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large and complex assemblage of interdependencies. Any change to one part could create multiple, hard-to-predict effects throughout the system. When making changes to a fragile system that serves so many, the watchword should be caution.

Of the long list of possible federal budget cuts released on January 17, the suggestion to eliminate the tax-exempt status for interest payments on municipal bonds is an item of particular concern. While it is too early to wager on any of the items on the list, the implications of this move for not-for-profit hospitals would be severe.

With extension of the 2017 tax cuts identified as a key priority for the incoming Trump administration, offsetting expense actions will be needed to avoid increasing the federal deficit. Hospital leaders should be prepared for potential cuts to both the Medicaid program and the enhanced ACA subsidies enacted in 2021.