Patient Affordability & Health Care Access — ACP 2026 Advocacy Priority

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Make health care more affordable and accessible by lowering patient cost sharing for primary care and preventive health care services and reducing the administrative complexity of complying with new community engagement or work requirements for Medicaid recipients.

Why Patient Affordability & Health Care Access Matters

Patient access to health care can be improved by lowering co-pays and deductibles for primary and preventive care services. The Centers for Medicare and Medicaid Services (CMS) has implemented a new program for Advanced Primary Care Management (APCM) services with the goal of more appropriately reimbursing physicians caring for patients with complex medical and social needs. ACP is concerned that cost-sharing associated with these services could hinder beneficiary consent and uptake.

Additionally, as of January 1, 2027, all non-excepted able-bodied adults age 19-65 who are enrolled in Medicaid expansion under the Affordable Care Act (ACA) must meet work or other community engagement requirements. Forty states and DC expanded Medicaid eligibility under the ACA, and non-expansion states with certain waiver programs – Tennessee, Georgia, and Wisconsin - must also comply. Eligible individuals must complete 80 hours per month of approved activities to maintain their Medicaid eligibility, unless exempted. Excluded individuals include pregnant women, those considered "medically frail," certain individuals with disabilities, and primary caregivers for dependent children under age 13 or disabled individuals. States have the option of adopting short-term hardship exceptions for individuals receiving inpatient hospital care, inpatient nursing care, people living in areas with high unemployment rates, and certain other reasons. States are required to verify compliance at application and renewal.

CMS has issued an interim final rule on the community engagement requirements to establish the standards states must use to implement these requirements, including expectations for eligibility determinations, exemptions, verification, and state reporting requirements. The interim final rule adds a stricter test that goes beyond what Congress approved last year, requiring enrollees to prove their health condition prevents them from working, participating in a work program or volunteering for at least 80 hours a month, caregiving, or being enrolled in an education program at least on a part-time basis. This is a more difficult frailty exemption to meet than the community engagement requirements as laid out in the law. Some 24 states, including DC and two Governors, have sued CMS over its interpretation of the frailty exception.

ACP’s Policy Position on Health Care Affordability

ACP supports efforts to make health care more affordable, particularly regarding evidence-based preventive services. This includes protecting coverage of preventive services without cost-sharing and lowering out-of-pocket costs and co-pays for primary care visits. We urge Congress to approve legislation to waive cost sharing associated with these services. APCM services, introduced to simplify and support comprehensive, team-based primary care, have traditionally carried cost-sharing obligations for beneficiaries under Medicare Part B. ACP supports CMS’ consideration of that stance in recognition that even minimal cost sharing may be a barrier to patient utilization of APCM services.

ACP is opposed to Medicaid community engagement requirements since most Medicaid enrollees already work, are in school, or are caring for a loved one. Previous attempts to implement work requirements resulted in confusion and loss of coverage, and we are deeply concerned that millions of patients may lose access to vital medical care because of these requirements. Community engagement requirements create a tangled web of red tape that diverts resources away from patient care and worsens the administrative burden on physicians.