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The definitive story of American health care today—its causes, consequences, and confusions
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. The ACA was controversial and highly political, and the law faced legal challenges reaching all the way to the Supreme Court; it even precipitated a government shutdown. It was a signature piece of legislation for President Obama’s first term, and also a ball and chain for his second.
Ezekiel J. Emanuel, a professor of medical ethics and health policy at the University of Pennsylvania who also served as a special adviser to the White House on health care reform, has written a brilliant diagnostic explanation of 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.
Emanuel also explains exactly how the ACA reforms are reshaping the health care system now. He forecasts the future, identifying six mega trends in health that will determine the market for health care to 2020 and beyond. His predictions are bold, provocative, and uniquely well-informed. Health care—one of America’s largest employment sectors, with an economy the size of the GDP of France—has never had a more comprehensive or authoritative interpreter.
- Sales Rank: #24501 in Books
- Published on: 2015-03-03
- Original language: English
- Number of items: 1
- Dimensions: 8.20" h x 1.30" w x 5.50" l, 1.37 pounds
- Binding: Paperback
- 400 pages
From Booklist
In this unabashedly pro-Obama-care book, prominent bioethicist Emanuel makes a convincing, albeit one-sided, case for overhauling what he sees as an unfair health system in the U.S. Deftly using numbers to make his arguments, Emanuel organizes his book into three parts: the current system (largely its financing), health-care reform (the nearly 1,000-page Affordable Care Act ACA and legal challenges to it), and the future (lots of hospital closings). Today more money goes to the 4,985 acute-care hospitals ($970 billion in 2012) than all of Social Security ($730 billion) or national defense ($650 billion). And before ACA, nearly 50 million Americans, including 12 million undocumented aliens, lacked insurance. He also touches on important history (the creation of Medicare in 1965) and clearly explains complicated issues. For example, he uses a menu-pricing analogy to explain bundled payments: “If fee-for-service is ordering à la carte, bundled payment is prix fixe.” A plain-English explanation of a tricky topic. --Karen Springen
Review
“For Americans poisoned by nefarious medical insurance companies and a G.O.P. dying to gut Obamacare, I prescribe Ezekiel Emanuel’s Reinventing American Health Care (PublicAffairs) to clarify how the Affordable Care Act can rehabilitate our nauseatingly unjust, grossly expensive, and senselessly complicated health-care system. My personal recommendation? Lay off the toxic propaganda.”—Vanity Fair
“Whether you agree with his conclusions or not, they’re well argued, and he has marshaled an impressive amount of information.”—Washington Post
“Infused with diagrams, charts, and tables, this book is informative, thought-provoking, and immensely important. Given his role in the program, and as is reflected in the subtitle of the book, Emanuel clearly wants to persuade, but he also wants to explain. And because he was an insider — and proves himself a gifted writer — he makes an able guide to the complexities of the landmark legislation… Clearly, if Obamacare is to fulfill its promise there will need to be significant changes and that will require collaboration among citizens, health care professionals, scholars, and lawmakers from across the political spectrum. And the only way this can happen is if people understand what exactly is at stake. ‘Reinventing American Health Care’ spells this out clearly, and by doing so, lays the foundation for this kind of collaboration to occur.”—Dennis Rosen, Boston Globe
“With this book, Zeke Emanuel has done the country an immense service. He does the impossible—explain the dysfunctional American health care system—and then takes it one better. For here he also makes the hard-eyed case for understanding that the passage of health reform—of Obamacare—has set us on a path for a health system that works. Our system has left millions without needed care, bankrupt, or both, and tied the fate of their health to where they work. This book explains how we got in this fix, how we will get out of it—and even more boldly, when. If you wanted to read one book to understand health care, this is the one you want.” —Atul Gawande, surgeon, staff writer for The New Yorker, and author of The Checklist Manifesto
“There are thoughtful doctors, savvy policy makers and profound scholars of morality. Zeke Emanuel is the only person in America who is all three. That makes him the right person to write the definitive primer on health care in America. It should be read by anyone who wants to understand what may be the most important set of domestic issues facing America.” —Lawrence H. Summers, former Secretary of the Treasury of the United States, & President Emeritus and Charles W. Eliot University Professor of Harvard University
“Zeke Emanuel has written a book that tells people interested health care policy what they need to know but all too often do not. He brings together a staggering variety of information, never before available in one place, on economics, medicine, legislative history, governmental operations, politics, and the gory, boring, and surpassingly important issue of implementation. No single book can tell one all one needs to know about the most complex health care system in the world, but this one comes very close indeed.” —Henry J. Aaron, the Bruce and Virginia MacLaury Senior Fellow in the Economic Studies program at the Brookings Institution
“The author, who serves as a special White House adviser on health care reform, is optimistic that its glitches will be resolved within the year and that it will transform how patients are cared for over the coming decades…He offers an insider’s account of some of the infighting that occurred within the Obama administration…The author takes a long view of the reforms beginning with incentives and penalties for the adoption of uniform electronic health records in the 2009 Recovery Act…An important challenge to the naysayers on both sides of the political divide.”–Kirkus Reviews
