Steve Reads

Healthcare, Guaranteed is a set of talking points, and a sales pitch. Ezekiel Emanuel wants to sell us on his Guaranteed Healthcare Access Plan. It promises a radical simplification of the American healthcare-delivery system. First, everyone would be entitled to basic health care, and could pay for additional care beyond the basics. Every citizen would be given a card entitling him to coverage through a qualified insurance provider. In order to keep costs under control, Emanuel’s plan would create an Institute for Technology and Outcomes Assessment that would decide whether new technologies and medicines are beneficial, and would publish statistics on the various health plans’ success at creating healthy patients. It would be funded through a 10% value-added tax, the proceeds of which couldn’t be used to fund any other program.

Finally, central to the whole thing is a National Health Board and twelve regional Health Boards patterned on the Federal Reserve; the health boards would approve insurance plans or kick them out. Like the Fed, the Health Board’s advertised virtue is its insulation from politics. Having just read a biography of Dick Cheney, who was old friends with Alan Greenspan and met regularly with the man in private, I have my doubts about this purported insulation.

Much more importantly, it strikes me as wrongheaded, depressing, and insufficiently principled to want to take power away from the democratically elected branches of government because of the failings of politics; why not just give up on the whole democratic process, then? I can certainly understand the justification: the Fed does control, and the Health Board would control, vast swaths of the economy; one dollar in every six goes to health care under our current broken system. While not denying the logic here, I’d like to see it applied to other important sectors. The Department of Defense, for instance. Surely we wouldn’t want something as sacred as the security of our homeland to be subject to bribery, wherein the states that manufacture new weapons systems or house military bases are chosen on the basis of political power? Surely not. Defense should be walled off from those who would weaken our country in the name of politics.

I hope others find it as disheartening as I do that the first thing politicians often want to do, when confronting a new problem, is to wall it off from their own work. Emanuel is not a politician, we must note — he’s the Chair of the Department of Bioethics at The Clinical Center of the National Institutes of Health with a political-philosophy Ph.D. from Harvard and an M.D. from the same university’s medical school — but this apolitical, technocratic dream is a common one. Tom Daschle (who is a politician, and will probably be Obama’s Secretary of HHS) lays out the same dream near the start of his book Critical.

Healthcare, Guaranteed works better as a series of talking points than as a detailed policy manual. First, it’s good to be reminded of exactly how broken our system is, and the various overlapping pieces that still fail to cover one in six of our countrymen: Medicare if you’re old, Medicaid if you’re poor, private insurance while you’re employed, the emergency room when you’re not, COBRA for a short window in between. And it’s good to be reminded of the consequences of this failure. People stay in jobs that they hate because they lose their safety net when they leave. People stay married because their spouse works and they don’t. Companies employ full-time staff just to sort through the details of competing health plans, thereby taking money away from the jobs that the companies actually specialize in; they’re software companies or automobile companies, after all, not health-insurance-picking companies. A rational system would take this burden out of the hands of companies and shift it onto some entity that specializes in doing it. (Though with that in mind, it’s worth looking to see whether companies already outsource HR. If not, why not? If so, then we have less reason to believe that the government needs to do this.)

Here, though, Emanuel again makes me uneasy: his plan would give the Institute for Technology and Outcomes Assessment the job of measuring medicines, technologies, and health. But doesn’t the FDA do that? Healthcare, Guaranteed doesn’t ask why the FDA is failing at its job. Read Marion Nestle’s What To Eat and Food Politics to understand some of the details there. The food industries have lobbied hard to hem in the FDA and make it less and less able to do its job. Insulating the FDA in some way from politics could certainly help here … but why would I — or any American who sees how his government works — expect Congress to construct a better system than the one we already have, when it can’t handle the system it’s already got? Here of course we get back to the politically insulated structure that Congress will apparently construct, and again I shake my head at Congress’s perception of its own fecklessness in the face of lobbying.

At some point I need details, specifically: how will the National Health Board be kept insulated from politics? If the Fed only has a lever or two to handle (mostly interest rates), I can see how it wouldn’t be the victim of much lobbying: just about as many people will probably want low interest rates as high ones. The new health administration, by contrast, will decide which medicines can be used and which insurance plans are available. That’s a lot of machinery and a lot of little gears. How exactly do we keep it under apolitical control?

These are the sorts of detail questions that Emanuel is loath to answer in Healthcare, Guaranteed. He considers his book ground-clearing, and suggests that thinking too much about the details is a strategy that opponents typically use so that nothing gets done. Perhaps so. Perhaps it’s best to start with what we want, aim for it, and let the details fill themselves in later. I have my doubts; the structure of government-as-she-is contains a lot of hard-won information that we ignore at our peril.