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Addressing Behavioral Health Needs in an Aging Population

America’s healthcare and behavioral health systems are not adequately supporting the mental health and substance use needs of older adults. Unless improved with targeted and innovative policies and operational changes, those systems will do an even poorer job in the immediate future as our country rapidly ages. The result will be an increased number of older adults with untreated mental health disorders, cognitive disorders, and/or substance use disorders, increased rates of hospitalization and institutionalization, and vastly increased care costs.

Available statistics make clear the challenges:

The number of older adults in this country is expected to grow from approximately 56 million in 2020 to 85 million in 2050. Without substantial breakthroughs in treatment and prevention, the number of older adults with diagnosable mental disorders will increase from about 11 to 17 million and those who misuse alcohol and other drugs will increase from 2 to 3.5 million.
During those three decades, the number of Americans with dementia will also nearly double from 7 to 13 million. Many of these elders will have co-occurring behavioral health conditions, such as depression, anxiety, psychosis, and behavioral disturbances which will greatly strain family resources and coping.

If present performance is any predictor of the future, our systems of care now in place will not be able to handle the coming needs. Today fewer than half of older adults with mental or substance use disorders get any treatment at all because of limited-service capacity and access. Much of the care that is provided comes from medical and behavioral health providers without specific training or experience in older adult mental health and substance use disorders. The so-called digital divide—in which many older Americans are uncomfortable with telehealth or lack the equipment or bandwidth to use it—disproportionately impacts those with behavioral health disorders who live in rural communities and/or have limited economic means.

To adequately care for these vulnerable older adults, our approach and systems must change. That will require increased attention, investment, and thoughtful planning. Fortunately, there is clinical, operational, and policy expertise available to guide what will necessarily be a decades-long effort.

How HMA can help

HMA works with a range of clients. We work with federal, state and local governments, trade associations, provider organizations and community-based provider organizations (CBOs), delivery systems, managed care organization (MCO) plans, and philanthropic funders, to design, implement, and sustain effective models and systems of care for older adults with mental health and substance use needs.

We bring together a cross-sector, multidisciplinary team of experts in older adults’ needs and mental health and substance use focused on strategy, policy, clinical, operations, and finance systems. Our team members have rich backgrounds across government, payers and provider systems. We understand our clients’ needs because we’ve been in your shoes.

Workforce & Capacity Building

Workforce planning: embedding peers, age-friendly training
Identify and implement caregiver support models
Develop mental health/substance use and aging coalitions

Policy, Planning & System Redesign

Plan state and local policy and system redesign
Incorporate mental health and substance use in multi-sector plans on aging and age-friendly communities
Build age friendly systems of health and mental health/substance use care

Integrated & Specialized Care Models

Establish integration models within and between systems
Implement care coordination/care transition models, including post-acute care
Develop housing models that integrate mental health and substance use care 
Establish specialized models of care for older adults with serious mental illness and/or substance use disorders

Evidence-Based & Preventive Interventions

Embed evidence-based practices for older adult mental health and substance use needs
Design suicide prevention and crisis systems that supports older adults
Integrate psychoeducation for older adults and their families

Financing & Technology Infrastructure

Design financing and optimization of revenue models
Embed tech-enabled care solutions

Provider Access

Conduct workforce planning, including age-friendly training
Identify and implement caregiver support models
Design financing and optimization of revenue models

Discrimination and Awareness

Provide psychoeducation for older adults and their families

Service Access

Plan state and local policy and system redesign
Establish integration models within and between systems
Implement care coordination/care transition models, including post-acute care
Incorporate mental health and substance use in multi-sector plans on aging and age-friendly communities
Build age friendly systems of health and mental health/substance use care
Embed tech-enabled care solutions

Recent Project Examples

Strategic planning

An Area Agency on Aging (AAA) hired HMA to assess the needs of its client population and develop strategies to enhance behavioral health services and supports. The mental health and substance use needs of older adults, and especially those with both Medicaid and Medicare are among the highest. Through this project, the AAA focused on finding ways to expand service access to older adults. HMA prepared several recommendations to contract with health plans to help older adults access behavioral health services.

