Health care remains one of the most closely watched policy areas in the country, driven by ongoing challenges around access, affordability and system sustainability. Many of the policy conversations that have emerged in recent years are moving from debate into action, with new rules and reforms beginning to influence how care is delivered and paid for. 

To better understand what’s ahead, we spoke with our Government Affairs team to identify some of the major topics shaping the health care landscape this year:

1. Prior authorization reform moves from policy to practice

Administrative burden has long been a pain point for patients and providers alike, and 2026 is a critical year for reform. New CMS requirements took effect January 1 of this year, mandating faster prior authorization decision timelines for Medicare Advantage, Medicaid and CHIP plans, along with new transparency and reporting obligations.

At the same time, states are pursuing their own reforms. In Massachusetts, Governor Maura Healey announced updates to state prior authorization rules — including eliminating requirements for many routine and essential services and establishing a 24-hour response time for urgent requests — reflecting a broader national push to remove administrative barriers to timely care. Point32Health has joined other health plans to voluntarily improve the prior authorization system by streamlining the process, protecting patients with continuity of care and improving communications. The goal is to ease administrative burdens on providers while preserving our ability to manage care appropriately for our members. 

2. Drug pricing reforms become reality

After years of policy debate, 2026 marks a turning point for federal drug pricing policy. For the first time, Medicare-negotiated prices for 10 high-spend Part D drugs took effect on January 1, lowering out-of-pocket costs for millions of beneficiaries. These changes are part of the Inflation Reduction Act’s broader effort to curb prescription drug spending and rebalance how manufacturers, plans and the federal government share financial responsibility. 

Earlier this year, the federal government also released a website called TrumpRx that facilitates access to discounted drugs through coupons or links to direct-to-consumer pharmaceutical manufacturer sites. Since the fall of 2025, the Administration has announced “Most-Favored-Nation” agreements with 17 drug manufacturers to provide discounted drugs.

TrumpRx discounts have not yet been connected to the larger health care system. To optimize the impact on Americans, it will be important to allow health plans to access these discounted drugs for their members. It also will be important to ensure that pharmaceutical manufacturers do not shift costs onto other parts of the market.

3. Increased focus on pharmacy benefit managers

Federal policymakers have been recently focused on pharmacy benefit managers (PBMs). Last year, the Federal Trade Commission sued ExpressScripts (ESI), Optum and Caremark over their practices. A potential settlement with ESI would require increased transparency to health plans, as well as access to TrumpRx drug pricing. 

In early February, Congress passed — and President Trump signed — the Consolidated Appropriations Act, which included extensive reforms on PBMs. These reforms require PBMs to pass their drug savings fully to health plans, as well as provide extensive data. 

4. Medicare Advantage at an inflection point

Medicare Advantage has now become the source of coverage for a slight majority of Medicare beneficiaries. More than half of all people with Medicare Part A and Part B (54% or 34.1 million in 2025) are enrolled in a Medicare Advantage plan, while 46% (28.7 million) remain in traditional Medicare. However, in recent years, payments to Medicare Advantage plans have not kept pace with increases in costs and utilization. Rate notices for calendar year (CY) 2024 and CY 2025 effectively reduced payments to plans by 1.12% and -0.16%, respectively. Meanwhile, overall Medicare spending increased 7.8% from 2023 to 2024 while per enrollee Medicare expenditures increased 5.4%. 

This disconnect is threatening the sustainability of critical benefits on which Medicare Advantage beneficiaries depend, such as dental, vision and transportation. These are especially important to Medicare Advantage enrollees as they are 1.5 times more likely than those enrolling in traditional fee for service Medicare to have costly and prevalent chronic conditions. Medicare Advantage enrollees also are 76% more likely to have five or more chronic conditions. 

It is critical that all health care stakeholders — including policymakers, plans and providers — collaborate to ensure a financially sustainable future for Medicare Advantage that preserves the coverage so important to the growing senior population in the United States.

5. Managing the next phase of digital health innovation

Digital tools have become a central part of how people receive care, and federal policy is beginning to catch up. For data sharing and interoperability, regulators have already put firm rules in place: HHS finalized the Trusted Exchange Framework and Common Agreement (TEFCA) in late 2024, establishing nationwide standards for how health information must be exchanged, governed and protected. These requirements took effect in early 2025 and continue rolling out in 2026, giving patients, providers and health plans clearer expectations around secure and consistent data flow across the health system. 

At the same time, the FDA has taken steps to clarify expectations for artificial intelligence in health care, issuing draft guidance in January 2025 that outlines how AI-enabled medical devices should be designed, monitored, updated and evaluated for safety. While not yet final, the draft provides an important roadmap for developers and signals the direction future regulation is likely to take. In 2026, these efforts mark a shift toward greater clarity and accountability, helping ensure new technologies support care without compromising safety or trust.