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Reinventing American Health Care: How the Affordable Care Act will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System
Health care is the largest employer in America, one of the largest perceived drains on the budget of the Federal government, a system with the capacity to bankrupt entire state economies, and one of the areas of personal expenditure that gives individual American citizens most financial anxiety. It matters like almost no other dimension of the government and private sector. Yet the system is widely misunderstood, and is a confusing maze to most of us who feel crushed by its complexities quite as much as we feel served by its doctors and nurses.
Coverage, Quality, Cost explains why the American health care system is the way it is (why, for instance hospitals are so dominant), and the five problems that confront any attempt at reform. Teddy Roosevelt, FDR, Truman, Kennedy and Nixon all came to power promising universal coverage, and all failed. Emanuel explains how this happened by way of showing how extraordinary the passage of the Affordable Care Act was: it completely bucked the trend, in the face of some very tough political circumstances. With his unique insider’s view, Emanuel explains why the Affordable Care Act took the shape it did, and in particular examines the political role of the American Medical Association. He then projects how the ACA will affect health care in the future, laying out the likely areas where further reform will be necessary.
380 pages, Hardcover
First published January 1, 2014
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2458 people want to read
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August 25, 2016
Zeke Emanuel’s book on the American health care system and the Affordable Care Act can be a bit of a bumpy ride, but on the whole this rather breathless tour de force well worth the attention of those interested in the country’s largest, most problematic industry.
Reinventing American Health Care comprises three roughly stitched-together parts, focused respectively on describing the American health care system and the origins of its crazy distortions, the process of creating and passing the Affordable Care Act, and the contents of the law itself - plus a sort of tacked-on set of predictions of how the system will evolve as a result of this legislation and other trends.
The first section would be a great short book in itself – the best (only?) comprehensive explanation of why the United States pays vastly more for health care than any other nation, yet gets at best average outcomes. It’s matter-of-fact, generally apolitical, and entirely masterful – absolutely worth the price of admission for anyone who wants to understand the system.
The second section’s focus on the inside baseball of policymaking is a more specialized. Kudos to Emanuel for highlighting the oft-unexplained role of the Congressional Budget Office score on the prospects of any policy. He brings clear attention to the resulting distortions that come with the CBO’s generally well-intended and well-executed purpose.
The third section feels a little rushed, especially its bonus predictions. Emanuel deserves credit for making quantitative forecasts about the impact of the ACA and trends in health care in general, though he often tries to tie the former too tightly to the latter.
Emanuel is full of personality, with an unabashed progressive bent – he takes as a given that central government policy is the solution to economic distortions. He acknowledges flaws in the legislation and that unforeseen problems will arise in its wake, but almost blithely asserts confidence that further legislation will fix them.
While my own views tend the other direction – that well-regulated but decentralized and transparent markets lead to better outcomes – I’ve not seen a path to improving the health care system as masterfully and thoroughly argued from that point of view.
In my field of software product management we’ve adopted a saying from mechanical engineering, “Ugly airplanes don’t fly.” While by any definition the ACA is a very complicated, inelegant, ugly airplane; and while I would prefer to see solutions that reduce rather than increase regulation, tax distortions, and the like – I came away from Emanuel’s book thinking that on the whole, Americans and the health care system will be better off with the ACA than continuing on the earlier course.
As one would expect from a book of this scope, as many questions are raised as answered. But occasionally those questions come from what seem like purposeful evasions that materially undermine Emanuel’s overall convincing argument.
Emanuel glosses over a key issue, one of U.S. health care’s two “Original Sins” (my term): how and why did “insurance”, a financial instrument to spread risk for catastrophic events, get conflated with “financing”, the way to pay for routine procedures? No other service or industry combines the two – people do not file auto insurance claims when they get their oil changed – and in health care, this tie has led to the devastating equivalence of access to “insurance” to access to basic health care.
He pays considerable attention to the second “Original Sin”, the employer tax break for health care benefits that led to the problematic linkage of access to insurance with full-time employment. Emanuel suggests removing the tax break, showing that it “costs” the government far more than any other tax break (including the mortgage interest deduction). But he conspicuously avoids the idea of breaking the link by simply extending that same tax break to individuals directly.
Self-insurance, the mechanism through which large employers bear their employees’ own health risk by paying for health care directly, is an important consequence of the employer-oriented system (and used by nearly all employers of a thousand employees or more). In itself self-insurance is neither good nor bad. But self-insured employer plans are regulated differently from the "fully-insured" plans purchased by smaller employers. Emanuel skips over a new fee (tax? the terms are infamously mixed when it comes to the ACA) on members of fully-insured plans. Insurance companies will pass those fees along to small employers, leading to more self-insurance, with important ramifications for the system.
Emanuel does address the Taft-Hartley Act and related legislation, which encourage labor unions to create their own pooled health plans (funded by employers). However, he avoids addressing the union objections to the ACA because of these structures (moving health insurance to the government, which the ACA generally does, takes away one of the few remaining benefits that unions claim to offer their members). From the outside, it looked like an embarrassing oversight by the authors of the legislation – where’s the story of how the labor-sympathetic policymakers overlooked this issue, and how the unions were ultimately bought off placated?
In many ways, Emanuel reveals the disingenuousness behind the idea that the ACA will reduce cost. For example, he never explains why the law requires new taxes and fees (described in detail, especially Nancy DeParle’s negotiations with drug and device companies on their new taxes to “fund reform”), while also arguing that the ACA reduces government spending. How is the lay reader supposed the need to “fund” legislation that is supposedly cheaper than what it replaces?
Reinventing American Health Care has other indications of bias and general carelessness that are big enough to detract from its ultimately convincing argument.
The term “reform” is used as an apparently self-evident synonym for “universal access to health insurance paid for by active wealth redistribution”. Why couldn’t “reform” mean a market-based system where people buy the care they need directly, in which insurance just provides protection from catastrophic expenses, or one in which people have the option to voluntarily purchase health insurance individually with the same tax advantages as employers?
