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‘Reinventing American Health Care’ well argued

REINVENTING AMERICAN HEALTH CARE: How the Affordable Care Act will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System, by Ezekiel Emanuel. PublicAffairs. 400 pp. $26.99. ISBN 978-1610393454

Early in his new book, Reinventing American Health Care, Ezekiel Emanuel pictures the late Pennsylvania senator Arlen Specter holding up an incomprehensible chart of the health care system – in 1993. What Emanuel calls “the interconnected weirdness” of the U.S. health care system has only gotten weirder since.

Yet what Emanuel does is enormously helpful: He sorts it all out and gives us a clear and straightforward accounting of the system that is anything but. He starts at the beginning (1790, to be exact) and progresses logically to the present, through the development, political wrangling and legal journey of the Affordable Care Act. Then he hurtles into cheerily optimistic projections about the future. Perhaps, indeed, more than a tad more optimistic than his own accounting of the past would warrant.

His review of how our health care system got this way is a depressing reminder of forces that have little to do with health care and nothing to do with health. How did hospitals become so dominant? How did the Depression lead to the spread of health insurance? How did World War II price controls help lock health insurance to employment? And what do tax breaks have to do with it?

Quick: What’s the biggest single tax break in the United States? Tax-free health benefits, nearly four times as large ($250 billion) as the mortgage interest deduction ($70 billion). With employers able to offer health insurance to employees free of tax, the benefits became an increasingly important part of pay over the years. Getting rid of that deduction, Emanuel makes clear, is one fix that he regrets was left out of the new health care law.

Despite these and other critiques of the legislation, it’s clear that he’s a wildly enthusiastic fan. Consider his view that “beginning in 2020 or so, the ACA will increasingly be seen as a world historical achievement, even more important for the United States than Social Security and Medicare has been. And President Obama will be viewed more like Harry Truman – judged with increasing respect over time.” Wow. His logic is that by 2020 the law and its aftereffects will arrest health care inflation to simply match the rise in gross domestic product, instead of the recent rate of 2 percentage points above the annual increase that has rocketed costs to 18 percent of GDP today. That would indeed be a major accomplishment.

Emanuel is no dispassionate outsider. The professor of medical ethics and health policy at the University of Pennsylvania was a special adviser to the White House on health care reform and worked directly on the Affordable Care Act. He also peppers his story with accounts of expletive-laden exchanges with his brother Rahm, current mayor of Chicago and Obama’s former chief of staff.

In 2009, Emanuel himself was labeled “Dr. Death” after Michele Bachmann and Sarah Palin, among others, twisted his medical ethics work to conclude that he favored withholding health care from the disabled and advocated so-called “death panels.” That’s sheer nonsense.

Whether you agree with his conclusions or not, they’re well argued, and he has marshaled an impressive amount of information. Some of the very simplest facts bear repeating. For example, how vulnerable every one of us was before passage of the new law: More than half of us got health insurance through our jobs. Three-quarters of the uninsured are in households with at least one paycheck, and nearly one in 10 uninsured households brings in over $94,000 a year. It isn’t money that keeps some people from having health care coverage, it’s access. For some, their job didn’t provide insurance. For others, they simply couldn’t afford it. And yet others were rejected, ironically, because they were too sick.

He also reminds us that there is so much more to the Affordable Care Act than the troubled exchanges. There are targets to induce hospitals to lower infection rates; inducements to adopt electronic medical records; rules for better pricing transparency (a current nightmare!) and more complete data on hospital safety and outcomes, as well as better access to free preventative services like immunizations and mental health screening.

Where he goes off the rails is in extrapolating from these provisions of the law to a vastly different future. He posits not only the end of health care inflation, but also of medical insurance as we know it. He sees employers ceding their roles as providers of access to health care, technology replacing costly hospital stays and specialists, hospitals closing in large numbers and the remaining ones becoming safer and more efficient.

That’s wishful thinking. His own, very persuasive review of history shows how exterior forces – and grabs for dollars – thwarted and distorted sensible plans.

Look at the advertising in the D.C. subways opposing cuts to hospital funding to see how rocky the path to hospital closings will be. Check out the sad fate of a Maryland nonprofit co-op startup, the faltering Evergreen Health Co-op, for a view of how hard it will be to create alternatives to traditional care. Anyone who has ever been part of a technology changeover anywhere can imagine what it will take to link the whole messy U.S. health care system electronically. And consider the travails of 23andMe, the genetics company whose medical service was shut down by the Food and Drug Administration, for an example of how hard it will be for newcomers to break into spaces that others already own.

The nightmarish launch of the health care exchanges alone should be enough to convince anyone that just because something is in a law doesn’t mean it will happen. At least not exactly the way it was planned. Or, as Bob Kocher, another Obama health care adviser, was recently quoted as saying, “It is actually harder to do some of these things in reality than we thought when we put it down on paper.”

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