The World's Fifth-Largest Economy: U.S. Health Care

Zeke Emanuel thinks the Affordable Care Act will shrink the $2.8 trillion system to something more sustainable -- and give doctors incentive to speed up that process.

As part of the grand finale to the Washington Ideas Forum yesterday, I talked with Dr. Ezekiel Emanuel, oncologist and chair of the Department of Bioethics at the National Institutes of Health, about the implications of the Affordable Care Act. Now that the election is over, even John Boehner called it the "law of the land," and a series of important spending decisions will be made over the next few months.

James Hamblin, a trained clinician himself, wrote about the part of the conversation that dealt with end-of-life care discussions -- the dreaded "death panels" that are nothing of the kind (only a way to give patients the dignity and options they say time and again they want and need). But, as Hamblin points out, the whole subject is hard for every doctor to raise -- there's little medical-school training for a subject that's uncomfortable for everyone.

Emanuel, unsurprisingly, was optimistic that despite campaign talk, all states will opt in to the plan. Governor Rick Scott, in Florida, is already backing away from his pledge to opt out; Emanuel was confident that Governor Rick Perry will eventually participate in the Federal Medicaid expansion.

"It's a great deal for states," he said. "Almost every state makes money." The pressure to force Perry's hand, he said, will come from hospitals themselves, which want easier and steadier payment to cover the costs of treating the uninsured. And states will be required to transfer less money than they have had to in order to pay those hospitals' costs, leaving them more money to insure their own employees.

Clear rankings of doctors, hospitals, and HMOs, using information the ACA requires them to disclose, will result in easier ways to decide where to get your care -- and, he insisted in reply to my question about the confusion of weighing plans now and maybe more confusion with new state "exchanges," people will be able to navigate the new choices more easily than they ever have.

 Washington Ideas Forum Conversations with leading newsmakers. A special report

"You really can make good decisions in 15 minutes," he said. "I've done it hundreds of times, when I've made students go on to the Massachusetts site that helps you pick between policies. And entrepreneurs will come in and give you a lot of software and programs that ride on top of the exchanges and let you put in what's important to you, to make a good choice."

This will not only give software developers a way to make money -- it will also start to make public the kinds of opinions many doctors already have, from word of mouth, but the public doesn't know. Like, for instance, "whether the Mayo Clinic is really great, and where it's not that hotsy-totsy."

These rankings might rankle the sacred cows of the health industry -- he seems to like singling out the Mayo Clinic -- but can also be an incentive for doctors to use the mentality that got many of them into and through medical school. There is fierce competitiveness and the need to be told they're the best. "Doctors want to excel with patients and also make a good living," he said with unusual understatement. What he really meant was that they want to be the best. I called it the "ego carrot": something that doctors, however uncomfortable with raising the topic of end-of-life care, can use as their own ACA stimulus.

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Corby Kummer's work in The Atlantic has established him as one of the most widely read, authoritative, and creative food writers in the United States. The San Francisco Examiner pronounced him "a dean among food writers in America." More

Corby Kummer's work in The Atlantic has established him as one of the most widely read, authoritative, and creative food writers in the United States. The San Francisco Examiner pronounced him "a dean among food writers in America." Julia Child once said, "I think he's a very good food writer. He really does his homework. As a reporter and a writer he takes his work very seriously." Kummer's 1990 Atlantic series about coffee was heralded by foodies and the general public alike. The response to his recommendations about coffees and coffee-makers was typical--suppliers scrambled to meet the demand. As Giorgio Deluca, co-founder of New York's epicurean grocery Dean & Deluca, says: "I can tell when Corby's pieces hit; the phone doesn't stop ringing." His book, The Joy of Coffee, based on his Atlantic series, was heralded by The New York Times as "the most definitive and engagingly written book on the subject to date." In nominating his work for a National Magazine Award (for which he became a finalist), the editors wrote: "Kummer treats food as if its preparation were something of a life sport: an activity to be pursued regularly and healthfully by knowledgeable people who demand quality." Kummer's book The Pleasures of Slow Food celebrates local artisans who raise and prepare the foods of their regions with the love and expertise that come only with generations of practice. Kummer was restaurant critic of New York Magazine in 1995 and 1996 and since 1997 has served as restaurant critic for Boston Magazine. He is also a frequent food commentator on television and radio. He was educated at Yale, immediately after which he came to The Atlantic. He is the recipient of five James Beard Journalism Awards, including the MFK Fisher Distinguished Writing Award.

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