Spelling errors are rife, especially of company names. “Medtronics” [sic], “Thompson Reuters” [sic], and “Endeon” [sic] (my employer, Emdeon - for whom I do not speak on this blog!) are just a few. What’s more, subject and verbs occasionally do not agree.
The terms “revenue” and “profit” are often used interchangeably. This error is perhaps a subtly revealing indicator of how the left-leaning policymakers (mis)understand corporate finance, but not acceptable in a book about the economics of the country’s largest industry.
The order of the discrete sections occasionally works against itself. For example, the section on the legislative and judicial history of ACA references individual provisions not explained until the subsequent "What's in the ACA?" chapter.
Emanuel tries too hard (and unnecessarily) to attribute broader trends in health care to the ACA, such as in his forecast on the increase in telemedicine.
Even with these flaws and omissions, Emanuel’s book is a success. It’s erudite, heartfelt, compulsively readable – and for all that, convincing. I would love to see its mirror image – a similarly passionate and masterful argument from the right. But until the point there’s a similarly convincing policy from that side, Emanuel has convinced me that we’re better off in the ugly airplane of the ACA than on the path we were on.
Reinventing American Health Care comprises three roughly stitched-together parts, focused respectively on describing the American health care system and the origins of its crazy distortions, the process of creating and passing the Affordable Care Act, and the contents of the law itself - plus a sort of tacked-on set of predictions of how the system will evolve as a result of this legislation and other trends.
The first section would be a great short book in itself – the best (only?) comprehensive explanation of why the United States pays vastly more for health care than any other nation, yet gets at best average outcomes. It’s matter-of-fact, generally apolitical, and entirely masterful – absolutely worth the price of admission for anyone who wants to understand the system.
The second section’s focus on the inside baseball of policymaking is a more specialized. Kudos to Emanuel for highlighting the oft-unexplained role of the Congressional Budget Office score on the prospects of any policy. He brings clear attention to the resulting distortions that come with the CBO’s generally well-intended and well-executed purpose.
The third section feels a little rushed, especially its bonus predictions. Emanuel deserves credit for making quantitative forecasts about the impact of the ACA and trends in health care in general, though he often tries to tie the former too tightly to the latter.
Emanuel is full of personality, with an unabashed progressive bent – he takes as a given that central government policy is the solution to economic distortions. He acknowledges flaws in the legislation and that unforeseen problems will arise in its wake, but almost blithely asserts confidence that further legislation will fix them.
While my own views tend the other direction – that well-regulated but decentralized and transparent markets lead to better outcomes – I’ve not seen a path to improving the health care system as masterfully and thoroughly argued from that point of view.
In my field of software product management we’ve adopted a saying from mechanical engineering, “Ugly airplanes don’t fly.” While by any definition the ACA is a very complicated, inelegant, ugly airplane; and while I would prefer to see solutions that reduce rather than increase regulation, tax distortions, and the like – I came away from Emanuel’s book thinking that on the whole, Americans and the health care system will be better off with the ACA than continuing on the earlier course.
As one would expect from a book of this scope, as many questions are raised as answered. But occasionally those questions come from what seem like purposeful evasions that materially undermine Emanuel’s overall convincing argument.
Emanuel glosses over a key issue, one of U.S. health care’s two “Original Sins” (my term): how and why did “insurance”, a financial instrument to spread risk for catastrophic events, get conflated with “financing”, the way to pay for routine procedures? No other service or industry combines the two – people do not file auto insurance claims when they get their oil changed – and in health care, this tie has led to the devastating equivalence of access to “insurance” to access to basic health care.
He pays considerable attention to the second “Original Sin”, the employer tax break for health care benefits that led to the problematic linkage of access to insurance with full-time employment. Emanuel suggests removing the tax break, showing that it “costs” the government far more than any other tax break (including the mortgage interest deduction). But he conspicuously avoids the idea of breaking the link by simply extending that same tax break to individuals directly.
Self-insurance, the mechanism through which large employers bear their employees’ own health risk by paying for health care directly, is an important consequence of the employer-oriented system (and used by nearly all employers of a thousand employees or more). In itself self-insurance is neither good nor bad. But self-insured employer plans are regulated differently from the "fully-insured" plans purchased by smaller employers. Emanuel skips over a new fee (tax? the terms are infamously mixed when it comes to the ACA) on members of fully-insured plans. Insurance companies will pass those fees along to small employers, leading to more self-insurance, with important ramifications for the system.
Emanuel does address the Taft-Hartley Act and related legislation, which encourage labor unions to create their own pooled health plans (funded by employers). However, he avoids addressing the union objections to the ACA because of these structures (moving health insurance to the government, which the ACA generally does, takes away one of the few remaining benefits that unions claim to offer their members). From the outside, it looked like an embarrassing oversight by the authors of the legislation – where’s the story of how the labor-sympathetic policymakers overlooked this issue, and how the unions were ultimately bought off placated?
In many ways, Emanuel reveals the disingenuousness behind the idea that the ACA will reduce cost. For example, he never explains why the law requires new taxes and fees (described in detail, especially Nancy DeParle’s negotiations with drug and device companies on their new taxes to “fund reform”), while also arguing that the ACA reduces government spending. How is the lay reader supposed the need to “fund” legislation that is supposedly cheaper than what it replaces?
Reinventing American Health Care has other indications of bias and general carelessness that are big enough to detract from its ultimately convincing argument.
The term “reform” is used as an apparently self-evident synonym for “universal access to health insurance paid for by active wealth redistribution”. Why couldn’t “reform” mean a market-based system where people buy the care they need directly, in which insurance just provides protection from catastrophic expenses, or one in which people have the option to voluntarily purchase health insurance individually with the same tax advantages as employers?
Spelling errors are rife, especially of company names. “Medtronics” [sic], “Thompson Reuters” [sic], and “Endeon” [sic] (my employer, Emdeon - for whom I do not speak on this blog!) are just a few. What’s more, subject and verbs occasionally do not agree.
