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Obamacare gets insider’s checkup

Most of the coverage and all of the political discussion these past few weeks about Obamacare has been more appropriate for a horse race, or a basketball tournament. How long does the website take to load? How many people have signed up? What do the polls say today?

Those who want to move beyond the shouting to really understand the revolution in health care that’s unfolding before us should consider Ezekiel Emanuel’s book, the title of which is nearly as long as the law it proposes to explain: “Reinventing American Healthcare: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System.”

This book looks beyond the latest denunciations and endorsements to deal with bigger questions. Where have we been on health care? And where are we going?

But a caveat is in order. Those who read it will realize they’re getting a darn favorable view of Obamacare, and for good reason. Emanuel, whose brother, Rahm, was President Obama’s chief of staff and now is mayor of Chicago, was one of the architects of this society-changing law. He’s a bioethicist and professor at the University of Pennsylvania.

That does not preclude Ezekiel Emanuel from delineating some of the law’s flaws and omissions. He is particularly disappointed, as noted in the excerpt above, that the law did not do more to change how doctors and hospitals are charged for services.

And his account of why malpractice reform did not make it into the Affordable Care Act – despite calls for it by the American Medical Association, Republicans and President Obama himself – provides an eye-opening and disillusioning insider look at the way the legislative process sometimes works to sideline indisputably meritorious proposals.

The first third of Emanuel’s book is an edifying journey through the history of American health care. In the 19th century, Emanuel writes, the forerunners of American hospitals began as places where chronically ill poor patients could be warehoused.

“Surgery was unsafe, often lethal. Infections regularly swept through the hospitals. Upper- and middle-class people avoided hospitals, preferring to receive their care at home.”

Medical advances such as the germ theory of disease and development of anesthesia, he recounts, made hospitals respectable and safer. Between 1890 and 1920, hospitals proliferated.

Physicians, once viewed as “quacks and snake oil salesmen,” began to evolve into the respected professionals of today during roughly that same period as standards for medical schools were raised and licensing requirements were instituted.

Health insurance in various forms is as old as the republic. Emanuel notes that during the Revolutionary War era, the first U.S. Congress passed a law requiring medical coverage for the crews of ships over 150 tons.

But health care didn’t become a standard benefit for workers until the World War II era, when employees were scarce because so many men were fighting overseas, but businesses were forbidden to raise wages. Health insurance was a perk that could be added in lieu of raises, which led to the employment-based insurance system of today.

The second third of Emanuel’s book deals with the long struggle to enact a national health care plan. “The United States has been trying to reform health care for 100 years,” he writes.

There is some interesting insider-baseball material for political junkies in this section. Emanuel, a longtime opponent of euthanasia, writes of how astonished he was to be personally vilified for supposedly favoring “death panels” – a mythological creation of Sarah Palin and other of the law’s most uninformed critics.

But the heart of Emanuel’s book is the final third, in which he explains what the Affordable Care Act is actually designed to do. Forgotten in the battle to attract signees to the health care exchanges is the ACA’s other mission – to lower health care costs.

Emanuel is confident that this will happen even as the quality of care rises. He sets out a “dashboard” to measure whether we’re moving in the right direction. And he lays out six “megatrends” that he thinks Obamacare has helped to set in motion or accelerate.

They include: “the end of insurance companies as we know them”; the decline of employer-sponsored health care plans; a focus on better long-term care for the chronically and mentally ill; the ascent of digital medicine, which he predicts will lead to the decline of traditional hospitals; big changes in medical education; and – most optimistically – “end of health care inflation.”

All this, of course, is filtered through Emanuel’s unique perspective: knowledgeable but involved. He is an acute critic of the health care system but also a proud papa of the Affordable Care Act.

Somewhere, no doubt, a fine journalist is preparing a great book that will give the world a clear, objective look at Obamacare. Emanuel’s book is not that book. But it can be read profitably if you keep the 21st century’s all-purpose benediction in mind: “It is what it is.”

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