Dr. Emanuel’s latest proposals, like the Affordable Care Act itself, focus on prices and policies while overlooking the only entity capable of enforcing value — the employer.
It is ironic, almost remarkable, that Dr. Ezekiel “Zeke” Emanuel, one of the chief architects of the Affordable Care Act, is now proposing “five fixes” to a healthcare system that was flawed in its design from the start. In a recent op-ed in The Washington Post outlining ways to stabilize the system, he repeats the same conceptual mistake embedded in the ACA: he puts the cart before the horse.
Before capping prices, reshaping provider incentives, or redesigning insurance rules, policymakers must first identify the most basic elements of any economic system: what is being paid for, who is paying for it, and how much it truly costs.
None of Dr. Emanuel’s five points addresses that foundational reality. And none acknowledges the central figure in the economics of American healthcare — the employer. The ACA ignored employers, and so does Dr. Emanuel’s new framework.
Take his first proposal, which focuses on capping hospital prices. Emanuel raises concerns about price variation across markets, but he never identifies the party that actually pays for most of that variation: the employer.
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When a national retailer or manufacturing company pays different rates for the same cardiac catheterization in different cities, the employer and employee absorb the cost. Yet employers cannot see the rates insurers negotiate on their behalf, despite federal transparency rules that technically require such disclosure (CMS Price Transparency Final Rule, 2021). The reality is that there is no unified, reliable, real-time data infrastructure to allow employers to compare prices, enforce accountability, or demand value. You cannot cap what you cannot see, and you cannot manage what you cannot measure.
Emanuel’s second proposal revives incentives for bundled payments, a concept that dates back nearly two decades. The idea is not new; the federal pilot program launched in 2011 promised savings, consistency, and accountability. It largely failed. As analyses from the Lewin Group and the Commonwealth Fund have noted (Commonwealth Fund, “Bundled Payments: Past Lessons, Future Implications”), bundled payments break down in real practice because it is nearly impossible for physicians to coordinate what other physicians are doing. Even today, with advanced technology, AI-enabled decision support, and national health information networks, the average clinician still has limited visibility into the care delivered by others, even within the same episode. Reinventing bundled payments without addressing the fundamental lack of integrated data simply rebuilds a failed house on the same cracked foundation.
His third point argues that insurer behavior needs further regulation, but insurers ultimately respond to the expectations and demands of the entities purchasing coverage. In the commercial market, that is almost always the employer. Decades of reporting from the Kaiser Family Foundation and the Business Group on Health have shown repeatedly that insurers alter networks, benefits, payment models, and quality metrics only when employers insist on it (KFF Employer Health Benefits Survey). Without empowered purchasers, insurer reform is little more than administrative shuffling.
The fourth point targets pharmacy benefit managers (PBMs), calling for greater transparency and accountability in drug pricing. Yet the most credible research on PBM practices — from the Government Accountability Office to the Federal Trade Commission — shows that PBM contracting practices persist because employers lack both the data and the leverage to challenge them (FTC PBM Report, 2023). PBM reform cannot happen without informed, engaged, and technologically equipped employers demanding clarity on rebates, discounts, and actual net prices. But again, Emanuel avoids mentioning employers, even though they are the primary payer of commercial prescription drug costs.
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His fifth point laments the extraordinary administrative complexity and cost of the U.S. system. Here again, he avoids the core issue: healthcare has never built the national data and technology infrastructure that every other major industry implemented decades ago. The fragmentation of claims systems, electronic records, prior authorization workflows, and benefit designs is not an accident—it is the predictable result of an industry that grew without unified standards, shared architecture, or federal enforcement of interoperability requirements. Equally striking is what Emanuel leaves out entirely: the transformative potential of artificial intelligence. AI can automate prior authorization, reduce coding errors, flag duplicative tests, support clinical decision-making, and dramatically reduce manual processing costs.
Yet in his entire oped, the word “AI” never appears. Nor does the word “employer.”
The ACA expanded access, but it never built a rational financial model. It never established a transparent data ecosystem. It never empowered the actual purchasers of healthcare. And it certainly never created the technological backbone required to manage costs or measure value. Dr. Emanuel’s five-point plan repeats that mistake. It addresses the cart—prices, rules, incentives, and administrative layers—without ever clarifying the horses that pull it.
And astonishingly, while the role of artificial intelligence is pervasive in healthcare, there have been few inroads made to address the fundamental flaw in the US healthcare system. The superhighway that connects data in every part of the healthcare system does not exist. It was never accounted for. It’s like building more cost-effective planes and cheaper tickets with no runways, control towers, or booking systems that everyone in the airline industry can access. In the most sophisticated healthcare system in the world, there is no single system that can integrate data from the employer to the doctor and everything in between.
Read more columns by Dr. Sreedhar Potarazu
Real reform begins with recognizing who pays for healthcare, who has the power to demand accountability, and who must be equipped with transparent pricing, reliable data, and modern technology. That entity is the employer. Until we build the infrastructure that allows employers to see, compare, negotiate, and enforce value, every proposed fix remains theoretical.
Only when we understand what it will cost to implement the infrastructure required to optimize data and artificial intelligence, and empower the employer as a purchaser, can we hope to fix the cart that Dr. Emanuel keeps trying to reshape.