Health Care Matters | March 27
Medicare Advantage Overpayments Drive Rising Premium Pressure
CMS announced a new Innovation Center model, ASPIRE (Accelerating State Pediatric Innovation Readiness and Effectiveness), aimed at transforming how Medicaid and CHIP support children with complex and rising health needs. The model will test a whole-person, coordinated care approach for children up to age 21, with states partnering with accountable entities such as managed care plans and ACOs to improve quality and manage total cost of care. ASPIRE is designed to address a core challenge in pediatric care delivery: fragmentation across physical health, behavioral health, and social services. The model emphasizes care coordination, early intervention, and wraparound supports, while introducing payment structures that incentivize providers to take on greater accountability for outcomes. It also builds on prior models by bringing an ACO-like approach to pediatric populations, aligning incentives for proactive, longitudinal care rather than episodic treatment. Read more here and here.
Why It Matters
ASPIRE reinforces CMMI’s growing focus on state-based Medicaid models, but its success will hinge on whether states and providers can operationalize these expectations in a constrained and evolving policy environment. States are balancing multiple, and sometimes competing, priorities including Medicaid rate cuts, implementing work requirements, and standing up their Rural Health Transformation Programs, while providers face real capacity limits in care coordination, data sharing, and cross-sector integration. Pediatric models add another layer of complexity: fragmentation across systems, thinner value-based infrastructure, and more limited opportunities to generate near-term savings compared to adult populations. We expect uptake and impact to vary based on states’ readiness and existing partnerships, with early activity likely concentrated among states and organizations that already have aligned managed care, ACO, and delivery system capabilities in place.
ACA Market Changes Highlight Growing Tension Between Coverage Design and Affordability
CMS’s proposed 2027 ACA marketplace changes are now drawing pointed stakeholder feedback, with hospital and physician groups urging the agency to scale back or revise key elements, particularly expanded non-network plan flexibility and catastrophic coverage options. Providers argue these changes could erode network stability, disrupt care continuity, and increase uncompensated care risk if patients enroll in plans with more limited or less predictable access. At the same time, emerging reporting suggests affordability pressures are already shaping consumer behavior, with some middle-aged adults delaying care or reconsidering coverage as premiums rise following the expiration of enhanced subsidies. Together, the feedback signals growing concern about how the proposed flexibilities could interact with an already strained affordability environment. Read more here andhere.
Why It Matters
The stakeholder response suggests CMS may face pressure to recalibrate the balance between flexibility and guardrails in the final rule, particularly around network adequacy and plan design standards. While final rules often reflect targeted refinements rather than wholesale changes, the breadth and consistency of provider concerns could prompt adjustments or clarifications in these areas. More broadly, this moment reinforces a structural tension in the ACA market: even well-intentioned design changes can have downstream effects when layered onto persistent affordability pressures.
Look for the Helpers: Philanthropy Expands Access to Care in Rural Communities
A major philanthropic effort led by the Helmsley Charitable Trust is investing in rural health systems across the Upper Midwest and Mountain West, funding facilities, equipment, and telehealth to expand access to specialty care. In Montana, for example, philanthropic funding helped build new local cancer centers so patients can receive chemotherapy and radiation close to home instead of traveling hundreds of miles. Since 2009, the initiative has invested more than $850 million to support services like cancer care, cardiac treatment, mental health, and telemedicine, helping close persistent access gaps in rural communities. This effort serves as a reminder that targeted, community-informed investment can make high-quality care feel truly local again. Read here.
What We Are Reading
CMS’s New Risk-Adjustment Model Had Limited Impact On Medicare Advantage Benefits, 2024–25
A Health Affairs study examines emerging trends in health policy and care delivery, highlighting how evolving models are shaping access, cost, and system performance across populations. Read here.
Implementing the 2024 Managed Care Final Rule? Download Our State Implementation Roadmap
Aurrera Health Group outlines key considerations for states implementing the 2024 Managed Care Final Rule, emphasizing new requirements around access, transparency, and quality, as well as the operational and data capabilities needed to support effective oversight. Read here.
RFK Jr. and Dr. Oz Have a Plan to Save Rural Health Care. Here’s the Catch.
The Washington Post reports on federal efforts to use AI and new technology to address rural health access challenges, while highlighting provider skepticism about whether these approaches can meaningfully offset workforce shortages and funding gaps. Read here.
Taking A Closer Look At JEC’s Reliance On MedPAC’s MA and Fee-For-Service Cost Comparisons
A Paragon Institute analysis examines how policymakers are using MedPAC estimates to compare Medicare Advantage and fee-for-service costs, highlighting key methodological limitations and considerations that may affect how these comparisons are interpreted. Read here.
CMMI Signals Medicaid-Focused, MAHA Models Coming Soon
An Inside Health Policy analysis examines emerging federal health policy dynamics, highlighting how ongoing debates across CMS, Congress, and stakeholders are shaping the direction of key programs and reforms. Read here.
What We're Attending
LEAD Right for Your Organization? Key Questions for ACOs Evaluating the New CMMI Model
Milliman is hosting a webinar on April 8, 2026 at 2:00 PM ET, that will explore how ACOs and provider organizations can evaluate the new LEAD Model and its implications for Medicare value-based care. The session will cover key technical and strategic considerations, including benchmarking, risk adjustment, quality measurement, and the model’s approach to high-needs populations and specialist engagement. It will also compare LEAD to MSSP to help organizations assess which model best aligns with their goals and capabilities. Register here.
Pop Health Podcast
From Concept to Model: The Making of LEAD
In this episode, Coral's Maria Alexander and Joy Chen welcome Meredith Yinger, Model Lead for the Innovation Center’s LEAD (Long-term Enhanced ACO Design) Model and Emily Bezold, Senior Advisor to the Center’s ACO portfolio. Together, they explore more about the mission and vision for LEAD, how the model came to fruition, the Center’s rationale for key design features, and what potential applicants may want to know before they apply.