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Blog

Five Takeaways on Medicaid, AI, Financial Sustainability, and Program Integrity from HMA’s 2026 National Conference

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From financial sustainability and program integrity to value, technology, and cross-sector collaboration, healthcare leaders are being challenged to rethink how their organizations operate. 

Healthcare leaders are entering a period in which the decisions they make now will shape their organizations for years to come. During the Health Management Associates (HMA) 2026 National Conference, US Healthcare 2026: Signals, Signs & Flashing Lights, conversations repeatedly touched on a common question: How do healthcare organizations adapt their strategies and operating models to deliver better outcomes in a more constrained environment? 

Across discussions on financial sustainability, program integrity, technology, AI, access, and the future of public programs, a clear imperative emerged: Organizations face more difficult choices about where to invest, how to define and demonstrate value, and how to work across traditional silos. The implications extend well beyond any one program or sector. 

Five takeaways stand out for healthcare leaders looking ahead.

1. Financial sustainability requires organizations to get much clearer about where they create value

Financial pressure was an ongoing topic of discussion at the conference, though conversations diverged from the traditional focus on managing tighter budgets. Instead, leaders are reconsidering where their organizations can have the greatest impact and the expertise they need to protect and strengthen, and where partnerships can improve effectiveness of service delivery. 

The conversation about sustaining access to care brought that challenge into sharp focus. Safety-net providers are confronting growing needs while also reassessing how far they can stretch their existing resources. Panelists emphasized the need for organizations to stay anchored to their mission, continually assess priorities and resources, and resist the temptation to pursue every potential opportunity or funding stream. Partnerships with government, philanthropy, schools, community organizations, and other healthcare organizations can help extend reach while allowing organizations to concentrate resources where they are uniquely positioned to deliver. 

What healthcare leaders should be thinking about

The organizations that emerge stronger will be clear about their mission and where they create distinctive value. Executive teams should be asking whether their resources, partnership, and operating models reflect those priorities.

That shift will require difficult decisions. Sustainability cannot be achieved by cutting costs indiscriminately or expecting existing models to absorb additional pressure indefinitely. Organizations will need a clearer view of the services and capabilities they must preserve, where operational models need to change, and which investments can produce meaningful results for the communities they serve.

2. Program integrity is moving closer to the center of healthcare operations

Program integrity is receiving heightened attention, particularly as public programs face greater scrutiny over how healthcare dollars are spent. Federal and state leaders highlighted the tension healthcare leaders must manage, specifically, improving stewardship of public dollars while preserving access to necessary services and avoiding undue burden on legitimate providers. They also highlighted the importance of provider management, including using data analytics to determine utilization and payment, quality, and member outcomes—all of which can help organizations identify problems earlier and make better decisions about where intervention is warranted. 

Across the sessions, healthcare leaders spoke of program integrity as a component of operations, signaling a movement away from the historical framing of program integrity as a stand-alone function. The shift creates an opportunity to connect program integrity more deliberately with quality and value.

 What leaders should be thinking about

Expect program integrity to become more integrated with operational and financial strategy. Organizations that strengthen data, governance, provider oversight, and cross-functional coordination now will be better positioned as federal and state expectations continue to evolve.

3. Managed care entities must create value across the healthcare ecosystem

Expectations for managed care delivery systems are changing, particularly for Medicaid managed care entities. Conversations throughout the conference centered on how to achieve value. Speakers discussed concepts for a financial framework that gives plans and their partners enough time, resources, and flexibility to demonstrate value. The number of years available to show results, the structure of incentives, reimbursement levels, and the allocation of financial risk all shape what plans, providers, and community partners can realistically deliver. As expectations rise, states and managed care entities will need to align these factors more deliberately so that accountability for outcomes is matched by the conditions needed to produce them. 

Plans need a clear understanding of where each partner can make a meaningful contribution, whether by strengthening primary and specialty care, addressing behavioral health and social needs, improving data exchange, or reaching members who remain disconnected from care. The value comes from how well those capabilities work together around shared priorities.

What healthcare leaders should be thinking about

Medicaid managed care leaders should not wait for the next contract cycle to determine whether their financial and partnership models can deliver the outcomes now expected of them. They should identify where incentives, reimbursement, risk, timelines, or data constraints are working against shared goals and address those gaps with states and partners.  

4. Technology strategy needs to start with the problem, not the tool

Throughout the AI preconference session and the main event, healthcare organizations grappled with the immediate challenge of deciding where AI adds value and whether they are prepared to use it responsibly. 

The AI preconference discussion focused on a framework to support key decisions and the need to put readiness before adoption. Core components of the readiness framework include reliable data, workforce preparation, engaged leadership, governance, and clear operational processes. Both technology experts and clinical leaders encouraged organizations to prioritize practical, high-value use cases rather than implementing AI broadly for its own sake. 

And, as the conference discussion of the Office of the National Coordinator’s Trusted Exchange Framework and Common Agreement (TEFCA) and the Centers for Medicare & Medicaid Services (CMS) Health Tech Ecosystem demonstrated, simply connecting more data is too little. The next step is making that information usable in ways that improve decisions, coordination, and care without creating additional work.

What leaders should be thinking about

Before making the next technology investment, organizations should be clear about the problems they are trying to solve. The strongest use cases will connect technology to a defined operational or clinical need, supported by the governance, data workforce, and measurement needed to determine whether is is actually working.  

