Financial pressures, a shifting regulatory environment, competition, and regaining patient/member trust are just some of the challenges health care organizations will need to address in the upcoming year.
RISE asked our corporate partners, sources, and conference speakers to offer their thoughts on what is in store for the industry in 2026 and strategies for the biggest challenges. Here are their responses:
Affordability
The industry’s biggest challenge will be affordability, driven by increasing financial pressure from rising utilization, and medical and pharmacy spend, forcing plans to shift from growth to disciplined, profitable growth strategies, according to David DeHommel, VP of payer strategies at Reveleer. "That means competing more selectively, deploying AI tactically instead of piloting endlessly, and treating compliance as a year-round operating requirement."
David DeHommel, VP of Payer Strategies at Reveleer
"We’re preparing by focusing on three imperatives:
- Transparent AI that directly improves value, ensuring accurate and complete reimbursement and reduces costs
- RADV readiness built into standard operations
- Continuous quality measurement shifting from the standard HEDIS® season.
Plans that embrace these operating shifts will protect margin while improving performance in an increasingly constrained environment."
HEDIS® is a registered trademark of the National Committee of Quality Assurance (NCQA) and any reference thereto by RISE Health does not imply any endorsement by NCQA of RISE Health and its offerings.
Escalating cost pressures
Joel Radford, co-founder and managing partner, Engagys,believes navigating escalating medical cost pressures will be the biggest challenge especially as traditional approaches (e.g., network and plan design tweaks, point solutions, broad outreach) are delivering diminishing returns.
"Health plans know where the high-value opportunities lie—preventable ED visits, inadequate chronic care, escalating medication costs, increased hospital utilization—
Joel Radford, co-founder and managing partner, Engagys
but the underlying obstacles are their immature approaches to achieving cost reductions through consumer behavior change. Payers continue to wring their hands and raise prices because their members make costly decisions.
Payers’ failure to rein in costs has been attracting the ire of regulators for decades, and failed attempts to do so via restricting benefits has drawn the ire of members at the same time. Unfortunately, there is no simple solution. However, there is an obvious one—do the work required to establish 1:1 relationships with members. Put in place the people, process, technology, and insights required to align with the individual needs of members—centralize member data; embrace behavior-based segmentation approaches; train teams on the application of behavioral science techniques as they apply to health care, enable and apply hyper-personalization. This will not be easy. It will not be cheap. But it will be effective. And some competitors are doing it right now. Do the work."
Growth strategy
Payers are stuck in a strategy that pushes most of their dollars into Google, according to Ray Mina, chief marketing officer, Freshpaint. "Not because it’s the only channel they need to drive awareness, engagement, and enrollments, but because incomplete data forces marketers to rely on last-click measurement. And in a last-click world, Google always wins.
But this creates a real problem: Google is an intent channel. It’s where people go after demand already exists.
Ray Mina, chief marketing officer, Freshpaint
You don’t generate demand with intent channels, especially when you’re trying to reach specific or harder-to-activate audiences. And with Google costs continuing to rise, relying on intent alone becomes both expensive and unsustainable.
A scalable growth strategy for payers requires a true multichannel approach. One that reaches and influences consumers long before they’re typing queries into a search bar. Channels like Meta, CTV, and emerging upper-funnel platforms are where demand is created. They build awareness, shape consideration, and prime audiences so you can eventually capture intent.
The path forward, and what we’ve been preparing our customers for, is consolidating and activating compliant first-party data so payers can finally measure the impact of the entire funnel, not just the last click. When you can prove how CTV influences enrollment, how Meta drives qualified audiences, and how your upper-funnel media shapes downstream intent, business goals are reached and teams break free from Google dependency. That’s how you escape the trap and build a modern, multichannel marketing engine capable of generating demand and scaling into 2026."
Health equity
Entering 2026, health care—particularly Medicare Advantage—faces mounting uncertainty driven by reimbursement pressure, regulatory scrutiny, and the scaling back of supplemental benefits that were previously used as engagement levers, says Rick Whitted, MBA, CEO at U.S. Hunger, conference chair and speaker at the upcoming RISE Healthy Communities Summit.
"At the same time, plans are confronting a shifting and often misunderstood member profile:
Rick Whitted, MBA, CEO at U.S. Hunger
many of the hardest-to-reach members are no longer best described as “low-income” or marginally connected to care, but rather as working, insured households spanning Medicare Advantage, Medicaid, Duals, and commercial lines of business.
These members are earning income or receiving benefits, yet remain economically fragile, time-constrained, and largely invisible to traditional outreach models.
As benefits become more constrained, transactional approaches—one-time offers, isolated distributions, or incentive-based engagement—are proving insufficient to build trust or sustain participation, contributing to persistent disengagement and year-over-year attrition. The plans that will succeed in this environment will be those that redefine health equity not as the volume of benefits delivered, but as a strategy of continuous, data-informed engagement that reflects the lived realities of the working insured.
In response to these dynamics, U.S. Hunger is working directly with a national health plan, and state partners, to embed equity into core engagement infrastructure rather than treating it as an add-on. This includes integrating food support into plan workflows as a behavioral engagement lever—using groceries to reinforce preventive care, healthy activities, and sustained participation, rather than as a one-time supplemental benefit. In parallel, with support from a leading national health organization, we are scaling a compliant, interoperable platform across nearly a dozen community-based organizations, connecting them directly into the care continuum as shared infrastructure. The goal is to move beyond outsourced referrals toward durable, trust-based engagement that plans can operationalize across lines of business."
Member engagement
Brett Zelkind, chief business officer, Wider Circle, believes the health care industry will have to face continued erosion of trust.
