Six for ‘26: Top Concerns for Benefits Leaders Heading into 2026 Planning

Benefits leaders at the nation’s largest employers are managing massive healthcare cost increases, and that’s driving change in how they design their health benefits offerings. I’ve talked to more than 100 benefits leaders in recent months, and one theme is clear: employers are willing to make bold moves and consider approaches they’d previously dismissed. The days of layering on new programs and hoping they drive engagement are over. Their focus now? Fewer, high-impact solutions that improve employee health and deliver hard-dollar savings. For many, that means eliminating solutions.

It’s hard, but benefits leaders shouldn’t let themselves be consumed by the hot-button issues dominating the news cycle, like GLP1s, cell and gene therapy and cancer. These are big and growing sources of spend, true, but they’re also sources for which it’s hard to control costs, so they’re not the first place to look to bend the cost curve. Employers need a strategy, but those buckets are more about benefits culture and health outcomes – not reducing spend. To do that, the biggest lever you can pull is the impactable cost drivers, and the ones that jump off the page are surgery and infusions. Control those, and you cut out a ton of waste, lower costs and improve the employee experience.

If you’re still evaluating benefits the same way you did five years ago, you’re already behind. Here are six ways to get ahead.

Fiduciary responsibility

Fiduciary pressures are building for employers. The new administration has shown they want to be aggressive on a number of fronts, including price transparency, PBM reform and preventive services. President Trump signed 76 Executive Orders in his first 100 days – more than any sitting president since 1985. He’s simultaneously increasing regulations while firing regulators, leaving many confused. Benefits leaders tell me they’re going on the offensive, stepping up their fiduciary governance, including: committees similar to those managing executive compensation; fiduciary training; adding insurance policies; increasing outside review even with a strong internal team; and running more vendor audits.

Less is more

For years, benefits teams have been pressured to increase their investment in total rewards programs to stay competitive. But historic trend increases are threatening that approach. In reality, more options don’t always translate to better outcomes. Employers are cutting ties with solutions that fail to show a hard-dollar ROI and leaning into a “less is more” strategy — prioritizing quality over quantity.

Leaders are also prioritizing stronger marketing and communication plans to make sure their people know what benefits are available and how to use them. “We’re great benefits leaders, but we have to start thinking like great marketers,” one of them told me.

Rethinking specialty care: A new approach to cost containment

Specialty care is 50% of an employer’s health spend – 2x pharmacy spend and growing at a faster rate, but few have designed a specialty care strategy. It’s one of the only benefit solutions you can implement that will impact a fraction of the population – only about 15% will need specialty care in a given year – and can deliver twice the savings compared to more disruptive changes like PBM or carrier changes that impact 100% of the population. Employers are increasingly moving toward supplemental specialty networks and mandatory plan designs—with spine surgery, joint replacement and bariatric procedures leading the way. Companies that mandate the use of networks of excellence are seeing $50+ per-employee, per-month savings while also improving clinical outcomes.

GLP1s – should we, or shouldn’t we?

Bariatric surgery is the gold standard for weight loss, but one advisor I spoke to, that we respect highly, predicts the surgery won’t exist by 2031. With 50% of Americans forecasted to have a BMI greater than 30 by 2030, our obesity problem is going to get worse before it gets better.

GLP1s are dominating the conversation, but half the benefits leaders I’ve talked to this year aren’t covering them for weight loss. Many that do aren’t thrilled about it, and who can blame them, with compliance rates around 30% after 3 months. According to a recent study published in JAMA, the price of GLP-1s would have to drop to $70 per week – nearly a 3x cost reduction – just to break even with bariatric surgery.

GLP1s will continue to get better and be approved for more indications, but injecting yourself everyday sucks. That, combined with the side effects and monthly cost, becomes a list of cons that can outweigh the pros of weight loss. Ozempic is set to become a generic in 2031, but oral delivery is still some way off. The FDA has removed the shortage tag on semaglutide, so compounders aren’t supposed to be able to distribute (enforcement remains a question) which means the pressure for big pharma to discount is alleviated, at least for now.

I’ve worked in specialty care, sleep, mental health and pharma, and I say this all the time – behavior change is hard; really hard. The majority on GLP1s are not changing their behaviors – like eating better/less or exercising more. If that’s the case and you want to retain the weight loss, you’ve got to stay on the drug in perpetuity. And if 70% quit, no one will see the downstream benefits like reduced cardiovascular risk, lower A1Cs, etc. I think bariatric surgery is here to stay for a while and employers should take a fresh look at how they’re covering these surgeries. Fifty percent of our new clients this year launched with it as a required procedure.

Hospitals are the real cost drivers

Pharmacy gets a lot of blame, but don’t overlook the price gouging you’re getting from some major health systems. Some hospitals charge 300-500% of Medicare rates, yet their pricing power remains largely unchecked. Even the country’s biggest employers struggle to influence major hospital systems due to a lack of centralized population density. Employers and unions are taking a bolder stance — removing specific health systems from their networks to control costs and partnering with direct contract partners who can crowdsource lots of distributed employer populations in the same geography to wield better negotiating power. And if Medicaid gets cut – which is anticipated – hospitals will look to their commercial payers to recoup the revenue loss, which means employers will see even higher hospital prices.

Emerging therapies

GLP1-s are today’s hot topic, but cell & gene therapy and CAR-T therapy are tomorrow’s. One benefits leader called them “a category 5 hurricane just offshore.” With advancements in these therapies, employers can dramatically improve health outcomes for patients living with some of the most difficult-to-treat conditions, including genetic disorders and rare cancers. Last year, 38 CGTs were approved by the FDA, and that’s expected to grow to 50 in 2026.

Employers want to do the right thing and make new treatments available to employees. But because these groundbreaking treatments are anywhere from a hundred thousand up to millions of dollars, cost is a real concern. “We have a chance to make a big impact, but we have to start preparing now. This is the specialty pharmacy problem of 15 years ago,” one benefits leader told me.

2026 is the year of impact. Employers that embrace this shift will not only control costs but will build a benefits strategy that truly works — for both their people and their bottom line.

Photo: DNY59, Getty Images

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