5. Some of the biggest opportunities are emerging between programs, sectors, and traditional lines of business

Healthcare may be organized around programs and sectors, but the problems leaders are trying to solve rarely respect those boundaries. 

That was particularly evident in conversations about behavioral health. People with complex needs often interact with not only healthcare providers, but also housing, social services, and criminal justice systems. Better outcomes, therefore, depend in part on connecting services and organizations that historically have operated separately. 

The same concept surfaced during the discussion about sustaining access. Speakers challenged organizations to move beyond a siloed mindset and focus more broadly on what patients and communities need while using partnerships to extend their reach. 

A conversation with leaders from the US Department of Veterans Affairs (VA) offered another perspective on this opportunity. The VA is taking steps to make its healthcare data more actionable and to ensure its Community Care program draws on core capabilities of industry and to ensures its approach is informed by both Medicare and Medicaid. 

There is an important strategic implication here. Expertise developed in Medicaid managed care, value-based purchasing, population health, provider networks, data analytics, program integrity, interoperability, and implementation does not necessarily have to remain within the business or program where it originated. Leaders have an opportunity to look across the healthcare ecosystem for proven approaches and consider where those capabilities can solve problems in new settings. 

What healthcare leaders should be thinking about

The next opportunity may site outside the line of business in which an organization has traditionally operated. Leaders who can identify where their expertise translates, and where partners bring complementary capabilities, may find new ways to address longstanding challenges.

From Responding to Change to Shaping What Comes Next 

The discussions at HMA’s 2026 National Conference point to a healthcare environment that is entering a different phase. Understanding policy change remains essential. The work ahead, however, needs to be strategic and transformational. 

The leaders best positioned for what comes next will know where their organizations create value, be able to demonstrate it, and recognize when bringing that expertise into a new partnership, program, or market can be transformative. 

HMA can help leaders move this work forward by bringing the right partners to the table and connecting strategy with execution. As a convener and strategic advisor, HMA combines market and policy expertise with data analysis and technology capabilities to help organizations assess changing expectations, align financial and operating models, and build partnerships that deliver measurable value. 

These conversations continue in 2026 through HMA’s State of Reform events, where policymakers, health plans, providers, community organizations, and other stakeholders come together to examine state and local market realities and develop practical solutions. HMA’s next national conference will be held October 12-14, 2027, in Nashville, TN. 

Blog

What CMS’s New Medicaid Quality Pledge Means for the Future of Measurement

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The Centers for Medicare & Medicaid Services (CMS) has launched the Investing in Health Outcomes initiative with a founding group of 37 states, establishing a voluntary Medicaid Quality Pledge intended to shift Medicaid and Children’s Health Insurance Program (CHIP) quality strategy toward outcomes that matter to beneficiaries. The initiative is an effort to redirect policy, tools, data, and improvement resources away from an expansive inventory of process-oriented requirements and toward a more focused system that can demonstrate progress in prevention, chronic disease management, and behavioral health. 

That direction matters now because Medicaid agencies, managed care entities, providers, and vendors are being asked to improve outcomes while managing extensive and often duplicative performance reporting expectations. CMS reported that its review of managed care programs in 42 states identified approximately 450 reporting requirements corresponding to roughly 260 unique quality measures, many focused on processes and utilization. A smaller, more coherent portfolio could reduce administrative burden, but only if the measures selected are meaningful, the data are trusted, and accountability is built into the policy and contractual structures that drive delivery-system behavior. 

Through this voluntary pledge, CMS is encouraging, rather than requiring participating states to apply the four principles, as they develop health outcome targets and consider outcomes-oriented measures for state quality strategies and upcoming procurements. A disciplined, multiyear approach focused on a limited number of priorities is therefore best understood as an implementation strategy that states can use to make the pledge actionable and establish a credible performance trajectory. 

To learn more about the four principles for an outcome-focused Medicaid quality system access the full report here. 

Brief & Report

CMS’s Medicaid Quality Pledge Is Redefining How Health Outcomes Will Be Measured

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What states, health plans, providers, and Medicaid partners need to know about the shift toward outcome-focused quality measurement. 

CMS’s Investing in Health Outcomes initiative signals a significant change in the future of Medicaid and CHIP quality measurement. 

The voluntary Medicaid Quality Pledge encourages participating states to move beyond extensive process and utilization reporting and focus more directly on whether Medicaid programs are helping people become healthier. 

That means prioritizing meaningful outcomes, rationalizing quality-measure inventories, expanding digital quality measurement, and aligning financial accountability with demonstrated improvement. 

Download the report to understand what this shift means, and how your organization can prepare. 

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Why this matters now 

Medicaid agencies, managed care organizations, providers, vendors, and associations are being asked to improve outcomes while managing complex and often duplicative reporting requirements. 

CMS’s review of managed care programs in 42 states identified approximately 450 reporting requirements corresponding to roughly 260 unique quality measures. The pledge creates an opportunity to replace fragmented measurement with a more focused and actionable system, but only if measures are meaningful, data are trusted, and accountability is aligned with the realities of care delivery. 

The report examines the four principles shaping this transition and the implications for organizations across the Medicaid ecosystem. 

What the report examines 

1. Prioritizing outcomes over process 

The future of Medicaid quality measurement will require greater emphasis on measurable changes in health, not simply whether a healthcare activity occurred. 

