruit, be staffed, be ready, and do some marketing - which brings us to the last lever.
Lever: Build a strong market presence: 2 to 4 years.
The slowest by a wide margin, and the one everybody defers, every single year, forever.
When I started at my health center, our brand recognition in the community was 27%. Fewer than three people in ten knew we existed - and most of the ones who did believed you had to be poor or uninsured to walk through our doors.
I want to be honest that I had assumed it was much higher. I think most CEOs do. You're in that building every day, and it's easy to mistake being important to your patients for being known in your town.
Four years later, we surveyed 700 people, and 94% knew who we were, what we did, and who we served.
There is no version of that project that takes eight months. You can't buy it. You rebrand - we did - and then you get out into the community over and over and over. You show up at the Rotary Club and the Lions Club and the church staff meeting, whether there are three people in the room or 40. I did that roughly once a week for almost nine years.
And this is the lever that makes every other lever cheaper. You cannot attract insured patients who don't know you exist. You cannot recruit providers to a place with a bad reputation - trust me, my health center had been failing at exactly that for five years before I got there. And you cannot hold a rate conversation with a payer from a position of weakness and desperation.
The five problems this creates
1. People pick levers by appeal, not by payout date. The lever that sounds best in a leadership meeting is rarely the one that pays when you need it.
2. The "January 1st" framing makes people think they have a deadline and then a clean slate. They don't. Losses roll all year.
3. The slow lever gets deferred every quarter, because there is never a calm quarter in which to start it.
4. The fast levers get mistaken for a strategy. Cost reduction stabilizes you. It does not change your business model.
5. By the time market presence feels urgent, it's four years too late to help.
The five things to do about it
1. Stop asking which lever is most important. Ask which one pays when you need the money. Put the four lead times on a whiteboard in front of your leadership team.
2. Pull your no-show number this week. It's a 20-minute conversation with whoever runs your schedule, and it's usually the fastest six figures in the building.
3. Start one slow lever this week too - even if starting means getting on the agenda of one civic group, or sending one email to one health plan's provider network director. Or just finding out what your brand recognition number actually is.
4. Use the fast lever to fund the slow one. Free up real money inside 90 days and reinvest part of it in the market presence work.
5. Take your lead times to your board before January. A board that understands why you're investing in something that pays out in three years is a board that won't panic in month six.
Which lever should I start first?
Here's where everybody goes wrong, and I did too.
You look at that list, you see the lead times, and the logical move seems obvious: start with the fast one, get a win, build momentum, then work down to the slow stuff when you have breathing room.
And honestly, I agree with part of that. When someone is overwhelmed, I tell them to start with one thing. I stand by that.
But the fast lever is available to you in January. It's available in June. Cost reduction doesn't expire - you can start it whenever you finally get to it, and it still takes about 90 days.
The slow lever is the only one with an expiring start date. If you don't start building your market presence now, you don't get 2029. It's just gone. You can't compress it, you can't buy it back, and you can't do it faster by caring more.
So the answer to "which lever should I pull first" is: two of them. One that pays this quarter, and one that pays three years from now.
And here's the cool part. The fast one doesn't only fund the slow one. It shortens it.
If you're reducing costs, if you're saving money on vendor contracts nobody has opened in four years, if you're finally getting a higher rate from your commercial payers - that money gets reinvested into your marketing. So that three-or-four-year lead time on market presence just shrank, because you had something to spend on it.
That's the whole mechanic. You pull costs and productivity, you free up real money inside 90 days, and you spend part of it on the work that starts paying you back in 2028 and 2029.
That's not doing two things at once. That's doing one thing. It's a flywheel, and the fast lever is what gets the wheel turning.
What I got wrong
I had 12 months to break even or my board was closing the doors and I was out of a job.
So I did what you'd do. I ran the fast levers hard - cost, productivity, revenue leaks. It worked. We broke even and finished that year with about a $300,000 profit. A $1.3 million swing in 12 months.
That first year saved us from closing the doors.
We also rebranded that first year, in 2015. New name, new look.
But here's what I see now that I couldn't see then. The rebrand wasn't the lever. The rebrand was a logo. The lever was showing up - week after week, year after year - and the real market presence work didn't start until year two.
And twelve months doesn't sound like much of a delay. It wouldn't be, if market presence were just one of four independent projects.
But it's the lever underneath the other three. So a year of delay there pushed recruiting, which pushed our capacity to see insured patients, which pushed the revenue that funds the next thing. That's how twelve months of hesitation turns into a ten-year turnaround instead of a five or six year one.
The fast levers saved the health center. The slow lever is what made it unkillable. Grant dependency from 62.5% down to 17%. Uninsured rate from 42% to 12%. Millions of dollars in reserves. None of that came from the cost work.
I sequenced them. I should have stacked them.
What to do next
Pick one fast lever and one slow lever, and start both this week. Not next quarter, not after the budget's done.
Then join us. Steve Weinman and I are hosting our free live webinar again this Friday, September 18th at 10:00 AM Pacific, 1:00 PM Eastern - same registration link as last week's session. Sixty minutes on all four levers, four health centers doing this right now, and how to pick yours. You'll leave with a next right action instead of pages of notes you'll never look at again. Show up live and you'll get the HR 1 exposure worksheet, the HR 1 90-day action plan, and the offense playbook.
If you want the full build - the payer negotiation templates, the 340B strategies, the staffing models, the implementation toolkits - that's the FQHC CEO Connect Bootcamp. Our fifth cohort starts on October 9th: www.fqhc-ceo.com
Or just schedule a call with me and we'll talk about which two levers are yours.
And if you're sitting there thinking you're three years behind where you should be - maybe you are. I was. It doesn't matter.
The best day to pull the slow lever was four years ago. The second-best day is today.
You're not doing this alone.
About the Author
Jill Steeley is the host of the Community Health Collective Podcast and an executive coach to leaders across community health centers, FQHCs, and mission-driven healthcare organizations. After two decades inside the healthcare leadership world and close to 250 healthcare leaders coached and mentored, she helps healthcare executives build the leadership skills they were never formally taught - and helps full leadership teams shift culture together rather than one leader at a time.
Learn more at jillsteeley.com.
