Payer Priorities 2026: Balancing Cost, Compliance, and Connection in a Time of Disruption 

The HealthEdge® 2026  Annual Payer Report, “The Great Rebalancing: Inside the New Realities Shaping Health Plan Performance,” reveals how health plans are navigating growing financial pressure, complex compliance demands, and rising expectations from both members and providers.

Based on responses from more than 550 executives across commercial, government, and dual-eligible plans, the report highlights how today’s leaders are rethinking investment strategies to stay competitive in an increasingly unpredictable environment.

5 Key Priorities for Healthcare Payers in 2026

Survey responses indicated that there are five key areas where health plan leaders are focusing their strategic attention in the year ahead. Instead of waiting to react to industry changes, executives are investing in tools that empower their teams to be proactive in addressing market demands.

1. Cost Pressures Reach a Tipping Point

For the second year in a row, cost containment is the top priority for payers, driven by the projected rise in U.S. healthcare spending to $7.7 trillion by 2032. With financial pressure mounting across all corners of the system, from shrinking plan margins to increasing member cost-sharing, executives are focusing their strategies on operational transformation.

• 34% are using artificial intelligence (AI) and analytics to automate manual work and reduce rework
• 27% are prioritizing core system modernization to eliminate inefficiencies
• 26% are investing in digital engagement tools to scale service and improve efficiency

These strategies signal a shift toward structural change, not just incremental savings.

2. OBBBA Drives Enrollment Uncertainty and Strategic Realignment

With the One Big Beautiful Bill Act (OBBBA) introducing more dynamic eligibility requirements and real-time enrollment validations, payers are navigating a new level of scrutiny. These changes are prompting leaders to rethink how they manage data, collaborate with providers, and assess risk.

Key payer responses include:

• 25% are expanding provider collaboration to enable real-time clinical data sharing
• 19% are enhancing risk assessment models to stay ahead of eligibility disruptions
• 17% are tightening data validation controls across administrative systems

As enrollment data becomes more fluid and more consequential, payer success will increasingly depend on infrastructure that can respond in real time with accuracy, transparency, and flexibility.

3. The Member Experience Perception Gap

The 2026 Payer Survey also revealed a clear disconnect between how payers and members view the plan-member relationship. According to the 2025 HealthEdge Consumer Report, 76% of payers believe they’re seen as true partners in care—while only 51% of members say the same. This 25-point gap has business implications: 27% of consumers say they’re likely to switch plans this year.

Based on their responses, health plans are taking steps to strengthen engagement, including:

• Investing in omnichannel communication and mobile tools
• Offering self-service options and virtual assistants
• Increasing personalization with health recommendations and incentive programs

While digital solutions are expanding, the challenge is ensuring they translate to meaningful connections and long-term loyalty.

4. Provider Engagement: Payers Focus on Self-Service and Accuracy

The survey highlights persistent challenges in provider engagement, with many health plans struggling to streamline interactions and reduce administrative burden. When asked about the biggest barriers to effective provider collaboration, payers cited the following challenges:

• Delays in claims processing
• Delays in responding to prior authorization requests
• Lack of self-service tools
• Limited access to real-time data

In response, payers are taking practical steps to improve operational efficiency and rebuild trust. The most common actions include improving payment accuracy (38%), expanding value-based care contracts (35%), and investing in modern provider data management systems (33%).

While provider relationships are not always viewed as a top strategic priority, these efforts show that many payers recognize the connection between strong provider collaboration and their ability to meet broader goals around compliance, cost containment, and member satisfaction.

5. AI Adoption Accelerates and the Gaps Are Becoming Clearer

AI is rapidly becoming embedded in health plans’ day-to-day operations. According to the survey, 94% of payers have gone live with AI tool or are actively adopting one, demonstrating how quickly the industry has moved past pilot experimentation. Nearly half of executives (47%) reported either widespread adoption or active departmental use across their organizations.

Yet while AI usage is accelerating, adoption is not uniform across the industry. Mid-sized plans (2–10M lives) are 30% more likely than their peers to report widespread AI adoption. Plans serving Dual-Eligible and Military/Veteran populations lead adoption by more than 10 percentage points over other segments.

Confidence in AI tool use also varies by role: 31% of executive leaders believe their organizations have achieved widespread AI adoption, compared with only 3% of operational and regulatory leaders, revealing a notable perception gap between leadership expectations and on-the-ground implementation.

While AI adoption rates may be high, operational readiness is uneven. Only 31% of payers report having a fully defined AI governance model with standards, guardrails, and accountability structures in place. The remainder are at varying levels of maturity:

• 44% have established some guidelines but are still refining them
• 28% are in exploratory or early pilot phases
• 16% are researching use cases without live implementations
• 6% have no governance in place at all

This gap underscores a growing operational risk for some payers. As AI becomes more deeply woven into claims workflows, care management, member engagement, and payment accuracy, health plans will need robust oversight to avoid compliance issues, algorithmic bias, and unintended administrative impacts.

The Next Phase: Agentic AI and BPaaS Models

The report highlights that AI’s momentum is pushing the industry toward a new operational paradigm. Future-state BPaaS models, powered by agentic AI systems capable of autonomous action, are expected to shape the next era of automation. According to the research, these models will help payers streamline end-to-end workflows, improve accuracy, and achieve real-time responsiveness across high-volume processes.

For payers, this shift represents more than a technology upgrade. It marks a transition toward adaptive, continuously learning operations, where AI augments human expertise and supports the demands of cost containment, compliance, and service excellence.

Looking Ahead to 2026

This year’s survey reveals an industry reshaping its foundations in response to economic, regulatory, and stakeholder demands. As payers work to modernize technology, streamline operations, and deepen collaboration with members and providers, those who invest in agility and connected infrastructure will be best positioned for sustainable growth.

Download the full 2026 report to learn more about how health plan leaders are preparing for the pressures and demands of the year ahead.

At HealthEdge, we partner with more than 130 health plans to support that transformation. Explore how we can help you move faster, reduce costs, and build stronger relationships across your ecosystem. Request a demo to see how the integrated HealthEdge solution suite can support your organizational goals.