The ground is shifting beneath the healthcare industry, and payers know it. With federal Medicaid funding under scrutiny, ACA subsidies set to expire, value-based care models continuing to evolve, and state legislatures moving at their own pace on everything from AI oversight to reference-based pricing, health plans are facing a policy environment that demands more than careful monitoring — it demands genuine adaptability. The next 12 to 24 months will test not just the operational resilience of payers, but their strategic clarity about what they stand for when the rules of the game are still being written.
What’s striking about how leading payers are responding is the degree to which the most forward-thinking organizations are refusing to simply wait and react. Instead, they are doubling down on the fundamentals — strengthening provider relationships, investing in flexible plan designs, deepening community partnerships and building the data infrastructure needed to move quickly when policy does shift. Becker’s asked 15 health plan leaders how they’re preparing for potential shifts in federal and state policy six months to a year from now.
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Editor’s note: Responses have been lightly edited for clarity and length.
QUESTION: How are you preparing for potential shifts in federal and state policy over the next 12 to 24 months?
Dennis Depenbusch. Director of New Ventures Initiative for Blue Cross and Blue Shield of Kansas (Topeka, Kan.): The only constant in this environment is change. Payers need to have more agile systems than ever before to react to shifts in federal and state policy, be it changes in benefits or substantiating documentation. Standing still is not an option anymore from a systems and communications perspective.
Ruchika Talwar, MD. Medical Director, Office of Episodes of Care Population Health, Urologic Oncology, Vanderbilt University Medical Center (Nashville, Tenn.): With federal regulations and CMS reaffirming value-based care, especially in high cost and complexity specialty and surgical populations, our team at Vanderbilt Health is laser focused on provider behavior as the most powerful lever —not policy itself. We’re aligning incentives, feedback and care pathways to reinforce high-value decision-making and ensure we’re rewarded for the high-quality care we already deliver. That foundation allows us to adapt quickly, regardless of how federal or state policies evolve.
Erin Weber. Chief Policy and Research Officer for CAQH (Washington, D.C.): Across both federal and state landscapes, we are preparing for a range of pathways, including more voluntary, market-driven approaches alongside traditional regulatory frameworks. That means investing in flexible infrastructure, strengthening partnerships and ensuring our data and insights can support stakeholders regardless of how policy evolves. We are also staying closely engaged with policymakers and industry leaders to help shape practical, scalable solutions and ensure alignment between public and private sector efforts, avoiding duplication that can inadvertently create additional friction. Ultimately, our focus is on advancing more efficient, connected business processes in healthcare through collaboration, innovation and delivering meaningful value across stakeholders.
Harlon Pickett. President of Eagle Care Health Solutions (Austin, Texas): We are preparing for potential policy shifts by building strategies that are resilient regardless of regulatory direction. The reality is that federal and state policy can change quickly, but the underlying challenges in healthcare remain the same. Costs continue to rise, access remains inconsistent and complexity continues to burden employers and patients.
Rather than trying to predict every policy change, our focus is on designing models that adapt while maintaining affordability and quality. That means prioritizing flexible plan designs that can accommodate evolving regulations while maintaining a strong foundation in transparency, data-driven decision-making and aligned incentives. It also means staying closely engaged with regulatory developments so we can proactively adjust, rather than react after the fact.
Equally important is educating employers and members. Policy changes often create confusion and confusion leads to poor decisions and higher costs. By helping stakeholders understand their options and the implications of new regulations, we can reduce disruption and maintain continuity of care. Ultimately, the goal is not to chase policy. It is to build a healthcare strategy that works in any environment by focusing on what consistently drives better outcomes: access to high-quality care, informed decision making and disciplined purchasing.
Kevin Knight. Chief Marketing Officer for Sidecar Health (El Segundo, Calif.): On one hand, it’s encouraging to see serious policy discussions. On the other hand, it’s alarming to see how many people want nothing more than minor tweaks.
A good example is CMS’ proposed change to allow network-free plans on the exchanges. Networks have failed on every front: costs have kept rising, out-of-network billing — especially for mental healthcare — has saddled families with crippling medical debt, and the tug-of-war between payers and providers has turned doctors into paper pushers.