Multi-sector plans on aging development

A county hired HMA to help develop a multi-sector plan on aging. Multi-sector plans on aging provide an opportunity to address the unmet mental health and substance use needs of older adults. HMA analyzed relevant assessments and plans and facilitated broad community engagement to help shape the development of the plan.

Skilled nursing facilities practice improvement

A state health department hired HMA to enhance the quality of care of skilled nursing facility residents with substance use disorders. Many residents, including older residents, of nursing homes have unidentified and untreated substance use conditions. HMA delivered on-site technical assistance, in-person staff training, policy and procedure development, community partnership building, and regional forums to foster shared learning.

Affordable housing with integrated services sustainability

A long-term care trade association hired HMA to develop a braided financial and partnership service model to integrate health, mental health and social services to support aging in place. Integrated service and financial models can better support the often co-occurring physical, mental, and social needs of older adults. HMA conducted stakeholder engagement, service gap analysis, and strategic alignment to support the development of a sustainable service model.

Post-acute care guide

A state-level hospital association hired HMA to support its hospitals and their staff on post-acute care transitions. Post-acute care transitions are critical to ensuring that older adults have a successful recovery. These transitions are important for preventing complications after leaving an acute care setting like a hospital. The association hired HMA to create first-of-its-kind post-acute care (PAC) guides to support clinicians and family members to find post-acute care resources to address behavioral health needs.

Rural access to services for older adults

A foundation hired HMA to improve access to integrated care for older adults who were dually eligible for both Medicaid and Medicare. Older adults residing in rural communities have poorer access and outcomes than their urban peers. HMA created a toolkit of actionable solutions for state policymakers to address older adults’ mental health needs and social isolation conditions in rural communities.

Contact our experts:

Barry J. Jacobs

Principal

Dr. Barry J. Jacobs is a noted clinical psychologist and family therapist whose passion for enhancing support for family caregivers … Read more

Patrick Meadors

Associate Principal

An expert in psychological processes and systems thinking, Patrick Meadors is a licensed marriage and family therapist with over 15 … Read more

Kim Williams

Principal

Kim Williams is an experienced executive, policy leader and social worker with a record of transformational growth, accomplishment, and innovation … Read more

Medicaid Managed Care Profitability: Navigating Margin Pressures and Regulatory Shifts in 2024

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This week, our In Focus section highlights findings from Health Management Associates Information Services’ (HMAIS’s) review of 2024 statutory filings submitted to the National Association of Insurance Commissioners (NAIC). These filings provide a nationwide view of Medicaid managed care plan profitability and medical loss ratios (MLRs) across 221 plans operating in 39 states, the District of Columbia, and Puerto Rico.

These data build upon and offer additional context to a previous analysis conducted by HMA and Wakely, an HMA Company, of increasing post-pandemic financial pressures driven by acuity increases resulting from the continuous eligibility unwinding and increases in behavioral health and home and community-based services access and utilization.

Medicaid Managed Care Underwriting Gains and Losses

As state Medicaid programs have increasingly moved from fee-for-service to managed care, a foundational assumption has been that efficient managed care organizations (MCOs) reduce waste and deliver high quality, cost-effective healthcare services. This transition has made Medicaid plan performance and sustainability a central focus for policymakers and actuaries alike.

Medicaid capitation rates must be actuarially sound, which means they must be projected to cover all “reasonable, appropriate, and attainable costs,” including medical administrative costs, plus a margin for insurance risk, even for nonprofit plans. According to the Society of Actuaries 2024 research, average underwriting margins in Medicaid rates ranged from 0.35 percent to 3.15 percent, with a consistent average between 1.2 percent and 1.3 percent.

However, actual results often deviate from projections for reasons that may be challenging to predict. Rate setting is an inherently forward-looking process, and even with conservative assumptions, unexpected shifts in enrollment, acuity, or service utilization can lead to significant deviations from projected results. Retrospective reviews show variability in margins over time (see Figure 1).

Figure 1. Historical Medicaid MCO Net Gains/Losses, 2012‒2024 (39 States, DC)

Based on HMAIS’s analysis, Medicaid MCOs sustained modest but steady gains from 2012 through 2017. After a decline between 2016 and 2019, margins rebounded to approximately 3 percent until 2022, narrowed in 2023 to 1.9 percent, and turned negative in 2024 at -0.9 percent.