“Prominent bioethicist Emanuel makes a convincing, albeit onesided, case for overhauling what he sees as an unfair health system in the U.S. Deftly using numbers to make his arguments, Emanuel organizes his book into three parts: the current system (largely its financing), health-care reform (the nearly 1,000-page Affordable Care Act [ACA] and legal challenges to it), and the future (lots of hospital closings) …He also touches on important history (the creation of Medicare in 1965) and clearly explains complicated issues…A plain-English explanation of a tricky topic.”–Booklist
“Few people have had a more favorable influence on the shaping of the current processes of health care reform than Zeke Emanuel has. And no one is a better, clearer, or wiser interpreter of the insanely complex non-system that we are trying to fix. This book is an instant classic—mandatory reading for anyone who wants to know how we got where we are in American health care and where we need to go.” —Donald M. Berwick, MD, MPP, president emeritus and senior fellow
at the Institute for Healthcare Improvement, and former administrator
of the Centers for Medicare and Medicaid Services
“Reinventing American Health Care is an informed and informative book and likely to be just as controversial as Zeke Emanuel was during his tenure in the Obama administration.”—Gail Wilensky, senior fellow at Project HOPE and former deputy assistant to President George H. W. Bush for policy development
“Emanuel provides an entertaining and informative mix of history, fact, argument, and speculation. His book’s subtitle to the contrary, it is not simply a defense of the ACA. Emanuel does a superb job of describing the history of health care in the United States, the complexities involved with it, and the various attempts that have been made to reform it. And while he is a defender of the ACA, he is also honest about the difficulties the law has faced during implementation…This is essential reading for anyone interested in understanding one of the most pressing issues of American politics today and in the future." — Health Affairs
About the Author
Ezekiel J. Emanuel is vice provost for global initiatives and chair of the department of medical ethics and health policy at the University of Pennsylvania. From January 2009 to January 2011, he was a special adviser on health care reform to the White House. He is the author or editor of ten books and over 250 scientific articles. He is currently a senior fellow at the Center for American Progress, a columnist for the New York Times, a regular contributor to the Wall Street Journal, contributing editor at The New Republic, and appears regularly on television, including Morning Joe, Real Time with Bill Maher, Hardball with Chris Matthews, and The Rachel Maddow Show.
Most helpful customer reviews
49 of 51 people found the following review helpful.
Six Megatrends: Agree or disagree?
By Philip Lederer
Ezekiel Emanuel just published an important book with a great title, "Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System." In it, he describes the history of health care reform in the US, gives an overview of the Affordable Care Act (ACA), and speculates about future trends in American health care.
The concluding chapter of Emanuel's book is entitled, "Six Megatrends in Health Care: The Long-Term Impact of the ACA." I will devote this review to discussing his six "megatrends."
Megatrend 1) The End of Insurance Companies as We Know Them
Emanuel argues that health insurance companies will "shift their business to focus on offering services they have expertise in, particularly analytics, actuarial modeling, risk management, and other management services...." or "transform themselves into integrated delivery systems," or they will go out of business. This seems quite plausible. However, I think it will depend on how the ACA implementation goes over the next several years. If insurance companies raise their rates, there could be major political fallout.
Megatrend 2) VIP Care for the Chronically and Mentally Ill
Emanuel argues that "tertiary prevention" for chronically ill people with diabetes, heart disease, cancer, etc, and mental health care for people with depression/anxiety, will become an increasing focus of our health care system. I agree. I've taken care of many patients with chronic diseases and mental illness who cycle in and out of the hospital. The question is if our fragmented health system can provide coordinated, community-based care for these vulnerable people. Doctors and nurses must learn to use a biosocial approach when taking care of marginalized patients with chronic disease and mental illness.
Megatrend 3) The Emergence of Digital Medicine and the Closing of Hospitals
Emanuel writes: "Digital medicine will allow physicians to monitor patients remotely anywhere they are, get labs and many imaging tests done, and perform interventions once done exclusively in the hospital." I agree - sort of. We are rapidly headed into a digital era. More health care will be provided in the community, and digital devices will continue to proliferate. But will these digital devices provide value for money? Or will the hype outpace their effectiveness? Unfortunately, so far, the hype is winning.
Megatrend 4) The End of Employer-Sponsored Insurance
This controversial megatrend was analyzed in yesterday's front-page New York Times article. I think this megatrend is very difficult to predict. It depends on a number of political and economic factors. Will America's health insurance system remain constant, or will it move 1) towards a Republican system based on tax credits, or 2) towards a single payer system based on universal health coverage, or 3) a Kaiser-like group model? The latter is the most likely.
Megatrend 5) The End of Health Care Inflation
I'm definitely not an economist, but I'm not sure I agree with Emmanuel that the ACA will succeed at controlling the growth in health care costs. In his book, Emanuel admits that the ACA didn't go far enough on payment reform, and that there remains "a serious misalignment between what we want physicians and hospitals to do in terms of improving value, efficiency, and reducing unnecessary care and how insurance companies, Medicare, Medicaid, and others pay them." As long as our fee-for-service system is around, and Medicare payments and RVUs are biased towards specialists, the growth of health care costs won't be controlled.
Megatrend 6) The Transformation of Medical Schools
I agree with Emanuel. Medical schools must change, and become much more team-oriented, community health oriented, and digital medicine oriented. The problem is that medical school curricula are very difficult to change. Can they begin to change rapidly? I'm not sure. If they can, it will require a major awakening of medical students and faculty.
With the enormous amount of material for physicians to learn, does reducing the length of medical school from 4 years to 3 years really make sense? I don't think so. I think it would be preferable to keep medical school at 4 years and subsidize medical school tuition, or provide 100% debt forgiveness for medical students who enter primary care careers. The National Health Service Corps is a good program, but it doesn't go nearly far enough. If medical school is reduced to 3 years, will the training physicians receive really be sufficient?
18 of 22 people found the following review helpful.
Somewhat optimistic
By Deborah Sue St Clair
This book, like the affordable care act, was born from a combination of idealistic beliefs that the dysfunctional health care system was somehow separate from the dysfunctional class divided society that it supports and that the health care systems fails because of inefficiency within itself. In reality the system re-aligns itself periodically according to the payments system, and in this sense delivers what society asks of it to do. The book supports the myth that better technology and electronic health records will allow advanced data mining to discover new medical truths and improve efficiency, in spite of the fact that every advance in technology beyond immunization has raised costs.. It celebrates the highly efficient veteran's administration hospital system as the best we have.
All this has some validity, but it was written before the Snowden revelations and before we discovered that the veterans hospitals cook the scheduling books before reporting their outcomes, bringing into disbelief all that these hospital system claims.
But I was happy to read this book, and it is a smooth fast read giving insights into what the health care planners of the federal government read before they wrote the bill that congress voted after a year of heated debate, but never actually read themselves.
1 of 1 people found the following review helpful.
An Excellent Presentation on American Health Care
By Randolph Eck
Ezekiel Emanuel has written a very interesting book about the U.S. health care system. In the introduction, he tries to make sense of how three individuals were affected by this system. He then proceeds to get into the nitty-gritty of the American health care system beginning with it roots. The book is divided into three parts. In Part I we review the history of the American health care system, in Part II we explore the efforts to reform the system, and finally, in part III, we gaze into the crystal ball of the future.
In the first part, he provides us with a brief history of healthcare in the U.S. It was interesting to learn how the employer-base system came to predominate in society. In the rest of the section we get a very detailed description of how healthcare is financed, who the providers are, how Americans get their healthcare, and interestingly, how this all works together to give us our current healthcare system. We are provided with many tables, charts, and diagrams, which provide some interesting statistics.
In part two Emanuel discusses the history of health care reform. He first covers the history of health care from Teddy Roosevelt, to Franklin Roosevelt, to Truman, to Lyndon Johnson, and on to Clinton. Truman was a strong advocate for national health care but was stopped by the first Republican controlled Congress since 1932. Johnson did manage to introduce Medicare and Medicaid laws, and most can remember what happened to Clinton’s proposal. Interestingly in 1971, there were 22 separate health insurance bills before Congress. Not one made it out of committee. We clearly see the difficult road that was followed to achieve some sort of national health care.
Emanuel continues on to explain to us the details of the enactment of the Affordable Care Act (ACA) and the immediate challenges to the law. Just minutes after being signed into law, over 20 states filed a lawsuit challenging its constitutionality. This was to be followed by an incessant barrage of lawsuits over the ensuing years, some of which the Supreme Court had to decide.
In Chapter eight, we get some very detailed information about exactly what is in the ACA. This is a very valuable chapter; it contains a wealth of information on the inner workings of the ACA. Many tables and charts are presented to explain to us exactly what this law does. It would behoove anyone interested in healthcare in American to read this over and learn the wealth of benefits provided by the law. Most people have no idea of all the things provided for by the law that ensures affordable healthcare, and it manages to (after ten years) be revenue positive, according to the Congressional Budget Office. In addition to access, according to Emanuel, “The ACA also addresses cost, quality, prevention and health promotion, health care workforce issues, and many other matters.”
In a following chapter, the author shows us what the ACA means to us, before delving into Part III, where he discusses the future of health care in America. We are introduced to various “dashboards” that cover coverage, cost-control, quality, and overall health status. The author also discusses various reforms that build on the ACA to advance health promotion and prevention, cost control, and quality improvement that he says are “shovel ready.” In the final chapter, we are informed of the long-term impact of the ACA. It is the author’s belief we will eventually see the demise of insurance companies as we know them, and even the end of employer-sponsored health insurance. We will see more accountable care organizations (networks of physicians, hospitals and other providers). He also discusses four other trends.
I recommend that anyone desiring an understanding of our American health care system read this book. It is as the author says, “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 has been.” I think you will share this conclusion after reading this book.
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