In March 2010, the Affordable Care Act was signed into law. It was the most extensive reform of America’s health care system since at least the creation of Medicare in 1965, and maybe ever. In this book, Ezekiel J. Emanuel details why health care in America has become such a divisive social issue, how money and medicine have their own–quite distinct–American story, and why reform has bedeviled presidents of the left and right for more than one hundred years. Edward Larkin suspects that Emanuel’s motive for writing a detail-heavy, wonkish tome is to provide an excellent contrast to bellicose Republican rhetoric about the socialization of American medicine.
Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System. Ezekiel J. Emanuel. Public Affairs. February 2014.
By the time one reaches the subtitle of Ezekiel J. Emanuel’s Reinventing American Health Care: How the Affordable Care Act will improve our terribly complex, blatantly unjust, outrageously expensive, grossly inefficient, error prone system, one gets a sense of the author’s personality. Emanuel, one of the key architects of the Affordable Care Act – the controversial American health care law of 2010 popularly known as Obamacare – is by most accounts just as opinionated and exuberant as his subtitle. It is peculiar, then, that his exuberance mostly ends in the subtitle. I began reading Reinventing American Health Care ready for a full-throated defense of the Affordable Care Act in vintage Emanuel-style. Instead, however, what we get is less an argument and more an explanation.
The book begins with a history of (mostly failed) health care reform attempts in the United States, and continues with an exhaustive section about how exactly the American health care system works. This is a topic that could – and does – fill textbooks and semester-long courses, but Emanuel’s 60-page description is among the most comprehensive and digestible summaries I’ve ever read. He then discusses the details of the Affordable Care Act, before spending a short amount of time on the implementation of the Act, as well as an interesting chapter on the healthcare.gov website fiasco, which he mostly attributes to the lack of a private-sector tech person serving as CEO of the effort. The book finishes with a chapter on possible future trends in health care.
Rather than spending most of its pages arguing the strengths and weaknesses of the ACA, Reinventing American Health Care mostly explains what the ACA actually encompasses. For people who want to understand exactly what each clause of the Act means and why it was included, this is the definitive source. Emanuel leaves no health policy stone unturned, no matter how small; for example, he lays out how much the federal government spends per year on the Indian (Native American) Health Service, spends multiple pages on small business insurance exchanges, and the differences between these and the more prominent exchanges for individuals (I’m confident that most health policy wonks didn’t even know there were two types of exchanges. He even devotes a box to a measure called “Modifiable Gross Adjusted Income”).
For those who want – and indeed, most of us who probably expected – both an explanation and an argument as to why the ACA will be effective, Emanuel’s book is curiously lacking. Few people expected Emanuel to be non-partisan; it’s clear throughout the book that he feels an intense affection for the law that he helped birth, describing it near the end of the book as “a world-historical achievement,” and “more important for the United States than Social Security and Medicare”. But perhaps even fewer people expected him to be as technical and oftentimes apolitical as he is in this book. Emanuel has morphed from fiery policy advocate to news anchor – the sort of person whose views are very clear but who can’t really officially state them.
Not that any of this is bad. For those who really want to understand the ACA inside and out in order to form their own conclusions based on the sometimes mundane specifics, the book is excellent. It’s like a piece of Ikea furniture: all the pieces are included, but it’s up to the reader to put them together. In an era of reading prepackaged narratives by partisans that really don’t teach the reader anything other than how to echo that specific narrative, Emanuel has chosen a different route. Just based on its granular level of detail, the book will be useful for people who oppose or embrace the ACA. Emanuel ought to be applauded for that.
I suspect, however, that Emanuel’s motive for writing a detail-heavy, wonkish tome is deeper. By emphasizing how technical and mundane the ACA actually is, Emanuel is slyly providing an excellent contrast to Republicans’ bellicose rhetoric about the socialization of American medicine or indeed the socialization of American life in general. It’s hard to read Emanuel’s section about the circumstances in which health care rises faster than GDP at a specific level to trigger recommendations from the Independent Payment Advisory Board and come out thinking of them as “death panels”, as Sarah Palin did.
One area of the book is especially valuable. Near the end, Emanuel presents six “megatrends” that he believes will shape healthcare in the next decade. These aren’t the vague, vanilla suggestions that most policy analysts offer; they’re specific, thought-provoking, and controversial. Emanuel suggests that mentally ill patients will receive VIP care in the future, a segment of the patient population that insurance companies currently don’t pay much attention to. Emanuel rightly infers that psychiatric comorbidities are probably a much larger driver of costs than we realize (being depressed is highly associated with bad outcomes for heart disease, for example). He also predicts the end of health insurance companies as we know them by 2025, and suggests that most people will buy insurance through government-based exchange websites rather than employers.
Perhaps the best part about this section on mega-trends – and the book in general – is that Emanuel resists the temptation to simply reiterate the party line on these issues. Most Democrats would never admit that most individuals will buy insurance through exchanges rather than their employer, because that would scare people, and scaring people is bad politics. Emanuel, true to form, chooses the route of intellectual honesty. It makes for a comprehensive read on the true implications of the ACA by one of its key architects.
Edward Larkin is a medical student at the University of Pennsylvania. He studied for an MSc in International Health Policy at the LSE in 2011-12, where his dissertation investigated the relationship between uncertainty and technological change in health care. He graduated from the University of Notre Dame as valedictorian in 2011, studying biology and classics. Interested in the intersection of science, technology, and society, Edward has worked in wireless health care and at the UK Department of Health, as well as in basic science laboratories. Read more reviews by Edward.