For the first time in over a decade, more plans experienced losses than gains in 2024 (see Figure 2), with only 42 percent reporting positive margins, down from the decade high of 84 percent in 2022. This shift raises critical questions about sustainability and participation in Medicaid managed care.

Figure 2. Medicaid Managed Plans Likelihood of Gain, 2012‒2024 (39 States, DC)

The “Likelihood of Gain” chart tracks the percentage of Medicaid managed care plans reporting an underwriting gain each year from 2012 to 2024. For most years, the likelihood that a plan posted a gain was relatively high, typically between 60 percent and 80 percent. The probability reached a recent peak in 2022, with 84 percent of plans reporting gains, and remained elevated in 2023 (74 percent). In 2024, however, the likelihood of gain dropped sharply to just 42 percent, the lowest level in the 12-year period.

Risk Corridors, Medical Loss Ratios, and Structural Policy Shifts

MLRs show the portion of plan revenue spent on medical care as compared with the costs to operate the plan and the underwriting gain or loss described previously. When MLRs rise or fall, it can be an indication that medical cost trends experienced by health plans differ from the assumptions used by state rate setting actuaries. High MLRs are the key driver of underwriting gains, and low MLRs are associated with higher profitability. All states report MLRs to the Centers for Medicare & Medicaid Services (CMS), and some enforce minimum MLRs with a remittance provision, requiring plans to return funds if their MLR goes below a certain level.

Risk corridors are another tool that states use to manage financial volatility. These mechanisms share gains or losses between plans and states when results deviate significantly from pricing assumptions, offering protection to MCOs and the state alike, in contrast to minimum MLR provisions with a remittance provision, which only protects the state. During the COVID-19 pandemic, many states implemented or expanded risk corridors to recoup overpayments because of lower utilization. Some risk corridors were set retroactively—a practice CMS now prohibits.

In 2024, MLRs reached a decade high of 90.8 percent, as indicated by HMAIS’s analysis. Driving this increase were heightened utilization rates, increased enrollee acuity, and the end of continuous Medicaid coverage protections in 2023. As healthier, lower-cost members left Medicaid, plans were left serving a more complex population with higher per-member costs. Inflation in medical costs—especially for behavioral health and home and community-based services—added more pressure. Delayed or avoided care during the COVID-19 pandemic may also have played a role, as members sought more services in 2022‒2024, resulting in a surge in utilization greater than what was priced into rates.

Many states put risk corridors in place to stabilize margins from 2020 to 2022, which may have contributed to the tight band of outcomes around the high underwriting gains in that period. However, many states have been removing them for 2024, 2025, and 2026. Without these protections, plans may face greater exposure to underpayment in 2025 and 2026 if cost trends continue to outpace rate assumptions.

What to Watch

Rate setting conversations between states and plans for 2026 are happening now, and in many cases they are quite challenging. In addition to meeting actuarial soundness requirements, states also must balance their budgets, and some may be facing limitations on their traditionally used tools.

Looking ahead, it will be increasingly important that states and plans partner to find cost savings that can ensure the program’s long-term sustainability.

A subscription to HMAIS provides access to comprehensive financial intelligence on Medicaid managed care. Far beyond surface-level snapshots, HMAIS delivers health plan-level financial performance metrics, enrollment trends, and state policy developments that directly shape rate setting and operational strategy. Whether you’re a state official, health plan executive, or policy strategist, HMAIS provides the financial clarity and policy context needed to anticipate regulatory shifts, benchmark performance, and make confident, data-driven decisions.

For questions about the analysis discussed in this article, contact our experts below.

August 13, 2025

Medicaid Managed Care Profitability: Navigating Margin Pressures and Regulatory Shifts in 2024

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Health Tech Ecosystem Leaders to Speak at HMA’s National Conference

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The Trump Administration’s new Health Tech Ecosystem initiative is reshaping how patients and providers access health data, with the bold Kill the Clipboard road map offering a federal blueprint for modernization. At its National Conference being held October 14–16 in New Orleans, Health Management Associates (HMA) is bringing together healthcare leaders to explore how federal policy and industry innovation are driving smarter, more connected care.

About the Sessions

Driving Digital Health Forward: Federal and Industry Enablers of Smarter, Connected Care
The Digital Health “State of the Art”: Success Stories, Trends and Opportunities
Seizing Disruption to Make a Lasting Impact in Healthcare

These and other sessions reflect the federal government’s evolving priorities around digital transformation, interoperability, and patient empowerment. The Health Tech Ecosystem initiative and CMS’s Interoperability Framework are setting new expectations for how healthcare organizations manage data, engage patients, and collaborate across sectors

Featured Digital Healthcare and Innovation Leaders Speaking at the HMA Conference

Our speakers will unpack the far-reaching impact of these advancements, spotlighting opportunities for smarter data exchange and care coordination in a connected ecosystem. In addition, experts from across the healthcare industry will share practical strategies for advancing digital maturity and overcoming operational challenges, with a focus on improving patient care and organizational efficiency.

Secretary Bruce Greenstein, Louisiana Department of Health
Jaime Bland, DNP, RN, Chief Executive Officer, CyncHealth
Ryan Howells, Principal, Leavitt Partners (an HMA Company) and co-author of Kill the Clipboard
Thomas Keane, MD, MBA, Assistant Secretary for Technology Policy and National Coordinator for Health IT, US Department of Health and Human Services
Martin Lupinetti, President & Chief Executive Officer, HealthShare Exchange
Juan Montanez, MBA, Managing Director, IT Advisory Services, HMA
Curt Schatz, Vice President, Enterprise Clinical Enablement, Optum
Chris Walker, Associate Vice President of Enterprise Transformation-Interoperability, Humana

Healthcare organizations need to prepare for a future regulatory environment that is significantly more digital, interoperable, and chronic disease–focused. From health plan executives and state Medicaid directors and policy teams, to provider organizations and health IT and digital health innovators, our speakers will discuss what changes are coming in the digital health space and how you can get your organization ready. Register for the conference today with the code HOTTOPIC25 to receive 20% off the standard conference rate through August.

Former Senior FDA Leader Julie Tierney Joins Leavitt Partners

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What’s Next in Quality: CMS Conference Highlights and Stakeholder Imperatives

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This week, our In Focus section covers the 2025 CMS Quality Conference. The event convened healthcare leaders, clinicians, researchers, and patient advocates to explore strategies for improving outcomes and modernizing service delivery. Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz and senior CMS officials emphasized the agency’s evolving priorities under the Trump Administration, with a strong focus on digital transformation, patient empowerment, and fraud prevention.

In this article, Health Management Associates (HMA) experts highlight key themes from the conference. We note where these themes align with the agency’s recent proposed rules and requests for information (RFIs), including several RFIs included in the 2026 Medicare Physician Fee Schedule (PFS) proposed rule, with comments due September 12, 2025. Finally, they advise healthcare organizations of the immediate need to evaluate their risks and opportunities in this digital health ecosystem.

Key Themes of the Conference

Empower Patients with Data

CMS leaders shared a vision for enabling Medicare beneficiaries to experience healthcare technology in the same way that they use in banking and streaming services. Within a year, CMS committed to enabling real-time digital communication with beneficiaries, becoming the nation’s “best payer.” Notably, a patient safety advocate challenged CMS to think about bi-directional data exchange where patients should be able to share data with CMS.

Subsequent to the conference, Administration officials announced elements of the Health Technology Ecosystem infrastructure, including conversational AI tools, diabetes and obesity management platforms, and efforts to “kill the clipboard” by simplifying data access for patients and providers.

Reducing Waste and Tackling Fraud

The conference coincided with the federal government’s multi-billion dollar healthcare fraud takedown, underscoring CMS’ commitment to curbing waste. CMS officials highlighted several aspects of CMS’ work, including application of predictive algorithms dubbed “the Netflix model” to identify suspicious billing patterns. They also talked about the new CMS Innovation Center model—the Wasteful and Inappropriate Service Reduction (WISeR) Model—to engage technology companies to improve prior authorization processes in traditional Medicare, particularly for high-risk items like skin and tissue substitutes.

