Out-Of-Pocket’s 2026 Predictions

This episode of Out-Of-Pocket is brought to you by…

Brought to you by Out-Of-Pocket! We’re mapping out all of our content sponsorship, sponsored dinners, sponsored courses, and more so drop us a line. In 2025 we:

• Did multiple sponsored courses with 1000+ signups with 250+ people showing up live and asking for the chat transcript because it was so valuable
• Hosted hackathons, conferences, dinners, etc. with 32 sponsors. At our hackathon, one sponsor actually sold a deal to another sponsor lol
• Created sponsored posts that generated so many leads that one company asked 3 days later if they could book a follow up post. And they’re 50% sold out already for 2026.

Let’s chat about ways we can work together. 

I predict this is the 10th predictions post you read, but mine is good actually

Another year where we fixed healthcare. Congrats everyone, we did it.

I’m a sheep doing predictions. I got like all of them wrong last year, but who cares. It’s all about the entertainment value baby.

SEND ME ONE PREDICTION YOU HAVE FOR 2026 (2 PARAS OR LESS) AND I’LL INCLUDE MY FAVORITE ONES IN NEXT WEEKS NEWSLETTER

Below are my predictions for 2026. 

• Uninsured rate explodes - second order effects
• Intellectual property lines are drawn with AI products
• States vs. Federal government rule making clashes
• Foundation model joint venture roll-ups
• Peptide crackdowns
• Screening, diagnostics, and at-home sample collection becomes the hot area 
• GLP-1s hit 30% of the population + don’t work in mental/behavioral health
• C-SNPs steal the show
• The Anti “AI in healthcare” movement solidifies
• CMS announces a new program
• Out-Of-Pocket grows up

Uninsured rate explodes - second order effects

Next year the number of uninsured people is going to skyrocket. Health insurance premiums are spiking and coincides with a lot of other aspects in life getting expensive. A lot of people are debating if it’s an expense worth cutting. I believe we'll land around 15% uninsured next year.

If the number of uninsured does spike, a few things will happen.

• Emergency departments are going to get flooded with people that can’t access doctors without insurance or delay care they need.
• Health sharing ministries and indemnity plans become way more popular
• The cash pay ecosystem will grow like GoodRx and compounding drugs.
• Hospital economics will go even further upside down with more uninsured people going through their doors
• Insurance premiums spike further with mostly sick people remaining in the pool
• Someone will start cooking meth to pay for their treatment and build a drug empire, only to discover it was all about power and never about the money.

Intellectual property lines are drawn with AI products

It’s been a little bit of the wild west when it comes to using IP with these generative AI tools. I mean it’s objectively insane that in 5 seconds I can make a picture of Elmo choking me out.

In 2025 there were a lot of fights around copyright that happened. The New York Times sued Perplexity and OpenAI, Anthropic settled with book authors for $1.5B, Disney has sent a cease and desist to Google. But also a lot of deals were struck - the New York Times also signed a licensing deal with Amazon, Disney invested in OpenAI and ismaking their IP usable in Sora.

Healthcare has a TON of companies that have copyrights and IP ownership over critical parts of healthcare information. OpenEvidence for example has signed several agreements with medical societies, NEJM, etc. Who will the AMA partner with for CPT codes? Which companies will the EHRs partner with to license their data? Will Milliman partner with an AI analysis tool to let them use their groupers?

Btw I think this also extends to influencers. Dr. Eric Topol is partnering with Doximity for their DoxGPT product. Who is Peter Attia going to license his protocols to? Where in the world is Dr. Mike, and which genAI product is he going to put his beautiful face next to?

States vs. Federal government rule making clashes

The states and federal government have always had some tension in rule setting. But next year I think these fights will become louder, more public, and more divergent.

A few examples:

1. Public health guidelines see a schism - We’re already seeing this when it comes to vaccine recommendations for example.
2. ERISA vs. State laws- Self-funded employers follow federal ERISA laws in terms of what they need to do/cover. This pre-empts the state laws, which are what fully insured plans typically follow. When trying to force changes on things like networks or utilization management at the state level, companies will say that violates ERISA. For example, see the Iowa PBM lawsuit, or the congressional bill saying to ignore their state-based rules around stop-loss insurance.
3. State-based exchanges - Section 1332 waivers let states redesign parts of their exchanges using federal dollars. But they have to meet certain federal “guardrails” around things like coverage and affordability. That creates recurring friction when states bump up against what HHS/Treasury thinks violates those guardrails. With exchange plans getting really expensive, states will try to get more creative here and you’ll see the federal government pushback.

4. AI governance - States are now trying to create their own AI policies. Some states want policies specifically preventing payers from using AI for prior authorizations for example. The federal government is fighting to stop states from doing that since they don’t want a patchwork of rules.

The patchwork of laws you have to navigate across states is only going to get wider. Shoutout to the lawyers, this is your year.