"Seniors are watching their health plans exit markets. Medicaid beneficiaries feel their benefits are under threat. Exchange members face uncertainty around premiums and coverage. Payers and providers who invesst in what matters most—being a consistent, empathetic, and
Brett Zelkind, chief business officer, Wider Circle
trusted partner that their members can count on will more successfully navigate these challenges.
And this requires deep community engagement and human-first support, to help people navigate uncertainty with confidence."
Political volatility
Dawn R. Carter, senior director, health care policy and regulatory affairs, Centauri Health Solutions, says that health care organizations will face unprecedented regulatory pressure next year due to a convergence of political, economic, technological, and enforcement forces. Political volatility, driven by election cycles and shifting federal priorities, creates uncertainty as administrations introduce new health care agendas, while state-level regulations add complexity for multi-state systems, she says.
Dawn R. Carter, senior director, healthcare policy and regulatory affairs
Centauri Health Solutions
"Heightened public accountability is also fueling stricter mandates, with consumer advocacy and media scrutiny pushing for greater price transparency and equitable access to care. Economic pressures, including inflation and cost-containment initiatives, have led policymakers to implement aggressive measures such as site-neutral payments and drug pricing caps, while budget constraints accelerate fraud and abuse audits like RADV. At the same time, technology and data governance are under scrutiny, with oversight tightening on AI-driven clinical decision support and software-as-a-medical-device, and cybersecurity mandates emerging in response to escalating ransomware attacks. Finally, regulators are shifting from education to enforcement for non-compliance with new requirements related to information blocking, prior authorization.
The key to overcoming this challenge is to treat compliance deadlines as design constraints for innovation: redesign workflows around people and process first, then let technology amplify speed, access, and trust through interoperability. That reframing is how organizations avoid the traditional hodgepodge of reactive compliance projects that lead to fragmented systems and higher costs. and instead build sustainable advantages that create lasting value. Integrated workflows aligned with compliance create this value through operational resilience and better patient experiences. Now more than ever, tools and technologies are available to support this goal and instead of treating regulations as obstacles, use them as guardrails to redesign workflows around people and processes first, then layer enabling technologies; most notably, AI, FHIR APIs, and TEFCA connectivity, to amplify speed, access, and trustation, and price transparency."
RADV audits
The biggest challenge for Medicare Advantage organizations will be navigating the ongoing uncertainty surrounding Risk Adjustment Data Validation (RADV) audits, according to Melissa James, CPC, CPMA, CRC, risk adjustment SME, senior consultant, Wolters Kluwer, Health Language.
"With federal courts vacating the RADV Final Rule and the Centers for Medicare & Medicaid Services (CMS) appealing that decision, Medicare Advantage Organizations (MAOs) are caught in a holding pattern being forced to operate in a regulatory landscape that continues to shift. While the ultimate implications for repayment methodology are still being litigated, CMS has not indicated any slowdown in its plans to continue administering RADV audits. That disconnect between legal ambiguity and operational reality is where the real pressure lies."
Melissa James, risk adjustment SME
Senior consultant, Wolters Kluwer, Health Language
"My advice for MAOs is simple: prepare as though nothing is changing. Whether the appeal results in a quickly reinstated rule or a prolonged period of limbo, the only viable strategy is operational excellence. That includes maintaining high-quality, defensible coding; conducting routine mock RADV audits; performing targeted deletion projects; and strengthening oversight of internal and external coding resources. Now is the time to explore and contract with state-of-the-art RADV response software to ensure that when the next audit happens, your teams are prepared no matter what repayment model is ultimately enforced.
The legal outcome will eventually settle, but the audits aren’t waiting. Organizations that treat RADV preparedness as a continuous discipline, not a reaction to external policy shifts, will be best positioned to weather 2026 and beyond."
Regulatory challenges
Navigating a rapidly shifting policy and regulatory environment as the new administration continues to set and execute its priorities will continue to be a challenge, says Ryann Hill, MPH, founder and CEO, Indigo Hill Strategies.
"Health plans will need to understand both the immediate implications of regulatory changes and the longer term direction signaled by policymakers. The plans that succeed will be the ones that build a culture of awareness and a culture of engagement.
Ryann Hill, MPH, founder and CEO, Indigo Hill Strategies
This means creating strong internal systems to track policy activity, investing in proactive government affairs strategies, and engaging early with political appointees, Congressional staff, and other key decision-makers and opinion leaders.
My work with clients has focused on preparing for this moment by strengthening their internal readiness, aligning quality and policy strategies, and ensuring they have trusted relationships across the administration and Capitol Hill. I recommend that health plans view government engagement as a core operational function in 2026, because the pace and scope of change will require consistent attention, clear communication, and strategic alignment across the enterprise."
Risk adjustment compliance
Chad Kinkead, EVP, health enablement, Cotiviti, says the biggest challenge will be navigating heightened risk adjustment compliance amid the full implementation of Model V28, increased regulatory scrutiny, and planned expansion of CMS RADV audits.
"Plans must avoid costly mistakes such as building technology without clear use cases and struggling with fragmented or inaccessible data. Instead, they should leverage their data and
Chad Kinkead, EVP, health enablement, Cotiviti
technology infrastructure to drive improvements across their risk, quality, Stars, and value-based programs, and integrate mature AI with human oversight to achieve both efficiency and compliant results.
Plans should also focus on early preparation, continuous education, and collaboration across clinical, compliance, and analytics teams. Strategies include training clinical teams on the impact of latest updates, leveraging CMS resources, and establishing strong frameworks for oversight using technology like NLP and AI—all while maintaining human feedback loops.
While maintaining retrospective excellence is crucial, adopting prospective and concurrent approaches enables shifting interventions earlier in the member journey to improve documentation alignment and audit readiness. Regular training, clear communication, and a balance between technology and human expertise are essential for maintaining high clinical standards and compliance."