Focusing on Prevention

CMS tied the Make American Healthy Again (MAHA) agenda to quality measurement reform. CMS officials encouraged moving to two distinct sets of quality measures: one for treating illness and another for maintaining health. These measures could focus on preventing or delaying onset of disease and on measuring outcomes.

Moving to Digital Quality

CMS also emphasized its commitments to digital quality measurement and interoperability through the adoption of Fast Healthcare Interoperability Resources (FHIR®) application programming interface (API) technology. For example, CMS’ Center for Clinical Quality and Standards is testing a FHIR-based assessment tool for inpatient psychiatric hospitals. Separately, the Centers for Disease Control and Prevention (CDC) is transitioning National Healthcare Safety Network’s measures to FHIR.

Policy Connections: From Conference Themes to Federal Action

The conference themes reflect and preview broader federal policy changes including:

The 2026 Medicare Physician Fee Schedule (PFS) proposed rule includes multiple requests for input on streamlining quality measures, enhancing chronic disease management, and expanding digital infrastructure.
On July 30, CMS announced an updated voluntary blueprint for modern health data exchange, which encourages healthcare organizations to become CMS-aligned networks. The agency’s Interoperability Framework describes the voluntary criteria for CMS-aligned in areas of Patient Access & Empowerment, Provider Access & Delegation, Data Availability & Standards Compliance, Network Connectivity & Transparency, and Identity, Security & Trust.

The Road Ahead for Healthcare Organizations

Healthcare organizations need to prepare for a future regulatory environment that is significantly more digital, interoperable, and chronic disease–focused. CMS is building the highway that will enable healthcare organizations to build and maintain the technology necessary for these new initiatives.

This will require state and local government, healthcare organizations, and other partners to retool their infrastructure and workflows to optimize needed operational transformations. All entities should have a strategic roadmap for obtaining and using interoperable clinical data for care management, population health and quality, among other use cases.

Payers will benefit from initiatives such as:

Exploring strategic partnerships to help accelerate technology advancement, such as digital identity providers and specialists in digital quality measurement
Exploring ways to increase focus on prevention, such as increasing uptake of the Medicare Annual Wellness Visit or considering new payment approaches for services like medically tailored meals
Staying current on AI tools and predictive analytics that identify individuals at risk for preventable conditions and working with their provider networks to intervene early

States can take steps to prepare, including:

Exploring strategic partnerships to help accelerate technology advancement, such as digital identity providers and specialists in digital quality measurement
Assessing the reach and impact of existing primary prevention programs to understand how they can use their levers to incentivize healthy lifestyles, encourage culturally responsive health education, and address root causes of preventable illness and disease
Identifying opportunities for aligned efforts and referral pathways, including with community organizations, to address upstream health factors

Health systems and providers will need to reimagine the care experience by:

Exploring early adoption of AI tools for medical documentation to improve both patient experience of care interactions and coding accuracy to support digital quality measurement
Developing age-tailored checklists to ensure face-to-face time with patients to identify and support top primary prevention goals
Evaluating and working with their patients to use digital tools that support chronic disease prevention, such as diabetes and obesity management platforms

Connect with Us

The CMS Quality Conference signaled a substantial shift toward streamlined regulatory approaches and expanded standard data exchange, digital quality reporting and measurement, and AI deployment in care settings and by payers. Stakeholders should anticipate additional federal guidance updates, including in the Medicare Physician Fee Schedule final rule in the fall.

HMA works with state agencies, payers, health systems, and providers to assess and implement digital health, quality systems, and information technology. We can help stakeholders develop cross-sector alliances, and organizations plan for and implement changes needed to react to these new initiatives. To discuss the implications of the Administration’s efforts in prevention, healthcare quality, and interoperability, contact our featured experts below.

August 6, 2025

What’s Next in Quality: CMS Conference Highlights and Stakeholder Imperatives

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Webinar Replay – Work That Works: Creating Sustainable Employment Pathways for Medicaid-Enrolled Communities

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This webinar was held on August 14, 2025.