That shift raises important questions about attribution, risk adjustment, benchmarks, social needs, and shared accountability across providers, plans, community organizations, and other partners. 

2. Rationalizing quality-measure inventories 

Fewer measures will not automatically mean less work. A smaller portfolio will be expected to do more: support improvement, enable accountability, work across diverse populations, and increasingly inform payment. 

States will need to match each measure to its intended use, whether learning, public reporting, contractual accountability, or payment. 

3. Using digital quality measurement as an enabler 

Digital quality measures, FHIR APIs, interoperability, and near-real-time data can improve timeliness and help organizations identify gaps earlier. 

Technology alone, however, will not produce trusted results. Successful digital measurement will also require common specifications, data-quality governance, validation, documentation, and practical feedback loops. 

4. Aligning financial accountability with outcomes 

As states and plans connect payment more directly to outcomes, methodological rigor and data trust will become increasingly important. 

Organizations will need to address questions such as: 

  • Who should receive credit for an outcome? 
  • How should performance be assessed when members receive care across multiple organizations? 
  • How can accountability promote improvement without penalizing organizations serving populations with greater needs? 
  • How should contracts and incentives reflect measure maturity, time horizons, and stakeholder control? 

What this means for Medicaid stakeholders 

The pledge will affect organizations differently, but all stakeholders will need to translate broad principles into practical decisions about policy, contracts, operations, data, and accountability. 

For states 

States will need to align quality strategies, managed care procurements, contracts, external quality review, value-based payment, data investments, and oversight around a prioritized set of outcomes. 

Key areas of preparation include: 

  • Defining priority outcomes 
  • Assessing stakeholder readiness 
  • Establishing governance 
  • Addressing attribution and risk adjustment 
  • Setting credible benchmarks 
  • Creating phased implementation roadmaps 

For health plans 

Health plans will experience the pledge through new contract terms, reporting specifications, performance targets, and procurement expectations. 

Plans should evaluate their readiness across: 

  • Data infrastructure 
  • Quality measurement capabilities 
  • Care management 
  • Provider partnerships 
  • Value-based payment arrangements 
  • Data-sharing and interoperability 
  • Performance improvement operations 

For providers 

Providers will be central to translating outcome priorities into clinical practice and measurable improvement. 

They will need clear expectations, aligned measures, practical workflow support, and data capabilities that enable care coordination and performance management. 

For associations 

Health plan and provider associations can help shape implementation by developing shared positions on measure selection, attribution, risk adjustment, phased timelines, and realistic data expectations. 

This collective perspective will be particularly important for local and safety-net providers serving members with complex medical and social needs. 

Key takeaway 

The Medicaid Quality Pledge is not simply a reporting-modernization effort. 

It represents a broader opportunity to create a more focused, trustworthy, and actionable quality-measurement ecosystem, one that connects policy, measurement science, technology, governance, operations, and quality improvement. 

The defining question is simple: 

Are Medicaid programs helping people become healthier? 

This report explains what it will take to answer that question with confidence. 

Solutions

Graduate Medical Education (GME) Consulting

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HMA Solutions

Graduate Medical Education (GME) Consulting

Build and sustain GME programs that strengthen the workforce and expand access to care. HMA provides graduate medical education consulting for hospitals, health systems, federally qualified health centers (FQHCs, both teaching health centers and those that are not) and GME consortia that want to assess, build, expand, finance, operate or improve GME programs.

Who needs GME consulting support?

Hospitals, health systems, FQHCs (both those that are teaching health centers and those that are not) and GME consortia use graduate medical education to address workforce shortages, expand access, develop new care models and align training with community needs. Establishing or strengthening a GME program, however, requires more than accreditation. Leaders must align strategy, financing, operations, educational quality, clinical capacity and long-term sustainability.

HMA helps organizations make informed GME decisions and move from planning to implementation. HMA supports clients across the GME life cycle, from early feasibility and strategic planning through program development, accreditation, launch, ongoing operations, performance improvement and growth.

Which organizations need this service?

Hospitals considering a new residency program

Health systems expanding existing GME programs

FQHCs and teaching health centers evaluating GME participation

GME consortia developing shared training infrastructure

Organizations seeking accreditation, financing, operational or compliance support

Why organizations choose HMA

Our team of experts brings together GME accreditation expertise, financial and reimbursement strategy, operational implementation experience, workforce and population health insight and health policy knowledge.

Our approach helps leaders:

Assess whether GME is the right strategy for their workforce and access priorities

Understand the operational and financial requirements of a new or expanded program

Build accreditation-ready infrastructure and applications

Strengthen existing programs and improve performance

Align GME investments with community health and physician workforce needs

Develop practical plans that can be implemented and sustained

HMA can help leaders move from opportunity to execution.

Assess GME feasibility and strategic fit

Organizations need to determine whether and how GME can support their broader goals. This process may include assessing physician workforce needs, specialty opportunities, organizational readiness, partnership options, population health priorities and the potential impact of a new or expanded program.

Build or Expand GME programs

We can support the major decisions and workstreams required to establish a GME program, including sponsoring institution applications, consortium development, GME infrastructure design, program director recruitment, specialty applications, curriculum development, site visit preparation, project management and launch planning.

