This is a year of reckoning for US health insurers. Years of incremental changes are colliding with increasing medical costs, heightened consumer price sensitivity, and mounting skepticism among employers, regulators, and members. Historic hesitation to act has left health plan leaders at risk for more churn, shrinking risk pools, higher costs, and reputational decline. This report helps leaders navigate this moment by identifying the most critical strategic shifts, where to focus investment, and how to move from experimentation to impact in 2026.