As Medicaid increasingly intersects with the social drivers of health, states have a unique opportunity to strengthen economic mobility for Medicaid-enrolled populations through strategic localized employment initiatives in partnership with municipalities, healthcare systems, and managed care providers. This webinar explored how state Medicaid agencies can lead and support the development of workforce pathways that are sustainable, inclusive, and tailored to the needs of underserved communities.

Learning Objectives:

Learn how collaboration and partnerships reduce employment barriers.
Explore how data-driven design improves health outcomes.
Identify ways to integrate workforce development into Medicaid.

Reference-based pricing – a tool to improve consumer behavioral health access and affordability

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Reference-based pricing is a tool that can help to address growing healthcare costs and ultimately improve healthcare affordability, especially for consumers with private health coverage. Two states —Oregon and Montana—have already implemented reference-based pricing (RBP), and several others have considered it or are in the process of implementation. RBP can be implemented in two ways- either through setting limitations on what insurers can reimburse for health services or by setting limitations on what providers can charge for services. The “reference price,” usually a percentage of what Medicare pays, can also function as a floor for provider payments. This is especially important to combat issues of access to behavioral health services, where payments are notoriously low, and workforce shortages and limited network participation issues are a significant barrier to patients seeking care.

Oregon has demonstrated significant savings since implementing caps in 2019 on what insurers can pay providers- $107.5 million over 27 months- and recently demonstrated reductions in out-of-pocket spending without unintended consequences such as hospital network disruptions or price hikes. `

In Washington, reference-based pricing was evaluated as a possible policy intervention in two reports prepared by Health Management Associates (HMA). The reports were produced for the Office of the Insurance Commissioner (OIC) to address healthcare affordability in 2023 and 2024. The first report included a landscape of the healthcare system in Washington as well as an overview of several policies for consideration, while the second report involved actuarial and economic analyses of selected policies to understand their potential impacts they might have in lowering healthcare costs and improving healthcare affordability for consumers.

HMA and Wakely, an HMA Company, worked closely with the OIC and other partners to select and model the impact of various policies. The process for developing a model to evaluate reference-based pricing involved Wakely accessing the state’s All Payer Claims Database (APCD), and included a review of claims from the state’s commercial and Medicaid health plans. To establish a baseline, Wakely compared different sets of healthcare services to what Medicare reimburses for that category of services, on average. This data showed vast differences in how much was being reimbursed by private plans relative to Medicare depending on service category- ranging from a high of 348% of Medicare for outpatient anesthesiology services to a low of 88% of Medicare for outpatient behavioral health services.

Recognizing the value of access to primary care services, Washington’s legislature established a goal in 2021 that 12% of healthcare dollars should be spent on primary care. Ever since, the state’s Healthcare Cost Transparency Board has been focused on tracking progress towards this goal. There had not been a similar focus on establishing targets for behavioral health services until this analysis. The low reimbursement rate for outpatient behavioral health services was not surprising and confirmed what had long been suspected as a contributor to challenges accessing outpatient behavioral health services for those with private insurance. Poor access to behavioral health services also contributes to healthcare affordability issues for consumers with private insurance, who end up going without, or paying for care out-of-pocket when they can’t find behavioral health providers that take private insurance. An analysis by the Kaiser Family Foundation found that privately insured adults who had a diagnosed mental health condition had twice as much out-of-pocket expense compared with those who did not have an identified mental health condition and that employers reported narrower networks for mental healthcare than their overall provider networks.

These findings, combined with the data from the APCD about low reimbursement rates, were catalysts for how Washington approached legislation to apply reference-based pricing for its public and school employee health plans in the 2025 legislative session. Recognizing that reference-based pricing could be used not only as a tool to improve affordability, but also to potentially increase access to important services, Senate Bill 5083, signed into law in May 2025, sets caps on how much insurers can pay providers for specific sets of services, but establishes floors for how much insurers must reimburse for primary care and outpatient behavioral health services to 150% of Medicare. Notably, Colorado was considering similar legislation, but it did not pass.

Healthcare affordability and access to behavioral health services are two persistent problems that contribute to poor health outcomes for many Americans and the relationship between the two is complex. It will be important to track how Washington’s new law impacts both of these issues to better understand and explore other questions, such as how expanded access to outpatient behavioral health services could improve overall healthcare affordability by addressing behavioral health issues before they become critical and/or emergent? Will it avoid or reduce traumatic and expensive trips to emergency room and crisis services? Washington’s new law offers an opportunity to closely evaluate and understand these types of questions and offers a potential model to address these intertwined and persistent problems.

