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Today’s Medicare program faces familiar cost and quality challenges. Medicare Part A is projected to be insolvent in 2033 and will start drawing down funds from the Part A Trust Fund in 2028. While moderating slightly during the COVID pandemic, spending growth has increased and remains high – 8.1 percent in 2023. Medical complexity also remains a challenge, with nearly all Medicare beneficiaries having at least one chronic condition and over half with four or more. Alongside the familiar challenges are new ones, including structural changes in the program with over half of beneficiaries receiving care through Medicare Advantage (MA), which is also contributing to overall fiscal strain. In Traditional Medicare (TM), 11.2 million beneficiaries now receive care through Accountable Care Organizations (ACOs) in the permanent Medicare Shared Savings Program (MSSP), but provider participation in the program has plateaued.