Marked by the launch of Obamacare, the past several years in American health care have been dedicated to a wholesale effort to achieve the triple aim: access and quality at a reasonable price. Access has improved as has quality in some areas, but the country has seen no convincing impact on costs. Myriad mechanisms are in place to motivate patients, providers and hospitals to refine patterns of behavior and practice to lower costs, but a monolithic challenge remains — a third party pays most of the bill.

Whether it is a government payer such as Medicare or Medicaid, a private payer, a workers’ compensation carrier or an auto insurance company, the patient receiving health care services is typically responsible for a copay and perhaps a small deductible. Only several decades ago insurance products were rare, and patients would pay cash or often barter for care rendered. Not today. I remember working through the night in an emergency facility as a young doctor when I was awakened to see a Japanese tourist with a tiny scratch on her thumb. She just wanted a Band-Aid. I asked why she didn’t go to the retail pharmacy next store to buy one. "It’s free with my travel insurance," she said.

In contrast, in so many other aspects of modern life, the role of the third party is beginning to erode as the peer-to-peer socioeconomic model comes to the fore. We no longer need to call a national reservation line to book into a hotel chain. Instead, Airbnb is at our fingertips. The same fingers can find the nearest Uber driver rather than call a central dispatcher for a taxi.

This is also true for energy resources. Increasingly, the public is moving away from dependence on gas stations and utilities in favor of rooftop photovoltaic. Last week this column took the position that the Public Utilities Commission decision to reduce the credit for rooftop solar power sent into the grid would further stimulate consumers to invest in increasingly efficient battery storage and move off the grid.

As a nation we are on the precipice of a dynastic change away from institutions that until now have been viewed as immutable. Even the keystone mechanism of initial public offerings for new stocks has begun to give way to private equity where investors, owners and operators work together more closely. This is aside from the more rogue trends that include crowdfunding, bitcoin and activities of the dark Web.

Unfortunately, American health care as a whole remains a laggard in comparison with widespread trends toward increased social responsibility, environmental sustainability in the context of an increasingly shared economy.

Years ago I had the opportunity to banter with Dr. Jack Lewin, then Hawaii’s director of health, about the prospect of medical savings accounts. We agreed that a low-cost, high-deductible plan with embedded preventive services would create a valuable opportunity to transfer more personal responsibility to the consumer. After helping to ensure customers would receive vital preventive screening, the next dollar spent would be out of pocket unless and until a catastrophic event arose which would then be covered. These models have been exercised over the years on the mainland, but the Prepaid Health Care Act in Hawaii has historically precluded the roll of medical savings accounts in this state.

The time-honored social contract has served tens of millions of Americans: Work your 40 hours, pay into the system and when you retire or become disabled, you will get what you need in return. However, the massive scale of the institutions responsible and the industries built up around the social contract have resulted in inefficiencies that are still proving difficult to correct. As efforts continue to streamline existing institutions and improve outcomes, more powerful and impactful cultural changes are afoot. These changes are empowered by the information age and built upon the spirit of genuine personal and social responsibility.

Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrated Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Submit your questions to info@manakaiomalama.com.