July 17, 2026
Dear Interested Readers,
Could Positive Change Be Possible Through Market Forces?
On my birthday and at Christmas, I frequently get bow ties and books as gifts. I wasn’t expecting anything for my birthday this year because there was no scheduled event. It was not one of those birthdays that end in zero or five. To my surprise, I received John Irving’s latest novel, Queen Esther, and, to even greater surprise, a book about healthcare, The Coming Healthcare Revolution: 10 Forces That Will Cure America’s Health Crisis.
I’ve been a fan of Irving’s since reading The World According to Garp. For reasons hard to explain, perhaps my favorite Irving novel is A Widow for One Year. Irving is a prolific writer, and I sometimes forget to check out his latest offerings. Looking at the list of his books, I have some catching up to do.
I received the healthcare book with some reservations because neither author was known to me, and a quick glance at the book jacket suggested that both of its authors might be involved in the “corporatization” of healthcare. Neither author has any type of discernible medical degree. The first author, David W. Johnson, was a former investment banker who is the founder of 4sight Health, a healthcare media and advisory company, whose website leads with a page that says in bold type: “Revolutionary Content. Perspectives, insights, and advice on market-driven healthcare reform. Get Smart.” The book’s cover notes that Mr. Johnson is a thought leader, strategist, advisor, lecturer, and policy analyst. I was skeptical, but tried to keep my implicit biases in check.
The second author, Paul Kusserow, was a little closer to care delivery, but still, it was easy to exercise my prejudices and consider him a “suit.” Mr. Kusserow is presented as the current chairman and former Chief Executive Officer of Amedisys (AMED), a publicly traded provider of “home health, hospice, palliative, personal care, and high-acuity care. The jacket cover further adds to his bona fides and expertise by noting that AMED operates in 39 states plus D.C., has 22,000 employees, and delivers care through more than 12.3 million encounters a year.
As I said, both authors seemed highly likely to suggest that there were market solutions to our current disastrous delivery-system challenges. That seems unlikely to me, and, as noted in my letter to you of May 1 this year, Nobel Prize-winning economist Paul Krugman has argued that healthcare cannot be reformed through market forces alone. If you are interested in his argument that healthcare is returning to the center of political debate, I suggest that, in addition to reviewing my post of May 1, you also look at my posts of May 8 and June 5. Those three letters review Krugman’s assertion that market forces alone can’t give us the healthcare we want and, in the end, suggest a transition process beginning with the development of a “public option.”
What seemed at variance with my lack of knowledge and fundamental suspicions about the authors was that Dr. Zeke Emanuel had written the foreword. Emanuel, a prominent oncologist and the brother of Rom Emanuel, was an advisor to President Obama and was closely involved in the evolution of the ACA. In the Obama administration, from 2009 to 2011, he served as the Special Advisor for Health Policy to the Director of the Office of Management and Budget (OMB) and the National Economic Council. At the same time, his brother was President Obama’s White House Chief of Staff. Dr. Emanuel is currently Vice Provost for Global Initiatives, the Co-Director of the Healthcare Transformation Institute, and the Diane V. S. Levy University Professor at the University of Pennsylvania. As a true academic, he backed up his lengthy foreword with a bibliography of 18 references.
Dr. Emanuel begins his foreword by calling the authors optimists because:
“They foresee a time in the not-too-distant future when American healthcare costs will be lower, access to services will be more convenient, care will be more personalized and more focused on prevention and wellness, quality will be uniformly high, and everyone–patients and clinicians–will be more satisfied.”
Is that before or after pigs fly? It turns out that the authors predict good times by 2034 based on their observation of 10 factors already underway. It is not a surprise to me that Emanuel briefly reflects on the optimism that was associated with the passage of the ACA fifteen years ago. He does credit the ACA with helping to plateau healthcare costs for several years, just shy of 18% of GDP, and, at its peak before Trump’s election, reducing the percentage of the population that was uninsured to about 7%. He also notes that about $ 4 trillion has been saved in Medicare expenses alone because of provisions in the ACA. Those benefits are evaporating. He cites projections indicating that healthcare costs will be 19.7% of GDP by 2032. In 2023, premiums for family coverage exceeded $24,000, which is “a whopping 32% of median income.” He implies that if a trend can’t go on forever, it won’t. I agree, but our society seems to have a proclivity for tolerating the intolerable for longer than anyone expects. Late in his foreword, he writes:
“But even with strong forces pushing change, it is also true that old, deteriorating dysfunctional organizations and systems can teeter for a long time, decades, even centuries, without being replaced. Witness the Holy Roman and the Ottoman Empire, not to mention antiquated and dangerous water and sewage systems, or almost any big city’s public transit system in the US, or antiquated companies.”
