The forces reshaping health plans over the next several years are converging fast. Across the industry, executives and clinical leaders point to three trends that will define which organizations will thrive: the rapid maturation of AI from pilot projects into core operational workflows, the intensifying pressure to make healthcare genuinely affordable, and the rising tide of consumer expectations for transparency, simplicity and personalized care.
Becker’s asked 16 health plan executives which trend they think will most influence health plans over the next few years.
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Editor’s note: Responses have been lightly edited for clarity and length.
Question: What trend will most influence health plans over the next few years?
Vishal Kaushik. Director of Strategy Advancement, Humana (Louisville, Ky.): The trend that I’d flag as most consequential for health plans over the next few years is Agentic AI moving out of administrative pilots and into core revenue-centric and clinical-adjacent workflows. This is being driven by heavy margin pressure and as medical loss ratios near regulatory ceilings. It feels like there are very few conversations one can have without AI making its way into the mix; this is with good reason. Operators within health plans are already past experimentation and are now into the mix of workflows where revenue actually lives: utilization management, claims, risk adjustment, enrollment, etc. But the important backdrop here is to ensure traceability and auditability in decisions being made. Everyone is racing to deploy agents. The race that matters is who can deploy them defensibly.
James Grana. Vice President of Value Based Care Programs, Network Development and Contracting for BlueCross BlueShield of South Carolina (Columbia): The biggest financial trends will continue to center on pharmaceuticals (GLP-1, gene therapies, etc.) and, separately, behavioral health costs. Cost trends in these two domains will impact both public policy and pricing. From an operational standpoint, the biggest trends will center on the use of AI. Plans are just scratching the surface on how they might employ AI to improve efficiency and delight both plans sponsors and insured members.
Kevin Knight. Chief Marketing Officer for Sidecar Health (El Segundo, Calif.): Price transparency — and not just because regulators and an expanding chorus of bipartisan leaders are demanding it. Consumers now expect healthcare to work like every other part of the economy — and it increasingly does. In fact, the growth of direct-to-consumer healthcare companies offering transparent prices on everything from labs and GLP-1s to therapy and primary care has even boosted HSA adoption. As more Americans look to take control of their own healthcare, health plans have to adapt to a shoppable healthcare model. Those that don’t are going to end up looking a lot like the long-distance phone and taxi industries, characterized by bloated costs, unnecessary friction, and a sense that nothing really needed to change. Until suddenly everything did.
Siva Balu. Senior Vice President of Chief Information and Digital Officer for Quartz (Madison, Wis.): Over the next few years, customer experience will be a leading trend, nothing like we have seen in healthcare so far. Customers will demand affordability and access to care in an easy way similar to their retail experience. Using modern technologies like generative AI, customers will do their own research, educate on trends and will be prepared to have a much deeper, meaningful conversation with their health plans and providers. Customer experience is not just customer service, but their whole health, including preventive care, pharmaceutical and therapeutic needs, any complex or specialty care — all leading to better health outcomes. “Consumer-driven healthcare” will be a leading indicator. Other key customers like employers will demand better transparency into their healthcare spend. The role of technology, data analytics and AI will be to bring disconnected systems and information together to look at the patient as a whole person. Regulations such as interoperability will drive some of these changes, but the customer expectations will evolve significantly to ensure the consumers have their data in the palm of their hand to make better decisions. Health plans, their partners, providers will find innovative ways to continue to improve the customer experience while gaining efficiencies and improving the outcomes.
Uche Olekanma, MD. Vice President of Clinical Operations for Blue Cross Blue Shield of Arizona (Phoenix): The most significant trend shaping health plans is the convergence of rising cost pressures with the shift to digitally enabled, value-based care.
For clinical operations leaders, this represents a move from traditional utilization management to actively orchestrating care delivery.
Cost and utilization pressures continue to intensify, driven by specialty drugs, higher service use, and growing behavioral health demand. At the same time, care is shifting from inpatient hospitals to lower-cost ambulatory and virtual settings, requiring tighter alignment across utilization management, provider networks and site-of-care strategies.
Finally, AI and advanced analytics are transforming clinical decision-making, enabling more proactive interventions, faster authorizations, and increasingly personalized care pathways.
