A coalition of 24 healthcare organizations has expressed concerns about value-based care provisions in the Medicaid state-directed payments (SDPs) rule in a July 21 letter to the Centers for Medicare & Medicaid Services (CMS). Several other associations have also spoken out about the proposed SDP rule. CMS also proposed several additional SDP regulatory changes to ensure compliance with the new payment limit. The organizations urge CMS to preserve state and managed care organization flexibility, align Medicare-based payment limits with the Medicaid fee-for-service process, and refrain from limiting services not required by statute. “So why does the proposed SDP regulation do so much more harm than the actual legislation?”