Earlier in his piece, Emanuel claims superiority for America’s cancer care, but notes our very shabby performance in the control of hypertension and diabetes, where our knowledge and cheap drugs should deliver great relief and extend and improve life through reductions in heart attacks, strokes, peripheral vascular disease, vision loss, and pregnancy complications. He notes that with our diet, almost 15% of adults (38 million) are diabetic, and only half have an A1C under 7%. According to data from NCQA, two-thirds of people with diabetes don’t have their blood pressure controlled, and only about 65% have an annual eye exam. It is not hard to find examples of the failure to manage chronic disease in a system focused on maximizing profit from invasive procedures and unnecessary, but expensive testing performed in hospitals where profits are maximized. Emanuel notes that the authors also focus on our transition to expensive “intermediaries,” such as management service organizations (which implement the non-clinical services of physician practices) and pharmacy benefit managers (PBMs). The status quo is larger and more entrenched than most of us realize. Much like the “military-industrial complex” that President Eisenhower identified and warned us about as he left office at the end of 1960, the authors describe our current healthcare system as Healthcare Inc. Healthcare Inc. is far more focused on the bottom line than on the health of the nation.
Early in their book, the authors call for “revolutionary” forces capable of producing “revolutionary change” to dismantle Healthcare Inc.’s market concentration and political power. Whereas Paul Krugman and many others, myself included, have seen this to be a process that will require government intervention, the authors see it as possible through the market. They cite 10 “macro and market forces” that are well underway and will deliver us from our current pain by 2032.
With the help of ChatGPT, they can be quickly summarized as “five top-down forces” and “five bottom-up forces.”
The Five Top-Down Forces
1. Demographic change
America is aging rapidly. The retirement of the baby boom generation, combined with rising rates of obesity, diabetes, dementia, and chronic disease, is placing enormous pressure on Medicare, Medicaid, hospitals, and the healthcare workforce. The authors argue that the existing system was designed for episodic acute illness, not for decades of chronic disease management.
2. Funding fatigue
The United States spends nearly one-fifth of its GDP on healthcare, far more than other developed countries, yet often achieves inferior outcomes. Johnson and Kusserow argue that employers, taxpayers, governments, and households have reached a breaking point and will increasingly demand lower costs and greater accountability.
3. Chronic pandemics
The authors use the phrase “chronic pandemics” to describe obesity, diabetes, cardiovascular disease, addiction, and mental illness. They argue that these conditions now dominate morbidity and mortality and cannot be solved by hospitals and specialists alone. Healthcare must shift toward prevention, lifestyle interventions, and community-based care.
4. Technological imperatives
Artificial intelligence, genomics, wearable devices, remote monitoring, telemedicine, and advanced analytics are viewed as transformative technologies that will alter diagnosis, treatment, and care coordination. The authors believe these technologies will increasingly move healthcare away from hospitals and into homes and communities.
5. Consumer and market pressures
Patients are becoming consumers who expect convenience, transparency, digital access, and lower prices. Employers and insurers are demanding measurable value rather than simply paying for more services. The authors argue that these market pressures will accelerate change.
The Five Bottom-Up Forces
6. Whole-person health
The book advocates a broader conception of health that includes nutrition, exercise, mental health, housing, social support, and the social determinants of health. The authors contend that healthcare must expand beyond treating disease to promoting well-being.
This theme overlaps with many of the issues we have discussed regarding rural New Hampshire: food insecurity, transportation, aging, and community health. [Note that ChatGPT is addressing me. From previous inquiries that I have made, it knows my interests and where I live.]
7. Care redesign
Johnson and Kusserow foresee major changes in how care is delivered:
- team-based primary care;
- integration of behavioral health;
- hospital-at-home programs;
- greater use of nurse practitioners and physician assistants;
- digital monitoring and telehealth;
- value-based payment.
They believe the traditional model of brief office visits and fragmented specialty care is becoming obsolete.
8. Care migration
Care will increasingly move:
- from hospitals to ambulatory centers;
- from clinics to homes;
- from physicians to multidisciplinary teams;
- from face-to-face visits to virtual encounters.
