Howard Fineman: The Real Emanuel Brother to Watch

Moving from hospital to hospital, a young oncologist named Ezekiel Emanuel made a startling discovery. The doctors he worked with often didn't know if the treatment they were administering was the most sensible one available or merely, as was often the case, the most expensive. They would say, "That's how we do it here," he wrote in a book he published last year. All too regularly, the result was a poor patient outcome and wasted money and time.

That story is making the rounds in the White House now, not (sadly) because it's exceptional but because of the author: he's the older brother of the White House chief of staff. "Entourage" fans focus on Rahm Emanuel's younger sibling, Ari, the inspiration for superagent Ari Gold. But in Washington, the brother to watch is Zeke, a medical ethicist who has just taken a key role advising the budget director, Peter Orszag. "Zeke is a very innovative thinker," Orszag told me.

In the view of the health-care industry, Zeke is a fundamentalist. He favors guaranteed care for everyone through a system of government vouchers; national boards, he says, should help decide which treatments work most effectively. Costs should be funded by a dedicated national value-added tax. It's the rational way to do it, he said at the Aspen Institute last summer.

Rationality and political reality tend not to overlap, however. Orszag distances himself from Plan Zeke: "There are lots of ideas floating around." More important, Rahm says that, while Zeke's ideas are worthy, the politics are impossible. Administration officials don't dare repeat President Obama's campaign pledge to ensure health care is available to all by the end of his tenure. It may be too expensive, given current economic realities. "Universal coverage is a desirable goal," says Orszag, "but it does cost money upfront."

In the federal budget he'll unveil this week, Orszag plans to offer a fiscal "path to sustainability." But the only way to get there is to cut the growth of spending on health care for 83 million Americans via Medicare, Medicaid, SCHIP and veterans' programs. "This is the ballgame for our long-term fiscal future," he says.

Even if the government could still afford the system that exists, it's become clear the country cannot. Health care in America is an infuriating contradiction: a cutting-edge technological marvel, but one so bloated, wasteful and jerry-built that it consumes one sixth of the nation's wealth without making us comparatively healthy. Obama and his aides recognize this: a feature of the stimulus is a billion-dollar program to establish a clearinghouse for research on "best practices" and ways to measure which ones are the most cost-effective. (It will have only advisory power.)

The next step, to be unveiled in the budget, will be to find ways to apply some of this research in federal programs. As always, the tangled but powerful branches of the health-care industry—doctors, hospitals, insurance and pharmaceutical companies—are searching for ways to not just survive, but thrive, no matter what changes are made.

If Zeke had his way, they would become bidders in a government-funded and supervised marketplace—which is not about to happen any time soon. For now, Zeke is lying low (Orszag's aides declined to make him available). Don't expect to see him on the talk shows. But health-care lobbyists are aware of his prescriptions even as they meet privately on the Hill to hash out their own strategy. They know that he talks to his brother—and that his brother talks to the president.