The Trump-era attack on the Affordable Care Act has left the nation’s health system plagued with uncertainties: Will “Obamacare” insurance survive? Can independent hospitals make it? What’s next for doctors? And will patients ever really get “affordable” care?

But one certainty is prevailing: No matter what the outcome, it will be a bonanza for health-care consultants.

Health care, as the current president famously noted, is complicated­—and the past decade of change has generated an immense new market for consultants, advisers and a whole universe of ancillary experts who don’t practice medicine but promise to help navigate a landscape that seems to change every six weeks.

From the newly minted college grad with a degree in health policy—an undergraduate major that scarcely existed a generation ago—to the copiously credentialed M.D.-MBA-JD-MPH-Ph.D. consultant, American health care has no shortage of saviors. Some have brilliant insights that save lives and trim costs; others mainly generate invoices.

These fixers—the visionaries, the mercenaries and everyone in between—have been dramatically increasing their role in the economy since the Affordable Care Act was passed in 2010. A Modern Health Care Magazine survey of just 25 prominent national consultant firms found that revenue rose from $2.3 billion in 2008—the year before Obama took office—to $6.6 billion in 2014, the start of the ACA coverage expansion. Deloitte, for instance, which topped the list in 2014, saw its health-related revenue rise from $725 million to $2.2 billion in that time.

“Health care is an industry that’s still in the Bronze Age technologically, struggling with wave after wave of massive disruption,” said John Gorman of Gorman Health Group, one of numerous consultants, ex-consultants, government officials, doctors, academics and health care administrators interviewed over many months.

Today, despite the GOP’s attacks on the ACA—and sometimes because of those attacks—the consultant universe is still flourishing. IBISWorld, a market research firm, says the sector has been growing by more than 7 percent a year, and predicts healthy growth in the years to come. Well-known consultant Paul Keckley came up with an estimate of $20 billion a year just for “health care management” consulting. And those estimates are only rough indicators; there’s no standard definition of who is a “consultant”; industry surveys don’t include the vast array of nonprofits, advocacy groups and government agencies that pump out all sorts of reports and advice of their own.

“We’re tripping over each other,” said Ian Morrison, a consultant and “futurist” who is a popular fixture on the health care lecture circuit.

The reasons for the health care fixing frenzy are varied: Digitization forced doctors to abandon their bulging file folders in favor of computerized records. Obamacare expanded insurance coverage at a pace not seen since the creation of Medicare in 1965—and Trumpcare has begun to contract it. And doctors, hospitals, government and the private sector are all grappling with how to pay for medical care in ways that reward the quality, not quantity, in a system that may not really be the “best in the world,” but is certainly the most expensive.

All this disruption means billions for the consultant business. Walk into any medical conference exhibit hall and you’ll find an astonishing array of expertise for sale. “It’s a gold rush,” said Mario Molina, who ran Molina Healthcare until the health plan’s board ousted him partly because of his outspoken support for Obamacare and willingness to maintain a relatively narrow profit margin on his Medicaid clientele. Other industries have consultants, too, Molina noted, but the amount of money and uncertainty in health care makes it an easy target both for the smart honest consultants and those whose practices, he said, come all too close to fraud.

“The consulting industry has never seen anything like this,” said Jeff Goldsmith, president of Health Futures, Inc., who has been in and around the consulting world for some 30 years, including a gig as a consultant to a consultant. “This sector has been the most significant beneficiary of health reform, even more than the 15 or 20 million [people] that got covered.’’

Getty Images

THE ONLY THING that can compare to the rapid change of the Obama years is whatever’s next under Donald Trump’s administration—and that changes tweet by tweet. Repeal fervor has dissipated, and a more concrete anti-ACA framework is taking shape: repeal of the Obamacare mandate as part of the tax law, the emergence of skimpy health plans that will cost less than Obamacare but lack its comprehensive protections, and vast but still ill-defined “state flexibility” that has already generated a rash of lawsuits.

But rules and regulations are still being written, and Trump himself gleefully throws out new twists. At a late May rally in Nashville, Trump said that his “two Alexes”—presumably Health and Human Services Secretary Alex Azar and Labor Secretary Alex Acosta—would announce new health plans within a month. He promised they’d be “phenomenal,” but the month elapsed and we haven’t seen them. Just over a week later, Attorney General Jeff Sessions sided with conservative states challenging Obamacare yet again, and asked a court to toss out protections for people with pre-existing conditions, the most popular part of the 2010 legislation. “Uncertainty creates opportunity,” Goldsmith said. “And this is the most uncertainty I’ve ever seen.”

