Foreword

Dave Johnson and Paul Kusserow are optimists. They can foresee a time in the not-too-distant future when American health care 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.

The authors term this future of medicine "3D-WPH"-Democratized and Decentralized Distribution of Whole-Person Health. Maybe 3D-WHP is not something yelled at the ramparts of a revolution-even a health care revolution-but it accurately describes what they think the future will bring. What makes them optimists is that they believe this future is not just a utopian vision, but is both inevitable and imminent, arriving by 2034.

There was optimism and excitement after the passage of the Affordable Care Act (ACA), but that was 15 years ago. Despite concrete gains in access and costs since then, optimism about American healthcare is distinctly out of fashion. Today, pessimism about and dissatisfaction with the US healthcare system are the norm. In this sense, Johnson and Kusserow are out of step with the times. But that does not mean they are wrong.it means they see things most Americans cannot discern.

On access, the passage of the ACA, and more recently, COVID-driven increased subsidies and prohibitions on Medicaid recertifications and redeterminations, drove the uninsured rate down to as low as 7.7%.1 This constitutes a huge achievement. However, today, those temporary COVID policies have ended, and the country is about 26 million people - and growing - short of universal coverage. There is no plausible path to that goal, certainly none in the next 10 years.

On costs, the 15 years since passage of the ACA have seen an unprecedented plateau in healthcare costs as a fraction of GDP. In 2022, the US spent about 17.3%2 of GDP on healthcare - about the same as it was in 2010 and much lower than predicted for 2022 at the passage of the ACA in 2010. This cost plateau generated almost $4 trillion in savings for Medicare alone.3 Simultaneously, however, premiums for family insurance coverage increased from $13,871 in 20104 to an average of just under $24,000 in 20235, which constitutes a whopping 32% of median household income. Furthermore, out of pocket costs, separate from premium costs, are nearly $1500 per person per year. And over 60% of Americans say they forego healthcare services because of cost.6 Even worse, predictions are for 5% or higher annual growth in healthcare expenditures through 2032.7 Whatever savings from reduced cost growth the ACA generated seem to be evaporating if they are not already gone. And predictions are for healthcare costs to be 19.7% of GDP by 2032.

Finally, healthcare quality remains uneven and not good, maybe even outright poor. Yes, the US is a world leader in cancer care, but for almost everything else, health outcomes are embarrassing.

Hypertension is a paradigm of bad outcomes in the United States. Nearly 120 million American adults, close to half of all adults in the US, have hypertension8, of which, estimates say that between 109 and 2410 million don't even know it. Hypertension control is dismal, at under 50% by a "loose" definition of controlled (a blood pressure under 140/90) and under 25% by a more "stringent" definition of controlled (a blood pressure under 130/80). The result and reality for our citizens is worse cardiovascular, renal, and stroke incidence and rising rates of maternal morbidity and mortality around pregnancy and delivery. Indeed, hypertension is associated with hundreds of thousands of deaths each year. And this number has increased, not decreased, since 2000.11 Keep in mind, this poor American performance occurs for a disease that is relatively easy to diagnose and treat with cheap, automatic blood pressure cuffs, a clear consensus care algorithm to guide treatment, and plenty of low-cost generic medications.

The story for type 2 diabetes is not much better. Fully 38 million, or 14.7% of all US adults, have diabetes.12 Of them, about half have their diabetes under control with a hemoglobin A1C under 7%. According to the National Committee for Quality Assurance (NCQA), about two-thirds of people with diabetes do not have their blood pressure "controlled"13 (by the more lax standard) and just under 65% had an annual eye exam14. With only half of people having their disease under control, it is no wonder diabetes causes over 100,000 deaths annually, making it the 8th leading cause of death in the United States.15

Given these data, it is no surprise the American public is far from optimistic about health care. According to various polls - Gallup, Ipsos, and Pew - 60% of Americans say the healthcare system is a hassle, and a similar proportion find it stressful.16 Indeed, the proportion of Americans who think the system has "major problems" or is in a "state of crisis" is, for the first time, over 50%.17

Such data and the pervasive dissatisfaction expressed by Americans make one wonder how Johnson and Kusserow can be so optimistic about the future of the US health care system?

There is no doubt that if the US pushed prevention and wellness, the country would be healthier, happier, with lower costs. What is exciting about Johnson and Kusserow's book is not just that they can envision this new future that really is better for all Americans - lots of researchers and commentators have done that - but that they discern the larger and powerful forces driving system-wide transformation and have described the types of actual companies and policies, that can overcome the barriers - especially the financial barriers - to bring the country closer to their 3D-WPH.

In particular, they discern 10 large macro and -economic market forces that are coalescing at the same moment to propel the American healthcare system not just to the precipice but tipping it over into revolutionary change. These forces include demographic changes: the aging of the population and increase in the incidence of chronic illnesses and mental health conditions. They also include limits to the willingness of businesses and the public to pay more for healthcare, forcing a focus on efficiency. They also examine positive forces from advances in digital technologies to more care in the community and in patients' homes to creative redesign of care to a shift in focus toward prevention rather than more treatment once diseases have manifest.

These forces, to change metaphors, make Johnson and Kusserow believe the US is entering the steep upward portion of the S-shaped curve of healthcare improvement. In Johnson and Kusserow's view, the 10 forces are "irresistible" and that creative destruction will produce a better healthcare system. Ultimately, in their view, in "2034 US healthcare will bear little resemblance to our current system."

How do these forces manifest? One way is a massive shift to virtual or digital care. They cite a McKinsey study that suggests "virtual care could replace $250 billion of in-person care." This "decentralization" will enhance patient access and convenience and produce cost savings. Another element of decentralization is the outmigration of procedures - the profit drivers at hospitals - from expensive, inefficient institutions to lower-cost venues including ambulatory surgical centers and outpatient physician offices. They see this occurring through a small but powerful change in payment termed "site-neutral payment" in which the pay for a procedure is the same regardless of where it occurs. Many policy experts, including myself, have been advocating for this for years, and it seems as if it will finally occur in the near future. They also recognize the numerous ways in which patients can receive whole-person care in the comfort of their own homes. One is a palliative care model which encompasses more than just pain management, incorporating "non-clinical home-based care that enhances delivery of ADL and SDoH/health multiplier services." Models like these can both enhance the quality of care and save money by employing patients' families and friends to provide some services such as preparing meals or even just chatting with patients.

Johnson and Kusserow profile many start-ups that are transforming care because of a change in financial and quality incentives being offered by employers. One company they praise as "interesting and promising" is Apree Health, a primary care company that is backed by JP Morgan Chase (JPMC) and is managing care for JPMC's 36,000 employees and dependents in and around Columbus, Ohio. Apree combines "independent advanced primary care clinics with easy-to-use technologies, risked-based payment models and performance metrics" to focus on whole-person health. Their clinics serve as a single point of contact that provide integrated clinical care teams - including navigators, coaches, and behavioral health specialists - to work seamlessly for each patient. To ensure convenience, Apree augmented "its robust digital and virtual care platforms with five new clinics.on or adjacent to JPMC's Columbus offices." Apree is rewarded not based on fee for more services but based on...