U.S. Healthcare Reform Proposals Overlook Employer Role and Data Infrastructure

Dr. Ezekiel Emanuel, co-architect of the Affordable Care Act (ACA), recently outlined five proposals aimed at stabilizing the U.S. healthcare system. However, these suggestions replicate a core oversight seen in the ACA by failing to address the fundamental economic role of employers as primary healthcare purchasers. Emanuel’s proposals focus on capping hospital prices, incentivizing bundled payments, regulating insurer behavior, increasing transparency in pharmacy benefit managers (PBMs), and reducing administrative complexity. Yet, each proposal neglects the critical element of employer involvement in cost management and accountability enforcement. Employers bear the bulk of healthcare costs in the commercial market but lack access to unified, transparent pricing data despite federal mandates like the CMS Price Transparency Final Rule (2021). This data gap prevents employers from negotiating effectively or enforcing value-based purchasing. Emanuel’s recommendation to cap hospital prices overlooks this lack of price visibility for employers, who ultimately absorb pricing variations across different geographies. Bundled payment incentives, revived in Emanuel’s plan, have roots in federal pilots from 2011 but largely failed due to poor coordination among providers and insufficient data integration. Modern health IT capabilities and AI tools have yet to solve these fundamental data sharing and clinical visibility issues, limiting the practical success of such payment models. Proposals for greater insurer regulation must consider that insurers respond primarily to employer demands, which shape network design, payment models, and benefit structures. Without empowered employers using transparent and comprehensive data, insurer reforms are likely administrative adjustments without substantive market impact. Calls for enhanced PBM accountability likewise depend on employer leverage and data insights to challenge contracting practices. Reports by the FTC and GAO confirm that the absence of employer engagement and technological capacity allows established PBM rebate and pricing models to persist. Emanuel’s final point about administrative complexity echoes a widespread complaint about the fragmented U.S. healthcare data ecosystem. The industry’s longstanding lack of unified national data infrastructure and interoperability standards hampers cost management efforts. Notably, Emanuel’s proposals do not address the expanding role and potential of artificial intelligence (AI) to automate authorization processes, minimize billing errors, detect redundant services, and support clinical decision-making, all critical for cost efficiencies. The article underscores that the ACA expanded insurance access but failed to create a sustainable financial model or empower employers as effective purchasers through transparent data and technology infrastructure. Without building the data superhighway connecting pricing, care delivery, and employer purchasing, current reform proposals are unlikely to produce meaningful cost control. Future reforms should prioritize developing comprehensive national data systems and AI-enabled tools to equip employers with real-time price and quality information. Only by empowering the primary healthcare payers—the employers—can market forces effectively drive accountability and value-based care in the U.S. healthcare system. Until then, reforms focusing solely on prices, provider incentives, or administrative processes risk repeating past errors of ignoring the purchaser’s critical role.