Customer Reviews

Healthcare, Guaranteed: A Simple, Secure Solution for America

5 star:		(13)
4 star:		(4)
3 star:		(0)
2 star:		(1)
1 star:		(5)

 

 

This book came highly recommended to me as a practical, non-ideologically driven approach to our present healthcare delivery system woes. I agree with Dr. Emmanuel that our present system is not sustainable and will bankrupt our country if we continue on our present path. His analysis of our present system, its history, problems with employer based systems, and alternative approaches including mandate and single payer approaches is well written.

His ideas for how an ideal system might be constructed de novo are not without merit. However, his prescription for how to arrive at such an outcome is terribly flawed.

The book describes using private insurance companies which will compete for the business of every American who will receive a health care certificate, However, to avoid our present circumstances, Dr. Emmanuel proposes the creation of an entirely new infrastructure consisting of both national and regional boards which will be charged with ensuring quality of care, appropriateness of care, coordination of care, cost control, fair funding, dispute resolution, and choice. Dr. Emmanuel likely made a tactical decision to write a focused book without getting bogged down in details and at least some criticism could be deflected on this basis. However, this entire proposal is based upon infrastructure which does not exist and is not likely to come into existence for a long time.

Not only do organizations, which would be charged with these various tasks, not exist, the tools they would need to function would require years of investment and study. Outcome measures such as life or death or surrogate measures linked to the same (blood pressure, blood sugar, weight) are fairly easy to measure. As Dr. Emmanuel points out much of medicine deals with chronic conditions and suitable outcomes deal with quality of life (pain, function, depression, malaise, or overall function) where metrics are much more difficult to assess. Much of current medicine practice is not strongly evidence based, but perhaps is still effective. The development of guidelines for what is acceptable for payment and the ongoing revision will be a Herculean task...not undesirable. Do we have the trained workforce in place? Do we have the information systems in place? I don't think so. Should we invest in building this? Absolutely, but don't expect to yield much fruit for a decade or more.

The author puts forth a system where 100% of Americans are covered.. specifically not 95% or 97%. if history is any guide, the marginal costs of those last increments will be frightfully high. Perhaps Dr. Emmanuel would be best served by remembering the adage perfection is the enemy of good.

Administrative cost control may sound attractive and have a certain populist bent. However, there is essentially no historical precedent for its success. From the Emperor Diocletian to contemporary New York City rent control, the results are all the same. This perhaps is the weakest link of the entire program. Who will set the prices and on what basis? Dr. Emmanuel speaks much about getting incentives correct. Without a correct pricing systems, incentives will always be wrong. It is a major problem with our current system.

On page 89 of this book is a passage which I believe reveals much about the author and his outlook. He states that "The current health care system to so complex that no single person understands all of its inner workings." This should not be a surprise that no single person understand how it works. Under no system can I imagine that this could be the case. The classic example of the lowly pencil as described by L.E. Read illuminates this for those who pursue the most rudimentary understanding of economic systems. No single person holds all the knowledge required to make even a simple pencil. It is inconceivable that any person could ever know all the inner workings of the entire health delivery system.

Making health care work is all about coordinating human efforts whether those efforts are made by physicians, those who answer the phones, those who negotiate the contracts, those who make the drugs, those who run the power plants to generate the electricity, or those who build and maintain the buildings. This coordination cannot be choreographed like River Dance by someone or some group which aims to understand and hold all the knowledge needed to make a large and complex organization work. That is not possible. Complex systems work because we all benefit from the activity of people who we will never know, who hold knowledge that we do not know.

Dr. Emmanuel rejects an further attempts at incremental change. We are implored to seize his vision of how an ideal system might look and push for immediate implementation. The political stars are now aligned (he is probably correct). The old system, unplanned and poorly engineered has almost no merits. Reading Dr. Emmanuel's rejection of incremental change reminded me of a passage from Thomas Sowell's "Quest for Cosmic Justice". "...that is, on the extent that what currently exists as the fruits of centuries of efforts and sacrifices is inferior to what they can produce in their imagination immediately at zero cost..."

