Health Care
4:53 am
Sat March 8, 2014

Affordable Care Act Isn't Perfect, But It's A 'Pretty Good Structure'

Originally published on Sun March 9, 2014 9:20 am

For the Affordable Care Act to be considered a success years down the road, Ezekiel Emanuel believes that all Americans must have access to health coverage, and it must be better quality and lower cost. "And I think it's well within our grasp," he says.

A special adviser to the Obama White House in medical reform, Emanuel was instrumental in advising the health care overhaul. He's just published a new book called Reinventing American Healthcare: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System.

"Is the Affordable Care Act perfect? No, but it's a pretty good structure to go forward," he tells NPR's Scott Simon. "Let's fix the problems that it has and move onto other improvements we can now recognize."


Interview Highlights

On the impact of the Affordable Care Act so far

It is complex, but the health care system is complex. And I do think it actually has improved the system. ... It's gotten a lot of people insurance that didn't have it — people under 26 on their parents' plan. It's gotten 4 million — probably in the end it'll be 6 million people this year — on insurance, and it's created a structure for getting insurance to everyone. It's reduced a lot of infections already, it's reduced hospital errors, reduced re-admission, so it's had an improvement in quality. And actually, for the last few years, costs have been under control. Not all of that is the Affordable Care Act, but certainly some of it is.

On the flawed rollout of HealthCare.gov

It has sort of colored people's view that the government can't do anything right, but that wasn't inherent. We didn't have to have that kind of mistake. You only need to look at a place like Connecticut, that's had a very good rollout ... similarly in Kentucky, California and other states.

There's still a lot of room to go. And as I like to say, this is an e-commerce website, it's like Amazon except for health insurance, and so there's going to need to be constant attention, constant management, constant efforts to improve it, to make sure it's using the latest technology, giving people the best health care options and choices.

On how the insurance industry will change

Health systems are going to begin offering coverage, and so you'll buy your coverage from the same organization that delivers the care, kind of like more Kaisers in this world. Similarly, health insurance plans are going to begin employing doctors, hospitals, and organizing them to deliver the best kind of care.

So I think insurance companies are going to get into providing health care as well as insuring, and hospitals are going to begin providing insurance as well as providing the care. You're going to see these, what I call "integrated delivery systems" that's going to be the dominant mode. So you're going to buy your insurance from maybe Cleveland Clinic, maybe Mayo, maybe Johns Hopkins, instead of from an insurance company.

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Transcript

SCOTT SIMON, HOST:

This is WEEKEND EDITION from NPR News. I'm Scott Simon. The Affordable Care Act is now law. One of the people who was most instrumental in advising health care overhaul was Ezekiel Emanuel, who was special advisor to the Obama White House on health care reform. He's a professor of medical ethics and health policy at the University of Pennsylvania and a senior fellow at the Center for American Progress.

Dr. Emanuel has written 10 books, but now he has a new one: "Re-Inventing American Healthcare: How the Affordable Care Act Will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System." Dr. Emanuel joins us in our studios. Thanks so much for being with us.

DR. EZEKIEL EMANUEL: It's a great honor to be here.

SIMON: I have to ask, how would you feel about a book subtitled: How the Affordable Care Act So Far Seems a Terribly Complex, Blatantly Inefficient, Outrageously Error Prone System that Raises Many Health Care Premiums and Prevents Some People from Keeping Their Doctor?

EMANUEL: Well, that wouldn't be accurate and so I think it wouldn't be a good subtitle. It is complex, but the health care system's complex and I do think it has actually improved the system in at least three ways. It's gotten a lot of people insurance that didn't have it. People under 26 on their parent's plan. It's gotten four million - probably in the end it will be six million this year - on insurance. And it's created a structure for getting insurance to everyone.

It's reduced a lot of infections already, it's reduced hospital errors, reduced readmissions. So it's had an improvement in quality. And actually, for the last few years, costs have been under control. Not all of that is the Affordable Care Act, but certainly some of it is.

SIMON: In this book even you use the word disastrous to describe the rollout of healthcare.gov. You say the mistakes were managerial, not fundamental to the plan. But did the website problems feed the worries of many that this - they see as going to be a huge government program that'll be impossible to manage, 'cause, you know, you can return a pair of shoes in the wrong size at Zappos. There's no return on health care mistakes.

EMANUEL: Well, I do agree with you that it has sort of colored people's view that the government can't do anything right, but that was not inherent. We didn't have to have that kind of mistake. You only need to look at a place like Connecticut, that's had a very good rollout, and I think had a very good exchange and will continue to; similarly in Kentucky, California and other states.

There is still a lot of room to go and as I like to say this is an e-commerce website. It's like Amazon except for health insurance and so there's going to need to be constant management, constant efforts to improve it to make sure it's using the latest technology, giving people the best health care options and choices.

SIMON: But isn't health care a good deal more serious to people than, you know, ordering a new plunger through Amazon?

EMANUEL: Correct, but you order a lot of important things for yourself over Amazon and this is actually about buying insurance. The website is not about delivering care. That we still do in hospitals.

SIMON: But you need the insurance for the care.

EMANUEL: Exactly, and this is a way of getting insurance to people and, again, I think over a couple of years we're going to work out most of the kinks and I do hope that they have a different kind of administrative structure that is really focused on execution going forward. And I've been calling for that and I do think that is very important for the future and to make sure that this is a viable operation for the next 10, 20, 30 years.

SIMON: You say in this book, you talk about the end of insurance companies as we know them. And now you also say they may have gotten a bad rap, that at least should be shared. What do you see over the horizon?

EMANUEL: One of the big ones, I think, is insurance companies as taking a premium, paying doctors, paying hospitals; that's going away. And it's going away for two reasons. One, is health systems are going to begin offering coverage and so you will buy your coverage from the same organization that delivers the care, kind of like more Kaisers in this world. Similarly, health insurance plans are going to begin employing doctors, hospitals and organizing them to deliver the best kind of care.

So I think insurance companies are going to get into providing health care as well as insuring, and hospitals are going to begin providing insurance as well as providing the care, and you're going to see these, what I call integrated delivery systems. That's going to be the dominant mode. So you're going to buy your insurance from maybe Cleveland Clinic, maybe Mayo, maybe Johns Hopkins instead of from an insurance company.

SIMON: A few years from now, five, 10, how would you define the success of the ACA? More Americans covered or more Americans getting better health care?

EMANUEL: I think we have to have both. Expanded access so everyone in America can get health coverage and improved quality with lower costs. And I think it's well within our grasp. Is the Affordable Care Act perfect? No. But it's a pretty good structure to go forward. Let's fix the problems that it has and move on to other improvements we can now recognize.

SIMON: Dr. Ezekiel Emanuel. His new book - let me take a breath - "Reinventing American Healthcare: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System." Thanks so much for being with us.

EMANUEL: It's my pleasure. This was great. Transcript provided by NPR, Copyright NPR.