Healthcare, Guaranteed: A Simple, Secure Solution for America, Ezekiel J. Emanuel, MD, PhD, 2008, PublicAffairs, New York, N.Y., 240 pp. (paperback)
A Simple, Secure Solution for America
In “Healthcare, Guaranteed,” Ezekiel Emanuel, MD, chair of the Department of Bioethics at the Clinical Center of the National Institutes of Health, presents his solutions to the U.S. healthcare crisis in a succinct, understandable and very readable manner. He is a medical oncologist who, with well-known Stanford economist Victor Fuchs, has published several articles on health policy reform.
Dr. Emanuel briefly reviews the reasons why the U.S. healthcare system must be improved and then gets to the meat of his solution, which embraces these seven goals: (1) guaranteed coverage, (2) effective cost controls, (3) high-quality, coordinated care, (4) choice, (5) fair funding, (6) reasonable dispute resolution, and (7) economic revitalization.
He proposes the Guaranteed Access Plan, which would cover all Americans with a generous benefit package that resembles the Federal Employees Health Benefit Plan. The package would include office and home visits, hospitalization, preventive screening tests, prescription drugs, some dental care, mental health care, and physical and occupational therapies, all without deductibles and with minimal copayments. Everyone would be able to choose a health insurance plan and healthcare providers. The plan would be financed solely by a dedicated value-added tax of 10 percent on purchases of goods and services, and Congress would have the power to increase or decrease the tax rate. Those desiring healthcare coverage over and above the standard benefits could purchase additional insurance or services with after-tax dollars.
According to Dr. Emanuel, the plan would improve efficiency by reducing administrative costs and fraud. Programs such as Medicare, Medicaid and SCHIP would be phased out and those patients would be covered through the new Guaranteed Access Plan; states alone would save $70 to $100 billion on administration of Medicaid and SCHIP. The new plan would have a mechanism for reducing medical errors, hospital-acquired infections and high-cost/low-to-no benefit treatments. It would encourage coordinated care and innovation in healthcare delivery, while holding providers accountable for outcomes. Quality would be evaluated constantly. The medical liability system would be revolutionized with a mechanism for rational dispute resolution. Healthcare coverage would have nothing to do with employment, which would make coverage portable. Because employers would no longer be paying for health insurance, businesses would be revitalized and wages would rise accordingly.
Oversight is patterned after the Federal Reserve System: A national health board and 12 regional health boards would autonomously oversee the new healthcare system. These boards would be independent of annual congressional appropriations and insulated from special interest lobbying. Each would create a center for patient safety and dispute resolution. An institute for technology and outcomes assessment would evaluate the effectiveness and cost of new drugs, medical devices, diagnostic tests, and other interventions.
After detailing his plan, the author compares it with possible alternatives: incremental reform, mandated reform, and a single-payer system. He concludes that: incremental repairs have been tried for decades and have uniformly failed; mandates succeed only in perpetuating a fragmented, fee–for-service dysfunctional mess for a delivery system; and single-payer systems may work for a financing system but do nothing to improve the delivery of healthcare.
So, after 80 years of trying can we really get this done? Dr. Emanuel believes that there is widespread support for reform of the healthcare system and that the major actors now must agree on the proposal and champion it to the American people. With “Healthcare, Guaranteed,” he has convinced me.
Gary VanderArk, MD, is clinical professor of neurosurgery at the University of Colorado Health Sciences Center in Denver. He is the 2001 recipient of the AANS Humanitarian Award. The author reported no conflicts for disclosure.