The Medicare Shared Savings Program in the Trump Era

Many providers have made substantial investments in ACOs for participation in the Medicare shared savings program.  As the Trump Administration makes significant changes to many government programs, many have questioned how the Administration will view this program.  That concern was stoked by an announcement in March that four smaller CMS alternative payment models would be ending early at the end of 2025.  Some have cited lack of sufficient cost savings as reasons to scale back such payment models.

On May 13, 2025, the Director of the Center for Medicare and Medicaid Innovation (“CMMI“) released a new web page and white paper about the future of value-based payment programs, including Medicare shared savings (more information here and here). The white paper describes its approach to such programs as a “strategy refresh” and is instructive in assessing how the Medicare shared savings program is likely to evolve and what this may mean for providers.  Notably, the white paper is not a radical departure from prior administrations and reflects continued use of models in which providers are directly accountable for the health outcomes of patients and the costs of their care.  CMMI states:

Our vision is to double down on our commitment to value-based care and take the learnings from these previous investments to build a health system that empowers people to drive and achieve their health goals and Make America Healthy Again.

While the white paper does not announce any new programs or changes to existing programs, it does set out several features that will guide such programs.  Several features stand out:

1. Focus on Prevention. This is to include primary prevention activities to avoid disease occurrence (e.g., health and nutrition counseling, tobacco cessation); secondary prevention to detect early signs of disease before symptoms (e.g., colon cancer screenings); and tertiary prevention, that is, disease management, to slow the progression of chronic disease and improve outcomes (e.g., diabetes and blood pressure control).  CMMI states this could include efforts working with community groups to resolve nutrition needs, lifestyle education, and access to evidence-based alternative medicine.
2. Wider Adoption of Value-based Care. CMMI aims to encourage wider adoption of value-based care to include original Medicare, Medicare Advantage, and Medicaid managed care with the potential for consistent models to be used in all such programs.
3. Waivers. CMMI describes the need for expanded waivers for ACOs to assume global risk.  Examples listed include reduced cost-sharing for high value or preventative services, payments to caregivers for support of those with cognitive or functional decline, and bypassing National Coverage determinations for DME that supports transition to or remaining at home.  There are likely other beneficiary incentive waivers that will be considered.
4. Greater Risk. CMMI says that payment model design could require downside risk and that a growing proportion of beneficiaries in global downside risk arrangements, and that providers themselves (rather than conveners) bear some of the financial risk.
5. Patient Choice. Patients should have more choice on where they receive care and who comprises their care team and models should support expanded scopes of practice, virtual care, and at-home care.  CMMI says that this should also include site-neutral payments and that hospitals should “reinvest hospital capacity in outpatient and community-based care through changes in certificate of need requirements”.
6. Rural Challenges. CMMI says it will pursue models that drive savings while creating custom pathways to account for the unique challenges of rural health care.  No other information was provided on this.

Update:  2026 Medicare Physician Fee Schedule Proposed Rule.  On July 14, 2025, CMS issued the 2026 proposed rule that includes proposed changes to the shared savings program, stating that the Trump Administration is committed to ensuring that participation in the program will promote better chronic disease management and prevention, more efficient use of resources, promote innovation, and drive increased savings for the Medicare Trust Fund.  The changes touch a variety of areas, including the number of minimum assigned beneficiaries, quality reporting, impact of “extreme and uncontrollable” circumstances, and changes to the ACO participant list.

All of this and more is likely to be rolled out over the next several months.  But it’s clear that the focus on value-based care will continue, albeit with different priorities and perhaps different models.  Just as the Administration describes a strategy refresh to alternative payment models, providers will need to be ready to refocus their approach towards such priorities and payment models as they are released.