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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.

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.

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"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.