Obamacare Architect Says Silicon Valley Tech Won't Steer Health Care

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Ezekiel Emanuel, in 2010. Emanuel is one of the main policy experts to help shape the Affordable Care Act.

Ezekiel Emanuel is one of the architects of the Affordable Care Act, aka Obamacare, aka dead-plan-walking.

He's also a  "techno-skeptic," as he called himself the other day during an interview with KQED health editor Carrie Feibel. When Feibel asked him if there should be any role to play for the "data gurus of Silicon Valley" in whatever comes after the ACA, he literally laughed.

"I do think there is an important role for tech, but I think the role is probably not what many of the startup companies around here are thinking of," he said, "around here" meaning San Francisco and Silicon Valley. Emanuel said tech should play a support role that "augments" what health care providers do, providing better data about the patient and where health care funds are spent.

"I am much more skeptical that the computer is going to replace a doctor," he said. "That a computer is going to interface with the patient and take care of them. Not gonna happen." (See our posts "Will Computers Ever Be as Good as Physicians at Diagnosing Patients" and "Would You See a Holographic Doctor?" for high hopes surrounding digital docs.)

Emanuel said he's also not big on efforts to achieve continuous patient monitoring for health indicators like glucose level and blood pressure. He  cited the failure of Fitbits and other wearable tech to improve health outcomes in research studies.


"It’s not that we don’t have information," he said. "The problem is what do you do once you have the information. And there, tech is not going to be the key thing. Medicine fundamentally is about human interaction. That is really the most important challenge, and I don’t think the tech sector has locked onto that part of it."

This sort of digital contrarianism is not unheard of in the health care biz, even at events and panels where tech-oriented medicine is the focus. Last September, for instance, at the Stanford Medicine X conference, Stephen Downs, the chief technical officer at the Robert Wood Johnson Foundation, said digital health companies weren't focused on solving the right problems. From a report by KQED's Lesley McClurg:

In this age of the Fitbit, Downs said, digital health companies are focused on monitoring the consequences of our notoriously sedentary lifestyles. But what is really called for from innovators is to stop treating symptoms and start remedying the roots of the problem.

“The system needs to be re-engineered,” said Downs. ... “We don’t need an app that counts steps, because that really just tells you that your day doesn’t naturally incorporate the time and space to walk.”

Instead of a focus on monitoring, he said, engineers and designers need to incorporate solutions --such as enabling urban farming --to core health problems like obesity and heart disease. 

Policy Versus Scientific Advances

Several times now at conferences I've witnessed one expert or another--in the midst of a coterie of big data boosters and monitoring mavens, no less--offer up a kind of indirect scolding by cautioning that the best way to improve health is not via smartphones, but smart policy.

That dichotomy to some degree echoes a conversation I once had with a longtime health journalist who thought even something as institutionally sanctioned and evidence-based as California's stem cell initiative was a waste of money, because the funds would have been  better directed toward policy prescriptions that address basic health needs.

I asked Emanuel to comment on this point, specifically mentioning stem cells.

"Here's a thought experiment," he said. "You know how many lives stem cells have saved? A tiny number compared to the 2.7 million people [in the U.S.] who die each year.

"Now, how many lives have been saved by the ACA?" he said.  "I don’t know, but it ain’t zero. I intersect with people all the time who happen to recognize me on the street and say I or a family friend got diagnosed with cancer and got therapy or got a heart transplant or something like that.

"In the future, even under a rosy projection, stem cells will not save tons of people," he said. "If you were to cure every single cancer in the U.S.-- no one in America ever dies again of cancer--we add three years to the average life expectancy. It’s a big improvement but it is not anything close to [gains achieved by] doing the basics."

The two most effective goals for increasing longevity, he said, would be to reduce smoking even further and to control blood pressure.

"We’re not talking high tech," he said. "There is nothing you can do that is going to come close to those two interventions."

Of course, medical value depends on your perspective, and Emanuel's is a public health view. Someone suffering from any number of horrendous diseases that stem cell research is targeting is not going to be thinking: "Boy, what a waste to be chasing stem cell cures. I sure wish they'd divert that money to anti-smoking programs."

And even on the health tech front, some doctors have come around to viewing digital monitoring devices like mobile EKGs as useful.

As for computers versus doctors, physician and author Bob Wachter, has written that radiology may be the canary in the coal mine in terms of algorithms replacing humans.