Navigating 2026: How lab data can help health plans address market, cost, and population risk pool changes

Early 2026 is primed to have headwinds due to an unprecedented convergence of market disruptions for health plans across Medicare Advantage (MA), Medicaid and the ACA exchanges. Major shifts are leading to historic membership turn-over or “churn,” rapidly changing risk pools, rising costs, and new barriers to care.

For health plans, Medicaid managed care organizations (MCOs) and accountable care organizations (ACOs), this creates an urgent imperative to rapidly identify and close care gaps for millions of returning and new members—many arriving with fragmented or nonexistent claims histories.

This rapidly changing environment presents unparalleled challenges for health plans but also offers opportunities for those who can effectively use data to navigate the choppy waters ahead. Plans that quickly identify and address gaps for new members will be better positioned to protect quality ratings and outcomes, while those who can't, may see their performance slide.

The 2026 coverage crisis: Understanding the changing dynamics

Several factors are converging to create an uncertain environment for health plans in 2026:

1.) Medicaid redeterminations causing significant churn

The resumption of Medicaid redeterminations, combined with major federal policy changes, has led to substantial state-by-state variation in coverage losses. Millions of members—many with complex health needs—are being pushed into ACA exchanges, employer-sponsored coverage, or becoming uninsured. According to the U.S. Government Accountability Office, approximately 27 million people, or roughly one-third of those reevaluated, were disenrolled from Medicaid. This level of churn has far-reaching implications for Medicaid programs and other coverage types, triggering massive enrollment shifts across plans and carriers.

The Medicaid “unwinding” is not simply moving volumes—it's reshuffling the entire risk pool for many plans. As millions with complex, chronic conditions lose Medicaid eligibility, they're flowing into exchanges, employer-sponsored plans or becoming uninsured. This is rapidly creating uncertainty and financial pressures for health plans and providers, while also changing the morbidity mix and care needs for affected plans that also need to be effectively addressed.

2.) ACA Marketplace instability

Many people losing Medicaid are transitioning to the ACA Marketplace, where enrollment hit record highs of 24.2-24.3 million enrollees in 2025. The combination of an influx of new members, changes to auto-enrollment, and exits of major carriers in various markets, presents both opportunities and challenges for plans.

The reshaping of risk pools comes precisely as ACA Marketplace dynamics grow increasingly unstable, with enhanced subsidies expiring at the end of 2025, and the likelihood of Congressional action to revive the subsidies still uncertain, and premium hikes for 2026 that could make coverage less affordable for many and worsen the risk pools as healthier individuals drop out.

Additionally, with changes to auto-enrollment occurring, there are new financial and eligibility constraints, and churn may be increasing. This could increase the risk of drop-offs and create higher administrative burdens, while simultaneously providing an opportunity to strengthen retention vis proactive outreach and improved program integrity.

3.) MA volatility

MA enrollment remained high for 2025 at about 54% of eligible beneficiaries, with rapid growth in Special Needs Plans (SNPs). But overall growth is slowing and projections show a potential enrollment dip in 2026. This is a stark reversal from years of steady expansion as plans tighten benefits, exit unprofitable markets and terminate plans.

This could impact an estimated three million people that will have to find new plans. These new plans could potentially have higher deductibles, reduced coverage, or increased out-of-pocket obligations may lead to many members foregoing needed care in order to manage expenses.

The pressure extends beyond enrollment volatility. Costs are rising sharply across government programs, creating widening gaps between premiums and medical spending that place additional pressure on margins and earnings.

CMS has also raised performance levels needed to reach certain Star Ratings, which means plans must improve performance over the prior year to achieve the same ratings and quality bonus payments. These shifts could impact risk profiles and revenue streams for MA plans.

4.) Premium pressures and affordability concerns

As premiums reflect the underlying cost of care, Medicare, Medicaid and the exchanges plans face significant upward cost pressures that create a widening gap between premiums and medical spending in 2026. Some Americans have seen their health insurance payments more than double, potentially leading to coverage losses, reduced access care, and a larger market of individuals shopping for alternatives due to premium and cost pressures.

A few major payers have already cut earnings guidance for 2026 as government program costs rise faster than expected. This trend puts additional pressure on plan earnings and forces difficult decisions about benefit design and market participation.

