Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System

395 Pages·2014·4.22 MB·English

by  Ezekiel J. Emanuel

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R E I N V E N T I N G
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is the only person in America who is all three. That makes him the right person to write the deinitive
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A M E R I C A N
I
This book explains how we got in this ix, how we will
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H E A L T H C A R E
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N
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“ Few people have had a more favorable inluence on the shaping of the current processes of health
insanely complex non-system that we are trying to ix. This book is an instant classic—mandatory
How the Affordable Care Act W ill Improve
scientiic articles. He is currently a senior our Terribly Complex, Blatantly Unjust,
Outrageously Expensive,
President Obama’s irst term, and also a ball and chain
Grossly Inefficient, Error Prone System
E Z E K I E L J .
E M A N U E L

author of H E A LT H C A R E , G UA R A N T E E D
R E I N V E N T I N G
A M E R I C A N
H E A L T H C A R E

R E I N V E N T I N G
A M E R I C A N
H E A L T H C A R E
How the Afordable Care Act
Will Improve Our Terribly Complex,
Blatantly Unjust, Outrageously Expensive,
Grossly Ineicient, Error Prone System
E Z E K I E L J . E M A N U E L
PublicAffairs

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Copyright © 2014 by Ezekiel J. Emanuel.
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Set in 12-point Dante
Library of Congress Cataloging-in-Publication Data
Emanuel, Ezekiel J., 1957– author.
Reinventing American health care : how the Afordable Care Act will improve
our terribly complex, blatantly unjust, outrageously expensive, grossly ineicient,
error prone system / Ezekiel J. Emanuel. — First edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-61039-345-4 (hardcover) ISBN 978-1-61039-346-1 (e-book)
I. Title. [DNLM: 1. United States. Patient Protection and Afordable Care Act.
2. Health Care Reform—United States. 3. Health Services—United States.
4. Health Services Administration—United States. 5. National Health Programs—
economics—United States. WA 540 AA1]
RA413
362.1’0425—dc23
2013049343
First Editio n
10 9 8 7 6 5 4 3 2 1
DISCLAI ME R
Health care is dynamic. Though progress can seem maddeningly slow,
the system is constantly reinventing itself. The cost estimates, enroll-
ment numbers, and other data in this book were accurate as of Decem-
ber 1, 2013—when I stopped writing. Accurate is a matter of degree since
diferent government agencies often repost diferent numbers for the
same data point and private organizations often have other numbers.
We have done our best to comes as close as possible to reality. Com-
plicating things even more is that health care is changing rapidly. The
Supreme Court will agree to hear new cases related to health care, the
Medicare actuary will issue new reports on cost growth in Medicare and
Medicaid and the overall rate of health care inlation, the Congressional
Budget Oice will publish new estimates of long-term health care costs
and their impact on the federal budget, and policymakers in Washington
will craft new policy ixes and stake out new positions. It is possible that
these or other changes could alter some of the trends, detailed numbers,
and speciic predictions discussed throughout this book. Nevertheless,
the direction of change and what statisticians call the central tendencies
are unlikely to be signiicantly altered.

To my many generous mentors
who supported, nurtured, and shaped
my ideas and intellectual drive
RAYMOND A . D WEK
RASHI FEIN
VICTOR R . FUCHS
GEORGE KA TEB
MICHAEL J . SANDEL
JUDITH N . SHKLAR
(in memorium)
DENNIS F . THOMPSON

Contents
Acknowledgments xi
Introduction: Erin’s Disease 1
PART I
THE AMERICAN HEALTH CARE SYSTEM
1 How Did We Get Here? 17
2 Financing Health Care 34
3 How Americans Get Their Health Care 68
4 Five Problems with the American Health Care System 95
PART II
HEALTH CARE REFORM
5 The Surprising History of Health Care Reform in the
United States 127
6 Enacting the Afordable Care Act 159
7 What the Supreme Court Said 188
8 What Is in the Afordable Care Act? 201
9 What Does the ACA Mean for Me? 259
PART III
THE FUTURE OF AMERICAN HEALTH CARE

10 ACA Implementation Problems 279