Keynote with Dr Ezekiel Emanuel
Dr. Ezekiel Emanuel closed the Wave Summit with a talk that was as sobering as it was forward-looking. From the outset, he framed the American healthcare system as a paradox—simultaneously poised for transformation and mired in dysfunction. He urged the audience to hold both optimism and pessimism in tension, because both forces, he said, will define the decade ahead.
On the optimistic side, Emanuel highlighted five powerful trends that, in his view, have the potential to bend the cost curve and improve outcomes. First, he pointed to artificial intelligence, beginning not in glamorous diagnostics or robotics, but in the back office. AI, he argued, will shave hundreds of billions off the trillion dollars wasted annually in administrative costs, before gradually expanding into decision support and eventually clinical care itself. Second, he noted the decline in drug prices, which have fallen about 2.1 percent annually since 2014 and could continue downward with mechanisms like most favored nation pricing or cost-effectiveness adoption. Third, he cited the movement toward site-neutral payments, a reform that pays the same for a procedure regardless of where it’s performed. This, he said, lowers costs, eases access, and enjoys growing support from CMS and Congress. Fourth, Emanuel spotlighted the expansion of value-based care into specialties such as oncology, cardiology, women’s health, and behavioral health—areas that represent nearly 40 percent of medical spending but remain largely untouched by value-based models. Finally, he described the widespread use of GLP-1 receptor agonists as a revolution not only in obesity and diabetes care but in heart disease, osteoarthritis, and even addiction. He called GLP-1s one of the five most significant medical breakthroughs since the mapping of the human genome, noting early evidence of dramatic reductions in hospitalizations and overall medical expenses among users.
Taken together, Emanuel made a striking prediction: by 2030, healthcare inflation will end. While the near term may bring pain, he argued, these five forces will converge to flatten costs and bring greater satisfaction for patients and clinicians alike. He even half-joked that he would bet a meal—or one of his homemade “Zeke Bars” of chocolate—on the outcome.
But optimism was only half the story. Emanuel turned sharply to what he called the “five reasons for pessimism.” On every major goal of a modern health system, he said, the United States is failing. Universal coverage remains elusive, with roughly 30 million Americans uninsured—“a country the size of Canada,” he said. Costs remain crushing, with the average employer plan for a family now topping $25,000 a year, which he likened to “buying a Toyota Corolla every year and throwing it off a bridge.” Quality is uneven: the U.S. leads the world in cancer care but falters in chronic disease, with only a quarter of hypertensive patients having their blood pressure under control. Disparities by race and geography persist, with Black infant mortality more than double that of whites and rural health in decline. And satisfaction has reached a 24-year low, with Gallup finding that most Americans view the system as in major trouble or crisis, and less than half rating the quality of care as good or excellent.
Emanuel traced these failures to three fundamental flaws: the fragmentation of coverage, with overlapping programs that leave people falling through cracks; the overemphasis on hospitals and specialists at the expense of prevention and chronic disease management; and the unraveling of the social safety net, from wages to food subsidies, which has left healthcare as the most expensive and inefficient safety net of last resort.
He argued that true reform will require a willingness to do something deeply counterintuitive: subtract rather than add. Instead of layering on new programs, subsidies, and codes, the system must be simplified. He envisioned reducing the ways Americans get health insurance to just two—employer-sponsored or a streamlined national exchange. He advocated standardizing deductibles, co-pays, and provider payments. He called for shortening physician training and shifting resources to prevention and primary care, and he suggested changing food subsidies to encourage fruits, vegetables, and dairy rather than ultra-processed foods. Reform, in his words, would demand not incremental change but a fundamental redesign.
Emanuel closed with a forecast that was both sobering and galvanizing. In the short term, he predicted, both optimism and pessimism will intensify. By early 2030, with Medicare’s trust fund running dry, the country will face a crisis that forces action. “The 2028 election won’t be about healthcare,” he said. “But 2032 will. The real issue is: are we ready? Do we have a reform package ready to go?” His challenge hung over the room like both a warning and a call to arms.
Q&A with Dr. Emanuel
Insurance churn: Emanuel called annual re-enrollment “the dumbest thing I can imagine.” Constant churn, he explained, undermines investment in prevention and continuity of care. His solution: five-year insurance contracts that would give providers and payers confidence to invest in patients’ long-term health.
Is there a single silver bullet? Emanuel was adamant that no one reform could fix the system’s complexity. But pressed to choose, he said broadening value-based payment across specialties would have the most impact, aligning incentives to reward prevention, efficiency, and outcomes rather than volume.
Complexity and MLR: Asked about medical loss ratio rules, Emanuel dismissed them as a distraction. The real issue, he said, is the sheer complexity of American pricing. “In Europe they have one price. We have a dozen for the same service. It’s mind-boggling.” Simplification, not tweaking ratios, is where savings would come from.
Realistic reforms on the horizon: Emanuel was cautious. He predicted some expansion of site-neutral payments and incremental drug pricing reform but warned against expecting sweeping changes. “CMS is not bold,” he said. “Don’t expect them to lead the charge.”
Malpractice reform: He noted malpractice costs are a perennial political talking point but trivial in practice—less than one percent of spending. Even full reform wouldn’t materially change healthcare economics.
End-of-life care: While acknowledging its ethical importance, Emanuel emphasized that end-of-life spending accounts for only about eight percent of costs. Even dramatic reductions would be swallowed quickly by overall inflation.
Pediatrics: In one of his bluntest moments, Emanuel said, “We don’t give a shit about kids.” He cited chronic underfunding and lack of workforce planning, and proposed universal nurse visits during the first year of life as a basic step the U.S. should adopt.
Primary care shortages: The cause, he argued, is not cultural or educational—it’s financial. “It’s money. Nothing else.” His solution is to cut hospital and specialist reimbursements and raise primary care pay by 50 percent, shifting resources to where they matter most.
Pricing reform: Emanuel criticized the AMA’s role in setting physician reimbursement as “a total conflict of interest.” He argued CMS must reclaim control if there’s to be meaningful reform.
Political reform: Major healthcare reform, Emanuel insisted, will only come during a moment of crisis, much like the creation of the Federal Reserve or the Constitutional Convention. He predicted such a moment would arrive when Medicare’s trust fund runs out.
Consumer empowerment and AI: Finally, Emanuel expressed skepticism that AI tools for patients would save money. In his view, they’re more likely to increase utilization, as informed patients push for more—not less—care.
