The Most Audacious Medicare Experiment of 2026—and It’s Not a CMS Initiative
Health at Home - community care at scale
If 2025 was the year that the CMS Center for Medicare and Medicaid Innovation (CMMI) grabbed the headlines, 2026 may be the year a much smaller federal agency quietly attempts one of the most interesting experiments in Medicare.
That agency is the Administration for Community Living (ACL). And the experiment, launched this year, is the Health at Home Challenge.
Created in 2012 through the merger of three smaller agencies, ACL’s mission is to “maximize the independence, well-being, and health of older adults, people with disabilities across their lifespan, and their families and caregivers.” Its work has traditionally focused on community-based programs outside the formal healthcare system—including chronic disease self-management, health promotion programs, nutrition, transportation, housing and other services that help people live independently in their homes and communities.
Now that is evolving in a particularly promising way.
The missing infrastructure
ACL’s mission has always been closely connected to Medicare and Medicaid. Medicare provides healthcare coverage to many of the people ACL serves, and Medicaid is a critical source of long-term services and supports for millions of older adults and people with disabilities.
Over the past decade, the connection between healthcare and community services has become increasingly difficult to ignore. Healthcare organizations have recognized that factors such as food insecurity, housing instability, transportation and social isolation have profound effects on health. As a result, health plans, accountable care organizations and health systems have increasingly looked to community-based organizations (CBOs) to help address their patients’ and members’ health-related social needs.
This has proven easier said than done.
Many CBOs are small organizations that have historically relied on grants, government funding and philanthropy. They weren't built to negotiate contracts with health plans, manage healthcare referrals, exchange data, meet healthcare compliance requirements, or process payments at scale.
In other words, the barriers to care haven’t necessarily been about finding the right community organizations. It was building the infrastructure necessary to connect those organizations to healthcare.
Enter the community care hub
A community care hub (CCH) can serve as that infrastructure. It organizes networks of community-based organizations and provides many of the administrative and operational functions that individual CBOs may not be able to manage on their own—including contracting, billing, referrals, technology, data, compliance, and reporting.
Put simply, CCHs serve as a front door for healthcare organizations seeking community partners.
As a relatively new innovation, though, CCHs as a whole have not reached the geographic scale needed to reach their full potential.
From first steps to national experiment
This is where the Health at Home Challenge gets interesting.
In 2026, ACL took a bold new step to turbocharge the community care hub concept, launching a national prize competition designed to help established community care hubs develop and scale advanced community care networks providing core whole-person health services for some of the people with the most complex needs: Medicare-Medicaid dual eligibles and near-dual populations, including those at high risk of becoming dual eligible.
The Challenge has two explicit goals: increase the number of days these individuals spend at home rather than in hospitals, rehabilitation facilities or nursing homes, and reduce their total cost of care.
But that undersells what the Challenge is really doing.
The real experiment is whether we can make community-clinical integration work at scale.
There is growing evidence that some community interventions addressing health-related needs can improve outcomes and reduce healthcare utilization and costs. But translating that evidence into sustainable, scalable delivery has proven much harder.
Health at Home is building out new approaches to develop stronger community infrastructure at scale to help solve that problem.
In July, ACL announced 12 Phase 1 winning teams representing partnerships across 22 states, sharing $2.2 million in prize funding. Those teams will move into Phase 2 of the three-phase Challenge, developing and implementing their approaches with the goal of eventually reaching as many as one million dual-eligible and near-dual-eligible beneficiaries.
That's a pretty big experiment for an agency most Americans have probably never heard of.
Why this could be revolutionary
What makes Health at Home particularly interesting is that it turns the traditional federal healthcare innovation playbook on its head.
Most CMMI models begin with healthcare organizations. CMS establishes a model, health systems, providers, or payers participate, and those organizations are asked to change how they deliver and pay for care.
Health at Home takes a different tack.
It brings healthcare organizations and community care hubs together as partners and asks them to develop and scale solutions jointly.
That's an important distinction.
Rather than expecting healthcare organizations to build community capacity themselves, the Challenge recognizes that much of that capacity already exists—but that it needs infrastructure, coordination and sustainable relationships with healthcare organizations to reach its full potential.
It is also a fundamentally more bottom-up approach.
Instead of designing a single national intervention and asking communities to implement it, ACL is supporting organizations that already understand their local populations, have existing community relationships and have demonstrated an ability to connect social care with healthcare. The federal government, via ACL, is providing funding, incentives, and technical assistance for those partnerships to grow rather than prescribing exactly what they must look like.
That is particularly important for dual eligibles and people at risk of becoming dual eligible.
These individuals often have combinations of medical, behavioral, functional and social needs that don't fit neatly into the traditional healthcare system. They are also among the highest-cost populations served by Medicare and Medicaid.
It’s a tighter focus than a typical federal program, and for good reason. There is an unavoidable tension in running a national program like Medicare: standardization and scale are powerful, but they can make it difficult to respond to the very different circumstances of particular populations and communities.
A smaller, more targeted effort focused on the infrastructure capable of serving the neediest populations may have a better chance of moving the needle than another broad intervention aimed at all of Medicare.
The real innovation is the partnership
I like to say that if any healthcare problem could be solved by a single approach, it probably would have been solved by now.
The hardest problems in healthcare increasingly require partnerships—across payers and providers, medical and social care, government and community organizations.
Health at Home embodies that formula.
A health plan or health system brings clinical expertise, data and resources. Community organizations bring trusted relationships, local knowledge and the ability to address needs that healthcare organizations cannot solve on their own. The community care hub provides the infrastructure that allows those pieces to work together.
That is potentially a very different way of catalyzing complex care.
If it succeeds, ACL will have done something unusual for a relatively small federal agency.
It won't simply have created another program.
It will have helped build the infrastructure for a different way of organizing care: one in which community organizations are not peripheral to the healthcare system, but partners in care delivery.
That could make the Health at Home Challenge one of the most consequential healthcare experiments of 2026—and one worth watching well beyond ACL.
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