If you want to understand where federal healthcare payment is heading, start with one word.

"Affordability," said Abe Sutton, Deputy Administrator at the Centers for Medicare & Medicaid Services and Director of the Center for Medicare and Medicaid Innovation (CMMI), when StartUp Health co-founder Unity Stoakes asked him to sum up CMS's core priority for health tech founders.

It is not an abstract goal. CMS administers Medicare, Medicaid, and CHIP, representing roughly $1.75 trillion in annual spending. As Sutton put it, that scale means CMS does not just react to the healthcare system. It shapes it. "As the largest payer in the country, we in some ways set the standard, not just using regulatory authority, but using reimbursement authority, for what is the norm and what is expected when you interact with the healthcare system."

For health tech founders, that context matters because it frames everything the CMS Innovation Center does.

Congress gave the CMS Innovation Center statutory authority to test new approaches to paying for care. Two new technology-focused models, WISER and ACCESS, represent the CMS Innovation Center’s first deliberate effort to apply that authority specifically to health technology companies. ACCESS, launched in December 2024 with a first cohort beginning this summer, is built around a simple but significant principle. "What we pay for is an outcome," Sutton said. Participants are measured on improvements in A1C levels, BMI, and other condition-specific metrics, and payments are structured to reward achieving those outcomes for at least half the patient population in a given track.

More than 150 companies have already been provisionally approved for the first cohort, with a mid-May application deadline for summer launch and a subsequent round open before year end.

Sutton also highlighted Geo AHEAD, a model he described as receiving less attention in the startup community than ACCESS, but one he sees as a compelling opportunity for the right company. Under Geo AHEAD, CMS is assigning accountability for Medicare beneficiaries in participating states who are not currently attributed to any provider. Technology companies can take on accountability for defined geographic populations without needing to build a physician network or qualify as a health plan.

The vision Sutton laid out is striking: a company could offer every assigned beneficiary in a population access to an AI-powered care tool at no cost, and take on financial accountability for their utilization. "That would be a pretty cool on-ramp into the healthcare system," he said.

Sutton was candid about how founders often misframe their pitches to the CMS Innovation Center. Proposals framed as small pilots for a single company tend not to go far. Every model, regardless of size, must clear the same approval chain: the CMS Innovation Center leadership, the CMS administrator, the Secretary of HHS, the Office of Management and Budget, and the Domestic Policy Council. "Why would I use a shot on goal on something small?" he said. What moves the needle is a proposal that addresses a broad, system-level challenge and makes a compelling case for savings to the Office of the Actuary.

His deeper advice was about durability. He encouraged founders to read the regulations that govern the spaces they operate in, and to build businesses that align with the actual intent behind those regulations, not loopholes within them. Companies that exploit gaps may survive for a year or a decade, but eventually someone will name it waste and close it. "If your business is built on delivering better clinical care and improving the standard of care in this country, no one's going to come around with an incentive to say we should try and curtail that."

Sutton closed with an open invitation: CMS wants to hear from founders about the barriers they are hitting, and the team actively updates its published guidance in response to questions it has not yet answered publicly. He also noted that the CMS Innovation Center is actively hiring, with more than 60 new hires since he joined in January 2025, and is looking for people who understand the operational realities of building in healthcare.

The outlook, from his perspective, is genuinely optimistic. "I'm excited about the next five years and what we'll see unlocked in terms of giving everyone in this country great access in a more affordable manner."