Culture

Mary Carmichael: Health Care Made Simple

This Monday a modest little paperback will show up in bookstores offering a suggestion for health-care reform. It won't contain any wrenching human stories like those in last year's big health-care book, Jonathan Cohn's "Sick." It won't be accompanied by gonzo stunts à la Michael Moore's "Sicko." But "Healthcare, Guaranteed," by Dr. Ezekiel Emanuel, may nonetheless be the most exciting book yet to come out of the country's medical crisis. What it offers is a radical yet straightforward proposal, one a layperson can understand. If the complexities of health-care policy give you a headache, this book is aspirin. Read it twice and call your congressman in the morning.

Emanuel, an oncologist who chairs the department of bioethics at the National Institutes of Health, advised the Clintons on their disastrously complex health-care plan of 1993. He's come a long way since: he now seems to subscribe to the "keep it simple, stupid" school of policy design. Too many details can scare away those of us who aren't wonks, so he mostly leaves them out of his new plan. Instead he proposes big, systemwide changes, starting with the butchery of some of health care's most sacred cows. Medicare? Over time, it would be phased out. Medicaid? Same. Employer-based health insurance? It's a bureaucratic system built "by accident," he writes, originally designed for post-World War II workers; let's get rid of it. In place of all these institutions, Emanuel says, the government should offer every American a voucher for health insurance—one that covers the same benefits that members of Congress get. Insurance companies would have to accept the vouchers, and each person could choose from a variety of private networks of docs, hospitals and health plans. A National Health Board would oversee it all. And that's pretty much it.

Now the big question: how do we pay for it? Emanuel's plan lowers some taxes by gutting costly programs, but it also adds a new fixed tax on some goods and services to pay for the vouchers. "Americans will come out revenue-neutral on average," he says. "The poor will pay less." And the rich will probably pay a lot more. Sweeping changes are one thing, but sweeping changes and a new tax? Even if the plan could save health care, it'll be a hard sell.

Still, Emanuel knows politics (his younger brother Rahm is the fourth-ranking Democrat in the House). He also knows the art of the deal (younger brother No. 2, Ari, is the model for superagent Ari Gold on "Entourage"). And he sees at least one scenario that gives his plan a chance. While he likes Barack Obama's and Hillary Clinton's proposals more than John McCain's, he's underwhelmed by all of them. "I don't think anything they've put out so far is what they're going to end up advocating," he says. "They'll want another plan eventually. I want to be that second choice."

There's one more problem with Emanuel's simple plan: if it does ultimately come to pass, it'll get churned through the legislative process and bogged down with so many riders that it won't be simple anymore. That's OK with him, as long as the essentials are still in place. "In the end the bill is going to be 1,000 pages," he says. "But reform is only going to happen if average people can understand it and live with it. Otherwise, they'll get nervous and decide to not do anything." That's an even simpler option—but it's the worst one.