HMA’s work on reference-based pricing was supported in part by Arnold Ventures.

As states struggles to address healthcare costs and invest in behavioral health, reference-based pricing and supporting analytics are one tool that HMA can offer to organizations. Contact us to learn more.

60 Years of Medicaid and Medicare Impact: From Milestones to Momentum

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This week, the nation celebrates two major milestones: the 60th anniversary of the Medicaid and Medicare programs and 40 years of Health Management Associates’ (HMA’s) commitment to advancing healthcare and improving lives. As we look ahead, HMA is investing in human-centered strategies, digital tools, and analytics to help our clients and partners build a healthier future—all topics that will be discussed at the 2025 HMA National Conference, October 14‒16 in New Orleans, LA.

October 14–16 | New Orleans
Early Bird Registration Ends July 31

The HMA National Conference is a three-day immersive experience designed to equip healthcare leaders with the insights and tools to adapt and lead in a changing landscape.

As new federal priorities unfold, this year’s conference, Adapting for Success in a Changing Healthcare Landscape, will feature insights from healthcare leaders on how organizations can respond to change, align with new expectations, and strengthen their impact. With early‑bird registration ending Thursday, July 31, 2025, here’s our “Weekly Roundup” of what we’ve shared so far—and why you won’t want to miss the HMA National Conference in New Orleans.

HMA’s National Conference offers an immersive, three‑day experience that combines strategic insight, peer collaboration, and interactive learning.

Networking & Community

Welcome Reception at a landmark New Orleans venue
Facilitated breakfast discussions, coffee conversations, and evening receptions
Networking lunch and dedicated breaks to keep ideas flowing

Big Picture Plenary Sessions

Opening keynote Asa Hutchinson, Arkansas’ 46^th Governor, on policy, politics, and a vision for healthier communities
Expert panels unpacking transformative shifts in Medicaid and Medicare, value‑based care, behavioral health innovation, and cross‑sector population health strategies
A closing conversation on government’s evolving role in healthcare innovation with nationally recognized leaders Dr. Bechara Choucair, Executive Vice President and Chief Community Health Officer, Kaiser Permanente, and Bruce Greenstein, Secretary, Louisiana Department of Health

Workshops

Policy & Trends: Medicare Advantage reforms, Medicaid work requirements, digital health guardrails, and 988 crisis care expansion
Use Cases & Responses: Operational strategies for payment reform, community resilience investments, digital health success stories, and coordinated care solutions for complex behavioral health needs

Streamlining Healthcare with AI: The Administration’s Plan and What Comes Next

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On July 23, 2025, the Trump Administration released Winning the Race: America’s AI Action Plan, a comprehensive federal strategy designed to position the United States as the global leader in artificial intelligence (AI). The plan, developed in accordance with Executive Order 14179, outlines over 90 policy initiatives across three strategic pillars: Accelerating Innovation, Building AI Infrastructure, and Leading International AI Diplomacy.

Healthcare and Medicaid Impacts

CMS AI-Enabled Prior Authorization Pilot
The AI Action Plan explains the Centers for Medicare & Medicaid Services (CMS) plan to launch a six-year pilot to improve, streamline, and where possible, automate prior authorizations using AI. Consistent with the AI Action Plan, CMS on June 27, 2025, announced a new Innovation Center model, the Wasteful and Inappropriate Service Reduction (WISeR) Model. WISeR will test ways to improve the prior authorization process relative to Original Medicare’s existing processes. This initiative is expected to dramatically reduce approval times—from days to, potentially, minutes in some cases — while easing administrative burdens for providers and improving access to timely care for beneficiaries. CMS will evaluate the pilot using metrics such as efficiency gains, cost savings, satisfaction levels, and decision accuracy.

Enhanced Fraud Detection and Program Integrity
CMS will also expand its use of AI to detect and prevent fraud, waste, and abuse (FWA) in Medicaid and Medicare. By leveraging predictive analytics and real-time data, the agency aims to identify anomalies and improper payments before they occur—enhancing program integrity and public trust. CMS is also encouraging state Medicaid agencies to bolster its investments in FWA systems, and enhanced federal funding continues to be available for such investments.

