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 J. Emanuel

There are 4 things the average physician can do. One is to begin the process of transformation to more efficient practice, knowing that payment changes that move away from fee for service are inevitably coming.

Second, part of this transformation means that physicians will need to change their business model to increasing efficiency in their delivery of the services.

Third, physicians should engage insurers to try to modify contracts so that they have a financial reward for being more efficient.

Finally, these impending changes confront many physicians with the major existential question of whether to sell their practice to a hospital system or remain independent.


Six megatrends

* End of insurance companies as we know them

Insurance companies will either become purveyors of management analytics, and actuarial services, or integrated delivery systems actually employing (or contracting with) hospitals, physicians, and other providers to render patient care.

* VIP care for the chronically and mentally ill

Physicians and hospitals will focus on keeping patients with chronic illnesses healthy and out of the emergency room and hospital, thereby decreasing the frequency of avoidable complications and rate of hospitalization. Then they will begin routinely screening for depression and other mental health problems and develop standardized rapid interventions.

* The emergence of digital medicine and closure of hospitals

Over 1,000 acute-care hospitals will close. We will see a slew of new technologies for remote monitoring, testing, and treating patients in real time outside of the hospital and physicians’ offices.

* End of employer-sponsored health insurance

Fewer than 20% of workers in the private sector will receive traditional employer-sponsored health insurance.

* End of health care inflation

Health care inflation will be GDP+0%.

* Transformation of medical education

Medical education will be transformed in 4 fundamental ways: (1) three-year medical schools and shorter residencies; (2) half of medical school clinical training will be outside of hospitals; (3) integration of nurses, pharmacists, social workers with medical students in multi-professional team training; and (4) formal incorporation of population health and management skills in training.


Regardless of the short-term political costs, in the longer sweep of history, 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 had been. And Barack Obama will be viewed more like Harry Truman – judged with increasing respect over time.…

Ezekiel J. Emanuel, speaking about his book, “Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System”

Politics and Prose, April 16, 2014


At 39:30

Harvey Fernbach:  I’m a member of Physicians for a National Health Program. We believe in single payer simplicity, Medicare for all. As you know the president was for single payer, he said it, he’s for Medicare for all. Nancy Pelosi has come out for it. Harry Reid has. John Podesta when he signed up for Medicare said, “Hey, I signed up for Medicare in five minutes; how about single payer?” At a recent discussion at the Center for American Progress, Sen Daschle said very vigorously he was for single payer, if it was not for the politics. Do you have any philosophical problems with single payer, aside from the politics?

Ezekiel Emanuel:  Well, first of all, I think someone once said, “It’s not going to happen so I’m not wasting any time on it.” I think that was Jonathan Gruber, economist at MIT. It isn’t going to happen, so let’s just get clear. It ain’t gonna happen! We barely got the Affordable Care Act through. Single payer, zero chance! Okay, so let’s just be clear on that.

Dr. Fernbach:  No, I don’t think that’s clear. You can go twenty-five years back, and I’m not saying we’d do in six months, or by the end of this talk, but to say that sixty percent of the American people who are for it can’t have what they want…

Dr. Emanuel:  Let me repeat myself.

Dr. Fernbach:  Please.

Dr. Emanuel:  Certainly in my lifetime, not happening. Okay, so I’m not wasting any of my time on it. Okay? Let me just say philosophically I also do have some disagreements with it. Okay? It depends what you mean by “single payer.” You need.. you don’t want to have one system determining payments like Medicare does for 310 million people. I don’t think that’s an efficient system. There are many things Medicare does that aren’t efficient, that they can’t do, and they have to do slowly because they’re affecting so much of medical practice and so many people. Second, you do get a lot of political gridlock; a lot of what Medicare does is a response to political pressures rather than to top quality policy pressures or policy ideas. Second, you do want to have a lot of experimentation. We don’t know the best way to care for someone who’s got chronic conditions or mental illness. We just don’t. We need to experiment a lot, and I think if you have single payer it gets hard to experiment on those things. So, for those reasons, I’m not a wildly big advocate of it because I think it would slow down the ability to make changes. Having said that, you know, I also don’t think it’s politically gonna happen, so.. We couldn’t even, look, we couldn’t even get the public option. Okay? I mean… and we barely got this bill through! It has failed a hundred years worth! Okay?

Ezekiel Emanuel’s “Reinventing American Health Care” is largely a history of reform efforts and a description of the enactment and early implementation of the Affordable Care Act. The last section is his view of the future of American health care – the source of the excerpts above.

Some of his suggestions are mere platitudes. Others are “it-sounds-like-a-good-idea” abstractions, but have little solid policy support as to how they would be accomplished. Other recommendations are basic functions physicians already provide. Several of his ideas have already been suggested by others and hold little promise of benefit, and still other ideas are simply sort of weird.

One example is he says that we should replace fee-for-service with bundled payments. Yet Medicare representatives objected for three reasons. There was too much uncertainty without extended testing; the computer infrastructure would have to be very complex to pay based on bundles; and the delivery system is not organized to handle bundles. Although Medicare was adamantly opposed, they were able to slip into ACA ten demonstration projects with the proviso that the administration could then mandate bundled payments throughout Medicare without the need to return to Congress.

In several interviews while promoting his book he has been asked if he sees the changes he predicts as steps toward single payer. He is quite emphatic in rejecting any such possibility. His response to Harvey Fernbach, transcribed above, is typical.

His opposition to single payer dates back to his previous efforts to sell the concept of vouchers for private insurance, paid for by a value-added tax, as the ideal model for reform – a proposal he shared with Victor Fuchs. Although he did not get that, tax credits for the purchase of individual “marketplace” plans seem to be close enough for him.

In his previous book, “Healthcare, Guaranteed,” he devotes an entire chapter to single payer. He concludes, “In their zeal, single-payer advocates seem to forget how American institutions and governmental agencies actually operate. They envision superbly efficient, incorruptible bureaucracies capable of rational policy choices. Unfortunately, American governmental agencies do not spontaneously operate this way.” Thus he dismisses single payer with the trite “incompetent government” meme.

The good news is that you do not have to put “Reinventing American Health Care” on your “must read” list, though some may find it of value as escape literature. But be forewarned that it is not humorous.