Editor's Notes: When Will We Be Able to Nail the “Golden Spike” in the Foundation of the New Healthcare?

June 8, 2018
Some of the challenges of the present moment in U.S. healthcare, as our healthcare system struggles forward in its journey into value-based care delivery and payment, brought to my mind the construction of the First Transcontinental Railroad in the 19th Century.

Some of the challenges of the present moment in U.S. healthcare brought to my mind the construction of the First Transcontinental Railroad in the 19th Century.

With more than 5.6 million articles in the English language alone (not even counting several million articles in dozens of other languages), there’s a lot to read at Wikipedia. But one of the more fascinating entries in Wikipedia is this one: the article on the First Transcontinental Railroad, which was created in the United States between 1863 and 1869. As the Wikipedia article notes, the railroad “was a 1,912-mile (3,077 km) continuous railroad line constructed between 1863 and 1869 that connected the existing eastern U.S. rail network at Omaha, Nebraska/Council Bluffs, Iowa with the Pacific coast at the Oakland Long Wharf on San Francisco Bay. The rail line was built by three private companies over public lands provided by extensive U.S. land grants. Construction was financed by both state and U.S. government subsidy bonds as well as by company issued mortgage bonds.”

The venture involved was absolutely unprecedented, and exceptionally difficult—above all, not surprisingly, creating tracks through California’s Sierra Nevada, and through the Rocky Mountains in Wyoming and Colorado.  “The manual labor to build the Central Pacific's roadbed, bridges and tunnels was done primarily by many thousands of emigrant workers from China under the direction of skilled non-Chinese supervisors,” the article noted. “Labor-saving devices in those days consisted primarily of wheelbarrows, horse or mule pulled carts, and a few railroad pulled gondolas. The construction work involved an immense amount of manual labor, and was accomplished through the hiring of imported Chinese laborers, who did immensely difficult, backbreaking work, noting that “Their hard work was also crucial in the construction of 15 tunnels along the railroad's line through the Sierra Nevada mountains.”

Ultimately, all of that backbreaking work paid off (though many of the Chinese laborers were cheated out of even basic wages, and some were forced back to China after construction was over): “Six years after the groundbreaking, laborers of the Central Pacific Railroad from the west and the Union Pacific Railroad from the east met at Promontory Summit, Utah Territory. It was here on May 10, 1869, that Leland Stanford drove The Last Spike (or Golden Spike) that joined the rails of the transcontinental railroad. The spike is now on display at the Cantor Arts Center at Stanford University, while a second ‘Last’ Golden Spike is also on display at the California State Railroad Museum in Sacramento.”

At various moments in the Sierras and the Rockies, the railroad workers had been reduced to working with pick axes, and making daily progress in stretches of feet and yards. So yes, it was very difficult to lay the core railroad tracks.

And really, all of this resonates with me with regard to the present moment in U.S. healthcare, as our healthcare system struggles forward in its journey into value-based care delivery and payment. As our four-part special report on value-based healthcare, Managing Editor Rajiv Leventhal and I look at a range of issues facing the leaders of patient care organizations, as they navigate a shifting policy and payment landscape, rethink what quality measures mean and how they’ll be used, move forward into value-based contracts, and work to align incentives with their affiliated physicians.

All of it is very difficult work, and even the leaders of the most advanced patient care organizations in the U.S. are managing delays and setbacks. But as Rajiv and I note in our report, progress is accelerating. And when we look back on this era in U.S. healthcare, I’m convinced we’ll look back and see the laying of the foundations of value-based healthcare as similar to the laying of the tracks of the First Transcontinental Railroad—a very difficult phase that led to an entirely new world of possibilities—and that Golden Spike.

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