Regulatory Streamlining and Innovation Incentives
The plan calls for removing outdated regulatory barriers to AI adoption in healthcare. Proposed measures include revising compliance requirements and offering financial incentives or preferential funding access to states that foster innovation-friendly environments. While specifics are pending, states are encouraged to modernize regulations to support AI adoption.

Key Differences from Prior Administration’s AI Policy

The following table outlines key differences between the Biden and Trump administrations’ approaches to AI policy:

Considerations for Healthcare Organizations and Partners

Medicaid agencies, healthcare providers, and industry stakeholders should track the next wave of federal actions to implement the AI Action Plan and the healthcare sector’s response. Data from pilot initiatives will inform future federal policy decisions on broader AI deployments within Medicaid administration. In addition, healthcare organizations will need to remain nimble as variability may emerge in how states pursue regulatory changes to align with federal incentives under the Action Plan.

Sector specific considerations include:

Health Plans: Plans should proactively pursue initiatives such as AI-driven prior authorization, claims adjudication, fraud detection, and member engagement to improve their operations, their position in the markets in which they operate, and ideally, their performance. This effort will require significant investments in information technology, new workflows, and continuous quality improvement initiatives, staff training, enhanced compliance protocols, and a culture that embraces AI. In addition, plans must implement robust AI oversight mechanisms that incorporate the necessary level of transparency, avoid bias, and are appropriate across all functions that use AI, including population health analytics, member engagement, care management, prior authorization management, claims processing, and fraud detection.

State Government: States will face pressure to modernize health and human services regulatory frameworks to align with federal requirements and access federal incentives. Moreover, states should proactively pursue initiatives that improve the operations of health and human services agencies with a particular focus on improving program design, oversight, and evaluation functions. In addition, agencies should assess current rules regarding AI and consider how to support AI adoption while safeguarding desired outcomes and accountability.

Health Systems and Providers: Providers can benefit from reduced administrative overhead, improved care delivery, and the use of AI to augment the ability of providers to diagnose and treat patients. Providers will have to adapt to new workflows that incorporate use of AI, ensure data quality, and monitor data for unintended consequences such as unintended bias. In addition, providers must incorporate AI literacy training to align with federal expectations and remain competitive in a deregulated, innovation-driven landscape. Providers will also have to implement robust compliance protocols.

Looking Ahead

The AI Action Plan signals a substantial shift toward streamlined regulatory approaches and expanded AI deployment in Medicaid and broader healthcare administration. Stakeholders should anticipate federal guidance updates, pilot program evaluations, and further clarifications regarding state incentives in the months ahead.

To discuss the implications of the AI Action Plan or for further policy analysis, contact Health Management Associates experts below.

CMS and Tech Leaders Unite to Build a Patient-Centric Digital Health Ecosystem

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The White House and Centers for Medicare & Medicaid Services (CMS), on July 30, 2025, announced new commitments from leading technology firms—including Amazon, Apple, Google, OpenAI, and Anthropic—to create a smarter, more secure, and patient-centered digital health ecosystem. At the Make Health Tech Great Again event, CMS unveiled voluntary criteria for trusted data exchange across networks, electronic health records (EHR), and tech platforms, emphasizing interoperability, personalized tools, and reduced provider burden.

This announcement echoes many of the priorities laid out in Leavitt Partners’ Kill the Clipboard road map—a federal policy and industry blueprint for modernizing patient and provider access to health data. The priorities outlined at today’s White House event and the administration’s recent regulatory announcements closely reflect the multisector road map’s recommendations. A recent webinar hosted by Leavitt Partners, an HMA Company, explored how the recommendations are shaping federal policy and creating strategic opportunities for early adopters.

What’s Next

Health Management Associates (HMA) experts, including those with Leavitt Partners, will delve further into the new initiative and considerations for the healthcare industry in an upcoming Weekly Roundup.

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Addressing Behavioral Health Needs in an Aging Population

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Addressing Behavioral Health Needs in an Aging Population