America’s health care system is facing the need to care for increasing numbers of older patients with complex needs. Almost one million older persons are hospitalized per year in the United States for treatment of an acute illness. At the same time, the entire framework of practice and reimbursement is changing as a result of the implementation of the Affordable Care Act. Many American hospitals will participate in Accountable Care Organizations (ACOs). These ACOs will shift the overall quality and costs of care to a shared responsibility between the health system and the Center for Medicare and Medicaid Services. As we look toward the future of the Acute Care for Elders model, we will describe that future in the context of the reform of our health care system. We will describe several of these changes and the implications for ACE.