Value-based care requires enrollment stability as structural precondition because prevention ROI depends on multi-year attribution and semi-annual redeterminations break the investment timeline

The OBBBA introduces semi-annual eligibility redeterminations (starting October 1, 2026) that structurally undermine VBC economics. VBC prevention investments — CHW programs, chronic disease management, SDOH interventions — require 2-4 year attribution windows to capture ROI because health improvements and cost savings accrue gradually. Semi-annual redeterminations create coverage churn that breaks this timeline: a patient enrolled in January may be off the plan by July, transferring the benefit of prevention investments to another payer or to uncompensated care. This makes prevention investments irrational for VBC plans because the entity bearing the cost (current plan) differs from the entity capturing the benefit (future plan or emergency system). The CBO projects 700K additional uninsured from redetermination frequency alone, but the VBC impact is larger: even patients who remain insured experience coverage fragmentation that destroys multi-year attribution. This is a structural challenge to the healthcare attractor state, which assumes enrollment stability enables prevention-first economics.

Extending Evidence

Source: KFF Medicaid GLP-1 coverage analysis, January 2026

State Medicaid coverage instability now extends beyond enrollment churn to coverage policy reversal. Four states eliminated GLP-1 obesity coverage in 2025-2026, meaning patients who began treatment under coverage may lose access mid-therapy. This policy-level instability compounds enrollment churn, further undermining the multi-year attribution required for prevention ROI in value-based care models.