The best joke in Zeke Emanuel’s new book is told near the beginning but referenced throughout, which makes the joke yet richer and more multi-layered by the book’s dense 349 page end. It goes like this: There are two people who actually understand the American health system, and both Victor Fuchs and Alain Enthoven are 90 and 83 years of age, respectively. I don’t care if Zeke Emanuel wrote the joke because what he did write is the book that should make all of us a little less fearful in light of these truths.
The best parts of Reinventing American Health Care might really be seen as two shorter books, intertwined. Several chapters, particularly the descriptive chapters in Part I on the American Health Care System could be a standalone book as a primer on the American health care system or what the anthropologist Clifford Geertz described as “thick description.” More than an entry level overview of the status quo, these chapters (particularly Chapter Two on Financing Health Care) represent something I might assign to my health law students. The second book on the process of health care reform up to the present might be called “How the Sausage Got Made” and essentially offers a standalone account of the history of health care reform – real and attempted – in the United States.
The weakest parts of the volume I would leave out entirely, were this my version to create of a newly edited palimpsest. No one needs to read any more apologies for the failed rollout of healthcare.gov, particularly short sighted ones declaring (in December, 2013 when the manuscript was ostensibly put to bed) that all is well. Really? This rings a little less true in the very week when Oregon is reported to be considering abandoning its state operated exchange and directing all Oregonians to healthcare.gov.
This book, though showing some evidence of the great haste with which it must have been written, does offer a valuable overview for a health care reform bookshelf remarkably short on overview and synthesis. I am, as a result, less concerned that Zeke Emanuel thinks physicians are “convicted” (a criminal law term) of medical malpractice liability than that he actually takes the time to talk about the legal challenges to the ACA in terms a literate layperson could understand.
More concerning, however, is his assertion that the far more important and interesting provisions of the ACA do not concern Medicaid expansion but concern the exchanges/marketplaces. This one I cannot let pass. As I have argued elsewhere and Zeke Emanuel himself has argued within this very book, the development of the health care exchanges and the so-called individual mandate were the incremental reforms. It is the now optional Medicaid expansion that was to have been revolutionary and may yet still be revolutionary but in a far more incremental way itself — ironically.
Still, so much is right about this book, I commend it to you for the overview it is and the primer it could be.