Population Health Analytics

The Affordable Care Act (ACA) individual market is in a period of significant disruption. After several years of continuous Medicaid coverage through the COVID-19 pandemic, states began reviewing Medicaid eligibility — a process known as redetermination. As a result, millions of people are losing Medicaid eligibility and turning to ACA plans for coverage.

Conventional thinking suggests that higher enrollment spreads risk and creates more stability. However, recent analyses from Wakely Consulting Group show a more complex picture: many of these new members have unmet health needs or delayed care — factors that may actually increase overall risk and cost.

What This Means for Health Plans

• Medicaid redetermination is reshaping the market. Many of those losing Medicaid eligibility are entering the ACA marketplace with more complex care needs. Successful health plans will adopt more sophisticated approaches to understanding risk, managing costs and meeting member health needs.

• Premiums are rising sharply. Proposed 2026 premium increases — with a median increase of 18% — reflect growing financial pressure from medical cost trends, inflation, specialty drug spending (including GLP-1s) and policy changes.

• Risk composition matters as much as enrollment size. Monitoring who enrolls — and understanding their clinical and social needs — will be key to both financial sustainability and care planning.

• Traditional models may underestimate future costs. Delayed care, evolving utilization patterns and a shifting policy environment can quickly weaken the assumptions underlying older risk frameworks.

• Enrollment growth doesn’t guarantee stability. True success depends on how effectively health plans manage risk, control costs and meet evolving member needs.

Next steps for health plans should include:

• Reassess your risk models: Ensure your analytics capture not just enrollment numbers, but the clinical complexity of your new and renewing members. Develop targeted risk mitigation strategies, utilizing the ACG System predictive analytics and medication data insights to manage rising risk, improve care outcomes and contain costs.

• Plan for rising costs: Develop proactive strategies to offset the effects of inflation, specialty drug utilization and federal policy changes on 2026 pricing and financial performance.

• Strengthen data-driven decision making: Apply evidence-based segmentation and predictive analytics to anticipate service demand and allocate resources effectively. Leverage these data to anticipate morbidity trends and care demand.

• Act now to stay competitive: With ACA premiums projected to rise sharply, early action matters. Use advanced analytics and ACG System insights to anticipate risk, manage costs and maintain stability in a shifting marketplace.

What This Means for Providers

• Shifts in coverage affect patient mix. Many patients moving from Medicaid to ACA marketplace plans have higher unmet needs or delayed care. This can increase demand for services and strain capacity.

• Premium changes signal rising cost pressures. Providers can expect greater pressure from payers on cost management and value-based performance.

• Patient complexity is increasing. Chronic conditions, specialty medications and complex procedures are on the rise, requiring proactive care planning and coordination.

• System-wide impacts are coming. Policy shifts and cost drivers will directly affect operations, staffing and financial sustainability. Providers must anticipate higher service demand and evolving payer expectations.

Next steps for providers should include:

• Understand your patient population: Use segmentation and risk analytics to identify patients with unmet or delayed care needs. Prioritize outreach and care coordination to address gaps and improve outcomes.

• Prepare for higher demand: Anticipate increased utilization among newly covered populations and adjust resource planning accordingly.

• Strengthen value-based care strategies: Demonstrate measurable quality outcomes and cost-efficient care to align with payers facing higher premium pressures. Additionally, focus on ensuring timely and accessible care to prevent avoidable emergency department visits, by implementing strategies such as expanded clinic hours, telehealth services and care coordination programs that connect patients with community resources and support services.

• Leverage data for smarter decisions: Apply evidence-based analytics, such as the ACG System, to forecast service demand, allocate resources effectively and manage financial risk across your patient population.

Bottom line:

The ACA marketplace is evolving rapidly — and so are the risks. For health plans and providers alike, success will come from moving beyond enrollment metrics to truly understand who their members are, what they need and how best to deliver care in a changing economic and policy landscape.

To learn more about how the ACG System can support your organization, visit hopkinsacg.org or contact us at acginfo@jh.edu. If you are a current ACG System customer, please reach out to your Account Manager.