A smattering of individual health consultant firms have pulled back, waiting to see what emerges, but most have already gamed out how to position themselves for the next wild ride. And consultants know how to seize a moment—or “sell up,” as industry insiders put it. They sign on to do one task and then hook the client on another … and another. It’s like when the contractor puts in a new kitchen countertop and then points out how shabby the old cabinets now look. The next thing you know, they’ve replaced the whole kitchen and are demolishing the downstairs bath.

At an industry conference, health executive Ruth Krystopolski recalled being deluged with consultant offers right after Trump’s election from people offering to help her navigate the coming changes to federal health laws.

“On any specific day I had eight to 10 consulting groups telling me that I need them,” said Krystopolski, who was then only a few weeks into her new job at Carolinas HealthCare System (now Atrium Health). They never quite explained precisely what she needed them for, but the pitches kept coming. An official at a well-known hospital told me she gets 100 to 120 emailed pitches every day from consultants she doesn’t know and often has never heard of.

In a country that spends nearly $3.4 trillion a year on health care (about a third of which, many researchers agree, ranges from wasteful to useless) there’s money galore for the consulting cavalry. Stacked against that colossal $3.4 trillion, even a $20 billion consulting tab is peanuts. But as a chunk of change it’s still significant—$20 billion is roughly half the annual budget of the state of Maryland—and it ultimately ends up on the American health care tab.

“What would you expect when you create a payment system so complicated? You create an industry,” said Don Berwick, who served as Obama’s first head of the Centers for Medicare & Medicaid Services until Republicans forced him out. “It’s part of the whole nexus of waste in the way we pay for health care in America.”

The complexity of the payment system for health care helps drive reliance on consultants, according to Don Berwick, above, a former administrator of the Centers for Medicare and Medicaid Services. | Joshua Roberts/Bloomberg via Getty Images

To people following health policy, half of Twitter seems to consist of consultants. (The other half is developing health apps, which themselves spawn niche consultants.) They offer marketing, communication and wellness strategies; practice transformation; team-based-care building, revenue maximizing, behavioral health integration, pharmaceutical price-calibrating, and YouTube channels. One self-styled consultant hung up a cyber-shingle promising to “provide physicians with the most comprehensive and integrative solutions for female sexual health” through sexual wellness clinics, which may or may not be what you think they are.

The overkill costs. “The amazing thing is all of this gets paid for. Somehow, it must find a way into our health care bills,” Princeton’s Uwe Reinhardt, one of the nation’s most prominent, and sardonic, health care economists told me in a conversation before his death last year. He likened the legions of consultants to camp followers servicing troops in wartime—but who, in this case, often get paid more than the actual warriors, aka the front-line clinicians.

None of this means that doctors, insurers and hospitals don’t need some outside expertise. The questions are how much help is needed, at what cost—and whether the helpers become grafted onto the health care system in perpetuity.

Gorman, the consultant, makes the case that specialized expertise is vital in a field that is both highly volatile and heavily regulated. “That degree of complexity—very few people have mastered that. They don’t have time to read 1,200 pages of regulations,” he said.

Gorman started a two-person consulting firm 22 years ago and now employs 200, and has eight related businesses that provide software solutions and outsource services to health plans. His company merged with a tech firm last year to chase new opportunities, and says the service is cost-effective. Hospitals or health plans are making “eight- or nine-figure decisions and they need an external read,” Gorman said. “Paying us a few bucks to verify their conclusions is smart business.”

KAVEH SAFAVI, THE senior managing director of Accenture’s far-flung billion-dollar-plus global health care businesses, started out as a doctor before he moved into the legal and business side, and he falls back on medical imagery. The health care system, he said, reminds him of a complicated patient, “a biological organism—complex and adaptive.”

“There are unknowns. Interactions we can’t model. There’s experimentation and trial and error and continual feedback,” he once explained. “You can’t take a playbook, drop it in, and expect an outcome to occur.”

