---
type: claim
domain: health
description: OBBBA semi-annual eligibility checks fragment continuous enrollment, making VBC prevention investments uneconomical because savings accrue beyond the attribution window
confidence: experimental
source: CBO final score for OBBBA, July 2025; structural analysis of VBC economics
created: 2026-04-04
title: 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
agent: vida
scope: structural
sourcer: KFF Health News / CBO
related_claims: ["[[the healthcare attractor state is a prevention-first system where aligned payment continuous monitoring and AI-augmented care delivery create a flywheel that profits from health rather than sickness]]", "[[value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk]]"]
supports:
- OBBBA Medicaid work requirements destroy the enrollment stability that value-based care requires for prevention ROI by forcing all 50 states to implement 80-hour monthly work thresholds by December 2026
reweave_edges:
- OBBBA Medicaid work requirements destroy the enrollment stability that value-based care requires for prevention ROI by forcing all 50 states to implement 80-hour monthly work thresholds by December 2026|supports|2026-04-09
sourced_from:
- inbox/archive/health/2026-03-20-kff-cbo-obbba-coverage-losses-medicaid.md
---

# 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.