On May 27, 2026, the Northern Virginia Health Policy Forum hosted a discussion on The Future of Medicare Accountable Care Organizations (ACOs). Moderated by Jim Scott, President and CEO of Applied Policy, the conversation featured Emily Brower, President and CEO of the National Association of ACOs (NAACOS), and Sean Cavanaugh, Chief Policy Officer at Aledade and former Deputy Administrator and Director of the Center for Medicare at the Centers for Medicare & Medicaid Services.
The session considered how ACOs have become a central component of Medicare’s value-based care strategy and explored the two pathways Medicare offers providers: the Medicare Shared Savings Program (MSSP), a permanent program established under the Affordable Care Act, and models operated through the CMS Innovation Center (CMMI). Brower described ACOs as a model that “better supports the care delivery model primary care would do every day, if that’s what was paid for.” Cavanaugh noted that the concept has attracted bipartisan support because it seeks to improve care while lowering costs without reducing benefits or relying on provider payment cuts.
Much of the discussion focused on the Long-term Enhanced ACO Design (LEAD) model, CMMI’s newest ACO model. LEAD is set to launch on January 1, 2027, following the conclusion of the ACO Realizing Equity, Access, and Community Health (REACH) model at the end of this year. Brower explained that LEAD introduces a “whole practice” approach, often referred to as a full-TIN approach, that aligns more closely with MSSP by requiring all providers within a participating tax identification number to be included, rather than providing for the inclusion of only certain clinicians. She noted that this practice-based network configuration will result in more patients in the practice being included in the ACO. LEAD’s ten-year performance period, which is the longest CMS has tested for an ACO model, is intended to provide greater stability and predictability than prior CMMI models and to attract organizations that have historically remained outside of ACO participation, including smaller, independent, rural, and safety-net providers.
Brower and Cavanaugh observed that some organizations have been reluctant to participate as ACOs given the uncertainty inherent in CMMI models. Adjustments to payment methodologies and benchmarking rules can complicate long-term financial and operational planning. Both panelists said that periodic benchmark adjustments within MSSP—known as rebasing and ratcheting—can reduce shared savings even for ACOs whose performance continues to improve. Brower said that with most fee-for-service Medicare beneficiaries now receiving care through ACOs, long-term sustainability of ACO financing has become a systemwide concern.
Scott, Brower, and Cavanaugh all observed that ACOs have enjoyed consistent bipartisan support across four presidential administrations. Differences in approach have existed, with the Biden administration focusing on health equity and the first Trump administration pushing for faster movement to downside risk, but the commitment to expanding ACO participation has remained constant. Cavanaugh cited a recent statement by Chris Klomp, Director of the Center for Medicare, that “accountable relationships outperform on virtually every single quality metric that we track at the Center for Medicare” as a strong signal of the current administration’s commitment to growing the program.
Scott asked the panelists how quality is measured in ACO programs. Brower explained that ACO quality assessment incorporates a combination of traditional Healthcare Effectiveness Data and Information Set (HEDIS) measures related to chronic disease management, utilization measures tied to preventable emergency department visits, hospitalizations, and readmissions, and patient experience measures such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS). She also noted that LEAD restores certain clinical HEDIS-type measures that had not been included in ACO REACH.
Cavanaugh said that more than twelve years of program experience suggest that ACOs generate savings primarily through improved care management and coordination rather than through restricting access to services. As a result, he argued that some of the original rationale for expansive quality reporting requirements has diminished over time. Both panelists also flagged implementation challenges associated with CMS’s move toward electronic clinical quality measures (eCQMs), particularly for ACOs whose member practices operate across many different electronic health record systems.
Scott asked whether ACOs can succeed in rural areas. Cavanaugh said they can and do, noting that a significant share of Aledade’s network operates in rural communities where independent primary care practices remain more prevalent. He said that rural ACOs face a structural benchmarking challenge because an ACO may represent a large share of a rural county’s Medicare beneficiaries, its own performance can drive down the local benchmark against which it is measured, a problem multiple administrations have attempted but not fully resolved.
Both panelists suggested that addressing program predictability and aligning financial incentives with sustained care management investments would encourage broader ACO participation and strengthen the program’s long-term results. Brower encouraged organizations that have previously considered ACO participation but found existing models a poor fit to “take another look,” citing the design features of LEAD and anticipated improvements to MSSP as reasons for renewed interest. Cavanaugh agreed, framing ACO enrollment as joining a growing and durable policy movement and noting that accountable care has become “a permanent part of the Medicare program” that has enjoyed consistent support across administrations.
A recording of the event is available below.