Worse, in many markets, narrow exchange networks are so restrictive that families technically have coverage but can’t actually access care. If that rule goes through, it’ll be fascinating to see how good old-fashioned competition works its magic on our broken system.
Caleb Hemmer. Vice President of Sales for Belong Health (Philadelphia): We expect policy changes over the next 12 to 24 months to push Medicare Advantage toward greater accountability, specialization and cost discipline, which aligns closely with Belong Health’s focus. CMS will likely continue emphasizing chronic condition models and more rigorous care management, particularly in [dual-eligible special needs plans], which we see driving interest in expanding [chronic-condition special needs plan] strategies alongside stronger clinical operations.
At the same time, potential Medicaid policy shifts, including work requirements, may increase churn among dual-eligible populations, reinforcing the need for flexible, longitudinal care models that maintain engagement. With anticipated rate pressure, plans will need to more aggressively reduce unnecessary costs, especially among complex Medicare members, while preserving quality.
Additionally, the mandatory ambulatory specialty model will require plans to better engage specialists in value-based care, an area where many are not yet fully prepared. Overall, we see these changes accelerating demand for the kind of clinically focused, value-based infrastructure that we help plans build and operate.
Nishant Anand, MD. President and CEO of Altais (Oakland, Calif.): Policy will continue to evolve, but the underlying direction is clear: greater accountability for cost, quality and access. We’re preparing by focusing on what matters most — building the capabilities that help physicians succeed in value-based care at scale.
That includes reducing administrative friction, strengthening care management and aligning incentives so that doing the right thing for patients is also the easiest thing for clinicians. We’re also thoughtful about how we deploy technology, including AI, to support clinical judgment and create more space for human connection in care.
Ultimately, the goal isn’t to react to policy — it’s to build a care model resilient enough to thrive under any policy environment.
Mark El-Tawil. Chief Administration and Finance Executive for Blue Cross Blue Shield Arizona (Phoenix): First, we are staying on top of what the specific changes actually will be and how and when they will be rolled out to make sure our analysis does not get stale or stuck in expectations we have today.
We know these kinds of changes do not always come together as initially expected and we have a great team of government relations folks led by a recently-hired former leader from the Arizona legislative branch but that also includes consultants at both the state and federal levels to make sure we have our finger on the pulse of coming changes and, where appropriate, we also engage constructively with policymakers to help educate and inform implementation considerations and unintended consequences.
Second, we are engaging with leadership from across the industry to make sure we understand how others are expecting to be impacted, both payers and providers but especially our provider partners, so that we can ensure our planning contemplates not just changes that impact us directly in our businesses but also our partners in the delivery of care to our members.
We are adjusting our business plans, both near term and longer term, to accommodate the coming changes. We recognize that even changes that are intended to be limited to certain, specific, direct impacts will have broader consequences across the healthcare ecosystem than what is specifically intended and so we must re-think and adjust our business plans, our offerings and our cost structure much more broadly than would be required if our focus were limited to the intended consequences.
We know we don’t know exactly how all the coming changes will affect all our constituents, so we will continue to be ready to adjust as needed.
Latha Raja Shankar. Chief Medical Officer of Blue Cross Blue Shield of New Mexico (Albuquerque, N.M.): As a company with nearly a century of experience navigating changes in both state and federal policy, HCSC remains focused on our mission to ensure access to affordable healthcare for all. We are closely monitoring potential shifts in Medicaid reimbursement, particularly as they affect rural communities and the broader delivery system.
Our strong local presence enables us to stay attuned to evolving needs, support providers and drive improvements in affordability and population health. We are proactively adapting to policy developments to continue supporting our members and partners.
Meredith Duncan, President and CEO of Texicare (Austin, Texas): Policy shifts are a constant in healthcare, what changes is whether you’re ready for them and how you’ll adapt to create the best possible outcomes for your members.
For Texicare, that foundation starts with our parent company, Texas Mutual Insurance Co., whose 30-year track record navigating Texas’ regulatory and legislative landscape gives us a trusted level of institutional knowledge that informs how we prepare and evolve. Our primary goal in the coming years is to invest in our relationships with our regulators, and most importantly, the communities and people we serve.
