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The federal accountable care organization (ACO) landscape continues to twist and turn, with one of the most recent developments being the drop of participants in the Medicare Shared Savings Program (MSSP), down from a membership high of 561 in 2018 to 477 at the start of 2021. Leaders at the National Association of ACOs (NAACOS) assert that the reason for the decline in program participants is related to several Trump administration-era policies, including 2018 changes from the Centers for Medicare & Medicaid Services (CMS) called “Pathways to Success,” which gave ACOs limited time before taking on financial risk and cut the share of savings most ACOs are eligible to keep. Last year, CMS also removed the opportunity for new ACOs to apply to join the Shared Savings Program in 2021, citing the pandemic. Nonetheless, NAACOS calls the MSSP the largest and most successful value-based payment program, pointing out that the model served 11.2 million seniors in 2019, and collectively saved Medicare $2.6 billion that year, and $1.2 billion after accounting for shared savings bonuses and collecting shared loss payments.