Foundation model joint venture roll-ups

All of the large foundation model companies (OpenAI, Anthropic, etc.) continue to make bigger and bigger promises on what their technology can do. A lot of the issue in actually getting productivity gains is the implementation of the technology. It’s faster to demonstrate those gains by acquiring companies and implementing it, and healthcare in particular is a target market for that.

I think you’re going to see more foundation models form joint ventures with financiers that want to do PE-style rollups that inject AI into their operations. OpenAI’s + Thrive Holdings is one version of this relationship. It’s also a great narrative for the foundation models to tell to raise more money, and our entire economy is basically built on the idea that these productivity gains are real so let’s root for them! (*cashes out 401k*).

Crackdown on gray market peptides

Your favorite influencer is railing against big pharma but injecting themselves with experimental compounds sourced from China with names that sound like 2FA verification codes.

Peptides are amino acid chains bonded by a peptide. Lots of approved drugs we know today fall into this category like GLP-1s. However there’s an entire category of unapproved peptides that you can buy from kinda shady online stores and inject yourself (or take as a pill). A very common one is BPC-157, which people swear helps with muscle repair and cures various joint ailments they’ve been dealing with.

This has become a very popular area in the last year, crossing over from biohacker communities into more normie circles. Personally I’m in the camp that people should be able to experiment however they want as long as they know the risks, but there’s no good way to verify the source of these peptides. It gets worse when influencers start promoting their own compounded peptides which they’re making money from.

My guess is there’s some big contamination scandal that happens next year when a lot of people get sick from a bad batch of compounding or overseas supply (which has precedence). This is going to force the FDA to:

1. Ban imports of overseas peptides
2. Create a list/pathway for “legit” compounding facilities to get approved

Screening, diagnostics, and at-home sample collection becomes the hot area 

The end of 2025 has really been a big year for screening and diagnostics.

• BillionToOne went public for its molecular diagnostic tests
• Medicare created payment codes for AI heart scans and private insurers are on board
• Hims invested in GRAIL, the blood-based cancer detection company
• Freenome is going public via SPAC (had to double check what year it was)
• Cologuard was acquired by Abbott for $23B. Cologuard also has a disturbing awareness campaign with Lil Jon where they remix Get Low but it’s about getting a stool sample, and yes that’s a real sentence.

2026 is going to see even more activity here. I think this administration is going to try and simplify reimbursement and approvals for AI diagnostic/screening + provide some guidance around Lab Developed Tests. New CPT codes are coming out for AI to assist physicians. Old school testing companies are going to acquire some of the new “AI diagnostic” companies to seem innovative. 

The ancillary here that will pop off in particular is at-home sample collection. Teal has an FDA authorized at-home sample collection test for cervical cancer screening. Home blood collection via capillaries is becoming more en vogue with YourBio being acquired and Tasso is used for many of the home hormone tests. Where there’s a sample to be shipped, there’s a way.

Featured Jobs

Weeeee got some companies hiring!

Morgan Health: Health Care Analytics Engineer (New York City, NY, Boston, MA, or Washington, D.C.)

• Looking for a new challenge for your healthcare data warehouse design, dbt, and product design skills? Join Morgan Health's collaborative data team to build scalable, user-centric warehouse solutions that advance our mission to improve quality, affordability, and equity in employer insurance. Apply here.

Percepta: Applied AI Engineer - Healthcare (Multiple Locations)

• Build the AI transformation playbook for U.S. healthcare. Full ownership of Summa Health (via GC) = huge access to ship production agents across clinical & ops workflows. What we prove here will expand nationwide. Apply here.

Percepta: Data Engineer - Healthcare (Multiple Locations)

• Build the AI transformation playbook for U.S. healthcare. Full ownership of Summa Health (via GC) = huge access to ship production agents across clinical & ops workflows. What we prove here will expand nationwide. Apply here.

GLP-1s hit 30% of the adult population + don’t work in mental/behavioral health

GLP-1s are being thrown against every disease and just seeing what sticks. The focus has been on big, reimbursable areas (obesity, diabetes, cardiovascular, MSK, etc.). Next year is going to be a big tipping point as the new pill GLP-1s hit the scene at much cheaper prices. I think we’ll see more than 1/3rd of the adult population on a GLP-1 next year (relative to 12% this year).

One area people have been talking a lot about is mental/behavioral health. GLP-1s seem to dull some part of the brain that causes “food noise” in the brain. A theory is that the food noise is caused by some dopamine dysregulation in the brain, which is a similar dysregulation that underpins other mental/behavioral health disorders. There’s a lot of interesting (but retrospective) analyses that suggest it’s useful in different addiction areas. And lots of anecdotal stories about people microdosing and seeing improvements.