Strengthen GME operations and compliance

Existing programs may need additional capacity, stronger processes or support in response to changing requirements. HMA provides GME office support, GME Committee (GMEC) planning and materials, policy and procedure development, Annual Institutional Review and Special Institutional Review support, Clinical Learning Environment Review (CLER) readiness, compliance audits, quality monitoring, technology-enabled services and updates on emerging GME issues.

Improve financial sustainability

GME programs require a clear understanding of costs, reimbursement, funding sources and financial risk. HMA helps clients evaluate financial performance and develop sustainable strategies through financial modeling, reimbursement analysis, direct and indirect GME payment strategy, FQHC prospective payment system (PPS) impact assessment, fiscal intermediary assistance, grant writing, teaching health center funding strategy, business terms for agreements and documentation and coding support for teaching physicians.

Build educational quality and leadership capacity

Strong programs depend on prepared leaders, engaged faculty, effective coordinators and reliable educational processes. HMA supports faculty development, curriculum design and evaluation, Annual Program Evaluations, Clinical Competency Committee and Program Evaluation Committee training, coordinator training, Designated Institutional Official (DIO) and GME leadership development, board and senior leadership education and resident and faculty well-being.

Align GME with workforce and population health priorities

GME is most valuable when it supports the communities and care systems an organization serves. HMA helps clients connect GME strategy to physician workforce needs, regional priorities, specialty access and population health goals. Support may include strategic planning, physician needs assessments, state and regional consultations, large data analyses, economic impact analyses, specialty program design, benchmarking, outcomes monitoring and disaster management or program closure support.

Transform primary care residency clinics

For organizations seeking to transform ambulatory training environments, HMA supports implementation of the 10 building blocks of high-functioning primary care residency clinics: engaged leadership, data-driven improvement, empanelment, team-based care, patient-team partnership, population management, continuity, access, comprehensiveness and care coordination, future-state clinic design, scheduling, resident engagement and work-life redesign.

Questions leaders should be asking

What workforce and access challenges should GME help us address?

Is our organization ready to sponsor, expand or strengthen a program?

Which specialties and training locations best align with community needs?

What infrastructure, leadership, partnerships and operational capacity will be required?

How will the program be financed and sustained over time?

Are our current systems supporting accreditation, educational quality and resident well-being?

How can GME strengthen our primary care delivery model and long-term workforce pipeline?

GME FAQs

What is graduate medical education consulting?

Graduate medical education consulting helps hospitals, health systems, FQHCs (those that are teaching health centers and those that are not) and GME consortia assess, build, expand, finance, operate and improve residency and fellowship training programs. HMA supports organizations across the full GME life cycle, from feasibility and strategic planning to accreditation readiness, program launch, operations, compliance and long-term sustainability.

How can an organization determine whether to start or expand a GME program?

Before starting or expanding a GME program, organizations should evaluate workforce needs, specialty demand, clinical training capacity, leadership readiness, partnership opportunities, accreditation requirements and financial sustainability. HMA helps clients conduct GME feasibility assessments and develop practical recommendations that align training investments with organizational strategy and community health needs.

What does a GME feasibility assessment include?

A GME feasibility assessment may include market and workforce analysis, specialty opportunity assessment, clinical site capacity review, organizational readiness evaluation, financial modeling, funding and reimbursement analysis, partnership strategy and implementation planning. The goal is to help leaders understand whether GME is viable, what resources are required and which program model is most sustainable.

How can HMA help with GME accreditation readiness?

HMA supports accreditation readiness by helping organizations develop the infrastructure, documentation, policies, governance processes, educational design and project plans needed to sponsor institution and residency program applications. This support may include application development, GMEC planning, curriculum design, site visit preparation, Annual Institutional Review support, CLER readiness and program improvement planning.

How can organizations finance and sustain GME programs?

Sustainable GME programs require a clear understanding of costs, reimbursement, funding sources and financial risk. HMA helps organizations evaluate DGME and IME payments, teaching health center funding, FQHC PPS impact, grant opportunities, fiscal intermediary considerations, business terms and financial models that support long-term program viability.

Can FQHCs and teaching health centers participate in GME?

Yes. FQHCs, teaching health centers and community-based organizations can play an important role in GME by supporting training models that expand access, strengthen primary care and build physician workforce pipelines in underserved communities. HMA helps organizations assess readiness, evaluate partnership models, understand funding implications and design sustainable clinical training environments.

When should an organization seek outside GME consulting support?

Organizations should consider outside GME consulting support when they are evaluating whether to launch or expand a program, preparing for accreditation, developing a sponsoring institution application, assessing financial sustainability, strengthening operations or compliance, transforming residency clinics or aligning GME strategy with physician workforce and population health priorities.

A practical partner for GME growth

Let HMA connect your GME strategy with the realities of accreditation, financing, operations, workforce development and care delivery. We combine GME accreditation expertise, financial and reimbursement strategy, operational implementation experience and health policy insight to help clients make defensible decisions and execute with confidence. Whether you need a focused readiness assessment, support with a new program, help improving an existing program or an end-to-end roadmap for sustainable growth, HMA can tailor the right level of support.

Ready to strengthen or expand your GME program?

Connect with HMA to assess readiness, evaluate financial and operational requirements or develop a customized roadmap for sustainable GME growth.