Jonathan Baran. Co-founder and CEO of Self Fund Health (Madison, Wis.): The trend that’s going to reshape health plans is the slow recognition that for 40 years employers have been buying health insurance — risk transfer with a markup — when what they actually need is to purchase healthcare. Those are different disciplines, and the insurance model has spent decades making sure no one in the value chain is a real purchaser. As self-funding spreads, employers are stepping into that role themselves, and they’ll behave the way they do in every other category of spend: aggressive buyers who pay for value and walk away from the rest. For hospitals, that means the next generation of contracting won’t hinge on network status — it’ll hinge on whether your price, outcomes, and patient experience hold up when a sophisticated buyer is comparing you to a cash ASC, an independent specialist, or a bundled-rate competitor down the road. The health plans that thrive will be the ones that help employers buy well; the ones that don’t will look increasingly like middlemen with nothing to sell.
Elizabeth Signorella. Senior Director of Payor Contracting for Clover Health (Franklin, Tenn.): The trend that will most influence health plans over the next few years is the shift toward AI-focused clinical delivery. Deploying advanced technology directly into the clinical workflow at the point of care can deliver high-density, comprehensive clinical intelligence, rather than just broad-based administrative automation elsewhere in the business.
Crucially, the success of this trend hinges on continued provider empowerment and clinical integrity. Maintaining the primary care provider’s central role as the decision-maker ensures that technology functions as a support tool, not a mandate engine.
An AI-focused, provider-led model will prove increasingly influential because it can help solve critical challenges for health plans like Quality and Outcomes, Cost Management, and VBC Engagement. For Clover Health, this is driven by Counterpart Assistant, an AI-powered physician enablement platform that provides clinically intuitive insights to help clinicians better manage chronic conditions and deliver high-quality care.
Karen Johnson. CEO of Clever Care Health Plan (Huntington Beach, Calif.): In the next few years, the biggest shift for health plans will be the move from a transactional claims-paying mindset to truly managing total health outcomes, improving affordability, and creating a positive experience for both members and providers. That will require a real transformation in how plans set their strategies and priorities around outcomes, quality, and total cost of care. At the same time, members and providers will demand more personalization, transparency and simplicity, which they expect health plans to deliver through smarter digital tools and technology. This is especially critical in Medicare Advantage, where trust, supplemental benefits, and the overall experience are the key factors that drive growth and retention. The plans that come out ahead will be the ones that can connect all of these priorities together while staying committed to putting their members first.
Beth Roberts. President and CEO of Blue Cross Blue Shield Vermont (Berlin): Affordability will continue to influence health plans for the foreseeable future. A recent study from KFF found that healthcare costs are Americans’ top economic concern, and the majority say healthcare costs will influence their vote. One factor heavily impacting healthcare affordability is rising pharmacy costs, especially specialty drugs, cancer drugs and the rise of injections and infusions in outpatient settings. In addition, funding of government programs — Medicare, Medicaid, ACA subsidies — and the downstream impact that has on commercial reimbursements will continue to impact premium affordability. To improve affordability for our members, Blue Cross VT is focused on a range of cost-saving efforts, including lowering drug costs through medication therapy management, formulary management, biosimilars and partnerships; proactive payment management and ongoing hospital contracting work; proactive clinical and case management; maintaining low administrative expenses and designing new, lower cost products.
Ifedayo Kuye, MD. Senior Medical Director for Oscar Health (New York City): The biggest trend we will see over the next few years is a massive shift toward true personalization. It is no longer enough to just offer broad network access and standard support; health plans must deliver a highly curated, intuitive experience. Today’s consumers have a very high bar for digital interactions. They expect their health plan to already know their medical history and proactively anticipate their needs.
This baseline will fundamentally change how plans are designed, leading to many more coverage options built for specific chronic conditions or distinct demographics. But the real test happens post-enrollment. Once a member is active in their plan, they expect a seamless and tailored care journey at every touchpoint. Delivering that experience will require health plans and providers to finally operate as a connected ecosystem, rather than separate, siloed entities. Real-time data integration, aligned incentives, and AI-driven insights will become foundational infrastructure for delivering individualized care, reducing friction, and improving health outcomes at scale.
Harlon Pickett. President of Eagle Care Health Solutions (Austin, Texas): The trend that will most influence health plans over the next few years is the growing collision between rising healthcare costs and consumer expectations for affordability, access and transparency.
