Health equity is no longer a reporting checkbox.

For Accountable Care Organizations (ACOs) operating under the Centers for Medicare & Medicaid Services (CMS) value-based care programs, equity is now woven into how performance is measured, how benchmarks are calculated, and how long-term financial sustainability gets built…or eroded.

The ACOs that will outperform over the next decade are already treating equity as operational infrastructure. Here’s what that actually looks like.

Why CMS Made Equity Structural, Not Optional

The shift started in earnest with the ACO Realizing Equity, Access, and Community Health (REACH) model, which required participating ACOs to develop and implement a Health Equity Plan – the first comprehensive equity requirement of its kind across CMS Innovation Center models. REACH ACOs were required to collect social determinants of health (SDOH) data using standardized tools and could earn up to a 5-percentage-point upward adjustment to their quality score for reporting that data.

ACO REACH is significant because it focuses on health equity, requiring participating ACOs to make and follow an equity plan to reduce care disparities for underserved communities. 

The Medicare Shared Savings Program (MSSP) has followed a similar trajectory, with CMS increasingly emphasizing stratified quality reporting and population-level adjustments tied to dual-eligible and low-income beneficiary status.

Now, with ACO REACH sunsetting at the end of 2026 and the Long-term Enhanced ACO Design (LEAD) model set to replace it, the equity infrastructure ACOs build today won’t just satisfy current program requirements – it will shape their readiness for what comes next.

The Performance Case for Health Equity

This isn’t just a values conversation – the data makes a financial argument.

Patients with unmet social needs such as housing instability, food insecurity, transportation barriers use emergency and inpatient services at significantly higher rates. When care is language-discordant, patients are less likely to follow discharge instructions, fill prescriptions, or show up for follow-up appointments. Chronic disease burden is disproportionately concentrated in the same populations where social risks are highest.

For ACOs operating under two-sided risk, this gap is not abstract. It shows up in preventable hospitalizations, readmission rates, and total cost of care.

Equity gaps are cost gaps. Closing one tends to close the other.

Where Most ACOs Get Stuck

The intention is usually there. The infrastructure often isn’t.

Common friction points include:

• SDOH data that lives in silos – collected during a screening, but never integrated into the patient’s risk profile or care workflow
• Demographic data that’s incomplete or inconsistently captured – making it impossible to stratify quality metrics meaningfully
• Engagement tools that default to English – creating a structural language barrier for patients who need the most proactive outreach
• Social needs identified but not acted on – documented in the chart, with no defined referral or response pathway attached

The result: equity efforts stay reactive, manual, and disconnected from the rest of the care management program.

What Operationalizing Health Equity Actually Requires

Getting from intention to infrastructure means building equity into four areas:

1. Stratified Data as Standard Practice
   Quality measures, utilization patterns, and outcomes need to be consistently segmented by race, ethnicity, language preference, geography, and dual-eligibility status. Not as a one-time audit, but as an ongoing operational view. You can’t close a gap you can’t see, and you can’t see a gap if your reporting isn’t designed to surface it.
   
   
2. SDOH Integrated Into Risk Stratification
   Two patients with the same diagnosis can have dramatically different risk trajectories. A patient with hypertension who also has unstable housing, no reliable transportation, and a language barrier is not the same risk profile as a patient with hypertension and none of those factors. Risk models that ignore social context will consistently underestimate need and misdirect outreach.
   
   
3. Defined Workflows for Identified Needs
   Screening for social needs without a clear response pathway creates documentation without impact. When a patient screens positive for food insecurity or housing instability, the next step shouldn’t be up to whoever is looking at the chart that day. It should be built into the workflow with a defined referral, a follow-up trigger, and accountability for closure.

What This Makes Possible

ACOs that build this infrastructure – stratified data, integrated SDOH risk, actionable workflows – are better positioned to improve chronic disease control, reduce preventable admissions, strengthen patient experience scores, and manage total cost of care over time.

They’re also better positioned for what CMS is signaling it wants next: accountable care organizations that don’t just report on disparities, but measurably close them.

Health equity isn’t a side initiative. It’s population health strategy and for ACOs in risk-bearing models, it’s increasingly where performance is won or lost.

This Is Where BettrAi Fits

BettrAi is built for the gap between identifying a need and actually closing it. Our platform connects population health analytics, care management workflows, and proactive patient engagement, so care teams can act on what the data surfaces without adding burden to already stretched teams.

If you’re working to turn your equity goals into measurable, operational action – reach out, we’d love to chat.