Shawn Larsen. Vice President of Quality Stars for Medica (Minnetonka, Minn.): Over the next 12 to 24 months, I’m focused on keeping our organization agile as federal and state policy continues to evolve across Medicare, Medicaid and commercial markets. We’re closely tracking policy direction while strengthening the core capabilities that matter most — quality performance, affordability and member experience.
At the same time, we’re investing in strong governance, data and analytics so we can adapt quickly and make informed decisions as new requirements emerge. As a nonprofit health plan, our goal is to remain compliant and financially sound while delivering meaningful outcomes for the communities we serve.
Rhonda Mims. Executive Vice President of Chief Public Affairs and Risk Officer for AmeriHealth Caritas (Newton Square, Pa.): Our focus is on being a strong partner to states where we operate, along with the federal government, by bringing expertise and innovation to policy implementation. As policy changes create new demands, good health outcomes must still guide our work to help keep eligible members enrolled and minimize disruption to their care.
Beth Roberts. President and Chief Executive Officer of Blue Cross Blue Shield Vermont (Berlin, Vt.): The affordability crisis in Vermont is significant — as our residents spend nearly 20% of their income on healthcare, more than double the national average. We’re working alongside our legislature to shape new policies to address affordability, including preparing for and shaping the implementation of reference-based pricing, which has the potential to deliver significant savings for Vermonters, especially for high volume services like labs and radiology.
Blue Cross VT is also delivering meaningful savings to members through enhanced payment integrity reviews, generating tens of millions of dollars in savings. At the same time, we’re evaluating our product portfolio to expand plan options across a range of price points, while continuing to support growth in our Medicare supplement plans.
Felix Aguilar, MD. Quality Medical Director for L.A. Care (Los Angeles): At LA Care Health Plan, we are preparing for possible changes in federal and state policies with urgency and responsibility. We are sincerely concerned about the instability these changes could create — both for our communities’ access to care and for the overall strength of the healthcare system in our region.
As a publicly operated health plan, our mission is to provide access to high-quality healthcare for nearly 2.5 million vulnerable and low-income members in Los Angeles County and to support the safety net system that enables this. That mission guides every step we take.
One of our main strategies is embracing our role as a convenor. LA Care has brought together leaders from across the Los Angeles County safety net to identify shared priority areas that will enable us to collaborate more effectively to strengthen the delivery system and better support patients. This approach ensures we coordinate efforts among hospitals, clinics and community partners.
LA Care works with hospitals and other providers to improve post-acute care. This includes improving transitions of care, reducing avoidable readmissions and increasing coordination between hospitals and skilled nursing facilities to help patients recover safely and smoothly.
At the same time, with a record number of people likely to lose access to care in the next 12 to 24 months, we are doing everything possible to ensure timely access to comprehensive and effective primary care. Our goal is to make sure that patients — especially those most at risk — receive the care they need without delay.
Together, these efforts show our dedication to keeping access open, supporting the safety net and preparing Los Angeles for any policy changes.
Deborah Adewale. Investor for Care First (Washington, D.C.): As a fund, we prioritize monitoring federal and state healthcare regulations to guide our investment strategy. Right now, the industry is bracing for the 2027 expiration of ACA subsidies and the implementation of Medicaid work requirements, while navigating emerging state rules on AI utilization.
This creates a paradox for healthcare enterprises and startups: AI is the most effective tool for lowering administrative costs to prioritize care, yet it faces increasing scrutiny and ongoing testing and iteration. With this in mind, we believe the best path forward is a disciplined focus on core operations: identifying underinvested categories that benefit from new tech, while advising a balanced adoption of AI. Our goal is to ensure clear ROI without creating a risky dependence on any single vendor or solution.
At the Becker's 5th Annual Fall Payer Issues Roundtable, taking place November 2–3 in Chicago, payer executives and healthcare leaders will come together to discuss value-based care, regulatory changes, cost management strategies and innovations shaping the future of payer-provider collaboration. Apply for complimentary registration now.