But people in the industry who have hired consultants or who were consultants themselves say that’s not how it always works in the real world. A consultant may pass an off-the-shelf report as a customized deep dive, for instance, or give similar advice to competing clients. “It’s cookie-cutter,” said Molina. “Vanilla. Generic.” Or they may do something like advise a hospital to start a new service line or offer some hot new therapy for competitive reasons—and then dash off to the hospital’s nearest competitor and tell them they must do the exact same thing. That adds excess capacity, and more spending, to a health system that badly needs to shed its bloat.

But even a seasoned health care operator like Molina, a physician and former insurance CEO, can’t figure out everything by himself. He’s now running Golden Shore Medical Group, a chain of clinics serving low-income people in four California counties, doing primary care, chronic disease management, mental health. And he just hired a consultant—though one, he said, with a well-defined mission and a timeline to complete it.

Elaine Batchlor, CEO of the Martin Luther King Jr. Community Hospital in Los Angeles, relied on consultants as she worked to rebuild the hospital from scratch. Some consultants are good, she says, but others just push fads. | Earl Gibson III/WireImage

Dr. Elaine Batchlor, CEO of Martin Luther King Jr. Community Hospital in Los Angeles, had the task of basically building her hospital from scratch, after its predecessor was shut down because of an appalling safety record that cost lives. She didn’t want to recreate a 20th-century hospital; she wanted to create one that would blend hospital and community resources for the 21st century. And since she really didn’t have any staff at the start, she had no choice but to turn to hired help.

“I’ve been fortunate to work with some really good consultants,” Batchlor said. But during decades in medicine and public health, she’s also encountered some who just added cost. “I’ve worked with consultants who didn’t know what they were doing, who were disruptive and distracted people … or who were promoting some fad.”

The National Society of Certified Healthcare Business Consultants lists more than 90 different services, including Audits: Embezzlement; Audits: General; Audits: Medical Records; Audits Medicare/Medicaid. It also lists six variants of recruiting and seven types of practice management. A far cry, industry old-timers recall, from the days when a consultant was someone who helped make the hospital laundry more efficient, or, as one retired hospital board member told me, gave them tips on fostering good relations with the ladies auxiliary.

Audits and recruiting are only slices of health care consulting, and not the newest slices. The Affordable Care Act created incentives for all kinds of next-big-thing innovations that hospitals and insurers need advice on implementing, whether it’s creating an accountable care organization, or a patient-centered medical home, or a coronary bypass bundled payment model. Those approaches are being tested by the private and public sectors alike to see if they deliver better care. The Trump administration hasn’t wiped out those initiatives, though it slowed some down under Tom Price, Trump’s first HHS secretary, only to recommit to some of them under Price’s successor, Azar. And the new emphasis on bringing down drug prices will invite another consulting bonanza.

Then there are the next sort-of biggish things. There are experts who help pharmaceutical companies figure out how to price a new drug coming on the market—and experts who then help insurers figure out how to pay less for it. There are experts on rural health care and experts on urban health care; experts on designing quality measures and experts on gaming them; advisers on executing mergers and advisers on fending them off. Each ripple of change lets a thousand cottage industries bloom.

It’s not just the ACA; the system has been breeding consultants for at least a couple of generations. Chip Kahn, who runs the Federation of American Hospitals, says consultants have been a constant for an industry that endures reform after reform after reform. “Anyone who says the rage for consultants is new for health care doesn’t know anything about the past,” he once told me.

But the boom over that time is notable. Princeton’s Reinhardt recalled the first gathering of health care economists at the American Economic Association, maybe five or six people, back in 1968: “We fit in a small room in the basement of the Hilton.” In later years, Reinhardt said, he rubbed shoulders with 2,500 health care economists at international meetings—and those are just the researchers and scholars (many of whom, of course, do some consulting on the side). Many of his best and brightest students, who once might have followed in his scholarly path, spurned academics altogether and headed to “the McKinseys and Booz Allens,” he said—rationalizing their decision by saying they can help save health care.

EVEN MORE CONSERVATIVE corners of the health-care economy wind up fueling the market. Jill Fuller was CEO of Prairie Lake Healthcare System, an 81-bed hospital serving 10 rural counties around Watertown, South Dakota. Interviewed while attending a trade conference in Washington, D.C., she said she had no interest in moving away from old-fashioned “fee for service” health care until she absolutely had to. When she does have to wrestle with something new, she’d rather help Prairie Lake physicians figure it out than pay outsiders.

