The Medicare Advantage (MA) landscape is evolving rapidly, carrying significant implications for providers, payers, and beneficiaries alike. In a recent webinar titled The Future of Medicare Advantage in the Trump Transition – Will AI Help Pave the Way?, InfoMC Board Member and renowned population health expert Dr. David Nash joined fellow industry leaders from the provider, policy, and technology sectors to explore both the challenges and opportunities shaping the future of this vital program.
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Has Medicare Advantage Lost Its Way?
Dr. Nash argues that Medicare Advantage has strayed from its original mission. The goal of MA was “to improve health by coordinating care, practicing based on the best available evidence, helping people with chronic illness, doing things that traditional Medicare couldn’t do,” he explained. But despite these intentions, most MA plans have fallen short of truly managing care.
Today, nearly half of all Medicare beneficiaries are enrolled in MA plans. These members often face higher levels of chronic illness and socioeconomic hardship. Following the COVID-19 pandemic, utilization has surged. To stay competitive, plans frequently offer supplemental benefits—such as gym memberships or meal delivery—that are not always tied to improved health outcomes.
Leveraging AI to Realign with the Mission
Dr. Nash sees artificial intelligence as a key to realigning MA with its “True North.” AI can bring precision to benefit design and resource allocation. For instance, rather than offering gym memberships to all members, plans can use AI to predict which members are most likely to use them—lowering costs while increasing engagement and impact.
“Better AI-enabled risk stratification would go a long way in helping us determine what services people actually need,” Dr. Nash noted. AI can also identify less obvious but impactful interventions—like providing transportation to reduce social isolation, or addressing in-home safety risks that could prevent costly hospitalizations.
Risk-Based Models Must Catch Up
Another concern is the gap between process and outcomes in most MA models. Dr. Nash emphasized the need for true risk-sharing arrangements that incentivize value-based care. “If we (physicians) really were at economic risk for clinical decision making, that’s at the heart of what MA was supposed to deliver. So, we would be focused on care coordination, the right resources to the right patient at the right time. If that were the true north, then the coding would take care of itself. We would be doing the right thing at the right time.” Dr. Nash contends that we need a stronger connection between process measures and outcome measures—particularly the STAR measures that are designed to drive improvements in health.
Prior Authorization and the Promise of AI
Prior authorization remains a friction point in care delivery—but Dr. Nash believes AI can play a transformative role here as well. “Unexplained clinical variation is the Achilles heel of the system and has been for 35 years,” he said. AI could finally close the feedback loop and support better, faster decision-making.
He envisions a future where AI supports evidence-based practices not just 18% of the time, but 60–70%—helping clinicians make better decisions in real time, while reducing unnecessary utilization and provider burden. “It’s a two-step journey. One is there is an existing process and there’s a lot we can do to make that existing process better with automation and intelligence.”
What’s Next for Medicare Advantage?
Looking ahead, Medicare Advantage is expected to continue its growth trajectory, fueled by strong beneficiary interest and competitive innovation. Yet challenges remain—regulatory shifts, provider network stability, and rising costs loom large.
To navigate this complex landscape, stakeholders must embrace collaboration, technology, and flexibility. As Dr. Nash and other experts suggest, the future of MA depends on our ability to return to its core purpose: delivering better care, smarter spending, and healthier people—with AI as a critical enabler.
View the full webinar here:
