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Healthcare, Guaranteed: A Simple, Secure Solution for America Paperback – May 27, 2008
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“How to Fix Healthcare: Readers may recall an article by Ezekiel Emanuel and Nobel Laureate in Economics Victor Fuchs in TNR a while ago about their truly brilliant and, in my view, ineluctable proposal for paying for basic health care in America. Some time later we alluded in an editorial to the provocation of their plan to all the other policy contortions that pass as the foundations of legislation. Zeke has now expanded this work into a book, Healthcare, Guaranteed, published by PublicAffairs. By the way, he has a PhD in political philosophy from Harvard and an MD from the Harvard Medical School, and is now chairman of the department of bioethics at the National Institutes of Health. Years ago, he started his career as an intern at The New Republic. What a story that would make: those who began right here. In any case, Clive Crook has written a rave review, a truly rave review of the book in Monday's Financial Times. Before you read the review and the book, you should know that at the base of the financial plan is a value-added tax. This is one value-added tax that you might like.”
"This Monday a modest little paperback will show up in bookstores offering a suggestion for health-care reform. It won't contain any wrenching human stories like those in last year's big health-care book, Jonathan Cohn's "Sick." It won't be accompanied by gonzo stunts à la Michael Moore's "Sicko." But "Healthcare, Guaranteed," by Dr. Ezekiel Emanuel, may nonetheless be the most exciting book yet to come out of the country's medical crisis. What it offers is a radical yet straightforward proposal, one a layperson can understand. If the complexities of health-care policy give you a headache, this book is aspirin. Read it twice and call your congressman in the morning."
“Healthcare, Guaranteed is beautifully written. It describes many flaws of American healthcare with maddening clarity. Some of its building blocks should be included in anyone’s health plan”
"Healthcare, Guaranteed is a broad discussion of pervasive problems in our health care system, and it lays out a comprehensive plan to remedy them...Policymakers and all Americans troubled by [the system's] injustices will find Healthcare, Guaranteed a valuable resource for considering solutions to our health care dilemmas."
"The best of recent books on this question is happily the shortest and clearest and comes out this month. I think it has the answer. The proposal laid out in Healthcare, Guaranteed by Ezekiel Emanuel ... has convinced me. Whether it will convince others is in doubt for reasons I will come to. But if you are going to read one book on the subject, make it Mr. Emanuel's."
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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. [update: I found an introduction to that in T. R. Reid's The Healing of America, which led me to further research.]
[Update, 2013: Obamacare, though an improvement over the pre-existing non-system, provides completely for none of the seven goals above. There is incomplete progress on goals 1 and 4, in that there is a increase of coverage, and thus choice. And if we retain a committed HHS Secretary, and she is supported by Congress, there is a possibility that progress will be made toward goals 2 and 3.]
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.
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