Blog

CMS Marketplace Anti-Fraud Actions: Financial and Strategic Implications for ACA Health Insurers

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Program integrity has become an urgent, administration-wide healthcare priority, placing the Affordable Care Act (ACA) Marketplace under heightened scrutiny. On September 22, 2026, the Centers for Medicare & Medicaid Services (CMS) announced Federal Marketplace anti-fraud actions with immediate operational and financial implications for insurers. 

This week, actuaries from Wakely Consulting Group, an HMA company, examine how Marketplace disenrollment actions could affect health insurers in 2026 and beyond across enrollment, morbidity, risk adjustment, financial reporting, operations, distribution strategy, and future pricing. 

CMS Marketplace Anti-Fraud Actions and Unauthorized Enrollment Cancellations 

CMS’s three-part program integrity strategy focuses on preventing fraudulent and improper enrollments, removing confirmed unauthorized enrollments, and enforcing Marketplace requirements for agents and brokers. The agency also established a Federal Marketplace anti-fraud coordination group comprising leaders from CMS and the US Department of Health and Human Services (HHS) to direct these efforts. 

CMS reported canceling approximately 315,000 enrollments covering more than 760,000 individuals after determining that the coverage was unauthorized. The agency expects approximately $2.2 billion in advance payments of the premium tax credit (APTC) to be returned and will continue working with insurers to identify additional cases, prevent improper subsidy payments, and recoup prior payments. 

This action follows a June 2026 report from the HHS Office of the Assistant Secretary for Planning and Evaluation, which identified approximately 1 million highly suspicious agent- and broker-assisted HealthCare.gov enrollments involving applications without a Social Security number and members paying no premium. 

Although the absence of a Social Security number does not independently establish fraud, the September announcement sends a strong signal about CMS’s willingness to cancel enrollments confirmed as unauthorized. 

Financial and Operational Implications for ACA Marketplace Insurers 

Enrollment Losses and Morbidity Risk for ACA Marketplace Plans 

In their August 2026 white paper, Implications for Potential Marketplace Unauthorized Enrollment Actions, actuaries from Wakely noted that while the overall enrollment reduction is known, its distribution across issuers and markets is not publicly available. If canceled members are disproportionately healthy or had limited healthcare utilization, their removal could increase average claims among the remaining population. For example, if non-utilizers represented 10 percent of an issuer’s enrollment, removing them would increase average claims per member per month by approximately 10 percent, assuming no other changes. 

ACA Risk Adjustment Implications of Marketplace Disenrollments 

Changes in enrollment and morbidity could materially affect ACA risk adjustment transfers, but the results will vary according to each issuer’s concentration of confirmed or potentially unauthorized enrollment. Issuers with greater exposure to canceled enrollment could see more favorable risk adjustment results even as average claim costs increase. Those transfers may not fully offset deterioration in the remaining risk pool, which underscores the need for plan- and state-specific analysis. 

APTC Recoupment and Financial Reporting Considerations for Insurers 

The timing and process to recoup approximately $2.2 billion in APTCs has near-term financial reporting considerations. Issuers should evaluate potential effects on: 

  • Premium and APTC accruals 
  • Risk adjustment transfer accruals 
  • Per member claims cost estimates 
  • Premium deficiency reserve considerations 

According to CMS, the cancellations announced in September 2026 will be applied retroactively to original effective dates. The full effect of this heightened scrutiny, however, will depend on how CMS approaches recoupment and how quickly issuers process enrollment and financial adjustments.  

Issuers may also incur near-term costs associated with identifying and investigating suspicious enrollments, reconciling records with CMS, processing cancellations, adjusting revenue accruals, supporting affected consumers, and updating broker oversight. Lower enrollment also leaves fewer premium dollars available to cover fixed administrative expenses. 

How CMS Disenrollments Could Affect Future Marketplace Premiums 

As 2027 premiums are finalized, issuers will need to consider enrollment and morbidity shifts for 2028 prices. Insurers with established monitoring and projection processes will be better positioned to assess new CMS information and adjust forecasts as policy and enforcement evolve for 2026 and 2027. 

CMS Broker Enforcement and Marketplace Distribution Risks 

In addition to strengthening oversight of enrollment data, CMS has intensified enforcement of agent and broker requirements. Since January 2026, the agency has sent termination notices to more than 200 noncompliant agents and brokers and issued 569 notices of intent to terminate Exchange Agreements associated with 2026 applications that lacked identifying applicant information. Issuers should assess concentration by broker, monitor enrollment quality, and consider how enforcement may affect acquisition channels, member mix, and future growth. 

Market-Level Variation in Marketplace Disenrollment Risk 

The effects of CMS’s actions are limited to Federally Facilitated Marketplace (FFM) states and state-based Marketplaces using the federal platform (SBE-FM) and do not extend to state-based Marketplaces operating their own eligibility and enrollment systems. Individual issuer effects could vary materially based on several factors, including state, county, issuer, product, broker channel, and member premium contribution. 

Some issuers will be more exposed than others, particularly those with more enrollees paying low or $0 net premiums, greater broker reliance, substantial automatic reenrollment, or a strong presence among lower-cost plans. Understanding the financial impact will require analysis at the plan and market levels. 

Key Actions for Health Insurers Following CMS Marketplace Disenrollments 

Health insurers should assess a range of outcomes at the plan and state levels. This analysis should show how the concentration and health profile of canceled enrollment could affect claims, APTCs, risk adjustment, financial accruals, administrative expenses, distribution, and future rates. 

