New Year's Healthcare Predictions for 2026
2025: A Particularly Bad Year for Health
Over the past year, the Trump administration dismantled the core functions of HHS and closed USAID, eliminating health as an effective tool of "soft power" and more importantly leading to many thousands of deaths across the globe. Moreover, Congress passed consequential legislation, "the One Big Beautiful Bill" (OBBBA), that will have ugly consequences for millions of people.
Before making predictions, let's review what has occurred this year. This Administration:
undermined scientific independence, with career scientists sidelined, advisory processes shortened or bypassed, and evidence-based recommendations overridden for political considerations.
weakened the scientific integrity of vaccine policy through the appointment of anti-vaccine voices to the once-respected Advisory Committee on Immunization Practices (ACIP).
enacted deep cuts to federally funded medical research, including terminating billions of dollars from active research grants for cancer, child health, HIV/AIDs, among other vital research.
discontinued mental health and substance use disorder initiatives, particularly grants and demonstration programs aimed at community-based care and overdose prevention.
curtailed vital reproductive and maternal health programs, including funding restrictions and administrative barriers affecting family planning, prenatal care, and women’s health services.
politicized public health agencies, including increased political review of CDC guidance and limits on agency communications with states and the public. The politicization also includes misrepresentation on CDC websites and pulling of data sources vital to state and local public health and the public.
reduced support for pandemic and biosecurity preparedness, including staffing cuts and delayed investments in surveillance, stockpiles, and early warning infrastructure putting us at risk for the next pandemic or other public health emergency
changed policies/regulations overseen by the Assistant Secretary for Technology Policy (formerly ONC) that weakened long-standing guardrails on health data use, interoperability, and clinical safety—raising concerns about increased data misuse, erosion of patient trust, and the deployment of digital health technologies without sufficient accountability or evidence standards.
refused to expand enhanced subsidies for Affordable Care Act (ACA) premiums so that they are affordable for almost 24 million people that will lead to many having to forgo coverage and healthcare in 2026.
rolled back ACA protections, including weakened oversight of insurer compliance with coverage and consumer protection rules.
passed the OBBBA that will increase administrative burden on Medicaid recipients and on states, cut Medicare benefits and lead to many being left uncovered. Provisions in the OBBBA will not only lead to increased health inequities, but increase food insecurity and the national debt
proposed reductions to Medicaid and public health block grants, shifting costs to states and threatening coverage for low-income, rural, and disabled populations.
reversed the federal government's position that medical debts not be reported to credit agencies and considered by lenders.
over 300,000 federal employees across the federal government terminated, pushed out ("forked") or retired, including many HHS civil servant leaders, VA leaders and front-line health care employees and USAID that provides vital aid to our allies and partners.
These actions represented a broad retreat from evidence-based policymaking and significantly weakened the federal government’s role in safeguarding the public's health. Together with cuts to research funding, weakened public health infrastructure, and the politicization of scientific advisory bodies, these changes compounded systemic risks to patient safety, equity, and public trust in the healthcare system.
None of these changes will "make America healthy again" so expect more stories of frustration and harm due to these policies.
So What's in Store for 2026?
2026 will not see many fixes to what has been broken. But I predict changes that will chip away at some frustrations in healthcare. Here are my predictions for 2026:
1. Congress Will Extend the Enhanced ACA Subsidies
Under pressure due to the midterm elections and "affordability" being the buzz word for both parties, Congress will pass an extension of the ACA enhanced subsidies.
While there are standalone bills on increasing accessibility and flexibility for HSAs and providing direct payments to users of these accounts, they are not likely to pass due to the partisan divide with thin margins despite the Republican majority.
2. Congress Passes the First Bipartisan PBM Structural Reform Bill
Congress enacts legislation that forces functional separation between PBM (pharmacy benefit managers) rebate negotiation and pharmacy ownership (or at minimum bans spread pricing and retroactive direct and indirect fees nationwide). While not a full PBM breakup, the new law will materially reduce PBM profit opacity and shift leverage toward employers and states. Congress will feel empowered to act due to broad employer backlash, FTC scrutiny, and bipartisan state AG pressures.
