Governance
When the Future Finally Arrives: Governing Health Care in 2050
The Governance Choices Today That Will Define Health Care Tomorrow
By Kara Witalis
Boards are planning for 2026, but what about 2050?
The decades ahead promise profound change. Widening social and economic divides, demographic shifts, technological advances and rising consumer expectations will reshape nearly every aspect of our lives. Health care will be among the systems most deeply affected.
No one knows exactly what health care will look like 25 years from now. What is becoming clear, however, is that the current system is not designed to meet the demands ahead. The U.S. now spends roughly $5 trillion a year on health care, outpacing every other nation in per-person spending. But by even the most basic measures, the U.S. performs poorly compared to other wealthy nations, ranking near the bottom on life expectancy, infant mortality and preventable deaths.
An Unsustainable Imbalance
There is a fundamental imbalance between what we expect, what we can afford and what the system delivers today. Future pressures on supply and demand will amplify these gaps. By necessity, the system must be redesigned to expand access, manage higher demand, reduce cost, simplify experience and improve health outcomes. The question is how.
The hospital or health system board exists to protect the mission and ensure the organization delivers on its promise of health, access and affordability today. It is also responsible for holding the long view and making the hard decisions today that will influence how the organization will work in the future.
The Long View of Governance
The question is this: If today’s hospitals and health systems are struggling to meet access and affordability needs now, how will we prepare for the challenges ahead? What would we build if given the chance?
Consider a health system intentionally designed to be affordable, coordinated and effective. Health improvement is the primary goal, supported by strong public health infrastructure and universal access to primary, mental health and preventive services. Care is delivered through connected regional networks and enabled by shared data and technology that expands access and efficiency.
Payment models reward outcomes rather than volume. Regional funding stabilizes rural and safety-net services and ensures broadly available coverage, independent of employment. This is not a vision of health care solving every social challenge but of a system designed to work and to be affordable.
For some, this vision reads like fantasy. For others, elements of it are already underway. There will be no one-size-fits-all model; different regions will adopt different approaches based on local needs and realities. But one thing is clear: The future will not be supported by simply scaling up today’s model nor by governing as business as usual.
Governing Today for the Future: How and Where to Start
Governing toward this future begins now. Boards shape the organization through the priorities they set, the questions they ask, the investments they approve of and the partnerships they pursue. Decisions about capital allocation, market strategy, digital infrastructure, workforce models and policy engagement will determine whether this future becomes achievable or remains aspirational. The governance challenge is to move beyond oversight and begin intentionally creating the conditions for changes to emerge.
1. Assess Whether Governance Practices Enable the Future
First, boards should assess whether their current governance practices enable future-focused leadership. That starts with an honest look at how the board operates today, what it spends time on, how decisions are made and where authority and accountability truly reside. It means naming which cultural habits and ways of thinking support governing for the future, and which quietly reinforces the status quo, then being willing to challenge and evolve them.
The govenance question: Are we governing in ways that prepare us for the future? If not, what needs to change for the board to govern differently?
2. Reaffirm Purpose Through a Future-Oriented Lens
Second, boards should revisit and reaffirm their shared understanding of purpose and the problem they are trying to solve through a future-oriented lens. Clarifying purpose is foundational governance work, but it becomes even more critical when boards are seeking to reshape entrenched organizations rather than sustain them. Without this clarity, even well-intended strategies and decisions risk reinforcing the very elements that need to change.
The govenance question: Are we clear on our fundamental purpose and what problem we are trying to solve today — and what problem we must be solving for the future?
3. Define Long-Term Success and Legacy
Third, boards must imagine what long-term success looks like. This is generative work — looking beyond today’s constraints to envision what health, access, affordability and experience could look like in the future if the system were truly working.
The govenance question: What legacy do we want to leave for our community decades from now? If we were designing health care from scratch without restraint, what would it look like?
4. Work Backward to Create the Conditions for Change
Fourth, boards must work backward from that vision. That means identifying what is holding the organization back today — financing models, contracts, relationships, assumptions and “we’ve always done it this way” practices — and deciding what must change to make the future possible. This is where boards begin shaping the conditions that allow a new model to take root.
The govenance question: What conditions in our market or in the broader system are preventing us from creating the future we say we want — and what, specifically, must change? Be specific.
5. Lead Beyond the Organization
Finally, boards have an important role as stewards of today and change agents for tomorrow. That work cannot be done in isolation. Building a different future requires working across organizations and sectors; shifting how we think, how we behave and how systems are designed; and moving beyond the mental models that shaped the current system.
This is where relationship building, advocacy and public policy matter. Many of the barriers to change — financing models, workforce rules, digital infrastructure and regulatory constraints — sit outside any one organization’s control. Boards must help build relationships, make the case for what their communities need and engage constructively with policymakers and partners to shape conditions that allow better systems to emerge.
This means building relationships beyond the routine and traditional, imagining what is possible together and advocating for new ideas. It requires showing up, listening and recognizing that we share common goals even when our realities differ and working constructively to move forward. Boards have the opportunity and the responsibility to be the system architects for the future.
The govenance question: How can we come together for a common purpose? How might we use our voice, relationships and influence beyond the organization to advocate for the policies and conditions our future organization will require?
The Future Is Calling Boards to Govern Differently
That future is not far off, and for some, it is already taking shape. The governance choices made today — what boards prioritize, which questions they ask and which trade-offs they are willing to make — will determine what communities inherit tomorrow. This requires boards to move beyond oversight and performance monitoring to generative conversations about purpose, care delivery re-design and long-term impact. This is not a theoretical exercise. The future is calling boards to govern differently.
Kara Witalis, MHA, (kara@witalisllc.com) is governance advisor at Witalis, LLC.
Please note that the views of authors do not always reflect the views of the AHA.