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Zeke Emanuel, Obama's Health Care Alchemist

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Ezekiel Emanuel has a fear of failure. Months into the administration, the prominent bioethicist and brother of chief of staff, Rahm, has emerged as an important player in President Barack Obama's efforts at overhauling health care. But with the elevated role has come an elevated responsibility. And as the White House pushes for the largest expansion of coverage in well over two decades, the eldest of the Emanuel brothers refuses to get ahead of reality.

"My biggest fear is that we fail," said Emanuel in an interview with the Huffington Post. "You said, 'failure, obviously, is not an option.' But it is not clear that it is obvious. Stuart Altman, who many people consider the dean of health policy up at Brandeis University, he has this rule -- the rule of second best. You poll people and everyone is for health care reform, whether it is mandate or single payer. But everyone has a second best, and that is to do nothing. Well, I think this time it is different. Doing nothing, keeping the status quo, is not the second best. It is the biggest disaster that we can do."

This is not, necessarily, a form of expectations-setting superstition. Emanuel, who came to the administration with the title Special Advisor for Health Policy, knows that overhauling America's health care system has been an elusive goal of administrations dating back to Franklin Roosevelt. His task, while not his solely, is to find success where others have failed.

"Is reform going to be difficult? Is it going to be painful? Look, any change inherently is painful," he said. "Is keeping the current system painful? It is even more painful."

While not a student of politics like his brother, "Zeke" is acutely aware of the lessons from past health care reform efforts. Too much secrecy, a la Hillary Clinton's attempt in the early 90s, creates skepticism; too much orthodoxy, like the efforts in the 50s and 70s, gins up infighting and opposition. As such, he refuses to delve into the details of the administration's preferred policy, emphasizing instead how organic the process truly is.

Asked, for instance, whether the president is contemplating a public insurance plan -- which would provide a cheaper option for coverage, but could, as critics say, significantly hamper private insurers -- he replies: "I'm not talking about it." Pointing at the tape recorder on the desk, he adds, "You get paid for screwing me and I don't get paid for screwing myself."

In a similar vein, he only touches from afar issues like mandates requiring people to buy coverage, or removing tax exemptions for employer-based health insurance. "Look, that is a very complicated policy issue," he says of the latter. "I think the budget was very clear about not taking anything off the table."

But he is not just playing coy. In many ways, Emanuel is trying to perform "health care alchemy." He views reform and the system itself as a web of interconnected parts: make one policy move and it effects countless others.

"There are just a huge number of choices," he said. "And as you go down, further and further, there are multiple choices that you have to make. And so the permutations of that become enormous. To pull out one thing and say 'tell me about that' is very artificial."

And yet, for as open a process as Obama has pursued, there are veterans of the health care reform movements who worry the president is already pointed in the wrong direction. Professor Altman, who Emanuel cited as the "dean of health policy," said he is concerned that the White House is focused on the wrong challenge, giving preference to cost containment over expanding coverage.

"I have known Zeke for a long time and I have tremendous respect for him," said Altman. "He is a thoughtful and decent guy... And his boss, [OMB director] Peter Orszag is a very smart guy. And I'm very supportive of what they are trying to do with this collaborative process. I'm just giving you the benefit of 40 years... Their emphasis to make health care cost reform the number one issue is going to doom health care reform. Because that is what all the forces will line up against."

On this front, however, the White House position seems bolstered by public opinion. A CNN poll released on Thursday found 82 percent of Americans satisfied with the quality of their health care, but 77 percent dissatisfied with the cost of health care in the country.

Moreover the administration has, as Emanuel notes, "already done a lot of things" to facilitate long-term savings. The stimulus bill passed this February included unprecedented investments in health IT, comparative effectiveness research, prevention and community health centers. The next fight will be over the administration's budget proposal, which contains $633.8 billion over the next ten years for health care.

The key is to encourage or spur short-term sacrifice (Emanuel uses the term "contributions" -- "it sounds softer") in exchange for long-term benefits. Stepping into a new room in his no-frills office in the Old Executive Office Building, he hand-draws what's known as a 'potential energy barrier graph.' Starting in the middle of the vertical axis, his pen climbs an upwards slope; it hits a peak, then falls back down, well below the height of where it started. His inner chemist is coming out. Short-term investments (climbing the hill) lead to lower costs (finding the lower plateau).

"We ask businesses to invest now in their research and product development for better and higher profits in years from now," he says. "We need to do the same thing in the health care system. We need to invest today, whether it is health IT, comparative effectiveness, changing the incentive structure. The return is going to come in a few years. That is really at the heart of the notion of health care reform."

And so it is that Emanuel and the White House are attempting to reorganize the delivery and reimbursement systems of health care, changing what the types of procedures doctors rely on, making people more aware of disease prevention, encouraging insurance companies to expand coverage, and so on. It is a process rife with sensitivities, trickeries and, of course, the potential for failure. It is not, he insists, impossible.

"It is a complicated process and we have to try and make the choices clear and give people good reasons for making them," Emanuel explains. "I don't think that's an impossible task and thankfully we have one of the great communicators, Barack Obama, at the helm of this ship of state."

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