Emanuel - Prescription for the future: the twelve transformational practices of highly effective medical organizations

A LTHOUGH THEY FAILED TO repeal the Affordable Care Act in toto, President Trump and the Republican Congress did repeal the individual mandate, eliminate the cost-sharing subsidies that helped lower-income Americans, reduce the open-enrollment period, and cut funding for its advertisement and assistance in navigating the health insurance marketplaces. The landscape looks very different in 2018 than it did before the 2016 election. With so many setbacks, its fair to ask: Is a book advocating reform and transformation of the American healthcare system irrelevant?

The short answer is: No. In fact, the ideas that form the core of this bookideas aimed at showing how to develop an innovative, value-driven healthcare delivery system in the United Statesare probably more relevant today than ever.

To many people, that answer may seem counterintuitive. While a burst of healthcare reform zeal fueled the 2008 election and the passage of Affordable Care Act (ACA) in 2010, the Republican sweep in 2016combined with the subsequent legislative and regulatory reversals of central portions of the ACAlook like a repudiation of government-propelled, indeed, any, healthcare reform. But the response to these repeal efforts has not been what most Republicans predicted. Debate about repealing the individual mandate boosted support for the Affordable Care Act. Slashing the open enrollment period for the exchanges in half and reducing advertising for the exchanges by 90% hardly affected enrollments. Indeed, the back and forth since the 2016 election contains three important messages. First, the majority of Americans do think everyone is entitled to health coverage and that the government has an indispensable role in guaranteeing it. It is no longer acceptable that hardworking Americans lack health insurance. Second, while the ACA may not be the best way to cover everyone, Americans will not give up on it without some concrete alternative. They do not want a repeal without a coherent replacement that addresses the key problems of the system such as preexisting conditions. Third, and most importantly, Americans feel the system is still not working as it should. It is becoming increasingly clear that the American healthcare system is plagued by two fundamental problems: it underperforms on almost every metric and it is increasingly unaffordable. Improving the American healthcare system is something every patient, every corporate executive, every physician, nurse, and practitioner, every politician and policymaker cares or should care about. Beyond debates about the various provisions of the ACA, the exchanges, and subsidies, all Americans realize the overall system still needs more fixing.

No matter how you measure it, the American healthcare system continues to malfunction. Tens of millions of people are still uninsured. Health expenditures remain astronomically highnearly $10,000 per American and 20% higher per capita than the next highest spending country, Switzerland. Despite these exorbitant expenditures, health outcomes in the United States are not 20%, 10%, or even 5% better than in other developed countries. While we may match the rest of the world in a few health outcomes, such as cancer survival, trauma, and organ transplantationand even these are contentiously debatedwe lag behind in most other areas. On even the most basic measures of health system qualitylife expectancy, maternal, infant and youth mortality, immunization rates, asthma survival, heart attack survival, control of diabetes, and mental healththe United States falls well below other developed countries. There are also endless complaints about impersonal care, hospital-acquired infections, rushed office visits, excessive admissions to the ICU, and too many high-tech interventions at the end of life. Such inconsistent and relatively poor performance at such a high cost should infuriate any responsible corporate executive. It rightfully infuriates the American public.