Lilly is already running trials in areas like addiction. However, my prediction (with no inside info) is that you’ll see negative phase II results here next year for these mental/behavioral health disorders. If you look through previous clinical trials in this area, there’s a lot of failures focused on a similar pathway (exenatide for drinking, dulaglutide for smoking). Combine that with the failure for GLP-1s in Alzheimer's, and I think future trials will focus on cardiometabolic issues for the near future. 

But this won’t stop people from off-label microdosing them for mental acuity purposes. 

C-SNPs steal the show

Chronic Special Needs Plans are a type of Medicare Advantage plan catered to people with a chronic condition from this list. They’ve become extremely popular in recent years for a whole host of wonky reasons we’ll write a post about in the future. 

Some big ones being more favorable risk adjustment, being able to enroll around the year vs. just one period, and more flexible ways to cover things that are specific to the disease (including food and other supplemental benefits).

This is going to continue to be a big area of growth, potentially the only area of growth in Medicare Advantage next year. I also think you’ll also see a wave of new, interesting startups going after this space that are more purpose-built for SNPs vs. large carriers tacking it on next to all of their other MA plans.

The Anti “AI in healthcare” movement solidifies

There’s a generally populist movement happening against AI today. People are worried about losing their job, they’re worried AI is making decisions for them that will make their lives worse, and a whole lot of other reasons. 

IMO this will extend into healthcare. You will see healthcare labor strikes happen and pushbacks against AI as part of their demands. You’ll see clinicians push back against what AI is allowed to say or do in the medical realm. You’ll see more people fight against health insurance companies using AI for anything. Admin and call center jobs will demand AI not be used at doctors offices and hospitals.

There will also likely be some kind of lawsuit where an AI summarization tool gets something wrong, the doctor doesn’t catch it, and it’s put in the patient file. Or an AI tool misdiagnoses a patient, they get downstream care, and something bad happens. As the scale of these tools increases, the likelihood a regular mistake happens increases, but the fans of the fire will be fueled by the general anti-AI sentiment.

CMS announces a new program

CMS will be announcing the Data-enabled Episode-based Evidence-driven Zipcode Networks Using Total-cost Zones model. A combination of upfront payment and lots of adjusting.

DEEZ Payments (Upfront)

Participants may receive Delivery Enablement Enhancement Zones (DEEZ) payments to support:

• Care coordination
• Analytics modernization
• Slide deck creation
• Their valuation

NUTZ Adjustments (Downside)

Network Utilization Threshold Zones (NUTZ) introduce downside risk if:

• Savings exceed benchmarks too quickly
• Providers appear profitable
• If they’re capping on capitation (risk adjustment audit)
• They use “health” in their name

[All jokes…unless…]

Out-Of-Pocket grows up

Out-Of-Pocket is entering year 6. We hired our first full time employees this year. We changed the direction of our business from just content and virtual courses to events. We rolled out Asana, in what has to be a karmic retribution for all the jokes I’ve made about productivity tools.

It’s been weird to suddenly realize this is an actual business with livelihoods dependent on it. I can’t just dip out and write children’s books about clinical trials anymore solely because I think it’s funny. We have to plan, think in advance, and make real tradeoffs.

It’s been fun navigating into a new phase for the company. But for all of the parts that feel daunting, I also feel equally excited. 2026 is going to be our best year yet. Or at least we’ll be having fun while it goes down in flames, idk.

Anyway, a reminder that we’re doing a ton of events next year and would love to see you there.

• Healthcare 101 learning summit in New York 1/29-1/30.

• 2 hackathons planned. One for healthcare hardware in SF in April and a Pharma hackathon in the fall.
• Healthcare Ops Knowledgefest in SF for operations people, Healthcare Data Camp for data folks in Boston. 
• A soon to be announced Healthcare Software Engineering conference in New York
• Some private hackathons and AI workshops in the works on site with companies
• Lots of happy hours and dinners were doing with sponsor

If you want to hear about the events when signups open, you can sign up here. If you want to know how you can get involved/sponsor, email sales@outofpocket.health.

If you have a space that can fit up to 100 people and want to host, email events@outofpocket.health

SEND ME ONE PREDICTION YOU HAVE FOR 2026 (2 PARAS OR LESS) AND I’LL INCLUDE MY FAVORITE ONES IN NEXT WEEKS NEWSLETTER

Thinkboi out,

Nikhil aka. “Four-eyed raven”

P.S. thanks to the many of you that offered to help after last week’s newsletter. I wrote all the ways you could help us if you wanna be a part of the journey 🙂

Twitter: ​@nikillinit​

IG: ​@outofpockethealth​

Other posts: ​outofpocket.health/posts​

{{sub-form}}

‎If you’re enjoying the newsletter, do me a solid and shoot this over to a friend or healthcare slack channel and tell them to sign up. The line between unemployment and founder of a startup is traction and whether your parents believe you have a job.