Affordability vs. cost containment: What health plans will face in 2026

Health plans are trying to seek balance between affordability and cost containment pressures.

Analysts at Avalere Health described their health care outlook for 2026 in a recent webinar, and said that maintaining affordability and managing utilization will be challenges for health plans in the coming year and beyond.

“Affordability, as we have seen before and will continue to see over the next few years, is a dominant force right now. It’s reshaping how we see Medicaid and the commercial market, as well as what this looks like for access,” said Chani Seals, associate principal with Avalere Health.

Medicare plans also are challenged by the tradeoff between affordability and cost, said Robin Duddy-Tenbrunsel, principal with Avalere Health.

“Affordability for beneficiaries – think out-of-pocket costs – and affordability to the government are what come to mind,” she said.

Medicare Advantage plans, in particular, are challenged to provide affordability to beneficiaries while determining what levers the plans have to maintain the affordability, she said.

“We see the push for affordability and keeping premiums stable,” she said. “Seeing things like out-of-pocket maximums creeping upward.”

Duddy-Tenbrunsel predicted the Medicare Advantage market will continue to grow “but will face challenges as we think about a number of policy changes happening relatively quickly and as we think about rising utilization trends that plans have experienced for the past few years.”

She described the challenges as “a bit of a balancing act.

“How do we navigate that system where we have pressures on both ends in terms of affordability but keeping the things that members value?”

GLP-1 drugs: Access vs. cost

Use of GLP-1 drugs continues to expand, leaving health plans to grapple with the issue of access versus cost.

The Centers for Medicare and Medicaid Services launched a program called BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth), in which certain Medicaid and Medicare Part D beneficiaries will be able to access GLP-1 medications for $50 per month. CMS will also launch a short‑term Medicare GLP‑1 payment demonstration in mid‑2026 as a transition period. The demonstration is intended to give earlier access before BALANCE fully starts, and allows some beneficiaries

The coming year will see “some innovative approaches and it will be up to payors to decide in this growing patient population who gets what medication at what point in time and for how long,” said Mariia Salova, senior research scientist at Avalere Health.

“There have been multiple solutions offered by policymakers and payors. In 2026 and beyond, we as a society and a health care system will be in dire need of innovative approaches to addressing access and affordability.”

GLP-1s represent a long-term behavior change journey, said Milo Elmir, head of experience design at Avalere Health.  “They don’t just treat a condition, they reshape daily life,” he said.

“The patient who takes a GLP-1 is not the same patient six months or 12 months late but too often we treat them as if they were.”

Elmir predicted that 2026 will bring a shift from whether patients are able to obtain access to GLP-1s to whether patients can sustain a benefit from them. This shift will require real-world evidence, real-world experience, and an understanding of long-term outcomes.

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Susan Rupe is editor in chief, magazine, for InsuranceNewsNet. She formerly served as communications director for an insurance agents' association and was an award-winning newspaper reporter and editor. Contact her at [email protected].