The Affordable Care Act (ACA) defines a new type of organization to deliver health care—the Accountable Care Organization (ACO), which is held out as a beacon of hope, providing ways to improve quality and reduce costs. When ACOs started to gain popularity following the passage of the ACA, of the two parties involved in their deployment—payers and providers—the providers had greater interest. In particular, providers and hospitals saw ACOs as an opportunity to gain leadership of the provision of health care without heavy oversight of health insurers and to deal with the concerns they had with the incentives of the FFS reimbursement system. Payers are particularly skilled at accepting risk. They are not very skilled at managing health care, despite being called managed care organizations, the exception being if the payer also owns a disease management company the way United Health Group owns Optum Health.