Conceptually, some of Dr. Emmanuel's ideas have merit but there are big holes (thus the two stars). Logistically, the meritorious elements (investment in IT, health outcomes research, dumping of employer based insurance) will have to implemented incrementally to have any sort of impact and avoid too much top-down control. Investment in information systems is the key element that will allow for better systems to evolve. Dr. Emmanuel's universal aspirations will be unfulfilled. Ultimately, whatever is put in place will have to rely heavily on market forces to set prices, allocate scarce resources, and coordinate human activity. Man has found no substitute as of yet.

If the United States hasn't passed the threshold of interest in health care reform, it must be darn close. Thus, now is the time for a clear and concise argument for any particular approach. Dr. Emanuel puts forward a specific proposal for health care reform that would address the seven goals he views as essential to success. His proposal has a strong appeal to common sense, and as such, it is one that will surely suffer the slings and arrows of outrageous ideologs. But, besides presenting his own distinct proposal for reform, Dr. Emanuel gives enough background on our present plight, along with a heuristic tool to equip us to evaluate the many different reforms out there already and the many yet to come. And, he does this without resorting to the use of extreme case histories, which have become the coin of the realm for authors of books on health care reform and which can have distorting effects on any objective analysis. Even members of Congress will not be able to get away saying they do not understand the concepts in this book.

This is an important book at an important time, and one that invites everyone into the health care reform debate whether they agree with Dr. Emanuel's proposal or not (count me among those who do). But, alas, important as this work is, it would never get Dr. Emanuel tenure at a major research university; it's much too accessible. He'll have to keep his current job.

Dr. Emanuel has been writing for some time on the subject of health care policy, usually in collaboration with Prof. Victor Fuchs, an eminent, but now-retired, health economist. Prof. Fuchs collaborated with Dr. Emanuel on this book, as Dr. Emanuel notes in it, but apparently the final version as published is mostly the work of Dr. Emanuel.

This and two other books that I highly recommend on health care policy, A Second Opinion and Health Care Policy, are written by physicians who know the science and practice of medicine as well as the economics of medical services. Another, also very good, book, Health Care Half Truths, is co-authored by a physician.

The book is fairly short, very well-written and well-organized. Dr. Emanuel spends the bulk of the book analyzing the current medical services delivery (and to a lesser extent the funding of the system), then at the end of the book makes cogent recommendations on reform.

Although my personal opinion on the particular form that the financing of medical services should take (I strongly favor a single payer/insurer scheme) differs from Dr. Emanuel's view, Dr. Emanuel presents compelling evidence why a single payer/insurer scheme is inferior to his recommendation: a voucher system that is funded by a dedicated value-added tax. Dr. Emanuel recommends the continued existence of private health insurers, asserting that their presence furthers choice and potentially at least engenders competition. My perspective is that private insurance simply has no place in a medical services system. The forces that drive private health insurance companies are immutable. Private insurers inevitably increase the administrative cost of effecting payment for services. They also have no ethical role as deciders of what treatment should occur. In particular very expensive treatments with whatever probability of lengthening a patient's life should not be decided by an employee of a private company. They also will continue to seek to exclude the sick and try to enroll the healthy in their insurance plans. Those are unavoidable characteristics that, at least in my mind, argue for a single payer plan, regardless of the pitfalls that Dr. Emanuel correctly notes.

I highly recommend Zeke Emanuel's book Health Guaranteed (we are on a first name basis since I watched him and his brothers being interviewed on Charlie Rose). The author is a practicing physician who outlines a very well thought-out system to fix many of the problems with our health care system. He compares his plan to other types of reform that have been proposed for the USA. He also explains briefly how we arrived at our health care delivery and financing system. Furthermore, he explains that the system, not the individuals who work within the system, that is to blame for its serious flaws.
Incoming Presidential Chief-of-Staff Rahm Emanuel's smarter brother's proposal includes: 1. guaranteed coverage (mandates and incremental reform fail here) 2. effective cost controls (mandates and IR fail here, too) 3. high quality coordinated care (incremental reform unlikely be effective; mandates and "single-payer" fail here) 4. choice of plans and providers (incremental reform and mandates only help some here, "single-payer" doesn't) 5. fair funding (mandates and incremental reforms fail here, and no fair funding proposal has been proposed for single payer) 6. reasonable dispute resolution (no such solution has been offered with mandates, single-payer, or incremental reforms, and here even Emanuel's plan is not bullet-proof) 7. economic revitalization (none of the other plans address this adequately) Emanuel's GHA proposal completely removes healthcare financing from employers, freeing them to do what they do best.
Dr. Emanuel answers so many questions that I cannot start to list them here. I kept reacting "yeah, but what about...?" and then he would answer. My only complaint is that for as short as the book is, it could have been much shorter, given the content. It is very repetitive, but I understand that part of its design must be to sell an idea which has been presented and refined in recent years. I do wish he had compared and contrasted it with the existing systems of other developed countries (especially recently designed ones like Taiwan and Switzerland), but I will have to find that information elsewhere.
Given his connections, I trust that he will be given an opportunity to try to sell his plan to HHS Secretary-designate Tom Daschle, since it appears that Daschle's plan (I haven't read his book yet) is only an incremental reform plan, the likes of which Emanuel convincingly argues have always failed.

