Think Big on Health Care

November 16, 2008, 9:30 pm

Think Big

By Ezekiel Emanuel

In this installment of Health Care Watch, Stuart M. Butler and Ezekiel Emanuel talk about what President-elect Barack Obama should and shouldn’t do on health care reform. Go to Mr. Butler’s post.

Ezekiel Emanuel, an oncologist, is the chairman of the department of bioethics at the Clinical Center of the National Institutes of Health. He is the author of “Health Care, Guaranteed: A Simple, Secure Solution for America.”(Full biography.)

The election of Barack Obama is a historical transformative event. As he and his new administration wrestle with health care reform here are five points to be kept in mind.

1) “Make no little plans. They have no magic to stir men’s blood and probably will not themselves be realized.” So said Daniel Burnham, the architect and urban planner (and fellow Chicagoan).

In health care, big plans are necessary not only to motivate people but as a matter of sound policy. The health care system is broken. It is not enough to just add more people to a broken system. Health care reform must reorganize the system to deliver higher quality care while keeping costs under control. Incremental change that just covers more people will not be sustainable. Reform must include changing the delivery system and how we pay for care. The health care system needs major surgery, not more Band-aids.

More important, as negotiation specialists note, you don’t begin with your compromise position. If we have to settle for incremental Band-aids, it should be only as a last resort.

2) Health care policy is fiscal policy.

Forget Social Security or defense, health care costs are the long-term driving force in federal and state budgets. To control the deficit and keep the country solvent, health care must be solved. Therefore, when the president-elect considers senior economic advisers, one test should be whether they really get health care policy.

Fortunately, Peter Orzag at the Congressional Budget Office does. So do some of the people rumored to be leading candidates for appointments — Larry Summers at the Treasury, Jim Cooper at the Office of Management and Budget and Jason Furman at the Domestic Policy Council. This is very encouraging.

3) Comprehensive health care reform is cheaper.

One of the secrets of health care reform that has not yet sunk in, is that bigger changes to the system actually cost less. Consider the Lewin Group’s analysis of the different health care from plans, which I wrote about in an earlier post.

4) No plan is perfect, institutionalize tinkering.

Health care reform will be incredibly complex. As improvements are made, problems will arise and unintended consequences will occur. There will need to be numerous mid-course corrections. Good reform will make addressing these issues easy by not requiring major legislation for each adjustment.

5) Everything is connected.

Health care reform cannot be considered in isolation. The new administration must remember that health care is so big — $1 out of every $6 in the economy, dwarfing automobiles and all other economic segments. Everything is affected by health policy, and every decision should be examined for its impact on health care reform.

Consequently, if the heart of Mr. Obama’s economic policy is job creation, then it is contradictory to have a health care reform built on an employer mandate or to fund reform with a payroll tax. Employer mandates and payroll taxes stymie job formation.

Similarly, every favor to a constituency should be linked to support for the health care reform agenda. If the automakers want a bail out, then they and their suppliers have to agree to support and lobby for the administration’s health care reform effort. This builds grass roots support.

Since 1913, the United States has been trying to achieve comprehensive health care reform. If the Obama administration finally does it, it will truly be history making. The challenge is huge, but the rewards — for the administration and every citizen — will be even “huger.