5.) Impact on member health outcomes

Rising healthcare costs are creating additional pressure on health outcomes. A concerning 25% of adults report skipping needed care in the past 12 months due to cost concerns. This avoidance of screenings and preventive care could lead to worse health conditions and more complex disease management challenges in the future, precisely the outcomes that undermine both quality scores and total cost of care. The downstream elects could be profound.

6.) Corporate healthcare costs increase

Boards and C-suite leaders continue to be concerned about member/employee well-being and the increasing costs of medical care in 2026. Cancer remains the leading contributor to claims expenses and the fastest-growing condition in terms of utilization and cost, with prevention and screenings identified as the most effective cost-reduction strategies.

7.) CMS Star rating challenges

Achieving high Star Ratings is becoming increasingly difficult for MA plans. CMS has made cut points tougher, with 58% of them increasing, 25% remaining unchanged, and only 17% decreasing—thus making them harder to achieve overall in 2026. This requires plans to be increasingly strategic about where they invest resources, prioritizing activities with high return on investment in quality improvement and member outcomes.

The ripple effects from the storm: Challenges for health plans and members

Membership volatility and market dynamics are creating a series of interconnected, fundamental challenges for new members and their health plans, leading to the convergence of multiple factors:

1.) Increased churn and new member inflow creates data blindness

When millions of members, many of whom may have complex health needs—transition plans or encounter periods of being uninsured, they arrive at their new plans with little to no accessible claims history, creating a temporary data blindness to their health status. The frequency and complexity of pre-enrollment changes are also increasing, making it more challenging for plans to prepare for incoming members.

2.) Shifting risk profiles increases population health risks

The movement of members between different coverage types is altering risk pools, making it more difficult for plans to accurately assess and manage population health risks. Traditional approaches to risk stratification, care gap identification and quality measure compliance depend heavily on longitudinal claims data—data that simply doesn't exist or remains fragmented across multiple systems and payers for newly enrolled populations. 

3.) Disruption in care continuity leads to gaps and worse health outcomes

The net result of a massive coverage disruption where members have to navigate new plan rules and provider networks is millions being at risk of disrupted care, skipped services and worse health conditions. This is especially concerning for those with chronic diseases like diabetes, cancer, kidney disease, and behavioral health issues, all who can experience destabilization of previously controlled diseases. Compounding these challenges, new members often face multiple barriers to care beyond fragmented data. Transportation limitations, social risk factors, language barriers, and unfamiliarity with new provider networks all contribute to delayed or foregone care.

4.) Pressure to identify and close gaps quickly

For quality, risk adjustment, and Stars program leaders, this creates pressure to quickly identify and address care gaps quickly for new and returning members to maintain quality performance and manage costs. Leaders need to do so without having the luxury of waiting months for claims to accumulate and reveal the true clinical picture. Regulatory expectations from CMS and state Medicaid agencies increasingly demand plans document and address health disparities and advance health equity—requirements that become nearly impossible to fulfill when unable to accurately identify which members members need what interventions.

5.) Increase in acute care utilization

Members changing plans may be more likely to use emergency room visits for preventable conditions, driving up acute care utilization and costs while potentially impacting quality metrics.

Using lab data to navigate the storm

In this volatile 2026 environment, health plans need tools to rapidly assess risk and identify gaps for new members, especially when claims histories are incomplete or missing. Here's how longitudinal lab data can make a major difference:

1.) Rapid risk assessment for new members

Standardized lab data offers a solution to this new- member risk dilemma precisely because it transcends coverage transitions. Unlike claims, which are payer- specific and often delayed, lab results follow the individual regardless of insurance status, provider network or plan enrollment. A hemoglobin A1c value, an estimated glomerular filtration rate (eGFR) or low-density lipoprotein cholesterol level provides immediate clinical insight via an HL7 claims feed into disease control and risk status whether the member got a test while using Medicaid, a marketplace plan, or employer coverage, or were uninsured.

2.) Early identification of open care gaps and rising risk

Longitudinal lab data can reveal trends in a member's health, highlighting potential gaps in care or early signs of rising risk that may not be apparent from claims or sporadic provider visits.

3.) Overcoming barriers

By analyzing lab data at a community Level, plans can identify geographic hot spots of poor health outcomes or underutilization of preventive services, helping to target interventions and address health inequities.

