Article

Three things
US Healthcare Payers
are prioritizing in 2026

John O'Day
VP, Citius Healthcare Consulting

05 - Mar

2026 marks a turning point for US healthcare payers, driven by a convergence of regulatory complexity, financial pressure, and rising consumer expectations that are reshaping competitive dynamics. Recent market research and industry surveys highlight three strategic priorities that will distinguish market leaders from laggards over the next 18 months.

1. Regulatory compliance as competitive advantage

The regulatory landscape in 2026 is not just about compliance. It is about turning mandates into market differentiation. The confluence of three major policy shifts is forcing payers to rethink their technology infrastructure from the ground up.

CMS Interoperability and Prior Authorization Final Rule
The CMS Interoperability and Prior Authorization Final Rule represent the most significant change. It,
- Maintains the existing 72-hour requirement for expedited requests.
- Compresses standard request timelines from 14 days to just seven calendar days, a 50% reduction that will significantly accelerate decision-making.
- Requires payers to implement HL7 FHIR-based Prior Authorization APIs by January 2027, signaling that technology modernization efforts must begin now.
One Big Beautiful Bill Act (OBBBA)
The OBBBA, comprehensive legislation signed into law in July 2025, introduces sweeping changes to government-subsidized health insurance programs. For payers, this means:
- More frequent eligibility determinations, requiring systems can process updates continuously and accurately.
- Real-time enrollment validations that demand infrastructure capable of responding with accuracy, transparency, and flexibility.
- Medicaid work requirements for able-bodied adults, increasing eligibility determination frequency.
- Limitations on provider tax funding mechanisms, requiring adjustments in financial and compliance workflows.
Industry surveys indicate that approximately one-quarter of payers are now prioritizing core system modernization specifically to meet these new requirements – not as a defensive move, but as an offensive strategy to improve operational efficiency while achieving compliance.

Expiration of enhanced ACA premium tax credits
The expiration of enhanced ACA premium tax credits on December 31, 2025, is projected to significantly impact individual-market stability. The Urban Institute estimates that approximately 4.8 million people will become uninsured without an extension, with 7.3 million losing subsidized marketplace coverage overall.^[8]

This contraction in membership is expected to worsen the risk pool and place additional pressure on individual-market economics. McKinsey research shows that healthcare industry EBITDA margins have already declined by 150 basis points since 2019, with payer margins in 2024 at their lowest point in a decade. These regulatory changes threaten to compress margins further.^[1]

The bottom line: Leading payers are not treating these regulations as isolated compliance projects. They are using them as catalysts to modernize platforms that have been limping along for years. Organizations that can simultaneously meet regulatory deadlines while reducing administrative friction will capture disproportionate market share as competitors struggle with manual workarounds.

2. AI-driven automation: From pilot purgatory to production scale

Healthcare payers have moved decisively past AI experimentation. According to EY's 2026 Healthcare Sector Outlook, US healthcare organizations are adopting AI applications at rates that outpace the broader economy by approximately three times.^[3] While health systems show adoption rates of 27%, payers have significant room for acceleration.

What's changed in 2026 is the focus: AI is no longer a technology curiosity but the primary weapon in the war against rising costs.

Managing costs remains the number one challenge for health plan executives for the second consecutive year, with projections indicating healthcare spending will reach $7.7 trillion by 2032. In response, industry surveys show that approximately one-third of payers now prioritize AI and automation to reduce manual processes. This makes it the top cost reduction strategy, displacing previous favorites like outsourcing and team restructuring.

The economic rationale is clear.

Healthcare professionals report losing time due to incomplete or inaccessible data in 77% of cases.
Nurses spend 15-20 minutes every hour on administrative tasks.
AI automation for billing increased from 36% to 61% between 2023 and 2024, making it the fastest-growing use case for predictive AI in hospitals.
Organizations using third-party or self-developed AI show billing automation rates of 73% compared to just 58% for those relying solely on EHR-sourced AI.^[7]

But here's the critical insight most analyses miss: the AI agents market in healthcare is projected to surge from $1.11 billion in 2025 to $6.92 billion by 2030, representing a compound annual growth rate of 44.1%.^[6] This is not just an incremental automation, it is a fundamental shift from scripted workflows to autonomous agents that can handle claims processing, prior authorization, member communications, and even provider outreach with minimal human intervention.

As one industry report describes it, we are witnessing a transition toward "intelligent agent economies" – subscription-based models with continuous learning systems that create measurable ROI through improved clinical outcomes, shortened diagnostic cycles, and streamlined claims processing.

The gap, however, lies in governance – and this represents both a significant risk and a competitive opportunity. Despite rapid adoption, industry research indicates that only about one-third of payers report having fully defined AI governance models and controls. This governance deficit creates substantial regulatory exposure, particularly as CMS increases scrutiny of automated decision-making in prior authorization and claims adjudication. Payers deploying AI without rigorous governance frameworks face potential enforcement actions, algorithmic bias liability, and erosion of member trust. Conversely, payers that can deploy AI at scale while maintaining robust governance will establish trust advantages that translate directly to member retention and regulatory favor.

The bottom line: Forward-looking payers in 2026 are moving beyond point solutions toward interconnected AI systems that continuously learn, adapt, and optimize across the entire value chain. The winners will be those who integrate AI deeply into their operational DNA rather than bolt it on as a productivity enhancer.

3. Closing the member experience gap: From payer to partner

One of the most striking findings in recent research is what can be termed "the perception paradox." Recent industry surveys reveal that 76% of payer executives believe their members view them as true partners in their healthcare journey.

The reality?

Only 51% of members actually share that view – a 25-percentage-point gap that represents billions in potential churn risk at a time when 27% of consumers report they are likely to switch health plans.

This is not merely a satisfaction problem; it is an existential threat in a market where margins are already at their lowest point in two decades. Payer EBITDA margins hit historic lows in 2024, driven by increased utilization post-pandemic, rising GLP-1 adoption, and membership losses following the expiration of the public health emergency.

To close this gap, leading payers are making three strategic investments:

Increasing auto-adjudication rates for faster claims processing.
Deploying increased personalization via data sharing.
Expanding omnichannel flexibility and member portals.

However, technology alone cannot solve this problem. According to Deloitte's 2026 Healthcare Outlook, 63% of surveyed executives expect strategic partnerships and joint ventures to become a higher priority this year. This reflects that payers cannot position themselves as true healthcare partners while maintaining transactional relationships with the broader ecosystem. Cross-sector collaborations, particularly with technology companies (70% plan to pursue such alliances), retail health providers, and community health organizations, are essential for delivering the holistic member experience that today's consumers expect.

The most sophisticated payers also recognize that member engagement is not about digital tools – it is about reducing friction at every interaction. This means AI-powered chatbots that can estimate costs and explain complex insurance terms, agents that can call providers on a member's behalf to verify network status, and predictive analytics that identify members at risk of adverse outcomes before crises occur.

The way forward

Regulatory transformation, AI-driven automation, and member experience redesign aren't independent initiatives. They're interconnected elements of a comprehensive transformation that will define payer competitive positioning in the years ahead.

The payers that will thrive in 2026 and beyond are those that recognize this moment for what it is: not a compliance burden or a cost crisis, but a strategic inflection point. Organizations that can simultaneously modernize infrastructure, deploy intelligent automation at scale, and fundamentally reimagine their relationship with members will emerge stronger. Those that treat these as separate, tactical projects will find themselves competing on price alone in an increasingly commoditized market.

The question facing every payer executive today is not whether to prioritize these areas – it is whether their organization has the strategic clarity, operational discipline, and cultural appetite for change necessary to execute on all three simultaneously. In 2026, partial transformation is not a viable strategy. The industry is undergoing a "great rebalancing,"^[11] and when the dust settles, the landscape will look fundamentally different than it did just 24 months ago.