Happy New Year!

There is still some time left to say that before hitting the Larry David statute of limitations!

As for predictions, even though we are two days into the new year, we figure there is still ample time for sharing those. In late December, we asked members of the Managed Healthcare Executive editorial advisory board and other analysts and leaders in healthcare to forecast the developments and trends that will leave their mark on U.S. healthcare in 2026. Here are several of the responses we collected.

Trump administration will issue new rules to boost noncompliant ACA health plans

In response to cuts resulting from the One Big Beautiful Bill Act, states will ratchet down Medicaid managed care rates, causing significant disruption in Medicaid as some for-profit carriers threaten to and, in some cases, will leave Medicaid in certain states. Health plans will continue to explore how AI tools to support process improvement, compliance, and redeterminations. And the Trump administration will issue new rulemaking that will expand and encourage take-up of noncompliant Affordable Care Act coverage, including association health plans and short-term, limited-duration insurance.

Cost and utilization increases will squeeze health plans

Policy and industry dynamics will put health plans under real pressure in 2026. Policies such as H.R. 1, the potential expiration of the enhanced premium tax credits and changes to provider tax provision will contribute to Medicaid enrollment restrictions and affect the affordability of ACA plans. This may negatively impact plan enrollments levels across lines of business and geographies. Rising medical and pharmacy costs and higher utilization will compound the squeeze as plans work with fewer resources. Expect a bipartisan focus on affordability. While the policy approaches may differ, the core affordability drivers may lead to bipartisan solutions. Finally, as AI moves from pilot to production, we will start to see separation of the hype from the value to see where there is clear value versus where promises have fallen short.

Medicaid enrollment reduction will cause harm

The recently enacted H.R. 1 law [the One Big Beautiful Bill Act] will undoubtedly strain Medicaid budgets across all states. However, the extent to which states address these challenges will be more influenced by the political considerations of their leaders rather than the immediate needs of their constituents. States that have successfully implemented Medicaid expansion and achieved significant coverage levels, such as Oregon’, will likely prioritize maintaining these levels by reducing or eliminating optional benefits and focusing on administrative cost savings. Other states may welcome the anticipated enrollment reductions, as these reductions are expected to naturally lead to decreased spending. Unfortunately, those proposed enrollment reductions will not only inflict substantial harm to Americans and communities but will ultimately exacerbate healthcare expenses by allowing preventable health issues to remain undiagnosed or untreated.

Employers will become price setters

In 2026, universal access to employer claims data will become the linchpin for tackling rising healthcare costs in the commercial market. Employers are no longer passive purchasers. They’re demanding transparency and actionable insights to drive smarter decisions. By unlocking the power of claims data, self-funded employers can negotiate fairer prices, design benefits that prioritize value, and hold vendor partners accountable.

This shift isn’t just about cost control. It equips policymakers with credible, employer-backed evidence, accelerates research into cost driver, and supports the transition to value-based care models that flatten cost growth. Employers will increasingly use these insights to advocate for systemic reforms and create a marketplace that rewards quality over quantity.

The bottom line: 2026 will mark a turning point where data access transforms employers from price takers into price setters, reshaping healthcare purchasing and policy for the better.

Coaching, job training offerings will become standard for Medicaid managed care plans

In 2026, work requirements will move from a back-office eligibility check to a requirement that directly influences how health plans support their members. States will expect partners to deliver active engagement strategies, not just administrative compliance. Some health plans have already introduced coaching and job training to help members meet these requirements; those approaches are likely to become standard. At the same time, plans will need to expand their efforts to address barriers like childcare and transportation, in addition to helping members meet the administrative requirements of the new work rules. Managed care organizations will need to draw on lessons from the recent redetermination process to meet the challenge of scaling their efforts quickly enough to avoid coverage gaps and keep care within reach.

Medicare Advantage will get more scrutiny

In 2026, Medicare Advantage (MA) will face more legislative and regulatory scrutiny than at any point in the last decade. Lawmakers will probe everything from payment accuracy to prior authorization as MA enrollment and federal spending continue to grow. Plans should expect more oversight, more data requests and a sharper focus on beneficiary experience. Staying ahead will require disciplined monitoring and early engagement with policymakers.

Medicare Advantage consolidation, market exits will challenge organizations

Expect Medicare profitability concerns driven by regulatory pressures and rising costs, including those associated with the administration of clinical programs, to continue to control the conversation in 2026. Consolidations and market exits will intensify challenges for organizations remaining in affected service areas, adding higher-cost, higher-need members and straining existing clinical programs.

Success will depend on more precise intervention identification, deeper partnerships with providers and pharmacies serving these beneficiaries directly and scaling back on broad-stroke solutions that were once effective. Leading organizations will leverage AI to refocus, rather than replace, clinical teams and apply technology ethically as policy lags innovation.

Those that rethink resource utilization, effectively offsetting administrative costs through drug therapy and cost of care savings programs while responsibly embracing technology, will reduce the impact of market changes, improve Stars performance, and weather ongoing Medicare landscape disruption.