The authors see this migration as essential for controlling costs and improving access.
9. The advantage of aggregators
Large organizations—integrated health systems, insurers, pharmacy chains, technology firms, and value-based-care companies—will gain influence because they possess the data, scale, capital, and analytics needed to coordinate care and manage risk.
This trend raises an important question: will large systems create efficiencies, or will they simply become more powerful monopolies?
10. Empowered caregivers
The authors argue that patients, families, and frontline clinicians will assume larger roles in managing health. Technology will give individuals more information and greater control over their care. Caregivers outside hospitals—including family members—will become increasingly important.
I agree with most, if not all, of the authors’ ten points, but I am sad to say I am skeptical that the realities they identify will amount to the changes they desire. It is not hard for me to find areas where I think that the authors are overly optimistic. They imply that all the change they advocate will occur through market forces and trends, and assign virtually no responsibility to the government for the evolution toward a focus on the social determinants of health or for the creation of better access to care through public policy initiatives.
At one point (page 164), they do call for the government to spend its money, not on more advanced hospital care but on what they call UP4C, which is their acronym for universal primary, prenatal, postnatal, and palliative care. I don’t know why they don’t just advocate for universal access. As one might expect, they are counting on a coalition of consumers and employers who are frustrated with the current state of care to drive change.
I must give them some credit for recognizing that the healthcare workforce needs some help. They do advocate for AI tools, telehealth, “whole person health,” and team-based care. There is a chapter on “Empowered Caregivers.” They call for a change from “old medicine” to “new medicine” and present a graphic to make their point (page 281). I decided to use ChatGPT to analyze page 281. When I asked it to do so, it said it could not do so without “seeing the page,” so I took a picture of the page and uploaded it. I was just hoping that it would give me an electronic version of the graphic since I could not “copy and paste” from a printed book. I was surprised when I got the graphic I wanted, plus an analysis in less than 10 seconds:
Thank you for uploading the image. The figure (Figure 10.4, “It’s time for a change: ‘Old Medicine’ vs. ‘New Medicine’ leadership models”) argues that healthcare transformation requires not just new technologies and payment systems, but a profound change in how physicians, nurses, administrators, and health systems think about leadership. The authors call these changes “learned leadership behaviors” because they believe they are not innate traits but skills and habits that clinicians and organizations can consciously develop.
The figure contrasts the assumptions of “Old Medicine” with those of “New Medicine” across ten dimensions:
| Leadership Dimension | Old Medicine | New Medicine |
| Mindset | Individualistic | Team-based |
| Worldview | Hierarchical | Outcomes-driven |
| Orientation | Autonomous | Collaborative |
| Focus | Specialized | Broad |
| Attitude | “My way” | “Our way” |
| Decision Bias | Trust myself | Trust others |
| Action Bias | Do it myself | Delegate |
| Trust | Assumed | Earned |
| Communication Style | Command | Persuade |
| Recognition / Accountability | Personal | Group |
The authors’ central message is that healthcare’s future will depend less on the traditional image of the heroic, autonomous physician and more on clinicians who can lead teams, share responsibility, and manage complex systems.
A few of these shifts are particularly noteworthy.
From individualistic to team-based. Medicine has historically rewarded independence and expertise. The book argues that modern care—especially for chronic disease, mental health, and older patients—requires physicians to work effectively with nurses, pharmacists, social workers, community health workers, data analysts, and AI systems.
From hierarchical to outcomes-driven. Traditional authority in medicine rested heavily on status, specialty, and years of experience. The new model suggests that leaders should be judged by measurable improvements in patient outcomes, quality, cost, and equity.
From autonomy to collaboration. Physicians have long prized professional autonomy. The authors contend that value-based care and population health require greater coordination among hospitals, primary care practices, public health agencies, and community organizations.
From “my way” to “our way.” This may be the most difficult transition. It implies that leadership means aligning diverse professionals around shared goals rather than relying on individual authority.
From command to persuasion. Healthcare organizations have become too complex to run by directive alone. Leaders increasingly need skills in communication, negotiation, coaching, and coalition-building.
The figure is optimistic, but it also raises some important questions.
First, many physicians would argue that some features of “Old Medicine” remain valuable. Clinical judgment, professional autonomy, personal accountability, and deep specialization are still essential in many situations—particularly in surgery, emergency medicine, and complex diagnosis.
