In 2010 President Barack Obama signed the Affordable Care Act (ACA) into law. The Act had the purpose of improving cost, quality and access to health care in the U.S. Six years later 20 million more people have health insurance, the rate of increase in health care costs has declined, and health care quality is improving. The planned health insurance exchange has not been as successful as hoped, though. In addition the ACA encouraged alternative payment models for physicians and in 2015 the bipartisan Medicare Access and CHIP Reauthorization Act (MACRA) expanded payment reform for Medicare patients with physician payment tied to quality and other factors instead of fee-for-service. The hope is that payment for prevention in addition to illness will improve cost and quality of care. However it should be kept in mind that health appears to depend more on socioeconomic than healthcare factors. In this Line One program we discuss the origins and expected effects of this change in payment to physicians with Dr Nancy Fisher, the Region 10 Chief Medical Officer for the Centers for Medicare and Medicaid.