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As President Trump and the Republican majority in Congress prepare to repeal Obamacare, they would be wise to listen to those who actually provide health care.

No one is better positioned to see how the health care system is working — and how it can be improved — than the doctors, nurses, and support staff on the front lines. Clinical professionals understand the strengths and weaknesses of the law because they’ve had to live and work within the requirements of the Affordable Care Act.

So they should have a say in its fate, or at least its replacement.


I spent more than a decade studying the implementation of health care changes in the United States (the world’s most privatized health care system) and the United Kingdom (the world’s most socialized health care system). The findings were eye-opening.

When change was imposed from above, without the input and engagement of health care workers, implementation was rarely successful. Recall the fee-for-service reimbursement programs in Medicare and private insurance that incentivized more care rather than better care. Ask providers about the time wasted on the phone with insurance companies, or the mind-boggling number of clicks needed to execute a simple function in their electronic health record systems.


As I describe in my book, “The Challenge to Change,” when change came from the bottom up, leveraging the expertise of those who are taking blood pressure readings, reading X-rays, and washing hospital gowns, institutions were better equipped to deliver high-quality, cost-effective care and provide broader coverage.

Indeed, the most effective changes of all — those that improved the quality of patient care without cost increases — came from the providers. At Johns Hopkins Hospital, for example, frontline workers developed checklists to enforce hand-washing protocols and prevent the spread of infection. At Maimonides Medical Center in Brooklyn, N.Y., providers devised a conflict management program to ensure that the patient is always at the center of the treatment plan.

One of the best examples came from the VA Medical Center in Tomah, Wis., where a nurse reported a doctor for overprescribing opioids to his patients. The case ultimately led to stronger whistleblower protection for federal employees, which will undoubtedly save lives. It was the frontline experience of a nurse that made it possible, not the remote understanding of legislators or regulators or administrators.

As the new Congress convenes, we are facing unsettling changes.

Health care workers have lived with the good and the bad of the ACA — the millions of Americans now eligible for preventive services and annual physicals, as well as the millions who are still without coverage because of gaps remaining in the system.

If repealing the law clogs emergency rooms with uninsured people, whose health crises might have been avoided by timely preventive care, it’s the frontline workers who will understand the big and small fixes needed to clean up the mess.

If Republicans insist on repealing the ACA, they would be wise to consult their health care providers about how to replace it.

Rebecca Kolins Givan is an associate professor in the Rutgers School of Management and Labor Relations and author of “The Challenge to Change: Reforming Health Care on the Front Line in the United States and the United Kingdom.”

  • While the intent of this brief article is correct, it does not take into account that among the largest systemic failures of healthcare delivery in the U.S. is that overwhelmingly, healthcare workers at the point of care are NOT engaged in the process of improvement. Low employee engagement continues with little in the way of trends upwards.

    Small projects as described show that small projects can succeed. What is needed is profound innovation in the way in which health systems and their employees engage in dialogue at a systems level.

    No one is asking the millions of dedicated souls at the point of care about much of anything. Ultimately, this is a leadership issue to confront…leadership from all sectors: administrators, physicians, insurers, community leaders, and the workforce itself, especially where the workforce is represented by a union.

    Whole systems change begins with profound engagement strategies to link intentionality with strategy and execution that goes far beyond “projects”.

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