Second, the transition to “New Medicine” may be especially challenging in rural communities. Small hospitals and practices often depend on clinicians who wear many hats and retain substantial autonomy because they lack the personnel and infrastructure of large systems.
Third, the rise of AI and data-driven medicine creates tension within this framework. The figure encourages clinicians to “trust others” and delegate more responsibility, but many physicians remain cautious about delegating too much authority to algorithms, administrators, or large health systems.
Several things about ChatGPT’s response to the graphic resonate with me. I think that if you are a regular reader of these notes, you will recognize that I currently advocate for all of these transitions, and I hope that you will trust me when I say that during my years of leadership, I advocated for them and made efforts, often against resistance, to make them the new culture of my organization. More than fifty years ago, Dr. Ebert proposed these transitions as a significant part of his thinking in creating the Harvard Community Health Plan. Throughout my years of practice, I was fully aligned with this evolution of practice. I have scars to verify the Bot’s concept that there will be resistance.
I have not yet read every word of the book, but I did learn a lot by using the index to explore how closely the authors aligned on subjects that are of great interest to me. To my delight, we are aligned on the social determinants of health, but to my disappointment, we are only partially aligned on universal access as a government responsibility. When I searched for Don Berwick, I discovered that they advocated for an expansion of the Triple Aim to a Quintuple Aim. They quoted Berwick:
“Improving the U.S. healthcare system requires simultaneous pursuit of three aims: Improving the experience of care, improving the health of populations, and reducing per-capita costs of healthcare.”
Since then, many have argued that “improving the work life of healthcare providers, including clinicians and staff” should become a fourth aim. More recently, some have argued that health equity” should become a fifth aim.
I agree, and I would like to think that the authors’ acknowledgment that health equity is a foundational goal could be a cornerstone of a new day in healthcare in the relatively near future.
Whether the authors’ predictions will come to pass, no one knows. I don’t see it happening in such an apolitical, market-driven way as they describe. Dr. Emanuel and the authors agree that the status quo will be a source of resistance. I continue to agree with Paul Krugman that an important next step on the road to health equity is a public option. I think that is much more likely than a coordinated effort between consumers and employers to create change in an environment where the status quo produces so much profit for corporations. I do plan to continue to process the ideas in the book as I hope for a miracle. Perhaps their ideas will become a bridge over the abyss between those who see the market as the answer to our healthcare concerns and those who favor achieving equity through public policy initiatives. In the end, I expect that if we ever do achieve real and lasting improvements, it will require understanding and compromise that can create a shared vision.
Summertime and The Flowers Keep Blooming
I have recently described how much I have enjoyed the wildflowers in the ditches along the roads where I walk this time of year. You may not think of day lilies as wildflowers, but the orange day lily (Hemerocallis fulva), which is not really a lily, that we have imported from Asia, does grow wild this time of year along the roads where I walk. We also have them in our flower beds, and they have been cultivated in other colors. I once had a patient who left a successful career in finance to spend all of his time growing day lilies. While I was inventorying the flowers growing in my yard this time of year, I learned that the orange day lily is also known by other names that make it sound more like a wild flower. Maybe you know it as ditch lily, roadside lily, outhouse lily, or wash house lily.
The previous owner of our house had a lovely garden. There are still a few of her plants, but as we have gotten older and developed orthopedic and neurological issues, maintaining them well has exceeded our capabilities. I was never much help. A couple of years ago, my wife hit on the idea of employing a woman who presented herself as a “wildflower” gardener. The result has not been what we had expected. Some of what she planted are “local” grasses and look kind of messy. I don’t think the lady meant for us to be overwhelmed with ferns and lupine, but we have been.
On the positive side, I have enjoyed watching a variety of native wildflowers appear before me. It is as if they all have their special time. Recently, “Sweet William,” another Asian import that is now a local “wildflower,” has caught my eye. You can see it in the header of this letter. About the same time, we have been invaded by purple coneflowers (Echinacea purpurea), which are native, and I can see the earliest signs of black-eyed Susans (essentially yellow coneflowers) and Queen Anne’s lace. Goldenrod still lies in the future, as does the blooming of my Rose of Sharon. It is like a stage presentation in which one virtuoso is followed in turn by the next. It is reassuring to see that this show goes on no matter what happens in Washington.
I hope that you are enjoying your summer and finding as much pleasure from the simple beauty around you as I am.
Be well,
Gene