The timing of CMS’s actions will shape those outcomes. Because the announced cancellations apply retroactively to original effective dates, insurers will need to account for APTC recoupment and related enrollment and financial adjustments. The ultimate impact will depend on the data CMS provides, the scope of additional reviews, processing timelines, and any appeals or corrections. Issuers should revisit their forecasts as these details emerge and federal actions continue ahead of the 2027 plan year. 

Assessing Marketplace Disenrollment Risk: How HMA and Wakely Can Help 

Health Management Associates (HMA) and Wakely Consulting Group combine policy, market, actuarial, and financial expertise to help health plans and state regulators assess the effects of Marketplace program-integrity actions. For insurers, our teams can develop plan-by-plan and state-by-state projections of enrollment, morbidity, claims, APTCs, risk adjustment, and premiums; test prospective and retrospective cancellation scenarios; and translate the findings into pricing, forecasting, distribution, and market strategy decisions. 

State insurance regulators in affected FFM and SBE-FP states will need a market analysis of how the cancellations are distributed across issuers and whether changes in enrollment and morbidity could affect rates, risk adjustment, capital, or continued plan participation. Regulators should also evaluate whether approved 2027 rates and financial assumptions remain supportable and monitor solvency and consumer access as insurers adjust to this and CMS’s broader program integrity actions. HMA and Wakely can support this work through state-specific market assessments, issuer-level stress testing, rate and risk-pool analysis, and scenario projections that help regulators identify emerging concerns and act before they threaten market stability.

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Pennsylvania Health Policy Conference 2026: What’s Next for Medicaid Enrollees, Rural Hospitals, and the Workforce

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State of Reform (SOR), an HMA Company, hosted its inaugural Pennsylvania Health Policy Conference in Harrisburg on September 16, 2026, bringing together more than 170 interest-holders, including state health and human services departments leaders, policymakers, providers, health plans, community‑based organizations (CBOs), and others to discuss the most pressing health-related issues in the commonwealth. 

The conference focused on how federal Medicaid policy changes, managed care challenges, and workforce shortages, are reshaping Pennsylvania’s healthcare landscape while highlighting prevention and cross-sector collaboration as essential to building a more sustainable system. Key discussions are highlighted below. 

Central Discussions: Federal Medicaid Policy, Managed Care, and the Workforce 

Pennsylvania Medicaid 

Valerie Arkoosh, MD, Secretary of the Pennsylvania Department of Human Services (DHS) opened the conference by examining how federal policy and fiscal pressures are likely to affect Pennsylvania’s health and human services system. She discussed the anticipated loss of Medicaid coverage for approximately 310,000 enrollees due to the 2025 budget reconciliation act (P.L 119-21, now known as the Working Families Tax Cut Act [WFTCA]) and the resulting strain on individuals, providers, and the broader healthcare system. 

WFTCA and broader financial pressures also raise concerns about the sustainability of hospitals, with closures threatening access to care, especially in rural and underserved communities. Hospitals and safety-net facilities are consistently working against staffing shortages, capacity constraints, and shifting payer dynamics. Pennsylvania is using funds from the Rural Health Transformation Program (RHTP) to support struggling rural hospitals as best it can. DHS has awarded $42 million in RHTP grant fund awards so far to support various rural facilities. 

Medicaid managed care 

Community HealthChoices (CHC), Pennsylvania’s Medicaid managed long-term services and supports (MLTSS) program, has been at the forefront of the healthcare conversation in the state as a result of the cancellation of its 2024 contract awards for the program. In June 2026, DHS released a request for information seeking responses on several topics that could shape a new CHC re-procurement, including the number of Medicaid managed care organizations (MCOs) within CHC, regional versus statewide coverage, length of contract terms, strategies to align coordination of Medicare and Medicaid, artificial intelligence (AI), and other program recommendations. 

During the managed care discussion, Sally Kozak, Deputy Secretary of the Office of Medical Assistance Programs, and Emily Katz, Executive Director of Pennsylvania Medicaid MCOs, joined health plan leaders in assessing how well the physical health managed care program is improving access, quality, and cost management. 

The conversation centered on persistent challenges involving provider participation, care coordination, the complexity of administering the programs, and the variation in performance by region. There are opportunities to reform or refine managed care to better align incentives with patient needs and system sustainability. 

Workforce shortages 

Like all states, Pennsylvania is facing a health professional shortage across all sectors. Jennifer Hale, Director of the Bureau of Policy and Regulatory Management in the Office of Long-Term Living, and Garry Pezzano, President and Chief Executive Officer of LeadingAge PA, highlighted how this issue is affecting people who need long-term care. Speakers emphasized that Pennsylvania’s ability to meet the needs of an aging population will depend largely on strengthening the workforce that delivers these services. They explained several of the strategies underway and being discussed to achieve this goal, for example by improving wages and benefits for direct care workers, strengthening education and training pipelines, expanding loan repayment programs, prioritizing recruitment, and investing in technology for telehealth services and AI-assisted workflows. 

Advancing Change: Upstream Interventions and Collaboration 

Paying for care continues to be a chief concern. While many of the financial pressures come from within the healthcare system as the result of policy and budgetary challenges, throughout the conference speakers emphasized that many of Pennsylvania’s most pressing healthcare challenges begin outside the healthcare system. Food insecurity, unstable housing, transportation barriers, limited caregiver support, and lack of social and community supports worsen health outcomes and lead to increased healthcare expenditures. 

