According to one expert at Pitchbook, two core issues are likely to dominate healthcare reform discussions in 2026: rising costs and flaws in Medicare Advantage.
Healthcare affordability remains a major systemic issue preventing millions of Americans from accessing care, and Medicare Advantage’s risk-adjustment system is “clearly broken,” creating incentives that pull excess money into the program, explained Brian Wright, lead analyst for healthcare research at Pitchbook.
On the Affordable Care Act and commercial market side of things, reforms will probably aim to improve affordability and risk pooling, he said. With Medicaid eligibility pressures pushing providers to shift costs to commercial payers, Wright suggested that lawmakers may look for ways to make the commercial market function more effectively rather than serve as the system’s subsidizer.
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“Medicaid eligibility issues are going to pressure hospital systems — and what do they do? They typically make up for it by billing to the commercial side. The commercial side always is that subsidizer for the rest of the healthcare system. So the thought process is ‘Okay, how can you go about making a market on the commercial side work better than it is now?’” he remarked.
One potential ACA-related reform involves loosening age rating restrictions, Wright noted.
Under the ACA today, payers can generally charge older adults no more than three times what they charge younger adults. If those limits were to be expanded to allow payers to charge older adults, say, up to five times more, then there would be lower premiums for younger people.
“That way younger, healthier people are incentivized to get into the risk pool,” Wright declared.
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Another potential reform would give states greater flexibility to define minimum coverage standards across the ACA’s metal tiers, Wright said. This would allow states to revisit which benefits must be included in bronze, silver or gold plans, rather than adhering to a blanket national standard — which might give payers more room to design lower-cost plans.
Wright also pointed to eliminating or reworking so-called “silver loading subsidies”, a pricing practice that raises premiums for silver plans to offset federal cost-sharing requirements. He said the approach can distort pricing across the market and influence how people choose their plans.
In addition, other reforms could include expanding wellness incentives and giving out larger financial rewards for healthy behaviors.
As for Medicare Advantage reform, Wright thinks this will likely center on addressing flaws in risk adjustment. He noted that while Medicaid also uses risk adjustment, it does not incentivize plans to increase coding in ways that drive higher overall spending. Moving Medicare Advantage toward using full claims and encounter data — rather than partial data — could help limit those incentives and rein in costs.
While none of these potential changes are guaranteed to materialize in 2026, Wright said they reflect a growing willingness among policymakers to rethink the long-standing rules that have shaped healthcare costs and coverage.
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