What’s Next for Health Plans? Potential Changes to Watch

With a renewed focus on cost containment, regulatory shifts, and evolving coverage models, health plans must be prepared for potential changes that could reshape the industry. As policy discussions unfold, organizations that take a proactive approach to strategy and operations will be best positioned to adapt. Here’s what leaders should focus on:

Potential Funding Shifts: Medicaid & ACA Subsidies

• Proposals to reduce federal healthcare spending could lead to:
• Changes in Medicaid eligibility and ACA subsidies, impacting enrollment and risk pools.
• Greater reliance on state-level program design, leading to a more varied healthcare landscape.
• Financial pressure on providers and payers, requiring new cost-containment strategies.

Action Item: Health plans should assess their exposure to these funding sources, model potential impacts, and explore diversification strategies, such as alternative plan designs and risk-based approaches.

Evolving Coverage Models & Consumer Choice

• A continued emphasis on flexibility and competition may drive:
• Expansion of short-term, lower-cost insurance plans, altering the individual market.
• Increased focus on personalized and preventive care, shifting how benefits are structured.
• More decentralized regulatory oversight, with states playing a larger role in defining coverage requirements.

Action Item: Health plans should monitor state-level changes and consider how plan offerings can evolve to align with shifting consumer preferences and regulatory requirements.

Focus on Cost Controls & Operational Efficiency

Efforts to rein in healthcare costs could include:

• New approaches to drug pricing and reimbursement models, impacting formularies and negotiations.
• Enhanced oversight of fraud, waste, and abuse (FWA) in public and private programs.
• A push toward operational efficiency and automation, reducing administrative burdens.
• Action Item: Now is the time to optimize cost structures, strengthen fraud detection capabilities, and leverage technology to improve efficiency and compliance.

External Market & Workforce Pressures

• Beyond direct healthcare policy changes, broader economic trends could shape the industry:
• Healthcare workforce challenges, requiring new talent strategies and operational efficiencies.
• Global trade and supply chain shifts, affecting costs for medical supplies and services.
• Employer-sponsored insurance adjustments, as organizations navigate tax and financial policy changes.

Action Item: Health plans should build resilience by assessing workforce strategies, supply chain risks, and cost containment opportunities.

Looking Ahead

As these discussions take shape, health plans that stay agile, scenario-plan, and optimize their operations will be better positioned for success. This PwC report provides key insights into the evolving healthcare landscape—worth a read for those preparing for what’s next.