Dr Ezekiel Emanuel was the man Barack Obama called upon to push through his controversial health reform package, writes JOANNE HUNT
‘A ONCE in a century achievement” – that’s how Dr Ezekiel Emanuel describes the changes happening to the US health system right now.
With health reform central to Barack Obama’s ‘Yes we can’ manifesto, once in office it was to fellow-Chicagoan Emanuel, an oncologist and medical ethicist, that the US President turned to help make his hustings pledge a reality.
Older brother to former White House chief of staff Rahm Emanuel and Hollywood agent Ari, said to have inspired the West Wing character John Lyman and Entourage’s Ari Gold respectively, Ezekiel is the only sibling not yet to have inspired a television character. Though, if his US health reforms succeed, the mantle of superhero might just fit.
The ills of the US health system were legion. According to Emanuel, despite spending $2.53 trillion (€1.64 trillion) on health annually – that’s twice the OECD average and the equivalent of the entire GDP of France – US citizens were less healthy than those of comparable nations. In fact, when compared with 29 developed countries, an American male aged 65 ranks 12th for life expectancy, while an American woman ranks 16th.
A traditional reliance on employer-paid health insurance means there has always been a swathe of US citizens who fell outside the system. This meant that millions of people, unable to afford their own cover and not poor enough to qualify for government-provided care, simply went without medical treatment.
The pattern of massive spending for less than stellar results was set to continue. “By 2080, if we did nothing, one out of two dollars would be spent on health,” says Emanuel.
Doing nothing was not an option. The Oval Office assembled a team, including Emanuel, to lead the charge on reform.
For the graduate of Amherst College, Oxford University and Harvard Medical School, politics and ethics are not the oil and water one might expect.
“Health policy raises lots of ethical questions,” says Emanuel, in Dublin recently to address the Amnesty International Ireland annual conference.
“One of the questions is equity, and what does equity mean in healthcare – what’s an appropriate doctor-patient relationship, what are people entitled to, what aren’t they entitled to.
“Inevitably health policy raises ethical issues. I had been working very intensively on these issues, so I wasn’t plucked out for no reason,” he jokes.
Temporarily leaving his bioethics post at the National Institutes of Health to become White House special adviser on health policy, Emanuel helped shape a health reform bill signed into law last year that will see the largest expansion of healthcare provision in the US in decades, guaranteeing access to medical insurance for an extra 32 million people by 2019.
So how will it work in practice, and can Ireland, poised for its own health reform, learn from what’s happening stateside?
“Now everyone in the United States is going to have a mandate to get healthcare,” says Emanuel, a premise that our own new government also favours. “The heart and soul of the legislation is really to continue the employer-based system – whereby most people get their coverage through their work – and then to provide subsidies to small businesses and families to help them afford insurance premiums.”
Medicaid, the government insurance scheme, will also expand to include those within a greater range of the poverty line and “exchanges” or marketplaces will be set up, enabling citizens to compare the coverage of rival insurance providers.
But with reforms bringing an extra 30 million citizens into the system, who is going to pay?
“The funding for reform comes from many sources, the primary of which are not increases in taxes but savings from within the system,” says Emanuel.
In fact, savings of more than $30 billion (€21 billion) have already been earmarked from using generic drugs, simplified administration, cheaper X-rays and insurance fraud enforcement alone, he says.
More co-ordination among medical professionals to provide better patient outcomes is being demanded too. Targets to reduce hospital-acquired infections and hospital falls, a goal to bring hospital 30-day readmissions down by 20 per cent and bundled payments to doctors to provide a more holistic and accountable approach to care are all part of the mix.
Insurance companies will have to play by new rules too. The changes mean that customers can’t be excluded based on pre-existing conditions, no limits are being put on how much a patient can claim in a lifetime and children are allowed to stay on their parents’ policies until aged 26.
Emanuel says the government’s target is “the sweet spot of higher quality at lower cost”. Instead of viewing healthcare as a financial black hole, he views its reform a gift horse.
“One thing that’s very important is that there’s no deficit financing for this healthcare reform,” he says.
“All of our estimates show that by the end of the decade – that’s by 2019 – healthcare reform should reduce the deficit by over $100 billion [€70 billion] and by the end of the next decade by almost a trillion dollars.”
For Emanuel, the uneven distribution of cost in the US health system brings the clearest quality and cost opportunities. “Ten per cent of the population [pays for] 64 per cent of all healthcare costs,” he notes.
It is these people with chronic illnesses for whom an improvement in quality of care can bring disproportionate cost savings. “Focus on that 10 per cent: that’s where the money is,” says Emanuel.
He says “unnecessary services” to those with chronic conditions are leading to waste and cites a study showing that across six chronic conditions – including heart failure, diabetes and hypertension – potentially avoidable complications account for 40 cent of every dollar spent.
With hospital-related expenses accounting for one-third of health spending, it’s no surprise that primary care will receive greater emphasis. Possible approaches to improving quality and reducing costs include the establishment of medical homes and accountable care organisations.
Reforms include the provision of dedicated non-physician care co-ordinators assigned to oversee groups of patients with chronic conditions, access to 24/7 primary care to keep patients out of the emergency room, IT investment to facilitate patient tracking and physicians being paid for performance.
Such a return to face-to-face connections between patients and care-givers, with nurse practitioners replacing doctors for routine tasks such as wound care, weight or medication checks, will not only reduce cost but improve outcomes.
As well as grants to doctors to upgrade their IT systems, a $600 million investment in comparative effectiveness research will enable the collection and analysis of data on the effectiveness of certain treatments or drugs – the results of which can benefit all countries.
Emanuel returned to his bioethics post in January, having completed his White House stint, though not without some battle scars.
Right-wing pundits and the New York Post dubbed him a “deadly doctor”, construing his proposed reforms to chronic illness care to mean worse care for the most sick.
Emanuel is philosophical about the attack. “Some [people try] to use healthcare reform for political advantage rather than for the good of the country . . . you know politics can be a very nasty contact sport, so you just have to have thick skin and not get absorbed in the trivialities and untruths,” he says.
With billions of dollars at stake and many vested interests, of course things were bound to get nasty.
“One in every six dollars goes on healthcare in the US, in Europe it’s closer to one in 10. That means there are a lot of people who have an interest in the healthcare system and any change is going to upset business as usual.
Quoting Stanford health economist and fellow pro-reformer Victor Fuchs, he says, “If you’re not really making people upset with healthcare reform, you’re not really doing reform.”
Dr James Reilly, take note.
Dr Emanuel was in Dublin to address the Amnesty International Ireland annual conference