Emanuel and Fuchs have provided us a readable and concise view of what ails our health care system and a practical and feasible plan to fix our broken health care system. Many alternative solutions fail to deal with cost controls. Importantly the Guaranteed HealthCare plan does change the cost drivers in the health system. If we don't stop health care inflation we don't have a fix and a health care system that is sustainable.

This book supplies an important new fresh look at both the problems and solutions for our health care system. Congress and the new President are going to need some new ideas like this to find a solution the majority of Americans can get behind and support.

After you are done reading this great book.........mail it to your Congressman!

Dr. Emanuel has a smart healthcare solution for what ails us! At the heart of his plan is the method of funding, which makes so much sense. Everyone wants healthcare insurance and everyone should be willing to pay for it. Using a dedicated Value Added Tax (VAT) to pay for vouchers would be progressive, as those with more means consume more. (Credits would be given to those below an income threshold.)

The VAT would capture a fair share from the illegals who currently crowd our emergency rooms for free service; it would also capture significant revenue from the illegal drug trade.

Democrats should want to back it - it is truly universal healthcare. Republicans should want to back it as the plan provides vouchers to afford consumers to choose, i.e., affords competition for efficiency. Companies should want to back it because it removes a huge direct cost and disincentive for employment; workers would benefit for the same reason.

Importantly, the VAT is the tax system of the era of globalization, as it is border adjustable, i.e., subtracted from exports and added to imports. The U.S. alone among its trading partners in not taking advantage of the VAT, which is supported under GATT rules and used by 135 countries today, including all of our trading partners, which get a competitive advantage over U.S. goods and services because of it. (For example, the cost of healthcare for Ford Motor is more than the cost of steel. Imagine subtracting the cost of steel from an exported car, and adding that cost onto an imported car. We would increase U.S. market share!)

I bought a copy of this book for my Congressman, and for a leader in healthcare. Spread the word.

Before I read this book, I was convinced a single-payer, Medicare for All reform was the only solution to our current crisis. I'm not so sure anymore. Dr. Emanuel argues eloquently for a system of national health insurance that keeps the private insurance companies, but does not allow them to turn people down for pre-existing conditions. He calls for a seemingly radical plan: every American should get as good a healthcare plan as members of Congress receive. Crazy, but it just might work!

No socialist, Dr. Emanuel argues that a single-payer system, i.e. Medicare for All, will lead to long waiting lines and customer dissatisfaction. This is one of the best, if not the best, health care books I have ever read and I cannot recommend it too highly. (Are you listening, Mr.President?) I'm not completely sold on the VAT tax idea, which is why I gave it 4 stars instead of 5.

Healthcare, Guaranteed is a set of talking points, and a sales pitch. Ezekiel Emanuel wants to sell us on his Guaranteed Healthcare Access Plan. It promises a radical simplification of the American healthcare-delivery system. First, everyone would be entitled to basic health care, and could pay for additional care beyond the basics. Every citizen would be given a card entitling him to coverage through a qualified insurance provider. In order to keep costs under control, Emanuel's plan would create an Institute for Technology and Outcomes Assessment that would decide whether new technologies and medicines are beneficial, and would publish statistics on the various health plans' success at creating healthy patients. It would be funded through a 10% value-added tax, the proceeds of which couldn't be used to fund any other program.

