After the passage of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) focused on implementing the most important Medicaid eligibility reforms in a generation: its expansion to cover previously excluded working-age adults. Today, Medicaid covers nearly 75 million people, making it the nation’s single largest source of insurance.

At the same time, the surge in enrollment under the ACA’s coverage expansion highlighted the need to improve the quality and efficiency of the health care Medicaid delivers. Under the expansion, the ACA added beneficiaries who fall into two categories: low-wage workers who can benefit from comprehensive primary care, and adults with serious physical and mental health conditions who can be managed in community settings. This shift required a close look at how traditional approaches to delivery and payment might need to change.

In addition, other structural, delivery, and payment challenges to the Medicaid program called for new federal policies. These new challenges included:

  • beneficiaries with low household income who face elevated health risks
  • a concentration of beneficiaries in poor communities that lack health care resources and other services essential to overall health
  • states’ limited experience addressing the physical and behavioral health needs of working-age adults, and
  • the need for a safety-net structure that can cope with the immediate and different health needs of newly enrolled beneficiaries.

The passage of the ACA kick-started a sustained, multiyear set of activities to help states tackle this array of challenges. In a recent issue brief, we examined the delivery and payment reform efforts in 10 expansion states. In this post, we focus on the CMS initiatives themselves.

CMS used various policy strategies to move delivery and payment reform forward. Some of these policy reforms were based on the agency’s long-standing oversight and demonstration authority. Others came through implementation of the ACA — including specific new demonstration authority vested in the Center for Medicare and Medicaid Innovation (CMMI) — and the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA).

Together, these CMS efforts have created a rich and substantial policy framework for delivery and payment reform. The table below summarizes these initiatives, along with their policy rationales, and the specific activities each is designed to foster to improve health care access, health care quality, and/or health outcomes.



Together these initiatives underscore the incredible scope of CMS activity in the wake of the ACA, with a special focus on state program transformation achieved through an array of technical, financial, and regulatory supports. In pursuing delivery transformation, CMS has emphasized high-cost, high-need populations and services.

The breadth of this activity has been so considerable that each effort merits thoughtful and comprehensive evaluation, each on its own and as part of a suite of interventions. It would be particularly valuable to know which CMS tools — policy guidance, technical support, state convening, direct investment — has had the most impact on the scope and speed of delivery reform. CMS evaluations to determine which tools have best promoted reforms are also key, particularly at a time when Medicaid’s role as an insurer never has been greater.