For years, the industry has managed rising costs by shifting more financial responsibility to employers and members through higher premiums, deductibles, and out-of-pocket exposure. That model is reaching its limit. Employers can no longer absorb endless increases, and consumers are becoming far more aware of how difficult and expensive it can be when navigating the healthcare system. At the same time, people increasingly expect healthcare to function more like other consumer-driven industries. They want clear pricing, easier access to care, better navigation, digital convenience, and confidence that the care they receive is actually high quality. Health plans that fail to adapt to those expectations will struggle to maintain trust and long-term sustainability. This pressure will accelerate several changes simultaneously. We will see greater demand for transparent pricing, stronger emphasis on primary and preventive care, increased adoption of value-based arrangements, and growing scrutiny around administrative complexity that adds cost without improving outcomes. Ultimately, the health plans that succeed will be the ones that simplify the healthcare experience, align incentives around measurable outcomes, and help members become more informed and engaged healthcare consumers.
Nishant Anand, MD. President and CEO of Altais (Oakland, Calif.): The shift from incremental change to true clinical transformation will define the next several years in healthcare. The current model is unsustainable if costs continue rising while physician burnout increases and outcomes remain stagnant.
Success will depend on transforming care delivery models to make care more connected, coordinated, and accessible for both patients and physicians. At Altais, we’re advancing that through technology-enabled care models and infrastructure that reduce friction, improve affordability, and help patients receive care at the right place and right time. Ultimately, the organizations that succeed will be the ones that make high-quality care easier to deliver — and easier for patients to navigate.
Dipul Patadia, MD. Associate Chief Medical Officer of Client Growth and Innovation for Cigna Healthcare (Bloomfield, Conn.): One of the biggest shifts shaping health plans over the next several years is the move from innovation to accountability. It’s no longer enough to have new capabilities, but to prove they meaningfully impact cost and outcomes. Most plans don’t have a data problem; they have a challenge translating insights into decisions that consistently change clinical and financial results at scale. As pressure on affordability continues to rise, there will be greater scrutiny on whether solutions are truly improving health outcomes, strengthening provider partnerships, and advancing value-based care in a measurable way. From a growth perspective, we’re also seeing clients demand more clinically credible, health outcome-driven solutions, not just new features. Health plans that can connect data, clinical expertise, and execution in a way that translates into personalized, timely actions for the customers they serve will ultimately be the ones that differentiate.
Ty Wang. Co-Founder and CEO of Angle Health (San Francisco): The future of health plans will be shaped by a growing demand for integrated care delivery. Patients continue to want their healthcare to be easier to navigate, more transparent, and more accessible, including care that can happen at home. Health plans that prioritize personalization and helping their members access the right care more easily will be best positioned moving forward.
Meredith Duncan. President and CEO of Texicare (Austin, Texas): Small businesses are the backbone of local economies across the country—in Texas we have more than 3 million small businesses that drive our communities forward, yet 73% of them don’t offer healthcare coverage. Health benefits are an important tool for recruiting and retaining great people, as well as ensuring they’re healthy and productive. The demand for plans that are purpose-built for small businesses and how their employees access care will continue to grow.
Beejadi Mukunda, MD. Vice President and Market Chief Medical Officer of CareSource (Dayton, Ohio): The most significant trend shaping health plans over the next several years is the growing use of AI and smarter data tools. These advanced capabilities can help care teams identify risks earlier and provide better, more customized support to members. Health plans will increasingly leverage AI to deliver highly personalized outreach, anticipate and predict both clinical and social risks, streamline processes and enhance population health management by bringing together information from across the healthcare system. The greatest impact will come from AI being used more consistently in day-to-day operations, helping reduce unnecessary ER visits, address care gaps, and improve quality outcomes. At the same time, organizations must carefully manage transparency, equity and compliance as regulatory expectations continue to expand.
Rishikesh P. Dalal, MD, MPH. Regional Vice President and Chief Medical Officer of Northeast Region for Humana (Louisville, Ky.): Focus on patient and provider centricity will be a trend over the next few years. Health plans will increasingly need to meet provider groups where they are to maintain contracting and effectively engage them to improve care across the continuum. Cost of care pressures due to chronic disease burden, specialty pharmacy, and market consolidation will demand more sophisticated value-based programming and incentives. Optimizing the patient experience with health plans with tech-enabled solutions and segmentation will be paramount to inspire loyalty and trust.
Brandy Thompson. CEO of Benefitbay (Kansas City, Mo.): As employers move away from group plans and give employees a defined dollar amount to choose their own coverage through Individual Coverage Health Reimbursement Arrangements, carriers will be forced to compete directly for individual enrollees in ways the traditional group market never required. That competitive pressure is already driving a proliferation of off-exchange plan offerings, with carriers investing in network design, plan differentiation, and member experience in ways we have not seen before. The plans that win in this environment will be the ones that earn the employees’ choice on their own merits, not because an HR department selected them. That is a fundamentally different dynamic, and it is only going to accelerate.
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