While the Alliance’s membership goal was always quality over quantity, its membership and consequent dues support ultimately dropped below the level necessary to sustain operations. Despite what were generally regarded by members as high-quality Alliance programs, resources and other accomplishments their interest waned as:

1. They perceived a lessening of threats to their nonprofit ownership status and/or tax exemptions; and
2. Heavy demands emerged to effectively respond to all the challenges posed by passage of the Affordable Care Act in 2010 and its myriad and complex implementing regulations.

Several members also withdrew as a result of a change in leadership in their organizations, with CEO replacements apparently less committed to their nonprofit missions and/or to the Alliance’s Cause..