2026: The year of uncertainty for healthcare financial leaders

Higher uninsured rates will affect payer mix

The big question on every healthcare leader's mind is: How will policy changes affect the uninsured rate?

The Trump administration announced an overhaul of federal healthcare programs, especially Medicaid. Everywhere leaders turned in 2025, the president and Congress were debating some aspect of healthcare. The most significant were Medicaid policy changes in the spending law passed in the summer of 2025, also known as the One Big Beautiful Bill, and the expiration of enhanced premium subsidies for the Affordable Care Act's Marketplace plans during the longest government shutdown in U.S. history.

These changes will affect how people access coverage and if they can maintain it in 2026 and beyond. In fact, 10 million people are slated to lose insurance coverage by 2034 under the One Big Beautiful Bill alone, according to estimates from the Congressional Budget Office.

The expiration of the enhanced premium subsidies for Marketplace plans is also likely to deter many people from reenrollment, as premiums are now expected to more than double in 2026, according to KFF calculations. That could translate to 4.8 million more uninsured people, according to the Robert Wood Johnson Foundation.

Wasson also advised healthcare leaders to look at the growing unemployment rate as it relates to their payer mix.

When you're talking about 1 and 2% margins, you get a couple of payer mix changes in your pool of patients, and that can really have an impact.

"Unemployment is not always talked about in the context of healthcare performance, but the reason that I keep my eye on it is that when you have unemployment ticking up one or two percentage points, people go from commercial to uninsured," he said. "That payer mix shift can really change the dynamic. When you're talking about 1 and 2% margins, you get a couple of payer mix changes in your pool of patients, and that can really have an impact."

The bottom line for the bottom line? Expect more uncompensated care costs and bad debt starting in 2026.

This year will bring the start of major changes to insurance coverage in the U.S., prompting healthcare leaders to prepare their organizations for how this shift in payer mix will impact their communities, specifically.

"As a CEO or CFO looking at 2026, all those variables are going to play out differently in your geographic region and your patient populations," Wasson stated. "So, it's hard to know what that's going to bring. That uncertainty is in your mind, and it brings delayed decision-making. It means, hey, we were going to do this thing, but maybe I'll wait and see."

The breaking point for healthcare affordability

With major shifts in payer mix coming down, healthcare leaders need to take a hard look at healthcare affordability. This is one of the areas in which patients are hyper-focused, with some even weighing costs with accessing care at all.

"Patients are increasingly demanding affordability, especially in a year where costs will skyrocket as Medicaid braces for cuts by 2027, and as premium costs skyrocket on the exchanges. This will have direct implications on access to care as well, as patients lose or forego coverage due to policy changes and rising costs," said Theresa Dreyer, CEO of the Health Care Transformation Task Force.

Delaying care will only exacerbate the affordability problem. When patients skip routine and preventive services, they are likely to land in the emergency department for more serious, possibly life-threatening conditions. Without insurance, that visit costs between $1,500 and $3,000, on average, according to BetterCare.com.

Affordability is on the radar for healthcare leaders, says Lauren O’Hanlon, principal at Deloitte. Deloitte's 2026 US Health Care Outlook report found that 26% of healthcare executives think affordability of coverage and medical services will remain a defining trend this year.

"Continued escalating cost pressures for patients are the main driver, as well as gaps in care and the rising cost of coverage," O'Hanlon explained.

Healthcare organizations positioned to survive this affordability crisis are those that earn and maintain consumer trust, explains Kulleni Gebreyes, M.D., Deloitte's vice chair and U.S. life sciences and health care industry leader.

"Consumers may be writing a prescription for their health care expectations: personalized, proactive, and purpose driven," she wrote. "Yet some organizations remain focused on the old regimen of episodic, transactional care."

As patients seek to squeeze the most value from their healthcare dollars, organizations must align with a more consumer-driven approach to operations. That means giving consumers what they want: price transparency, affordable medical services, more convenient accessibility and, of course, technology.

"Digital and artificial intelligence tools could be essential levers that redefine how care is delivered," O'Hanlon elaborated. "A path forward could also involve investment in digital platforms and AI tools that have the potential to expand access, enhance affordability, and drive improvements in outcomes and engagement."

AI leads to smarter healthcare financial planning

A trend that is likely to persist for years is the increasing use of artificial intelligence (AI) in healthcare, particularly in revenue cycle management and financial operations.

Healthcare organizations are rapidly adopting AI-enabled solutions, making the industry a new leader in enterprise adoption, according to a report from Menlo Ventures. Revenue cycle captured significant AI investments, with medical documentation and revenue cycle management representing nearly 60% of health IT spending for a combined market of about $38 billion, the report stated.

The AI technology for revenue cycle management is there for the taking. Revenue cycle functions, including patient intake and scheduling, prior authorization management and denials management, are "well-suited for tasks that combine variability, time sensitivity, and policy logic," O'Hanlon said.

Before diving into any agentic AI implementation, your first step should be calculating return on investment across all available options.

In these three areas, O'Hanlon sees major opportunities for AI adoption, including agentic AI adoption. For example, AI agents are currently well poised to "gather the necessary clinical documentation, validate payer-specific authorization requirements, and submit requests proactively before service delivery" for prior authorizations -- one of the biggest pain points in healthcare right now. These agents can also identify authorization needs at patient intake, monitor request statuses, flag issues for staff and even communicate with payers to prevent delays and denials.

Healthcare leaders also see an opportunity for AI to help them navigate payer mix and policy changes ahead. They want their solutions to be more predictive, showing them what is likely to happen in the different scenarios that could play out, Wasson explained.

"Given all the spaghetti of complexity -- I mean, I could rattle off four or five different things off the top of my head that could be super variable and have a big impact -- AI is actually a great technology resource to help think that through," he stated. "So, you could have scenario plans that make sense given the vast complexity."

But O'Hanlon provided a word to the wise when it comes to AI adoption in 2026, especially as buzzwords like "agentic" become reality for healthcare leaders.

"Before diving into any agentic AI implementation, your first step should be calculating return on investment across all available options -- whether that’s native electronic health record transaction fees, point solution capabilities, or full agentic platforms," she stated. "This ROI analysis becomes the strategic compass for determining timeline and speed to value."

Smart healthcare leaders, she added, will be the ones who understand that different approaches generate value at different rates and scales. For example, electronic health records may offer solutions with faster initial deployment but have limited long-term scalability, whereas standalone solutions require heavy upfront investments with potentially exponential returns later.

"By establishing clear ROI benchmarks early, you can make informed decisions about where to start, how aggressively to scale, and when to transition between different technological approaches based on measurable business outcomes rather than technology trends," she advised.

So, perhaps it's not the year of transformation, but it will likely be a year of quiet reflection, noses to the data and strategic thinking. Healthcare financial leaders will need to not only understand their organization's position but also plan for a wide range of market shifts that could sway that spot. Still, the opportunity to innovate through technology, partnerships and new care and payment models could bring some optimism back in 2026.

Jacqueline LaPointe is a graduate of Brandeis University and King's College London. She has been writing about healthcare finance and revenue cycle management since 2016.