3. Majority of States Mandate Real-Time Prescription Price Disclosure at the Point of Care
At least 28–32 states, including several GOP-led states, require insurers and PBMs to provide real-time, patient-specific drug prices to clinicians and patients before prescribing paired with strengthened enforcement. States appear to be moving faster than CMS, and conservative states increasingly frame this as “market transparency,” vs regulation.
4. CMS Expands Price Transparency Enforcement from Hospitals to Insurers and Begins Penalizing Noncompliance
Eventually and under pressure, CMS will enact meaningful financial penalties against insurers and hospital systems that technically comply but obfuscate usable pricing data, while also standardizing machine-readable formats that third-party tools can actually use. The rules already exist but enforcement and standardization have been the missing pieces.
5. Prior Authorization Is Simplified for High-Performing Clinicians
CMS and several states adopt “gold card” prior auth exemptions at scale, eliminating prior auth for clinicians with proven guideline adherence and low denial rates. Commercial insurers follow to stay competitive. This is already being discussed and piloted, is popular with physicians, and can potentially lower insurer administrative costs.
Additionally, states and CMS will begin publishing standardized denial and appeal rates by insurer, creating reputational pressure and enabling employers and consumers to compare plans on fairness and not just premiums.
6. Employer Coalitions Bypass Traditional Insurance for High-Cost Care
Large employers increasingly use direct contracting, bundled payments, and reference-based pricing for surgeries, oncology, and specialty drugs, shrinking the role of traditional insurers and PBMs in high-cost episodes. While the ACA price increases have been getting most of the media attention, employer-based insurance has also become unsustainable. Employers are done waiting for federal reform and now have data and scale to seek new ways of providing their employees coverage.
7. “Healthcare Administrative Harm” Becomes a Recognized Policy Category
Lawmakers and regulators will explicitly acknowledge administrative burden as a patient safety issue, leading to:
New reporting requirements on clinician time spent on non-clinical tasks
Pilot programs tying payment to administrative simplification
Early movement toward “administrative MIPS” measures
8. GOP-Led States Advance AI Guardrails Focused on Children, Behavioral Health, and Prior Authorization
Rejecting the Trump administration's anti-regulatory stance concerning AI and with additional pressure from AI companies that want guidance, a coalition of red and purple states will pass AI guardrail laws that:
Ban autonomous AI decision-making for pediatric mental health and crisis care
Require human review for AI-driven coverage denials
Mandate audit trails for clinical AI models affecting children
9. The Healthcare AI Market Consolidates as Growth Slows and Proof Replaces Promise
Growth in healthcare-focused AI companies slows noticeably (maybe not a bubble burst) not because AI fails, but because buyers demand evidence, integration, and liability clarity, largely because healthcare institutions are not experiencing financial ROI. Investment shifts away from horizontal “AI-for-everything” startups toward companies that are:
Deeply embedded in clinical workflows
Focused on narrow, high-value use cases (documentation, imaging support, revenue cycle simplification)
Willing to assume contractual accountability for accuracy, bias, and uptime
Increased state regulatory scrutiny, provider fatigue with pilots, and the end of tolerance for unvalidated tools will cause these changes. Therefore, fewer but stronger companies emerge. Winners are those aligned with providers and patients and not payers seeking automation for utilization control. Many lightly differentiated startups are acquired, pivot, or exit the market.
10. Physicians Elected in High Numbers for Congress
The 2026 election produces the largest number of physicians in Congress in decades due to healthcare access and affordability being among the top issues for voters. Physician burnout is translating into political candidacies, and voters trust clinicians more than career politicians on healthcare.
Conclusion
While some of these incremental moves may have some impact, it will be minimal and patients and physicians will continue to be frustrated. Real reform cannot happen until the mid-term elections when the Democrats, with more of an appetite for health care reform, are predicted to become the majority in the House and have the potential to also take over the Senate (though less likely). If this happens, then 2027 will be an opportunity to provide real oversight, holding HHS political appointees accountable for the harmful Trump Administration changes, and to put forward healthcare reforms that will truly and more effectively benefit patients.