ROCHESTER, Minn. — As recently as 2002, the most influential people in health care worked for either the federal government or as experts in health policy. The parties topping a list for that year's 100 most influential persons in the field included two cabinet officers, two senators, a member of congress, two policy organization heads, one professor and two CEOs.

By 2018, all but one of those slots had been replaced by CEOs.

Among those topping the latest installment of the influential Modern Healthcare power index are the corporate heads of Amazon, Apple, Aetna, Humana, CVS and Minnetonka, Minn.-based United Health/Optum.

According to new research this transformation, one that might be called the board-rooming of our national health care conversation, has been no aberration. Over the past 17 years in fact, the power to influence health care in the United States has seen a steady shift from the hands of academics, policy experts and elected officials to the nation's most powerful insurance, health system, pharmaceutical and tech industry CEOs.

That's the finding of an unusual new study published by the Knowledge and Evaluation Research Unit of the Mayo Clinic. Their recent letter in the journal Mayo Clinic Proceedings describes a 16-year transformation of the widely-read 100-person power list, one that came about after the authors categorized each influencer by broad class of occupation, then calculated their changing percentage of the list.

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"In the last decade or so there's been a takeover of the space of influence by chief executive officers," says Dr. Victor Montori, co-author of the paper and director for the KER Unit at Mayo. "The proportion of them increased in the last 16 years, from CEOs being about 23 percent of the list to being about 72 percent. Their influence has been steadily increasing over time, and especially since 2009."

Montori's data suggest the Affordable Care Act marked a sharp demarcation point in time for the list. Before its passage in 2009, academics, politicians and CEOs all held roughly the same influence over health care in the United States, at least as far as the widely-read list is considered.

"But after 2009 CEO influence takes off and never stops," he says. "That happened at the expense of the advocates and academics who once represented about a third of the list, and have since dropped to 10%. It was also at the expense of elected officials and people in government positions, who dropped from a fifth of the list to around 10%."

“In the current election cycle we are seeing presidential candidates raise the possibility of a single payer system. Those discussions likely will find the public unprepared to understand what that means to them.”

Other parties no longer helping to shape the direction of health care according to the analysis, are heads of medical and trade associations for health care workers, many of whom Montori speculates likely now advocate through the invisible pathway that is lobbying. Reformers, also once heard on mainstream media, have largely been consigned to Twitter.

"In terms of shaping policy in the public sphere," he says, "all of that space is now taken up by CEOs."

As a result, Montori says, Americans increasingly find themselves in a corporate-centric health care echo-chamber, one in which the public will invariably approach tough policy decisions having heard only the viewpoint from the top.

"The primary goals of CEOs are to advance the mission of their organization," Montori says. "If all that influences health care are the ideas of people who advocate for the success of their organizations, people who are not served by them will not have their voices heard.

"In the current election cycle we are seeing presidential candidates raise the possibility of a single payer system. Those discussions likely will find the public unprepared to understand what that means to them, because in the rest of the narrative all that they hear is about are the successes of biotech, the successes of tech companies, and the successes of health care corporations who achieve high levels of innovation thanks to the bold leadership of their executives. It's why we have been calling for greater awareness of the industrialization of health care for some time now."