Across healthcare, executives point to critical choices around technology investment, benefit design, care models and financial sustainability as key drivers of long-term success.
Many health plan leaders told Becker’s success will depend on moving from incremental improvements to more intentional, long-term strategy. That includes strengthening core capabilities, improving alignment across the healthcare ecosystem and maintaining a disciplined focus on affordability and outcomes. Organizations that balance innovation with operational rigor will be best positioned to navigate uncertainty and sustain growth.
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Editor’s note: Responses have been lightly edited for clarity and length.
Question: What decisions being made today will define the next five years for health plans?
Vishal Kaushik. Director of Strategy Advancement for Humana (Louisville, Ky.): It should come as no surprise, but there is a strong emphasis on investments and solution development of advanced digital and AI tools across the payer value chain — especially within personalized touchpoints/engagement. Decisions today are focused on the transition away from fragmented pilots to full-scale implementations that are agentic. The operating structure can differ, and some organizations are choosing federated models. In parallel, member health outcomes and cost containment continue to be front and center. Organizations are looking to expand access channels for coordinated care models and preventive services to help with early detection and personalized treatment plans. This ensures that member health remains the top priority while also unlocking options for cost controls.
Gretchen Wagner. Associate Vice President of Risk Management for Humana (Louisville, Ky.): The choices health plans make today about how boldly they invest in next generation data infrastructure, responsible AI and whole-person care models will set the trajectory for the next five years. As risk landscapes evolve, organizations that shift from reactive cost management to proactive risk mitigation — using predictive insights, intelligent automation, and deeper partnerships across the care ecosystem — will redefine what members and providers expect. Ultimately, the future will favor plans that build for adaptability now: those able to rapidly translate innovation into trust, simplicity, and better outcomes at scale.
Ken Kim, MD. Chief Medical Officer of Alignment Healthcare (Orange, Calif.): Over the next five years, health plans will need to continue to be disciplined on navigating evolving CMS policy around risk adjustment, star quality and affordability and medical management. Those that combine advanced analytics with high-touch, coordinated care to deliver clinical outcomes and address social determinants — like transportation, economic barriers, lack of support and enhance the member’s ability to age at home — will define success for Medicare Advantage plans in the future.
Ilan Shapiro, MD. Chief Health Correspondent and Medical Affairs Officer and Senior Vice President of AltaMed Health Services (Los Angeles): The decisions health plans make today around data integration, artificial intelligence and prevention will shape performance for the next five years. Plans that invest in AI to identify risk early, personalize interventions, and streamline operations will improve outcomes while controlling costs. Equally important is a stronger commitment to prevention and whole-person care, including nutrition, behavioral health and social drivers of health. Finally, collaboration across plans and providers to manage care transitions seamlessly, especially for patients who move between coverage types, will determine whether we reduce fragmentation or continue to pay for avoidable complications.
Kevin Knight. Chief Marketing Officer of Sidecar Health (El Segundo, Calif.): Everyone knows that health plans face pressure from all sides: members are frustrated by complicated processes and limited access to care and investors are anxious about profitability — especially in the face of rising healthcare costs. The question is whether health plans will go back to the future, expecting different results from the same old tactics of narrowing networks and restricting care, or whether they’ll look seriously at overhauling the model itself. Network-based healthcare has run its course. The question of the day is simply: What comes next? If we look to the pattern that played out during the end of pension plans, the answer likely lies in a more consumer-oriented model, where members have more accountability for costs but more empowerment over their care decisions.
Jeff Bak. President and CEO of Imagine360 (Wayne, Pa.): The decisions health plans make today — whether to stay the course or pursue fundamentally different models — will shape the next five years for employers and their employees. Healthcare costs are projected to rise another 30%-40% over that period, a pace that simply isn’t sustainable. As a result, more employers of every size are exploring alternatives, and for good reason. Every organization should be reassessing its options to ensure its health plan supports both employee health and long-term affordability. Continuing to rely on traditional strategies will only intensify financial pressure. Real progress requires challenging the status quo and adopting more cost-effective approaches, including strategies like reference-based pricing to ensure fair, transparent rates for essential care.
Steve Yurjevich. Payer Market CEO for Optum Insight (Eden Prairie, Minn.): Payers are at a critical moment where removing friction from the healthcare experience is paramount. It is the key to creating long‑term value for the people and communities they serve. When access to care is slowed by administrative steps, everyone feels the impact. By bringing real‑time data and responsible AI into core processes like prior authorization, clinical decisioning, billing and processing, we can accelerate access to needed services and simplify the experience for both clinicians and members. This level of integration reduces waste, strengthens trust and helps ensure that savings are reinvested back into affordability and better health outcomes.