The terms “revenue” and “profit” are often used interchangeably. This error is perhaps a subtly revealing indicator of how the left-leaning policymakers (mis)understand corporate finance, but not acceptable in a book about the economics of the country’s largest industry.
The order of the discrete sections occasionally works against itself. For example, the section on the legislative and judicial history of ACA references individual provisions not explained until the subsequent "What's in the ACA?" chapter.
Emanuel tries too hard (and unnecessarily) to attribute broader trends in health care to the ACA, such as in his forecast on the increase in telemedicine.
Even with these flaws and omissions, Emanuel’s book is a success. It’s erudite, heartfelt, compulsively readable – and for all that, convincing. I would love to see its mirror image – a similarly passionate and masterful argument from the right. But until the point there’s a similarly convincing policy from that side, Emanuel has convinced me that we’re better off in the ugly airplane of the ACA than on the path we were on.
April 20, 2014
Anyone interested in knowing exactly what is in the ACA should read this book. I considered myself fairly well-versed on what the legislation will do, but there is even more to it than I thought. Emanuel does a great job synthesizing a huge bill and making both its benefits and weaknesses understandable. Although not exactly a beach read, the information laid out in this book is important for all health care consumers to know. The ACA is here to stay and will impact all Americans in one way or another for decades. Having access to this type of information makes it harder for the "I don't really know what the law says, I just know I don't like it" mentality to take hold. The only challenge is getting those who think that way to actually read the book. This is the type of communicating the Obama administration should have been doing all along. A lot of the disinformation and subsequent backlash might have been avoided if they had. Death panels? Really? No one thought that sounded odd? Sarah Palin said it, so it must be true?
January 19, 2018
Reinventing American Healthcare is a pleasurable antidote to the ongoing misinformation about the ACA and the US healthcare system. In Part 1, Dr. Emanuel describes in great detail how the American healthcare system has evolved into its current overly complex state, riddled with misaligned incentives. As has happened in other industries, well-intentioned changes resulted in unfortunate, unintended consequences. For example, the VA greatly expanded their hospital system to accommodate the increased number of eligible veterans, many of them needing ongoing care due to war injuries. As part of other post-war recovery efforts, this was accompanied by the Hill-Burton Act of 1946 that fueled an enormous expansion of hospitals, many of which would not have otherwise been financially viable. In the following decades, major technical advances led to these hospitals being the sites of increased treatment that would have likely otherwise been performed at lower cost and greater safety in clinics and other low-cost facilities.
The second part of the book explains the ACA in rigorous detail. While increasing access to healthcare for more individuals was a very important part of the ACA, less than 25% of the ACA is actually about access. While more of the ACA should have been about controlling costs, the reality is that many compromises were made in order to pass any bill and the Republican-controlled government has actively worked to weaken most of the parts of the ACA that do control costs. The rollout of healthcare.gov was initially a disaster, though the site now works extremely well, due in large part to a lack of oversight of the private firms hired to build the federal exchange.
Emanuel closes the book with a look forward (as of 2013-14) on the future of the ACA and other potential healthcare reform. His optimism is so far not being delivered upon, as the opportunity for improving the ACA has been shut down by desperate attempts to destroy it, no matter how destructive the impact will be on the most vulnerable Americans. But with the growing popularity of the ACA now that more people know what it actually contains, I share his hope that it will be constructively improved.
The second part of the book explains the ACA in rigorous detail. While increasing access to healthcare for more individuals was a very important part of the ACA, less than 25% of the ACA is actually about access. While more of the ACA should have been about controlling costs, the reality is that many compromises were made in order to pass any bill and the Republican-controlled government has actively worked to weaken most of the parts of the ACA that do control costs. The rollout of healthcare.gov was initially a disaster, though the site now works extremely well, due in large part to a lack of oversight of the private firms hired to build the federal exchange.
Emanuel closes the book with a look forward (as of 2013-14) on the future of the ACA and other potential healthcare reform. His optimism is so far not being delivered upon, as the opportunity for improving the ACA has been shut down by desperate attempts to destroy it, no matter how destructive the impact will be on the most vulnerable Americans. But with the growing popularity of the ACA now that more people know what it actually contains, I share his hope that it will be constructively improved.
April 22, 2015
Should really be a must read for all Americans who want to comment on ACA or health care system in general :)
June 14, 2020
Read for work. 5 star review so I don’t get fired.
August 20, 2019
Reinventing American Health Care is really three books in one. It is a history of the United States healthcare system, offering something like an express version of Paul Starr's 1982 classic, The Social Transformation of American Medicine. Reinventing American Health Care is also an overview of the state of American healthcare, offering clear explanations about how the many different public and private pieces all fit together.
The real reason to read this book is its explanations of the vision behind the Affordable Care Act. It is a must-read if you want to be an Affordable Care Act completist. In that regard, it joins books like Steven Brill's America's Bitter Pill and Josh Blackman's books Unprecedented and Unraveled. It offers a fullthroated defense of the ACA from someone who was in the trenches when it was written.
I'm only giving three stars because the book already feels dated. Unfortunately, Emanuel's rosy vision of the future never came to be. We haven't stopped the increase in healthcare costs and people aren't quitting their jobs en masse to become entrepreneurs. Most importantly, the book asserts that the ACA successfully weathered its legal and political attacks. Even in 2014, that seemed naive. Fast forward to 2019, and the current administration has changed the reality of the ACA so much that much of Reinventing American Health Care is no longer applicable
The real reason to read this book is its explanations of the vision behind the Affordable Care Act. It is a must-read if you want to be an Affordable Care Act completist. In that regard, it joins books like Steven Brill's America's Bitter Pill and Josh Blackman's books Unprecedented and Unraveled. It offers a fullthroated defense of the ACA from someone who was in the trenches when it was written.
I'm only giving three stars because the book already feels dated. Unfortunately, Emanuel's rosy vision of the future never came to be. We haven't stopped the increase in healthcare costs and people aren't quitting their jobs en masse to become entrepreneurs. Most importantly, the book asserts that the ACA successfully weathered its legal and political attacks. Even in 2014, that seemed naive. Fast forward to 2019, and the current administration has changed the reality of the ACA so much that much of Reinventing American Health Care is no longer applicable
September 22, 2015
I am deeply involved in the Healthcare field so have been living the ACA for almost five years. Although this book could not have been written in the year 2010, it would have been a great primer. It gives an overview of the program that is often lost in the details. After hearing how difficult and destructive this program would be, I was pleasantly surprised at the gains we made early on. For those ongoing critics there are already some positive gains nation wide. The program will not deliver its full impact until 2020, but already the rapidly rising cost of healthcare has leveled off. Hospitals are rewarded for decreasing hospital acquired infections and penalized if they don't. Delivering more care in an outpatient setting when appropriate, installing Electronic Health Records so doctors can communicate and lower the incidence of duplicate medical tests, and working toward more transparent pricing are all positive developments. There are many more improvements that will make healthcare safer for all patients. One bit of warning: it is not an easy read. In some parts it reads much like a textbook, but well worth the time.
July 18, 2014
I read this book to better understand the Affordable Healthcare Act, Obamacare. It came to me highly recommended and it did not disappoint. I actually learned what's included in the ACA and it seemed to be spelled out succinctly and clearly. I do healthcare consulting for my job and I can definitely use what I learned in this book to help me explain the ACA to clients and others who want to learn more. It's far from a perfect law and I am extremely disappointed in how it was passed and implemented. Since it's now the law of the land, I hope we can improve on it. The bottom line for me is we need to figure out how to lower the cost of health care. I don't know if the ACA or government in general is ever very good at lowering the cost of anything or improving efficiency. I guess time will tell. The book was better that I expected and would recommend it to anyone who wants to understand the ACA.
February 7, 2020
Ugh, this book was overly-complex, didn’t illustrate its points well and was honestly kind of boring. We recently read another healthcare book for our course, and it was quite a bit better. By comparison, I didn’t feel like this book accomplished what it set out to do. I still don’t know too much about American healthcare. Also, the author’s predictions for upcoming changes in healthcare are nuts ha.
Read
November 14, 2014So, it took me about two months to finally get this one finished. This obviously wasn't my first choice when I was ready to curl up with a good book. At least now I have some idea about how all this insurance business works...maybe. ;)
January 21, 2016
I enjoyed the structured analytical approach to breaking down the ACA, its impacts, and very succinctly explaining why. Its informative and should be read by many different audiences, as it is well rounded.
July 13, 2016
Changed how I viewed the ACA entirely
This really put an amazing structure on how to think about ACA. This is the perfect book at explaining why the ACA was passed and all the political interest groups behind it. Easy and great read.
This really put an amazing structure on how to think about ACA. This is the perfect book at explaining why the ACA was passed and all the political interest groups behind it. Easy and great read.
November 22, 2014
It has been nearly impossible to get much accurate and easily understandable information on the Affordable Care Act (ACA). If it isn’t the right trying to demonize it, it’s the left trying to apologize for it. And there are those on far left who constantly opine about how it doesn’t go far enough. It seems the ACA doesn’t make anyone happy.
And yet, it is arguably the most important piece of health care legislation ever enacted. Emanuel is a top health care policy expert who is a professor at the University of Pennsylvania and one of the advisers that helped to craft the legislation. Granted, this doesn’t make Emanuel the most objective person to talk about the ACA. But there is no such thing as someone who’s completely objective, and Emanuel does a nice job explaining and arguing for the ACA without coming off as a partisan supporter. Good luck trying to find someone like this anywhere on the Internet.
The first part of the book discusses the history of health care reform in America. For the most part, it’s a history of failure. With the exception of Medicare and Medicaid, health care reform has been very modest. It’s been, until the ACA, a tragic history that would be worthy of Shakespeare if it weren’t considered such a dry subject by so many people to begin with. In the opening chapter, Emanuel gives an overview of the history of health care, including the history of physicians, the origins of health insurance and health care (28-29), the rise of employer sponsored health insurance in the US (31), the professionalizing of medicine (24-25), and more, and then explains how these dynamics have led to an American health care system whose most important characteristic is that it’s a convoluted mess of multiple health care systems all operating at once. Chapter 2 defines health care terms that every person should know (36-42) and discusses statistics on the employer based health care system model, government sponsored insurance (46-49), private/individual health insurance (51-56), and the uninsured (50). Chapter 3 breaks down health care spending and how opaque and nonuniform the pricing system is–the US has 6 different rates at which someone can pay for insurance for example (76). Emanuel then points out the five major problems of this type of system in chapter 4 in that is produces: a class of people who are uninsured, health care costs that rise much higher than the GDP, a surprisingly poor quality of health care for many Americans, a lack of transparency in costs and quality, and an inefficient medical malpractice system. The ACA is meant to address these concerns, although he admits that due to a variety of political factors (185) the ACA was unable to address the faults of the medical malpractice system to his liking. As an example of how difficult it is to reform medical malpractice, he brings up how George W. Bush had a Republican Senate and House and still couldn’t enact medical malpractice reform (123). Given that the coalition supporting health care reform was so tenuous and consisted of so many different interest groups, trying to slide in any meaningful medical malpractice reform into the ACA was seen as too risky. Except for the medical malpractice issue, the ACA is meant to improve the other 4 major problems with the American health care system.
The second part of the book focuses on the history of the ACA itself. The political and legal history of the ACA is fascinating. In these chapters he weaves a tale of negotiations, egos, economics, politics, and much else that engages the reader. These chapters are accessible to most readers. Emanuel always remembers that his audience is the American public and makes sure he doesn’t sacrifice accessibility for jargon filled content. Even for someone like me, who has almost no background in understanding health insurance, I was able to easily follow the topics and issues covered in the book. This section also explains what the ACA is and what it means for patients, doctors, and insurance companies. In chapter 5, Emanuel not only lays out previous health care reform failures but also discusses the lessons that the Obama administration learned from them that helped them pass the ACA (156-158). Chapter 6 tells the story of how the coalition was formed due largely to the efforts of Nancy Pelosi (161-162) and how it overcame the turbulence created by Ben Nelson (164-165), Joe Lieberman (164), Bart Stupak (172), and an unforeseen resistance by the Catholic Church (173). Chapter 7 presents the legal history of the ACA as it was challenged in the courts upon its passage in the House and Senate. Ultimately, the individual mandate became the legal focus of the challenge, requiring everyone to have health insurance of some kind. The irony of this, of course, is that the individual mandate was a conservative idea (189). The other interesting facet in this chapter is that during the course of debate in Congress the Republicans insisted that the individual mandate was enforced by a tax, while the Democrats said it wasn’t. But as the ACA moved through the courts, the lawyers for the administration argued it was a tax and therefore fell under the constitutional powers of the US to enforce while the lawyers for the GOP argued it wasn’t a tax and therefore didn’t fall under the constitutional powers of the US to enforce (193). Only in politics. Unfortunately, the SCOTUS found that the requirement to expand medicaid was “coercive,” as it threatened states that didn’t do this by cutting off federal money entirely for medicaid in their states. This part of the bill was controversially tossed out. Chapter 8 explains the details of the ACA and “is meant to serve as the definitive resource for finding out what is in the ACA” (204). This is your go-to chapter about what the hell is the ACA. And chapter 9 is an extension of this chapter and explains how the ACA benefits different segments of the population, businesses, health insurance companies, and other interested parties.
The final section discusses the implementation problems of the ACA, how we will be able to measure its effectiveness in the coming years, how the ACA can be improved over the years, and how “megatrends” in health care will be affected by the ACA. This section is the briefest but is very engaging in that it shares with readers proactive information that should help readers stay informed about health care in the future. In chapter 9, the chapter on the ACA’s implementation problems, Emanuel does not temper his criticism, calling it “a fiasco” (280). He discusses how politics got in the way of the ACA and hindered its implementation (282-283), why the White House didn’t bring an outside CEO type manager to oversee the implementation despite this being the best option (284), and the problem of GOP stonewalling and politicking (288-289). But Emanuel does not see any of these disasters as permanent and sees the ACA still moving forward and being a success in accomplishing its goals. Furthermore, he suggests ways to keep improving healthcare.gov (292-293).In chapter 11 he outlines specific criteria to judge how the ACA is improving health care. These are outlined in figure 11.1, which goes over expanding health insurance coverage (296); figure 11.2, which goes over reducing health care cost (299); figure 11.3, which goes over reducing hospital readmission and hospital-acquired infection rates, and increasing electronic health record adoption rates (302); and figure 11.4, which goes over improving obesity, infant mortality, and adolescent mortality rates (304). He adds in chapter 12 ideas to continue to lower health care costs, further streamline the health care process, and improve health.
Why should you take the time to read this book? Not only does health care reform affect every single person, but it is likely to remain a politically divisive topic for next couple of years. This book addresses every facet of health care reform and does the best job informing the American citizenry about these changes. There is, simply put, no other text that accomplishes anything close to what Reinventing American Health Care does.
And yet, it is arguably the most important piece of health care legislation ever enacted. Emanuel is a top health care policy expert who is a professor at the University of Pennsylvania and one of the advisers that helped to craft the legislation. Granted, this doesn’t make Emanuel the most objective person to talk about the ACA. But there is no such thing as someone who’s completely objective, and Emanuel does a nice job explaining and arguing for the ACA without coming off as a partisan supporter. Good luck trying to find someone like this anywhere on the Internet.
The first part of the book discusses the history of health care reform in America. For the most part, it’s a history of failure. With the exception of Medicare and Medicaid, health care reform has been very modest. It’s been, until the ACA, a tragic history that would be worthy of Shakespeare if it weren’t considered such a dry subject by so many people to begin with. In the opening chapter, Emanuel gives an overview of the history of health care, including the history of physicians, the origins of health insurance and health care (28-29), the rise of employer sponsored health insurance in the US (31), the professionalizing of medicine (24-25), and more, and then explains how these dynamics have led to an American health care system whose most important characteristic is that it’s a convoluted mess of multiple health care systems all operating at once. Chapter 2 defines health care terms that every person should know (36-42) and discusses statistics on the employer based health care system model, government sponsored insurance (46-49), private/individual health insurance (51-56), and the uninsured (50). Chapter 3 breaks down health care spending and how opaque and nonuniform the pricing system is–the US has 6 different rates at which someone can pay for insurance for example (76). Emanuel then points out the five major problems of this type of system in chapter 4 in that is produces: a class of people who are uninsured, health care costs that rise much higher than the GDP, a surprisingly poor quality of health care for many Americans, a lack of transparency in costs and quality, and an inefficient medical malpractice system. The ACA is meant to address these concerns, although he admits that due to a variety of political factors (185) the ACA was unable to address the faults of the medical malpractice system to his liking. As an example of how difficult it is to reform medical malpractice, he brings up how George W. Bush had a Republican Senate and House and still couldn’t enact medical malpractice reform (123). Given that the coalition supporting health care reform was so tenuous and consisted of so many different interest groups, trying to slide in any meaningful medical malpractice reform into the ACA was seen as too risky. Except for the medical malpractice issue, the ACA is meant to improve the other 4 major problems with the American health care system.
The second part of the book focuses on the history of the ACA itself. The political and legal history of the ACA is fascinating. In these chapters he weaves a tale of negotiations, egos, economics, politics, and much else that engages the reader. These chapters are accessible to most readers. Emanuel always remembers that his audience is the American public and makes sure he doesn’t sacrifice accessibility for jargon filled content. Even for someone like me, who has almost no background in understanding health insurance, I was able to easily follow the topics and issues covered in the book. This section also explains what the ACA is and what it means for patients, doctors, and insurance companies. In chapter 5, Emanuel not only lays out previous health care reform failures but also discusses the lessons that the Obama administration learned from them that helped them pass the ACA (156-158). Chapter 6 tells the story of how the coalition was formed due largely to the efforts of Nancy Pelosi (161-162) and how it overcame the turbulence created by Ben Nelson (164-165), Joe Lieberman (164), Bart Stupak (172), and an unforeseen resistance by the Catholic Church (173). Chapter 7 presents the legal history of the ACA as it was challenged in the courts upon its passage in the House and Senate. Ultimately, the individual mandate became the legal focus of the challenge, requiring everyone to have health insurance of some kind. The irony of this, of course, is that the individual mandate was a conservative idea (189). The other interesting facet in this chapter is that during the course of debate in Congress the Republicans insisted that the individual mandate was enforced by a tax, while the Democrats said it wasn’t. But as the ACA moved through the courts, the lawyers for the administration argued it was a tax and therefore fell under the constitutional powers of the US to enforce while the lawyers for the GOP argued it wasn’t a tax and therefore didn’t fall under the constitutional powers of the US to enforce (193). Only in politics. Unfortunately, the SCOTUS found that the requirement to expand medicaid was “coercive,” as it threatened states that didn’t do this by cutting off federal money entirely for medicaid in their states. This part of the bill was controversially tossed out. Chapter 8 explains the details of the ACA and “is meant to serve as the definitive resource for finding out what is in the ACA” (204). This is your go-to chapter about what the hell is the ACA. And chapter 9 is an extension of this chapter and explains how the ACA benefits different segments of the population, businesses, health insurance companies, and other interested parties.
The final section discusses the implementation problems of the ACA, how we will be able to measure its effectiveness in the coming years, how the ACA can be improved over the years, and how “megatrends” in health care will be affected by the ACA. This section is the briefest but is very engaging in that it shares with readers proactive information that should help readers stay informed about health care in the future. In chapter 9, the chapter on the ACA’s implementation problems, Emanuel does not temper his criticism, calling it “a fiasco” (280). He discusses how politics got in the way of the ACA and hindered its implementation (282-283), why the White House didn’t bring an outside CEO type manager to oversee the implementation despite this being the best option (284), and the problem of GOP stonewalling and politicking (288-289). But Emanuel does not see any of these disasters as permanent and sees the ACA still moving forward and being a success in accomplishing its goals. Furthermore, he suggests ways to keep improving healthcare.gov (292-293).In chapter 11 he outlines specific criteria to judge how the ACA is improving health care. These are outlined in figure 11.1, which goes over expanding health insurance coverage (296); figure 11.2, which goes over reducing health care cost (299); figure 11.3, which goes over reducing hospital readmission and hospital-acquired infection rates, and increasing electronic health record adoption rates (302); and figure 11.4, which goes over improving obesity, infant mortality, and adolescent mortality rates (304). He adds in chapter 12 ideas to continue to lower health care costs, further streamline the health care process, and improve health.
Why should you take the time to read this book? Not only does health care reform affect every single person, but it is likely to remain a politically divisive topic for next couple of years. This book addresses every facet of health care reform and does the best job informing the American citizenry about these changes. There is, simply put, no other text that accomplishes anything close to what Reinventing American Health Care does.
June 9, 2015
Everyone needs health care, yet most Americans feel negative about our health care system because 1) it’s too complex to understand 2) some practices are not at all updated for our current need 3) people spend lots of money in it. In this book, Emanuel writes about the past, present and the future of American Health Care. Specifically he talks in detail on why Obama care is a great step to alleviate problems in American health and why more reform is urgently needed. There are many problems raised and ideas proposed by the author, I found the following few peculiarly compelling:
1) Traditional health insurance should go away, in addition larger corporations will and should stop sponsoring health insurance to employees.
2) There should be less hospitals, more at-home patient care
3) Medical school training should and will be shorter, and the training course should be different
4) Health care administration needs to be improved and streamlined, making payment process less painful
5) On a high level, reforms are needed to reduce the growth rate of American health care cost.
6) Physicians need to provide more transparent care to patients, more diligently measure qualities of patient care.
The book isn’t a light read, yet it comprehensively covers major problems in health care.
Some great quotes explaining health care problems
Two other peculiarities about American medicine, a lack of organization in the delivery of care and an emphasis on specialization, have deep historical origins. Neither corporations nor government structure physicians’ delivery of care outside hospitals. Until recently, physicians worked in small groups and for themselves. For most of the 20th century physicians have strenuously resisted any large groups or other ways of organizing patient care.
Physicians have long defended their professional autonomy and, therefore, have been antagonistic to large, organized ways of delivering care, what physicians called corporate control of medicine. This resistance to any formal organization of the delivery of patient care was manifest in a vigorous defense of small practices and fee-for-service medicine.
Compared to other nations, the United States’ health care system places great emphasis on medical specialization.
During the 20th century physicians went from being seen as disreputable quacks to highly regarded practitioners. They also remained fiercely independent and opposed to any organized body outside of medicine, whether it be a company or voluntary association, that would organize and potentially have authority over them.
There are 3 primary reasons for health insurance to: (1) protect individuals and families from large financial losses, (2) reduce financial barriers to using necessary medical services, and (3) make utilization predictable and costs lower through pooling.
Health insurance reduces the effective price people see for health care services, leading more people to utilize those services. In the language of economists, this increasing demand for services is termed insurance-induced demand.
A small proportion of the US population accounts for half of all US health care spending. The 5% of the population with higher health care expenses (> $ 18,086 annually) was responsible for half (49.5%) of total health care spending, whereas the 50% of the population with the lowest expenses (< $ 829) accounted for only 2.7% of total spending.
Because whites and Asian Americans tend to be better off than African Americans and Hispanics, these privileged groups are more likely to have employer-sponsored health insurance.
Physician services account for about 20% of total national health expenditures. According to the American Medical Association’s Physician Characteristics and Distribution in the US, in 2010 there were 985,375 physicians in the United States, or 3.19 physicians for every 1,000 Americans (see Figure 3.5). Currently about 70% of physicians are male and 25% were trained outside of the United States as international medical graduates. But these ratios are changing with women occupying half of medical school classes.
The main reason physicians specialize is not hard to fathom: specialists are paid more— often vastly more— than primary care physicians.
Physicians deserve to be paid well. They tend to work long hours, typically over 50 hours per week. They have had at least 7 years of post-college training. But the differential between primary care physicians and specialists makes a significant difference in career choice even if money is not a physician’s primary motivator. The difference between a pediatrician and a spinal orthopedist is $ 400,000 per year. Over a 35 year career, that amounts to a $ 14 million pay difference. It is no wonder more physicians become specialists.
One of the most important issues facing the nursing profession is the scope of practice laws that determines what services health professionals, such as nurses, can provide, in what setting, and under what supervision.
Federal health care spending represents our single largest fiscal challenge over the long-run. As the baby boomers retire and overall health care costs continue to grow faster than the economy, federal health spending threatens to balloon. Under its extended-baseline scenario, CBO projects that federal health care spending for Medicare, Medicaid, the Children’s Health insurance Program (CHIP), and the health insurance exchange subsidies will grow from nearly 6% of GDP in 2010 to about 10% in 2035, and continue to grow thereafter.
Even people within the health care system do not know the total price of a service. A recent study called around to hospitals to ask about the total price for a hip replacement, including the operating room, hospital, the actual artificial hip joint, and the surgeon’s fee for a patient who did not have insurance— this would be the charge master price. Only 45% of orthopedic hospitals and 9.8% of other hospitals could provide that information.
Physicians are apprehensive about the ACA: the act is big, they are not trained to and do not regularly read legislation, and they know there is a lot of talk about cost control, electronic health records, and reporting. Uncertainty breeds fear and anxiety.
Physicians will also have to get used to being more accountable and transparent in their care. There will be more quality reporting, which will almost inevitably mean increasing transparency regarding their performance.
The ACA requires hospitals and physicians to report on quality— this is good. Unfortunately, different Medicare and Medicaid programs require different measures, and the differences often impose significant administrative burdens— and costs. The government should streamline and unify the quality measures across programs and require vendors producing EHRs to ensure they can report on these core measures electronically and directly without additional add-on interfaces.
In January 2012 Jeffrey Liebman and I predicted in the New York Times the end of health insurance companies by 2020. We might have been a bit optimistic— or provocative. But it is certain they will end. Insurance companies will largely cease to be the middle man— taking premiums, paying providers, saying no to consumers, and making a profit— that we blame. Whether we will come to love them is another matter. That depends on how well they actually care for patients.
1) Traditional health insurance should go away, in addition larger corporations will and should stop sponsoring health insurance to employees.
2) There should be less hospitals, more at-home patient care
3) Medical school training should and will be shorter, and the training course should be different
4) Health care administration needs to be improved and streamlined, making payment process less painful
5) On a high level, reforms are needed to reduce the growth rate of American health care cost.
6) Physicians need to provide more transparent care to patients, more diligently measure qualities of patient care.
The book isn’t a light read, yet it comprehensively covers major problems in health care.
Some great quotes explaining health care problems
Two other peculiarities about American medicine, a lack of organization in the delivery of care and an emphasis on specialization, have deep historical origins. Neither corporations nor government structure physicians’ delivery of care outside hospitals. Until recently, physicians worked in small groups and for themselves. For most of the 20th century physicians have strenuously resisted any large groups or other ways of organizing patient care.
Physicians have long defended their professional autonomy and, therefore, have been antagonistic to large, organized ways of delivering care, what physicians called corporate control of medicine. This resistance to any formal organization of the delivery of patient care was manifest in a vigorous defense of small practices and fee-for-service medicine.
Compared to other nations, the United States’ health care system places great emphasis on medical specialization.
During the 20th century physicians went from being seen as disreputable quacks to highly regarded practitioners. They also remained fiercely independent and opposed to any organized body outside of medicine, whether it be a company or voluntary association, that would organize and potentially have authority over them.
There are 3 primary reasons for health insurance to: (1) protect individuals and families from large financial losses, (2) reduce financial barriers to using necessary medical services, and (3) make utilization predictable and costs lower through pooling.
Health insurance reduces the effective price people see for health care services, leading more people to utilize those services. In the language of economists, this increasing demand for services is termed insurance-induced demand.
A small proportion of the US population accounts for half of all US health care spending. The 5% of the population with higher health care expenses (> $ 18,086 annually) was responsible for half (49.5%) of total health care spending, whereas the 50% of the population with the lowest expenses (< $ 829) accounted for only 2.7% of total spending.
Because whites and Asian Americans tend to be better off than African Americans and Hispanics, these privileged groups are more likely to have employer-sponsored health insurance.
Physician services account for about 20% of total national health expenditures. According to the American Medical Association’s Physician Characteristics and Distribution in the US, in 2010 there were 985,375 physicians in the United States, or 3.19 physicians for every 1,000 Americans (see Figure 3.5). Currently about 70% of physicians are male and 25% were trained outside of the United States as international medical graduates. But these ratios are changing with women occupying half of medical school classes.
The main reason physicians specialize is not hard to fathom: specialists are paid more— often vastly more— than primary care physicians.
Physicians deserve to be paid well. They tend to work long hours, typically over 50 hours per week. They have had at least 7 years of post-college training. But the differential between primary care physicians and specialists makes a significant difference in career choice even if money is not a physician’s primary motivator. The difference between a pediatrician and a spinal orthopedist is $ 400,000 per year. Over a 35 year career, that amounts to a $ 14 million pay difference. It is no wonder more physicians become specialists.
One of the most important issues facing the nursing profession is the scope of practice laws that determines what services health professionals, such as nurses, can provide, in what setting, and under what supervision.
Federal health care spending represents our single largest fiscal challenge over the long-run. As the baby boomers retire and overall health care costs continue to grow faster than the economy, federal health spending threatens to balloon. Under its extended-baseline scenario, CBO projects that federal health care spending for Medicare, Medicaid, the Children’s Health insurance Program (CHIP), and the health insurance exchange subsidies will grow from nearly 6% of GDP in 2010 to about 10% in 2035, and continue to grow thereafter.
Even people within the health care system do not know the total price of a service. A recent study called around to hospitals to ask about the total price for a hip replacement, including the operating room, hospital, the actual artificial hip joint, and the surgeon’s fee for a patient who did not have insurance— this would be the charge master price. Only 45% of orthopedic hospitals and 9.8% of other hospitals could provide that information.
Physicians are apprehensive about the ACA: the act is big, they are not trained to and do not regularly read legislation, and they know there is a lot of talk about cost control, electronic health records, and reporting. Uncertainty breeds fear and anxiety.
Physicians will also have to get used to being more accountable and transparent in their care. There will be more quality reporting, which will almost inevitably mean increasing transparency regarding their performance.
The ACA requires hospitals and physicians to report on quality— this is good. Unfortunately, different Medicare and Medicaid programs require different measures, and the differences often impose significant administrative burdens— and costs. The government should streamline and unify the quality measures across programs and require vendors producing EHRs to ensure they can report on these core measures electronically and directly without additional add-on interfaces.
In January 2012 Jeffrey Liebman and I predicted in the New York Times the end of health insurance companies by 2020. We might have been a bit optimistic— or provocative. But it is certain they will end. Insurance companies will largely cease to be the middle man— taking premiums, paying providers, saying no to consumers, and making a profit— that we blame. Whether we will come to love them is another matter. That depends on how well they actually care for patients.
February 11, 2017
A great overview of the ACA and a quality unpacking of some of the complexities, but it might be a bit dry for people who aren't policy wonks like me. If you're looking for a brief overview of the ACA a better resource would be some policy briefs from Kaiser Family Foundaton but this is a good book if you want historical foundation and a more extensive analysis. I also wouldn't necessarily recommend it on audiobook like how I read it; it would be much better in print copy to have as reference due to all the technical terms. Also if anyone from Congress is reading this review please don't repeal the ACA. It's super, super necessary and important.
December 27, 2021
The title tells you so much about what the book covers with its description of health care – terribly complex, outrageously expensive, grossly inefficient. The book provides an overview of the introduction of ACA (Affordable Care Act / Obamacare). Interesting to understand the political pressures – the need to get legislation, even if not perfect, passed quickly given the power of special interests. Given so much has changed since then – political challenges, years of change since the rollout, the Covid-19 pandemic, some of it is no longer relevant. However, some of the changes that ACA caused – e.g. coverage for preexisting conditions, are fortunately the norm now.
January 6, 2026
Effectively summarizes one of the most complicated policy areas. Some depth is lost as a tradeoff, but less than you’d expect.
Really funny reading bits and thinking “yeah this sounds like an effective cost-control measure, wonder how that’s going”, only to find out the measure in question was repealed.
I think that’s a big part of the explanation for his absurd optimism. A fully-realized ACA may have achieved so much more. Unfortunately, a bad mix of path dependence, politics, and perverse incentives led to a heavily gutted, far less effective ACA.
Really funny reading bits and thinking “yeah this sounds like an effective cost-control measure, wonder how that’s going”, only to find out the measure in question was repealed.
I think that’s a big part of the explanation for his absurd optimism. A fully-realized ACA may have achieved so much more. Unfortunately, a bad mix of path dependence, politics, and perverse incentives led to a heavily gutted, far less effective ACA.
March 30, 2022
I didn’t finish this because it became increasingly mind numbing. 😭 But it did the job. I wanted to understand better the American healthcare system and its flaws. I also wanted to understand better what the ACA did about it. This book is dated, but I figured it would still be helpful, and it was.
Will I retain it?? No. 😆 But I try to repeatedly get information in many forms about healthcare and economics in the hopes that more and more sticks.
Will I retain it?? No. 😆 But I try to repeatedly get information in many forms about healthcare and economics in the hopes that more and more sticks.
May 22, 2017
It was a little overly optimistic about the future of health care, especially toward the end. However, I learned a lot about the Affordable Care Act (aka, ObamaCare) and the history of health care bills in the U.S. government.
November 29, 2017
fascinating review of the growth of the healthcare system in the US including how we went from 15 - 20% employer coverage in 1930s to 70% coverage by 1960s.
There are so many problems with our system, so many entrenched interests that no one single bill will fix the entire thing.
There are so many problems with our system, so many entrenched interests that no one single bill will fix the entire thing.
April 17, 2018
I'm not convinced by all of Zeke's policy recommendations, and I'm more fearful of federal regulation than when I started, but I'll be dammed if I don't appreciate that someone with deep knowledge and influence wrote it down and made it public.
November 5, 2019
This book is already dated since the somewhat neglect of the Affordable Care act. I really wanted to read more about why Ezekiel Emanuel wanted to live to age 75, based on a recent Atlantic Magazine article.
July 1, 2020
Emanuel provides a much more thorough summary to the Affordable Care Act than other works I've read, especially on the history behind the health care reform. However, reading almost a decade after the book, it becomes apparent that many of Emanuel's predictions have fallen unbelievably short.
July 26, 2020
Great book if you want to understand the Affordable Care Act, US healthcare history and the healthcare industry. Can be a bit dry and information dense, but nonetheless informative. Important to note Ezekiel was an Obama Health Advisor and gives a pretty rosy view to an imperfect law.
March 12, 2017
80% solid analysis about the history, current state of American healthcare, the structure of the ACA, and the future of American health care; 20% Obama administration talking points.
November 12, 2018
Important read to understand how the components of health care and aca work
December 29, 2019
Interested in learning more about the ACA? This is a great resource. I learned a lot about the health care system: past, present and future.
February 10, 2020
Fantastic insights into the mess that is the US Medical system from an accomplished well educated brilliant MD and advisor on Obamacare. Very well written and researched.
July 23, 2020
this was basically a textbook lmfao but really good comprehensive intro to American healthcare
September 11, 2020
Brilliant.
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