2026 Health Care Outlook: Micah Cost, PQA

By Micah Cost, CEO of Pharmacy Quality Alliance

Over the last 20 years, Medicare Part D has been a resounding success for patients and our health care system by increasing access to needed medicines and reducing out-of-pocket costs for millions of beneficiaries. Pharmacy Quality Alliance (PQA) measures play an important role in this success. 

The 2024 CMS (Centers for Medicare and Medicaid Services) National Impact Assessment of CMS Quality Measures Report showed the economic benefits of PQA’s three adherence measures in Medicare Part D, estimated at up to $29.2 billion in health care costs avoided over the five-year period of 2016 to 2021. 

The changes proposed in the CMS Proposed Rule, released November 25, further demonstrate the importance and impact of quality measures which evaluate the quality of medication use. It is a testament to the work that PQA and our members do in this critical area of patient care.

Perhaps now more than ever, the rapid evolution of health care quality and value is allowing that vision to be realized. The need for meaningful and impactful quality measures which close gaps in care and access and ensure value related to quality medication use remains, especially in PQA’s core measurement areas of adherence, appropriate use, safety and medication management services. 

PQA stewards dozens of quality measures, including 16 PQA measures across CMS’ quality programs, and more in state and regional quality programs. Five PQA measures are included in the 2026 Medicare Part D Star Ratings, and PQA measures account for a significant portion of a health plan’s Part D Summary Star Rating.

From Incremental Progress to Radical Transformation

2025 was a year of radical change, and I believe 2026 will bring even more change. Traditional models of care and our public health infrastructure, once considered bedrocks of our health care system, have been restructured, removed or replaced. Institutional standards and historical norms related to science, research, innovation and delivery have been disrupted. At the same time, health care insurance premiums continue to increase, the number of uninsured or underinsured patients is growing, and costs for medications, care and services continue to skyrocket. 

With that in mind, here are five things that I believe are essential to keep an eye on this year. 

• Access will become a top priority across the health care ecosystem. Ensuring patients’ access to care and services (including medications) should be a requirement and not a recommendation. Access has been thrown around as a buzzword for a while now, but it will become a core priority across every facet of our health care system. Payers should recognize and incentivize insurers and providers who prioritize patient access to affordable, timely and appropriate care and services.

• Value will continue to take center stage. Value-based care design and delivery, including incentives for driving quality of care, will accelerate in the year ahead. More emphasis will be placed on measuring and improving outcomes of care, as indicated by CMS’ plans to refocus its programs to incentivize this. Payers aim to drive value-based innovation in care models and benefit design to produce improved health outcomes for beneficiaries. It is imperative that all stakeholders, including pharmacies, providers and health plans, align their practice and business models with this trend.

• Data interoperability will shift from theory to reality. Coordination of care, portable personalized health records and data sharing innovation will be incentivized and prioritized. However, this acceleration of innovation and drive to achieve interoperability will also bring increased scrutiny and new risks related to health privacy and cybersecurity. Achieving hyperconnectivity across systems through enablement by technology solutions is a noble and benevolent goal but could also introduce unintended consequences if not done correctly.

• Artificial intelligence in health care will continue to be tested and refined. Most of the use cases for AI in health care to date have been focused on improving operational efficiencies, automating manual functions and processes, and shoring up infrastructure related to care delivery. However, 2026 may usher in a new wave of AI health care support tools focused on clinical decision support, automated charting and documentation, billing and coding, patient engagement and education, navigation of coverage and benefits, and more. It will be vital for our health care system to adopt meaningful solutions which deliver optimized patient care at a reasonable cost to an overburdened and strained health care system.

• Prevention and lifestyle management will become core priorities and will be incentivized within our health care system. Benefits will be redesigned, and initiatives which incentivize healthy lifestyles and prevention will be prioritized. While healthy lifestyles and prevention have tremendous potential to improve outcomes for patients and drive down overall health care costs, this approach does not solve the needs of all patients. A significant and increasing portion of our health care dollars is utilized to treat and manage high-cost, complex conditions. For example, the direct medical costs in the United States for rare disease alone is more than $400 billion annually. Balancing quality and cost to achieve value is an imperative across all conditions, both in therapeutic and non-therapeutic as well as acute and chronic.

2026 may be a perfect storm with the convergence of so many different issues which have collectively spread our health care system far too thin, exhausted and isolated patients and providers alike, and threatened the volatile and fragile infrastructure for care. 

I’ve heard the term “tipping point” used to describe the situation our health care system is facing right now but, more accurately, our health care system is approaching its breaking point. According to the National Health Expenditure Accounts (NHEA) 2023 Report, U.S. health care spending grew 7.5% in 2023, reaching $4.9 trillion, or $14,570 per person. As a share of the nation’s Gross Domestic Product (GDP), health spending accounted for 17.6%. 

Further, NHEA projects that over 2024-2033, the average NHE growth (5.8%) is projected to outpace that of average GDP growth (4.3%), resulting in an increase in the health spending share of GDP from 17.6% in 2023 to 20.3% in 2033.

Unfortunately, there is not a single cure or a magical fix that will address the complex challenges facing our health care system in the days ahead and, undoubtedly, 2026 will test the limits of our health care system. It will be incumbent upon all of us to dig a bit deeper and evaluate the alignment between our efforts and their impact on the most important stakeholders in this process, the patients.

Micah Cost is CEO of Pharmacy Quality Alliance.