Whitney Stidom. Vice President of Consumer Enablement for eHealth (Santa Clara, Calif.): The decisions that will define the next five years for health plans are those that put consumers at the center and move beyond one-time enrollment transactions to lifelong relationships. In 2026 and beyond, plans that invest in data, technology, and connected experiences will be best positioned to guide members not just during open enrollment, but throughout major life stages and coverage transitions. That means using smarter tools and insights to personalize plan selection, anticipate changing needs, and deliver year-round support. Health plans that treat their book of business as an ongoing relationship rather than an annual event will drive stronger retention, deeper trust and better outcomes for the people they serve.
Dan Zohorsky. Managing Partner of Healthworx (Baltimore): Over the next five years, the most defining decisions for health plans will center on where to compete and how to transform core technology infrastructure. Choices around participation in Medicaid, Medicare Advantage, and the ACA will determine revenue mix, regulatory exposure and margin durability; plans must decide whether to double down on government programs with disciplined footprints or retrench to protect profitability. At the same time, investment in AI and modern data infrastructure will separate incremental cost cutters from structurally advantaged operators, particularly in areas like risk adjustment, care management, utilization management and member engagement.
Rob Andrews. CEO of Health Transformation Alliance (Westmont, N.J.): The decisions that will define the next five years for health plans capture a fundamental choice: Do we want to pursue a fee for service status quo or an outcome-based future? GLP-1s, gene and cell therapies are already reshaping pharmacy spending and exposing the limits of opaque, fee-for-service models. At the same time, emerging technologies will make it possible to match the right drug to the right patient. This shift moves prescribing beyond formularies driven primarily by economics and toward treatment decisions informed by genetics and comorbidities, where a drug can be highly effective for one patient, ineffective for another and occasionally harmful for others. Plans must decide whether to demand full data access and align payment to outcomes or continue absorbing escalating costs without the tools to control them.
Patrick Quigley. CEO of Sidecar Health (El Segundo, Calif.): The decisions that will define the next five years for health plans are simple: Do you double down on controlling care, or do you finally trust and empower the people providing it? Plans that continue to rely on prior authorization, narrower networks and cost-shifting are choosing friction over value, and that path leads to further alienation of the very people health plans are meant to protect. The plans that win will eliminate barriers, make pricing truly transparent and align incentives so that smart decisions lower costs for everyone, not just the insurer. In five years, the market won’t reward the biggest network, it will reward the model that delivers access, clarity and economic sanity.
Saria Saccocio, MD. Chief Medical Officer of Essence Healthcare (St. Louis): The decisions that will define the next five years for health plans center on sustainable benefit design, smart technology adoption and meaningful member support. Plans must deliver financially responsible benefits that meet real needs, including transportation, food, medicine and dental coverage, while addressing social determinants of health and advancing equity within the communities they serve. At the same time, AI and automation must enhance the human touch, using tools such as wearable-enabled sleep apnea detection, integrated with primary care to drive earlier intervention, stronger member experience and better outcomes.
Brett Bingham. Chief Network Development Officer of Banner Plans and Networks (Phoenix): The most consequential decision health plans will make over the next five years is whether we are ready to put primary care back at the center of health care delivery. Through years of misaligned incentives and inadequate compensation, the current system has incentivized primary care to function as “order takers and referral makers,” undermining outcomes, quality and affordability. While advanced analytics, automation, AI and interoperability are foundational to healthcare’s future, we must intentionally partner with providers built for integrated care models, aligned incentives and accountability for the right outcomes. The reality is simple: you get what you pay for, and it’s time to pay for prevention.
Kimberley Graham. Patient Access Director of AltaMed Health Services (Los Angeles): The decisions surrounding artificial intelligence adoption, governance and integration will significantly shape both care delivery and financial performance in the years ahead. AI is already being applied in areas that directly influence quality, patient satisfaction and cost, such as prior authorization automation, risk stratification and patient outreach. Health plans are embracing AI to improve efficiency, prevent avoidable hospitalizations and reduce administrative burden. How these tools are implemented will guide investment strategies and require thoughtful monitoring of member acceptance, along with careful attention to ethical oversight. Today’s decisions about AI are certainly about technology, but even more so, they are about affordability, equity and access in the future of care delivery.
Chris Gay. CEO of Evry Health (Dallas): Infrastructure, infrastructure, infrastructure. The plans that thrive in the next five years will be the ones that made the hard decision today to build modern technology responses to the needs of the populations we serve. How we reach and serve our members will be different in five years, will require more flexibility and must be more financially efficient.
Nora Leibowitz. Chief Medicaid Program Officer for CareOregon (Portland): The defining decisions for health plans over the next five years will be about sustainability and focus. As policymakers revisit eligibility, benefit structures and funding models, plans must prepare for greater volatility while preserving access and quality. At the same time, leaders must resist the temptation to chase every new technology solution and instead invest in capabilities — data integration, care coordination and community partnerships — that meaningfully improve outcomes. The plans that thrive will be those that combine fiscal discipline with a clear commitment to the populations they serve.
