Health Equity and ACOs

The World Health Organization (WHO) defines health equity as the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically, or geographically. Total cost of care models, such as ACOs, are incentivized to improve quality while controlling costs, and the upfront investments that ACOs make in health information technology (IT) and infrastructure to provide coordinated care make them uniquely poised to address health inequities. NAACOS is committed to advancing the value-based care movement and our members want to see an effective, coordinated, patient-centric healthcare system that focuses on keeping all individuals healthy. Improving health equity is critical to delivering high quality care in a cost-effective manner, as some research shows that social drivers of health contribute more significantly to health outcomes than medical care. Strengthening the ACO model and other total cost of care models provides an important lever by which health inequities can be reduced. NAACOS works with its members to provide resources and policy recommendations to CMS and Congress to ensure that ACOs are equipped to effectively measure, track, and address health equity in their work.

NAACOS Resources, Papers and Comments

  • NAACOS submits feedback in response to CMS RFI on health equity and provider burden
  • NAACOS hosts webinar on how ACOs are innovating to address health equity
  • NAACOS submits a Statement for the Record on a House Ways and Means Committee hearing on improving health equity for individuals with chronic conditions
  • NAACOS writes CMMI on its Health Equity Strategy
  • NAACOS publishes series of case studies highlighting ACOs’ health equity efforts
  • NAACOS authors position paper providing policy recommendations on addressing equity in quality measurement for ACOs
  • NAACOS submits comments in response to the Physician-Focused Payment Model Technical Advisory Committee (PTAC) request for input (RFI) on social determinants of health (SDOH) and health equity.
  • NAACOS published a position paper that outlines several policy recommendations to better position ACOs to address health inequities and social determinants of health (SDOH). The paper and its recommendations are the result of a working group of leading ACOs across the country
  • NAACOS submits comments in response to the Congressional Social Determinants of Health (SDOH) Caucus request for information (RFI) on challenges and opportunities to better address SDOH
  • Read NAACOS' detailed comments in response to the proposed 2022 Medicare Physician Fee Schedule rule, including comments on how to advance health equity in the context of ACO quality measurement
  • NAACOS and 13 other leading organizations support the Value in Health Care Act of 2021, which includes a provision to advance a study on health equity and APMs
  • NAACOS comments on OMB Advancing Equity RFI
  • NAACOS submits comments to CMS in response to 2022 proposed IPPS rule, including responses to a request for information on closing the health equity gap


The Healthy People initiative is designed to guide national health promotion and disease prevention efforts to improve the health of the nation. Each decade, the Department of Health and Human Services (HHS) releases an updated iteration of Healthy People. The following definitions were published in Healthy People 2020:

  • Health equity is the principle that everyone has an equal opportunity to be as healthy as possible. Healthy People defines health equity as the “attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.
  • Health disparities are metrics of inequity, defined as a (preventable) “health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”
  • Social determinants of health (SDOH) are drivers of inequity, defined as the social factors and physical conditions of the environments where people are born, live, learn, work, play, worship, and age that can positively or negatively affect a wide range of health, functioning, and quality of life outcomes and risks. SDOH can be categorized as economic stability, education access and quality, health care access and quality, neighborhood and built environment, or social and community context.

Evidence and Resources

ACO Learning Collaborative: Addressing Social Drivers of Health (Institute for Accountable Care and NAACOS, 2022)

Health Equity Challenges and CMS Resources to Help Address Them (Centers for Medicare and Medicaid Services Office of Minority Health, 2022)

  • This document highlights various barriers to health equity, known challenges contributing to those barriers, and specific CMS resources designed to help overcome those challenges. Barriers include issues with data, policies and regulatory issues, access to and quality of care, language access and health literacy, technology access, and distrust of the medical system.

Advancing Health Equity through APMs (Health Care Payment Learning & Action Network (LAN) – Health Equity Advisory Team (HEAT))

  • Guidance on Social Risk Adjustment (2022) This guidance document describes how social risk adjustment for payment can be leveraged to incentivize better care and outcomes for patients affected by health disparities and provide organizations with the resources needed to mitigate the negative impacts of longstanding health inequities and SDOH on the communities they serve.
  • Guidance for Equity-Centered Design and Implementation (2021) This guidance document outlines the interrelated features of alternative payment models (APMs) that can be leveraged to advance health equity including care delivery redesign, payment incentives and structures, and performance measurement. It also describes key design elements to drive more equitable health outcomes and provides examples for implementation.

How Are Payment Reforms Addressing Social Determinants of Health?  Policy Implications and Next Steps. (Milbank Memorial Fund & Duke Margolis Center for Health Policy, 2021).

  • This issue brief discusses the potential for value-based payment models to provide the financial flexibility and accountability that allows organizations to address SDOH at the population level.

Leveraging Medicaid Accountable Care Organizations to Address Health Equity: Examples from States. (Center for Health Care Strategies, 2021).

  • This report explores examples of states leveraging the ACO model to measure and address health equity within their state Medicaid programs.

Upstream With A Small Paddle: How ACOs Are Working Against The Current To Meet Patients’ Social Needs. (Health Affairs, 2020).

  • This qualitative study involved interviews and site visits with 22 ACOs across the country and found that 95 percent of the ACOs were working to address transportation needs, 86 percent were working to address food insecurity, and 77 percent were working to address housing instability among their patients.

Quantifying Health Systems’ Investment In Social Determinants Of Health, By Sector, 2017–19. (Health Affairs, 2020).

  • This study of health systems which were investing social determinants of health found that 86 percent of investing systems participated in an ACO.

A Framework for Advancing Health Equity and Value. (Families USA, 2018).

  • This report offers a framework for advancing health equity and value, including via payment systems that sustain and reward high-quality, equitable health care. Within this domain, the authors highlight ACOs as a promising model for advancing health equity and value-based care. They highlight the need for additional support to encourage safety net providers to participate in ACOs.

Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. (Kaiser Family Foundation, 2018).

  • This issue brief looks at the growing number of initiatives emerging to address SDOH. One example discussed state Medicaid programs which have leveraged the ACO model to provide incentives for providers to address the broad needs of beneficiaries, including SDOH.

Housing, Transportation, And Food: How ACOs Seek To Improve Population Health By Addressing Nonmedical Needs Of Patients. (Health Affairs, 2016).

  • This study of 32 ACOs found that the most common nonmedical needs that the ACOs addressed were the need for transportation and housing, and food insecurity. These ACOs used both individualized and targeted approaches, as well as mixed approaches