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A little more than four years after enactment of the Patient Protection and Affordable Care Act of 2010 (“ACA”), daily headlines still abound on newspapers and websites across the country highlighting both successes and failures of the ACA. In analyzing those successes and failures, especially in the context of care delivery, it is important to take a step back to consider the stated goals of the ACA, which goals have their origins in a premise first proposed by Dr. Donald M. Berwick and the Institute for Healthcare Improvement (“IHI”) in 2006 referred to as the “Triple Aim.” The Triple Aim is a framework for healthcare that, at its origin, was intended to “optimize population health, care experience, and cost.” It was with this Triple Aim in mind that legislators and policy makers established the framework for accountable care organizations (“ACOs”) and the Medicare Shared Savings Program (“MSSP”). This article examines the origins of the Triple Aim and its impact on the development of ACOs under the ACA. It then analyzes why academic medical centers and other integrated delivery systems such as the Mayo Clinic, which entities are leaders in research, innovation, and quality care, are opting out of a model of care in the ACO structure that was designed with the goal of functioning more like these entities. With that in mind, it examines the potential risks of maintaining an ACO structure that is not open, available, and accessible to academic medical centers such as the Mayo Clinic, suggesting that such a structure that does not encourage participation by entities such as the Mayo Clinic will be unable to achieve the goals of the Triple Aim that the ACA set out to accomplish. Finally, the article will offer some suggestions for amendments to the ACO model that might make ACO participation possible for the Mayo Clinic and entities like the Mayo Clinic and move the U.S. healthcare delivery system closer to its goals of achieving the Triple Aim.