Open Enrollment 2026: Premium shock, policy risk, and the new operating model
Open enrollment for 2026 coverage runs through January 15, 2026, with premium hikes unlike anything since 2018. Average ACA marketplace premiums are up 26% for 2026, with Healthcare.gov rates reportedly up 30% and some markets crossing 50%.
Last year set a record with 24.3 million enrolled in ACA marketplace coverage. This year, affordability is under pressure while Medicaid policy changes could strip more than $1 trillion in funding over the next decade. Payers and providers are responding by rethinking how work gets done - and moving fast on AI and automation, including agentic approaches that handle complex, multi-step work without human intervention.
What the numbers mean for revenue and access
Medical cost trends are hovering near 8%, driven by hospital rate growth and specialty drugs like GLP-1s. PwC projects 2026 trends of 8.5% for the group market and 7.5% for the individual market.
For organizations reliant on commercial and exchange populations, this shows up in revenue cycle performance, patient access, and collections. Rising prices, higher utilization, and workforce-driven labor costs are the key drivers cited by multiple carriers.
The enhanced subsidy uncertainty
The enhanced ACA premium tax credits expire December 31, 2025 - right in the middle of open enrollment. If Congress doesn't act, KFF estimates subsidized consumers could see premiums more than double, and up to 4.8 million people could lose coverage.
One example: a 60-year-old couple earning $85,000, just above the threshold, could face roughly $24,500 more per year in premiums without the enhanced subsidies. For health systems, that means more uninsured patients, lower collections, and higher charity care burdens.
Medicaid funding cuts deepen the risk
Proposed Medicaid reductions would remove more than $1 trillion in federal support over ten years. Rural hospitals could see $50.4 billion in lost Medicaid funding, and 1.8 million rural residents could lose coverage by 2034.
Over 100 rural hospitals are already at high risk of closure from Medicaid revenue loss. On top of this, state-by-state eligibility changes and work requirements add administrative overhead and increase churn between Medicaid, commercial plans, and the uninsured.
How AI and automation are changing operations
The shift is no longer about pilots. Health organizations are scaling AI and automation programs across the enterprise - especially agentic automation that can reason, act, and adapt across workflows.
Evidence is stacking up. AI-enabled prior authorization can automate 50% to 75% of manual tasks. Organizations deploying automation across prior authorization, billing, and patient engagement report 40% to 50% processing-efficiency gains and $500,000 to $2 million in annual revenue recovery.
Real-world examples include automating clinical record retrieval and validation for prior authorization, cutting manual workload by about 25%, saving tens of thousands of hours and more than $800,000 annually. Many health systems now process 35% to 45% of authorizations touchlessly. The latest agentic tools extend these wins by handling multi-step workflows, integrating systems, and adapting to exceptions without manual oversight.
Five priorities for providers and health systems
- Analyze cost-shift exposure: Model the impact of subsidy expiration and Medicaid changes on payer mix, uncompensated care, and cash flow. Stress-test by market and service line.
- Automate high-friction workflows: Target prior authorization, denial management, eligibility/benefits, and billing. Expect faster cycle times, higher first-pass yield, and measurable revenue recovery.
- Link clinical and administrative data: Stand up predictive analytics to flag rising-risk patients earlier and direct proactive outreach, care management, and scheduling.
- Strengthen patient engagement: Provide financial navigation, coverage renewal support, and digital self-service. AI chat and SMS can reduce no-shows, improve renewals, and lower bad debt.
- Manage transformation deliberately: Redesign workflows, redefine roles, and track progress using metrics like administrative cost per claim, denial rates, auth turnaround time, days in A/R, and staff hours saved.
Five priorities for payers
- Find high-acuity members earlier: Combine claims and clinical data to predict risk, time outreach, and prevent avoidable admissions.
- Deploy agentic automation at scale: Automate claims, medical management, credentialing, fraud/waste/abuse reviews, and member ops to reduce costs and errors.
- Collaborate with providers: Share data models, align incentives in value-based contracts, and standardize documentation requirements to cut friction.
- Invest in digital member engagement: Use assistants and self-service tools to simplify benefits, cost sharing, and prior authorization experiences.
- Redesign for scalability: Move beyond siloed departments and legacy point solutions. Build end-to-end processes that embed AI and automation to support growth without proportional headcount.
Metrics that keep you honest
- Administrative cost per claim and per authorization
- First-pass yield and denial rates by category
- Average auth turnaround time and retro-auth volume
- Days in A/R, cash acceleration, and net collection rate
- Staff hours saved and reassignment to higher-value work
Practical first steps this quarter
- Form a payer-provider working group to align on eligibility, prior auth, and data-sharing quick wins.
- Build a simple ROI model for two use cases: prior authorization and denials. Include baseline metrics and success criteria.
- Select a narrow pilot with clear upstream/downstream owners. Target 8-12 weeks to production.
- Use agentic automation for the "swivel-chair" steps: data gathering, document classification, benefits checks, and status updates.
- Retrain staff to handle exceptions, clinical judgment, and member interactions while bots process routine work.
- Stand up governance: privacy, model monitoring, audit trails, and change management.
Bottom line
Open enrollment 2026 is a stress test. Premium increases, subsidy risk, and potential Medicaid cuts are structural, not cyclical. The organizations that treat AI and automation as strategic levers - and measure the results - will keep care accessible and sustainable while others trim services and stall.
If your teams need practical upskilling on automation and agentic workflows, explore focused training and certifications at Complete AI Training.
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