Panelists called for greater investment in upstream prevention services that help people remain healthy and independent before their needs become more acute to contain costs over time. Speakers recommended approaches such as expanding housing supports, food as medicine initiatives, community health worker investments, caregiver supports, reentry services, and technology that allows people to receive care at home, as well as other initiatives to ensure people can remain healthy and independent. 

Pennsylvania has already begun investing in several of these areas. The fiscal 2027 budget allocated $1.9 million to the Investments in Health pilot program for housing stability services and reentry supports for incarcerated individuals. Federal matching dollars for the first year of this program total $5.2 million. Another tool, PA Navigate, connects people with CBOs, state agencies, and providers that can help people access basic necessities. 

Speakers also stressed that these efforts will have limited reach if organizations operate separately. Better coordination among healthcare providers, MCOs, CBOs, hospital systems, and state agencies can reduce the fragmentation, make services easier to navigate, and help funding and data systems support common goals. That message was consistently expressed throughout the conference: Pennsylvania’s healthcare challenges cannot be addressed by one sector alone, and progress will depend on sustained collaboration among the organizations that serve individuals and communities. 

Looking Ahead 

If you are looking for strategies and solutions to address urgent healthcare policy and operational challenges, Health Management Associates (HMA) experts are available to help you navigate these complex changes and identify practical paths forward. 

Through the HMA National Conference, State of Reform partnership events, and other HMA meetings across the country, we connect state leaders, providers, health plans, and community stakeholders to share insights, elevate lessons, and advance solutions. Join us at an upcoming event—including our next HMA National Conference in New Orleans, LA, October 5–7, 2026—or explore additional opportunities to engage with HMA and access the full schedule of conferences and resources. 

State of Reform develops its conference agendas through collaboration with HMA subject matter experts/market leads and stakeholders across the public and private sectors, including state officials, community-based organizations, providers, payers, and more.

Blog

VA Community Care Program: Richard Topping to Discuss NextGen VA at HMA 2026 Conference

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Health Management Associates (HMA) is pleased to welcome The Honorable Richard F. Topping, Assistant Secretary for Management and Chief Financial Officer at the US Department of Veterans Affairs (VA), to HMA’s US Healthcare 2026: Signals, Signs & Flashing Lights conference, October 5-7, 2026, in New Orleans, LA. His participation will give health plans, providers, technology companies, and other organizations interested in working with the VA Community Care program a timely opportunity to hear directly from senior VA leadership about the priorities shaping the program’s next phase. 

VA Community Care Priorities and Opportunities for Collaboration 

HMA’s Jean Glossa, MD, MBA, FACP, will join Mr. Topping during Community Care for Veterans—NextGen VA to discuss priority healthcare issues for the VA. They will examine the VA care delivery system, Mr. Topping’s areas of oversight, and opportunities to better integrate care delivered by VA providers with services furnished by contracted community providers. 

In addition to its direct care system, the VA operates six national payer programs, including VA Community Care—now the fourth-largest health insurer in the United States. Mr. Topping will describe how the VA is shifting Community Care from a network administration model toward a true healthcare purchasing and performance‑management model. CCN NextGen is the VA’s first major modernization of Community Care contracting since the MISSION Act, which took effect in 2019. This 10‑year, multiple‑award IDIQ structure will increase competition, enable regional adaptability, and support iterative improvements through sequential task orders opening up new opportunities for industry to partner with the VA. 

Explore Best Practices for Working with the VA 

Mr. Topping also will participate in one of HMA’s Coffee Conversations and Collaborations, a highly interactive format, which fosters practical discussion. Participants will have an opportunity deepen their knowledge about effective approaches to working with the VA, ask questions, and share experiences. This combination of senior-level perspective and smaller group dialogue makes Mr. Topping’s participation especially relevant for managed care plans, provider organizations, technology firms, and other partners monitoring the direction of VA Community Care. 

Join VA and Healthcare Leaders at HMA’s 2026 Conference 

HMA is honored to host Mr. Topping and create space for a substantive discussion about the future of VA Community Care. Register for HMA’s US Healthcare 2026 conference to hear directly from leaders who are shaping public healthcare and connect with peers working to turn policy priorities into stronger systems of care. 

Webinar

The Value of Home-Based Personal Care Services

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This webinar, supported by TEAM Services Group, will provide an overview of home-based care, including the populations served, key service types, and delivery models. Experts will discuss findings from a review of the value of home-based care, highlighting its potential to stabilize health, improve the care experience, reduce unnecessary healthcare utilization, and enhance safety and satisfaction for both individuals receiving care and their family caregivers. The webinar will also examine opportunities to expand access to high-quality home-based care, including policy and system-level strategies that can strengthen the structural components needed to make these services more widely available to those who could benefit.

Learning Objectives

  • Describe the fundamentals of home-based care, including target populations, service types, and delivery models.
  • Review evidence on the value of home-based care, including its potential to improve clinical outcomes, reduce unnecessary healthcare utilization, generate cost savings, and enhance patient and family caregiver satisfaction.
  • Identify policy levers and system-level strategies that can strengthen high-value long-term services and supports (LTSS), including home-based care, and improve access to quality services.
Solutions

Community Health Assessments & Improvement Plans

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Flexible, actionable support to help communities move from assessment to measurable community health improvement.