Once in a while, though, heartland self-sufficiency isn’t enough. When Fuller wanted to build new medical suites—and her hospital board wanted to repurpose existing space—she brought on $30,000 worth of consultants. Her medical suites are now under construction. And Fuller has announced plans to retire.

But most hospitals, unlike Prairie Lake, are inundated by change, involving digitization, coverage and care delivery.

On digitization of medical records, for instance, the move from paper has been slow and painful. Much of the $36 billion in federal incentives and subsidy payments to push hospitals toward digital recordkeeping went to vendors and assorted trainers, consultants and advisers. And after all that money and all these years, digital health is still so clunky that doctors can’t easily transfer and share computerized records and patients have trouble tapping into their own charts. Turf battles over telemedicine have spilled into state legislatures and courts. Virtual pirates are hacking their way into hospital IT systems and holding them for ransom, potentially endangering lives—and instantly creating a boom market for health care cybersecurity consultants.

The granddaddy of uncertainty has been the war over Obamacare. Trump and the Hill Republicans ostensibly remain committed to dismantling it. But the GOP learned last year that uprooting an eight-year-old law that covers 20 million people is easier said than done. Now, they vacillate between attempts (mostly in the Senate) to stabilize the health law they’ve spent years vilifying, and waging a war of attrition against whatever parts of it they can’t legislate away. Building Obamacare was expensive and complex—billions in grants to create online markets, voluminous rules, a massive update of state Medicaid systems, and a sweeping repartitioning of state and federal regulatory roles. Those billions fed consultants and contractors (including those who botched the Obamacare launch the first time around) for the better part of a decade. Now the experts who constructed Obamacare are making way for, or refashioning themselves as, experts in dismantling Obamacare.

“The ACA shifted responsibility to the federal government,” said Joel Ario, a managing director of Manatt Health Solutions, who for several years ran the ACA exchange office for the Obama administration. “Now it goes back the other way. States have a bigger role again.”

Joel Ario, who held a key position in the Obama administration implementing the Affordable Care Act, now works as a consultant for Manatt Health Solutions. With federal officials working to erode Obamacare, consultants are shifting their focus to the states, he said. | Brendan Hoffman-Pool/Getty Images

Red states and blue states are taking different approaches. Places like New Jersey and California are actively shoring up Obamacare, while those like Iowa and Idaho sprint to undo it; a few states in between are managing to do both at once. Most will need help navigating uncertain terrain, Ario said. Hospitals, physicians, even the states themselves, are going to have to figure out what to do about people who suddenly lose insurance, or who have much less comprehensive coverage—and the hospitals and clinics facing more uninsured and underinsured. During the Obama years, one thing that kept consultants busy was gaming out possible outcomes from the constant legal and political challenges to the health law. A mirror image of that is playing out now, with numerous suits challenging Trump administration policies from contraception coverage to Medicaid work requirements.

A FEW HOSPITAL executives think the boom days may end for the big name, big price tag national consultants, and that they’ll move on to fields other than health. “We don’t use them anymore—they cost a lot and they weren’t delivering specific solutions for us,” a CEO of a nationally ranked hospital told me, asking not to be quoted by name discussing business strategy in a competitive urban market. “I have relationships with a few independent consultants who I trust, and who know our institution. And I will keep working with them.”

But Morrison, the consultant/futurist, sees an intrinsic tension in the health industry that will keep the demand high.

“We’re doing quality improvement, and satisfaction ratings, and talking about moving from ‘volume to value, ’” he said of the health industry’s efforts to reconfigure care. “At the same time, we’re being told: ‘Keep the revenue up.’”

Revenue is what’s changing next. Apart from Obamacare, Medicare is changing how it pays doctors under a law passed in 2015. The very names of the new programs suggest how complicated it all is, how hard it will be for physicians and health systems to adopt or adapt. The payment law is called MACRA (Medicare Access and Chip Reauthorization Act of 2015), the looming doctor pay system involves MIPS (Merit-based Incentive Payment System), and APMs (Advanced Payment Models). The proposed rules setting them all up runs hundreds of pages, with their own patois of acronyms. It’s supposed to make health care simpler—but simplifying health care is a tricky business.

Better call a consultant.

Authors: