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Wednesday, May 7, 2014

Architect Of Health Law Says Reform Is ‘Never Finished’

Bioethicist Ezekiel Emanuel advised the White House on health care reform and tells Here & Now that "despite a bad rollout," the law is working. (ezekielemanuel.com)

Bioethicist Ezekiel Emanuel advised the White House on health care reform and tells Here & Now that “despite a bad rollout,” the law is working. (ezekielemanuel.com)

Two polls released this week reveal challenges ahead for the Affordable Care Act.

Gallup found the nation’s uninsured rate dropped to 13.4 percent last month, the lowest monthly uninsured rate since the company began tracking it in 2008. But that means 32 million people remain without coverage.

And a Pew Research Center poll shows that 55 percent of Americans disapprove of the 2010 health care reform law, which mandates that everyone have health insurance and that it be made available to even those with pre-existing medical conditions.

Bioethicist Ezekiel Emanuel advised the White House on health care reform and tells Here & Now’s Jeremy Hobson that “despite a bad rollout,” the law is working.

Emanuel predicts that enrollment in health plans will top 20 million people by next year, and he says there’s still work to be done on bringing down health care costs.

Interview Highlights: Ezekiel Emanuel

Does it bother you that so many people still don’t like this law?

“Yeah, I think it’s a misunderstanding and it points to a persistent problem around communication about what’s in the law, the advantages of the law, and more importantly, the disaster that would have befall the country had we not actually enacted reform. I think that’s the most important issue, is what’s the counterfactual. If we hadn’t had the Affordable Care Act, we really would have blown apart the system.”

On what went wrong with getting that message out

“The communication strategy, even going back to August 2009, where the Tea Party had its founding and all those town hall meetings and congressional districts, we just never got it right, I think, and never really convinced the American public why we needed to reform the system, and why this reform, while not perfect, is definitely a big step in the right direction. And the irony is, of course, on every one of the major issues — as you point out, access — we’ve had a really steep decline in the uninsured rate for the first time in a long time, we’ve had improvements in quality of care because of the Affordable Care Act and costs have gotten under control, although by no means is the cost level of health care completely whipped. But in four years, we’ve gone a long way in the right direction, and people should see that as a big positive, but I don’t think the message has really gotten out.”

On his goal for number of sign-ups a year from now

“There are lots of ways people are getting coverage — it’s not just in the exchanges, although that is probably the most important way, so we’re about 12 to 15 million people have gotten coverage through the Affordable Care Act. I’d like to see that number go over 20 million by next year.”

Is that goal possible?

“Of course. One of the things that the exchange shows you, that despite the bad rollout, despite the two months of really no one being able to get insurance through the exchange, we had 8 million people sign up. Americans really want affordable health care insurance. Whatever the Koch brothers and their minions say, people don’t want to go without insurance. They want insurance and the big problem has been affordability. And I think the exchanges offer a very good platform for most Americans to get coverage. And I think if we can continue to offer good insurance plans at a reasonable price, people are going to sign up — especially once they really understand that they can get subsidies both for the premium and, if they’re poor, they can get subsidies for co-pays and deductibles — that’s a very appealing package to most people.”

Guest

Transcript

JEREMY HOBSON, HOST:

Well, now to the world of polling, where it is good news, bad news this week for the Affordable Care Act, or Obamacare. Gallup found the nation's uninsured rate dropped to 13.4 percent last month, that's the lowest monthly uninsured rate since the company began tracking in 2008, but a Pew Research Center poll shows that 55 percent of Americans disapprove of the 2010 health care reform law.

Joining us now is one of the people who advised the White House on the law, bioethicist Ezekiel Emanuel, who teaches at the University of Pennsylvania. He's got a new book called "Reinventing American Health Care." Ezekiel Emanuel, welcome to HERE AND NOW.

EZEKIEL EMANUEL: It's my honor.

HOBSON: Well, does it bother you that so many people still don't like this law?

EMANUEL: Yeah, I think it's a misunderstanding, and it points to a persistent problem around communication about what's in the law, the advantages of the law and, more importantly, the disaster that would have befall the country had we not actually enacted reform. I think that's the most important issue is what's the counterfactual. If we hadn't had the Affordable Care Act, we really would have blown apart the system.

HOBSON: But there are very smart communications people working for the administration. Why couldn't they get this right?

EMANUEL: You'll have to ask them. I just, I think, as I point out in my book, that the communication strategy, even going back to August 2009, where the Tea Party had its founding in all those town hall meetings and congressional districts, we just never got it right, I think, and never really convinced the American public why we needed to reform the system, and why this reform, while not perfect, is definitely a big step in the right direction.

And the irony is, of course, on every one of the major issues, as you point out, access, we've had a really steep decline in the uninsured rate for the first time in a long time, we've had improvements in quality of care because of the Affordable Care Act, and costs have gotten under control, although by no means is the cost level of health care completely whipped.

But in four years, we've gone a long way in the right direction, and people should see that as a big positive, but I don't think the message has really gotten out.

HOBSON: Well, if we're talking about eight million or now more than eight million having signed up during the first signup period, what would be a good number to be at, in your view, a year from now?

EMANUEL: Well, wait a second, that's eight million just in the exchanges. You have to also remember we expanded Medicaid.

HOBSON: Medicaid.

EMANUEL: Even though a lot of states have not actually enacted it. We got almost five million people that way, three million people under age 26 who are still able to stay on their parents' plan. There are lots of ways people are getting coverage. It's not just in the exchanges, although that is probably the most important way.

So we're about 12 to 15 million people have gotten coverage through the Affordable Care Act. I'd like to see that number go over 20 million by next year.

HOBSON: You think that's possible?

EMANUEL: Of course. I think one of the things that the exchange shows you, that despite the bad rollout, despite the two months of really no one being able to get insurance through the exchange, we had eight million people sign up. Americans really want affordable health care insurance.

Whatever the Koch brothers and their minions say, people don't want to go without insurance. They want insurance, and the big problem has been affordability. And I think the exchanges offer a very good platform for most Americans to get coverage.

And I think if we can continue to offer good insurance plans at a reasonable price, people are going to sign up, especially once they really understand that they can get subsidies both for the premium and, if they're poor, they can get subsidies for co-pays and deductibles. That's a very appealing package to most people.

HOBSON: OK, on the flip side, though, there are a lot of people, even people who were supporters of the law in the first place, who are very upset by the idea of their employers potentially dropping them or trying to shift them over to some of the exchanges. There was a research firm, S&P Capital IQ, that predicted just last week that by 2020, 90 percent of American workers who are now getting health insurance through their employer would be shifted to government exchanges. First of all, do you agree with that? Do you think that that's true? And would that be a failure for the health care law, if that happened?

EMANUEL: I think that's a very extreme prediction, and I think that's probably not realistic and not going to happen. And I think if you look at the assumptions they made in their model, very unlikely to happen. So that's - while it got a lot of headlines, I do not think that prediction is likely to be true. I think there are lots of other pieces of data - Crane's(ph) from Chicago looked at employers, and some employers are looking at private exchanges. Others are looking at the public exchange.

There's a lot of uncertainty how the future is going to play out, and I think that's quite clear. And uncertainty, of course, increases people's anxiety, since you don't know whether you're going to be better off or worse off. I actually think for many people the exchange is going to be a better deal, and they ought to welcome it.

For one thing, most people who work for employers and get their insurance through employers don't have a choice of health plans. You'll have more of a choice in the exchanges. Second of all, if you switch jobs, or you change companies, or you start your own company, if you get your insurance through the exchange, you don't have to change your health care. If you get it through your employer, you have to change your health insurance company.

And I think that continuity is also going to be better, and I think for younger people who buy everything through the Internet, whether it's book or clothing or shoes or cars, I think buying health insurance through the Internet, where they have the choice, and soon there are going to be a lot more tools to help them shop, it's going to look like an advantage, not a disadvantage.

HOBSON: Although I can hear a lot of listeners in my head right now probably saying I like my health care at work just fine. Please do not make me move into one of these exchanges.

EMANUEL: And I think, and I think employers are going to look at that also. They're going to listen to their workers because a large part of the reason they offer health insurance, remember, there is no requirement, no legal requirement to offer health insurance yet by employers, and I think the large part of the reason they offer it is to attract good workers, to retain good workers.

My own view is, you know, over times workers are going to want it because it's going to offer a very attractive alternative to employer-based insurance.

HOBSON: That's bioethicist Ezekiel Emanuel, one of the architects of the Affordable Care Act. He's now at the University of Pennsylvania. His new book is called "Reinventing American Health Care." Stay with us, HERE AND NOW.

(SOUNDBITE OF MUSIC)

HOBSON: It's HERE AND NOW. We're speaking with bioethicist Ezekiel Emanuel, who advised President Obama on health care reform. He teaches at the University of Pennsylvania and is author of the new book "Reinventing American Health Care." And Ezekiel Emanuel, let's talk about cost, which was another big part of the Affordable Care Act, the affordable part, you could say, bringing down the cost of health care.

We did a story just last week with Bloomberg News that reported that the price of drugs is now going up 10 times the rate of inflation, that if you bought a cancer drug, let's say for $30,000 10 years ago, it could cost in the hundreds of thousands now.

EMANUEL: All right, let's make a few points. First, drugs account for about 10 percent of all health care spending. Hospitals account for about a third of health care spending and doctors about 20 percent. So if drugs are going up a lot, it's still a smaller portion of health care spending.

Second, we have, over the last decade, substantially increased our use of generic drugs, and generic drugs in the United States are extremely cheap. I just filled a prescription for 90 days' supply of a drug, $10. It is true that specialty drugs, high-end specialty drugs for things like cancer, hepatitis C and a lot of other orphan diseases, multiple sclerosis, they are extremely expensive, and that is a worrisome finding.

I think the idea that you're spending $100,000, $125,000, $200,000 for a drug that might extend life three, four months at most, I think many people are suitably outraged by that, and we may hit the tipping point. I think...

HOBSON: Is there anything we can do about it?

EMANUEL: Oh, most of them, that would require legislation. There are many things to do be done about it, but that would require legislation. And as you well know, at the moment legislation on health care does not look like it's on a fast track through Congress.

HOBSON: Right. So besides the drugs, would you say that the cost of health care, do you see a trajectory that you would like to see of it going down? And how is that going to happen?

EMANUEL: So over the last three, four, five years since the great recession, we have had a decline in health care inflation, although in the last quarter of 2013 and the early parts of 2014, it does look like health care inflation has picked up, which is not that surprising since you're adding millions of people to the health care system.

So we have had a period of relatively low inflation. Without additional work, that will not continue, and I think we are seeing, in the health care system, if you go around and look at various hospitals and health care systems and practices, great efforts to increase efficiency, great efforts to change. And I'd say that the two dominant processes I think that we need to control costs, one is a very, very strong focus on reducing what's called the unit cost, how much it costs to do something, to make a CAT scan, to take a surgical procedure.

The second and probably more important aspect is to really focus on the 10 percent of patients that consume about two-thirds of the health care spending. Those 10 percent of patients are people with chronic illness: diabetes; congestive heart failure; emphysema. And the real key is to keep those people healthy, to prevent the infection of the toe of the diabetic patient that eventually needs an amputation, to prevent the person who's got emphysema from it getting worse and being admitted to the hospital.

A lot of places are putting in new programs to address that problem, and as I predict in my book, I think health care inflation is going to come down to the growth in the economy, and I think that's possible by the end of this decade, 2020.

HOBSON: But does a lifetime of preventative care keep you out of the emergency room at the end of your life, where we see people spending a lot of money in the hospital?

EMANUEL: Yeah, well, I think most of the public and probably a lot of your listeners have a distorted view of how much we spend at the end of life.

HOBSON: Oh, well set the record straight, doctor.

EMANUEL: It is true that we spend a lot relative at the end of life, but it accounts for about 10 to 12 percent of total health care spending. And that is a lot for each individual person because less than one percent of the population dies each year. Nonetheless, we don't know the formula, as it were, for actually saving money at the end of life.

I think a lot of people are focused on that. My actual view is that what we should be focused on is improving the quality of care at the end of life, and guess what, we've actually gone a long way over the last 30 years in that direction. When I started out as a bioethicist, my main area in the mid-1980s was end-of-life care. At that time, over 70 percent of cancer patients were dying in the hospital, getting chemotherapy and other treatment. Today it's down to about 22 percent of cancer patients die in the hospital.

Most of cancer patients across the country actually get hospice care at the end of life. What we really need to do, in my opinion, are three things. We need to train doctors and nurses better in communicating with patients about end-of-life care and communicating much earlier to try to get patients' views about how they want to be treated at the end of life.

Second, we need to actually have the facilities to take care of patients both in the hospital and at home. And a lot of hospitals in this country don't have palliative care services, and it can't extend both from in the hospital to home and support the family. That's very important because if people really want to be at home, they need the support services for that.

And the last, of course, is we need to pay for it in a way that doesn't make it onerous and really burdensome either to a health system or to patients and patients' families themselves. Whether that saves a lot of money or just improves the quality of care, we don't know. We haven't run that trial yet.

HOBSON: As you know, there is a big movement in the Republican Party to repeal this law still, and I wonder, are you concerned that if the Republicans take the Senate this year, which is a possibility, and retain control of the House of Representatives, that they may if not repeal it significantly weaken it?

EMANUEL: Well, I think the notion of repeal is a lot of empty rhetoric. We've had more than 40 votes on that. It goes nowhere. Now we have 12 to 15 million people who have got insurance through the Affordable Care Act. Repealing it would really throw now more than 10 million people out of insurance. I don't think that's happening, and the president would certainly veto anything that substantially weakens the Affordable Care Act.

Similarly they have no alternative. You've never seen a Republican replacement option that has any teeth, that addresses the three big problems of access, quality and cost control. The final word I would say on this is I really think the Affordable Care Act is the Republican plan, and that's their problem. That's why they don't have a replacement, because it really is the Affordable Care Act.

What do we have in the Affordable Care Act? We have a marketplace where private insurance compete for customers, and the government subsidizes people who can't afford that insurance plan. Doesn't that sound very Republican-ish? Doesn't that sound very American and apple pie, private markets with companies competing for customers who shop...

HOBSON: Well then why have they disowned it? Why have the Republicans disowned their plan?

EMANUEL: Because the Democrats endorsed it, and, you know, politics being what it is, if your opponent endorses something, you've got to oppose it rather than seeing that this is something bipartisan, it's good for America. The Affordable Care Act is not a perfect law. What we should be focusing on now is how to improve it and especially improve its cost control measures so that we can keep health care affordable for Americans because there's a lot of work to be done.

We're never finished with health care reform. We are always constantly having to tweak the system and improve it, and lord knows we have lots of things to do in the health care system to improve it.

HOBSON: Ezekiel Emanuel teaches at the University of Pennsylvania. He advised the White House on health care reform, and his new book is "Reinventing American Health Care." Ezekiel Emanuel, thanks so much for joining us.

EMANUEL: Thank you for having me.

HOBSON: And we'd love to hear from you about what you think about the Affordable Care Act. Are you among the 55 percent of Americans who disapprove of it, or do you think it's a good thing? Are you one of the millions of people who have signed up for the exchanges under the Affordable Care Act? Let us know at hereandnow.org. You can also send us a tweet, @hereandnow, @hereandnowrobin, @jeremyhobson. This is HERE AND NOW. Transcript provided by NPR, Copyright NPR.


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Robin Young and Jeremy Hobson host Here & Now, a live two-hour production of NPR and WBUR Boston.

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