The forces reshaping health plans over the next several years are converging fast. Executives and clinical leaders across the payer industry point to three defining trends: the rapid maturation of AI from pilot projects into core operational workflows, the intensifying pressure to make healthcare genuinely affordable, and rising consumer expectations for transparency, simplicity and personalized care. Becker’s Healthcare asked 16 health plan executives which trend they believe will most influence health plans in the years ahead. Their responses reveal both urgency and consensus around the need for fundamental transformation.
Three Forces Converging on Health Plans
Why This Moment Feels Different
Health plans have navigated change before. However, the current convergence of financial pressure, technological capability and consumer demand is unlike anything the industry has previously faced. Margin pressure is intensifying. Medical loss ratios are approaching regulatory ceilings. At the same time, AI tools have matured rapidly enough to move beyond experimentation. Furthermore, consumers now arrive at every healthcare interaction with expectations shaped by retail, banking and technology — sectors that long ago delivered transparency and simplicity as table stakes.
Agentic AI Moves Into Core Workflows
From Pilot Projects to Revenue-Critical Operations
Vishal Kaushik, Director of Strategy Advancement at Humana, identifies agentic AI as the most consequential near-term trend. He notes that operators within health plans have already moved past experimentation. AI now lives inside workflows where revenue actually exists — utilization management, claims processing, risk adjustment and enrollment. The race is no longer about who can deploy AI agents fastest. Instead, it is about who can deploy them defensibly — with traceability and auditability built into every decision.
Beejadi Mukunda, MD, Vice President and Market Chief Medical Officer at CareSource, agrees. AI tools can help care teams identify risks earlier and deliver more customized member support. Moreover, he notes that the greatest impact will come from AI operating consistently in day-to-day operations — reducing unnecessary emergency room visits, closing care gaps and improving quality outcomes. At the same time, organizations must carefully manage transparency, equity and compliance as regulatory expectations continue to expand.
AI in Clinical Decision-Making
Uche Olekanma, MD, Vice President of Clinical Operations at Blue Cross Blue Shield of Arizona, highlights how AI and advanced analytics are transforming clinical decision-making. Proactive interventions, faster authorizations and increasingly personalized care pathways are all becoming achievable. Additionally, care is shifting from inpatient hospitals to lower-cost ambulatory and virtual settings. Tighter alignment across utilization management, provider networks and site-of-care strategies is now essential.
Affordability Reaches a Breaking Point
Healthcare Costs as a Political and Economic Issue
Beth Roberts, President and CEO of Blue Cross Blue Shield Vermont, emphasizes that affordability will continue to dominate the health plan agenda for the foreseeable future. A recent KFF study found that healthcare costs are Americans’ top economic concern. Moreover, the majority of Americans say healthcare costs will influence their vote. Rising specialty drug costs, gene therapies, GLP-1s and the shift of infusions and injections to outpatient settings all place significant upward pressure on premiums. Furthermore, the downstream impact of government program funding on commercial reimbursements adds further complexity.
James Grana, Vice President of Value Based Care Programs at BlueCross BlueShield of South Carolina, points to pharmaceuticals and behavioral health as the two biggest financial pressure points. Cost trends in both domains will continue to drive both public policy responses and commercial pricing decisions.
The Model’s Limit
Harlon Pickett, President of Eagle Care Health Solutions, argues that the traditional model of managing rising costs by shifting financial responsibility to employers and members is reaching its structural limit. Employers can no longer absorb endless increases. Consequently, health plans face growing pressure to simplify the healthcare experience, align incentives around measurable outcomes and help members become more engaged healthcare consumers.
Consumer Expectations Drive Transparency Demands
Healthcare Now Competes With Retail
Kevin Knight, Chief Marketing Officer at Sidecar Health, argues that price transparency is the defining trend — not because regulators demand it, but because consumers now expect healthcare to behave like every other part of the economy. Direct-to-consumer healthcare companies already offer transparent pricing on labs, GLP-1s, therapy and primary care. Health plans that fail to adapt to this shoppable healthcare model risk becoming irrelevant. Knight draws a sharp analogy: those that resist will resemble the long-distance phone and taxi industries — defined by bloated costs and unnecessary friction until disruption forced everything to change at once.
The Whole-Person Consumer Experience
Siva Balu, Senior Vice President and Chief Information and Digital Officer at Quartz, broadens the consumer lens further. Using generative AI, customers will increasingly conduct their own research and arrive at healthcare interactions better informed than ever before. Customer experience, he argues, encompasses the full health journey — preventive care, pharmaceutical needs, complex and specialty care — not just customer service interactions. Employers will also demand greater transparency into their healthcare spend. Additionally, interoperability regulations will accelerate consumers’ ability to hold their own health data and make better decisions.
The Shift From Innovation to Accountability
Dipul Patadia, MD, Associate Chief Medical Officer at Cigna Healthcare, frames the defining challenge precisely: health plans are moving from innovation to accountability. Most plans do not have a data problem. They have a challenge translating insights into decisions that consistently change clinical and financial results at scale. As affordability pressure rises, scrutiny will intensify around whether solutions genuinely improve health outcomes, strengthen provider partnerships and advance value-based care in a measurable way.
Self-Funding and the New Employer Buyer
Jonathan Baran, Co-founder and CEO of Self Fund Health, identifies a structural shift that has been building for decades. For 40 years, employers purchased health insurance — risk transfer with a markup — when what they actually needed was to purchase healthcare. As self-funding spreads, employers step into the role of sophisticated buyers. They compare providers the way they compare any other vendor — on price, outcomes and patient experience. Consequently, the health plans that thrive will be those that help employers buy healthcare well. Those that fail to evolve will look increasingly like middlemen with nothing to offer.
Karen Johnson, CEO of Clever Care Health Plan, adds that the shift from a transactional claims-paying mindset to genuinely managing total health outcomes requires real transformation in how plans set priorities. This is especially critical in Medicare Advantage, where trust, supplemental benefits and the overall member experience directly drive growth and retention.
Small Business Coverage and ICHRA Growth
Brandy Thompson, CEO of Benefitbay, points to Individual Coverage Health Reimbursement Arrangements as an accelerating force reshaping the competitive landscape. As employers move away from group plans and give employees a defined dollar amount to choose their own coverage, carriers must compete directly for individual enrollees in ways the traditional group market never required. Plans that win in this environment earn employees’ choices on their own merits. That is a fundamentally different competitive dynamic — and it is only going to accelerate.
Meredith Duncan, President and CEO of Texicare, highlights the enormous untapped opportunity in small business coverage. With more than 73% of small businesses in Texas alone not offering healthcare coverage, the demand for plans purpose-built for small businesses and their employees will continue to grow.
What Health Plans Must Do to Survive
The executives surveyed collectively point toward a clear direction. Health plans must treat AI deployment as a governance challenge, not just a technical one. They must address affordability structurally — not simply by shifting costs. Moreover, they must redesign member and provider experiences around transparency, simplicity and personalization. Nishant Anand, MD, President and CEO of Altais, frames the ultimate challenge clearly: success depends on making high-quality care easier to deliver and easier for patients to navigate. The organizations that do both will define the next era of health plan leadership.