Community health leaders need clear, credible, and actionable community health assessment/community health improvement plan (CHA/CHIP) processes that satisfy accreditation expectations while helping partners align around shared priorities. Health Management Associates (HMA) supports public health agencies, hospitals, collaboratives, and community partners with right-sized services that move efficiently from assessment to strategy to measurable improvement.

Why Communities Choose HMA

Practical support designed around local goals, capacity, and community priorities

Right-Sized Scope – Select the level of support that fits your timeline, budget, staffing, and readiness

Meaningful Engagement – Bring community members, partners, and decision-makers into the process in purposeful ways

HMA’s CHA & CHIP Service Offerings

Three flexible pathways—plus add-on support tailored to your community

Every community starts from a different place. HMA’s flexible CHA/CHIP pathways make it easy to select the right level of support and add only the enhancements that advance local priorities.

FOUNDATIONAL

Foundational CHA
MAPP Essentials

Best for: Smaller or rural communities, limited budgets, & routine CHA updates.

Focus: Efficient, PHAB-ready assessment.

COMPREHENSIVE

Comprehensive CHA
MAPP Standard

Best for: Most counties, regions, and accreditation-driven efforts.

Focus: Full MAPP process with comprehensive community engagement.

ADVANCED

Deep Engagement & Equity-Centered CHA
MAPP Advanced

Best for: Large jurisdictions, regional collaborations, and transformation-focused initiatives.

Focus: Community co-creation, equity, systems change, and implementation readiness.

Optional Enhancements

Add targeted support to any pathway based on local priorities, accreditation needs, and implementation goals.

Community Engagement

Focus groups, surveys, listening sessions, and culturally specific outreach

Advanced Analytics & Equity

Neighborhood analysis, equity assessments, and disparities analysis

Data Visualization & Communications

Geographic Information Systems (GIS) mapping, dashboards, and public-facing materials

Accreditation & Planning Support

PHAB documentation, CHIP facilitation, and early implementation planning

Project Examples

Community Health Assessment and Improvement Planning Resources

How can communities move from a compliance-driven assessment to a connected system for improving health?

These four reports demonstrate how HMA partners with communities to conduct Community Health Needs Assessments (CHNAs), CHAs, CHIPs that examine local health conditions, identify priority needs, advance health equity, and inform measurable strategies for action.

The reports represent communities in Oregon, Washington, California, and Colorado. They demonstrate the value of combining community voice, quantitative and qualitative data, cross-sector partnership, priority setting, implementation planning, and performance measurement.

A Community-Informed and Equity-Centered Health Assessment of Clackamas, Multnomah, and Washington counties in Oregon and Clark County in Washington State

Prepared for the Healthy Columbia Willamette Collaborative, this regional assessment brings together community input and data to identify health needs across four counties and support coordinated, equity-centered planning for a collaboration across public health, hospitals, and health systems.

Read the 2025 Community Health Needs Assessment →

San Bernardino County: Our Community Vital Signs

Prepared for San Bernardino County Department of Public Health, this community health assessment provides information about the health and well-being of San Bernardino County residents. It is designed to support community understanding, priority setting, cross-sector collaboration, and evidence-informed health improvement efforts.

Read the San Bernardino County Community Health Assessment →

Prepared for the Imperial County Community Health Improvement Partnership, this CHIP translates identified health priorities into strategies and actions designed to improve health outcomes across Imperial County.

The plan illustrates how communities can connect assessment findings to implementation, partnership, accountability, and measurable progress.

Read the Imperial County Community Health Improvement Plan →

Prepared for the Yampa Valley Regional Collaborative, the Yampa Valley Community Health Needs Assessment was developed through a collaborative effort involving The Health Partnership, Memorial Regional Health, Northwest Colorado Health, Routt County Public Health, UCHealth Yampa Valley Medical Center, and United Way.

The report combines community survey findings, community meetings, and public health and socioeconomic data. It identifies two priority areas for Yampa Valley:

  • Behavioral health
  • Access to culturally and linguistically responsive health care

It also identifies four important drivers of health: 1) access to healthy foods; 2) affordable housing; 3) economic opportunity, including jobs and wages; and 4) transportation.

Read the 2022 Yampa Valley Community Health Needs Assessment →

From Assessment to Action

A CHA or CHNA is more than a compliance document. It can serve as the foundation for a connected planning system.

Community engagement → Data and assessment → Priority setting → Implementation → Measurement and accountability

These reports offer practical examples of how HMA approaches this important work with communities to gather input, analyze local conditions, identify priorities, plan responses, and create stronger pathways from assessment to measurable action.

Communities represented

  • Clackamas County, OR
  • Multnomah County, OR
  • Washington County, OR
  • Clark County, WA
  • San Bernardino County, CA
  • Imperial County, CA
  • Yampa Valley and Routt County, CO

Topics covered

Community health assessment, community health needs assessment, community health improvement plan, CHA, CHNA, CHIP, health equity, community engagement, community voice, behavioral health, access to health care, culturally and linguistically responsive care, social determinants of health, social drivers of health, cross-sector collaboration, public health planning, hospital community benefit, priority setting, implementation planning, performance measurement, and community health improvement.

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