Finally, central to the whole thing is a National Health Board and twelve regional Health Boards patterned on the Federal Reserve; the health boards would approve insurance plans or kick them out. Like the Fed, the Health Board's advertised virtue is its insulation from politics. Having just read a biography of Dick Cheney, who was old friends with Alan Greenspan and met regularly with the man in private, I have my doubts about this purported insulation.

Much more importantly, it strikes me as wrongheaded, depressing, and insufficiently principled to want to take power away from the democratically elected branches of government because of the failings of politics; why not just give up on the whole democratic process, then? I can certainly understand the justification: the Fed does control, and the Health Board would control, vast swaths of the economy; one dollar in every six goes to health care under our current broken system. While not denying the logic here, I'd like to see it applied to other important sectors. The Department of Defense, for instance. Surely we wouldn't want something as sacred as the security of our homeland to be subject to bribery, wherein the states that manufacture new weapons systems or house military bases are chosen on the basis of political power? Surely not. Defense should be walled off from those who would weaken our country in the name of politics.

I hope others find it as disheartening as I do that the first thing politicians often want to do, when confronting a new problem, is to wall it off from their own work. Emanuel is not a politician, we must note -- he's the Chair of the Department of Bioethics at The Clinical Center of the National Institutes of Health with a political-philosophy Ph.D. from Harvard and an M.D. from the same university's medical school -- but this apolitical, technocratic dream is a common one. Tom Daschle (who is a politician, and will probably be Obama's Secretary of HHS) lays out the same dream near the start of his book Critical.

Healthcare, Guaranteed works better as a series of talking points than as a detailed policy manual. First, it's good to be reminded of exactly how broken our system is, and the various overlapping pieces that still fail to cover one in six of our countrymen: Medicare if you're old, Medicaid if you're poor, private insurance while you're employed, the emergency room when you're not, COBRA for a short window in between. And it's good to be reminded of the consequences of this failure. People stay in jobs that they hate because they lose their safety net when they leave. People stay married because their spouse works and they don't. Companies employ full-time staff just to sort through the details of competing health plans, thereby taking money away from the jobs that the companies actually specialize in; they're software companies or automobile companies, after all, not health-insurance-picking companies. A rational system would take this burden out of the hands of companies and shift it onto some entity that specializes in doing it. (Though with that in mind, it's worth looking to see whether companies already outsource HR. If not, why not? If so, then we have less reason to believe that the government needs to do this.)

Here, though, Emanuel again makes me uneasy: his plan would give the Institute for Technology and Outcomes Assessment the job of measuring medicines, technologies, and health. But doesn't the FDA do that? Healthcare, Guaranteed doesn't ask why the FDA is failing at its job. Read Marion Nestle's What To Eat and Food Politics to understand some of the details there. The food industries have lobbied hard to hem in the FDA and make it less and less able to do its job. Insulating the FDA in some way from politics could certainly help here ... but why would I -- or any American who sees how his government works -- expect Congress to construct a better system than the one we already have, when it can't handle the system it's already got? Here of course we get back to the politically insulated structure that Congress will apparently construct, and again I shake my head at Congress's perception of its own fecklessness in the face of lobbying.

At some point I need details, specifically: how will the National Health Board be kept insulated from politics? If the Fed only has a lever or two to handle (mostly interest rates), I can see how it wouldn't be the victim of much lobbying: just about as many people will probably want low interest rates as high ones. The new health administration, by contrast, will decide which medicines can be used and which insurance plans are available. That's a lot of machinery and a lot of little gears. How exactly do we keep it under apolitical control?

These are the sorts of detail questions that Emanuel is loath to answer in Healthcare, Guaranteed. He considers his book ground-clearing, and suggests that thinking too much about the details is a strategy that opponents typically use so that nothing gets done. Perhaps so. Perhaps it's best to start with what we want, aim for it, and let the details fill themselves in later. I have my doubts; the structure of government-as-she-is contains a lot of hard-won information that we ignore at our peril.

A very disappointing book. It's comes down to a list of talking points, overly generalized and mostly wishing away reality without engaging with it.

And this is not the plan working its way through Congress.

The book is in great condition, brand new i believe. And most importantly the shipping was fast and the order was processed right away.