4.) Improving HEDIS, Stars, and quality ratings

Complete and timely lab data can significantly enhance a plan's ability to meet quality measures, particularly those related to chronic disease management and preventive screenings. Even when claims history is sparse or nonexistent, lab values mapped to HEDIS, CMS Stars, and quality measures can rapidly flag members with uncontrolled diabetes, advancing chronic kidney disease or cardiovascular risk factors requiring intervention.

5.) Enhancing risk adjustment and coding accuracy

Lab values provide objective clinical evidence to support more accurate risk adjustment and coding, potentially uncovering millions in missed reimbursement opportunities.

6.) Identifying previously closed gaps to prioritize care management outreach

For new members, longitudinal lab data can also proactively reveal gaps in care that may have already been addressed and whether their condition is stable, deteriorating or undiagnosed—insights that would otherwise require months of claims accumulation to detect. A comprehensive lab record can show a new member completed a diabetic kidney disease screening, colorectal cancer screening, or appropriate monitoring for chronic conditions with a prior carrier, or provider outside of their network, before their coverage transition. This prevents duplicative outreach, reduces member abrasion from redundant testing requests and allows care management resources to focus on members with genuine open gaps for high-risk and rising-risk members rather than pursuing care that's already been delivered.

7.) Supporting population health strategies

Comprehensive lab data helps plans develop more targeted and effective population health strategies. Beyond individual risk stratification, ZIP code-level laboratory trend analysis reveals geographic hot spots where membership churn is high, disease prevalence is concentrated and barriers to care are most pronounced. Plans can use these community-level patterns to target interventions, allocate resources strategically and align with CMS's growing emphasis on health equity and social determinants of health. When lab data shows clusters of elevated A1c values or declining kidney function in specific communities experiencing high Medicaid redetermination rates, plans can deploy mobile screening units, partner with community health centers or provide transportation assistance in precisely the areas where impact will be greatest.

How Labcorp's robust data can help you navigate the storm

Labcorp's national dataset provides longitudinal clinical histories that follow members as they move between plans. This continuity gives plans a “warm start” with new members instead of starting cold. Our pre-enrollment insights tap into over 45 billion lab results covering approximately half of the U.S. population. This gives health plans access to more than two years of historical lab data, alleviating churn impact by providing timely and actionable new member data from day one.

Operationalizing lab data for immediate impact

To leverage lab data effectively in this volatile environment, health plans must make sure several operational capabilities are in place.

First, lab feeds must be standardized, mapped directly to HEDIS and Stars measure specifications, and integrated into existing care management and operational workflows. This technical foundation allows for automatic flagging of new members who require outreach, testing or intervention based on lab evidence of gaps or rising risk.

Second, plans need the ability to track gaps longitudinally across coverage transitions. A member moving from Medicaid to a marketplace plan in January, should not receive outreach in March advising them to have a diabetic kidney examination they completed in January—yet without longitudinal lab and screening data, this kind of inefficient, frustrating duplicate contact occurs regularly. National lab networks that serve members across all coverage types provide the continuity necessary to avoid these gaps in institutional knowledge.

Third, rising-risk models that incorporate laboratory trend analysis let health plans identify members whose clinical status is deteriorating before that deterioration manifests in expensive acute events. A member with steadily increasing Arc values, declining eGFR or worsening liver function tests can be prioritized for intensive care management intervention—potentially preventing hospitalizations, emergency department visits, and disease progression that would otherwise occur.

The practical benefits extend across multiple organizational priorities. For Stars program managers, complete lab data improves performance on measures like diabetes care, controlling high blood pressure, and reducing the risk of falling. For Medicaid quality teams, lab-driven insights support Adult and Child Core Set measure performance and quality incentive payment achievement.

For risk adjustment and coding teams, lab evidence of chronic conditions supports accurate diagnosis capture and appropriate revenue recognition. For population health leaders concerned with total cost of care, early identification and management of high-risk members based on lab markers can reduce unnecessary utilization and improve outcomes.

For finance and line of business teams managing profit and loss, complete lab data improves quality  performance, quality bonus payments, and revenue incentives, in addition to reducing total cost.

The 2026 imperative: Making lab data your head start

As health plans, MCOs and ACOs face unprecedented membership volatility in 2026, lab data can provide the most reliable early signal available for understanding new member risk and needs. When claims history is thin, fragmented, or delayed, lab values provide immediate clinical insight.

When quality measure performance faces pressure from both harder CMS cut points and shilling risk pools, complete lab data supports gap closure and performance stability. The question health plan leaders should ask is straightforward: