Obamacare's Architect Talks about the Law's Making

Ezekiel Emanuel – brother of Rahm, with whom he shares a charm deficiency – shared his behind-the-scenes stories in the recent Wall Street Journal essay “Inside the Making of Obamacare.”  To my ear, Emanuel’s abrasiveness and arrogance in his radio and television appearances undermine his defense of ObamaCare,  and this piece of writing likewise does little to improve my opinion of President Obama or his signature law.

Emanuel is often called the “the architect of ObamaCare.”  Although no one person put together the Rube Goldberg contraption of a law, Emanuel was certainly a key player.  He describes his role in the Journal:

As a White House special adviser on health policy, I was party to many of the internal debates that shaped the Affordable Care Act. Looking back, I believe that three key issues were emblematic of the sometimes tortured interplay of policy and politics in crafting Obamacare.

His three key issues are as follows:

1. Emanuel pushed for a “bundled payment” system to replace “fee-for-service,” but “the Medicare bureaucracy wouldn't budge.”  I expressed my doubts in an earlier AT article about bundled payments, currently being implemented by the new Accountable Care Organizations – the invasion of patient privacy, the probability that care will be rationed, and the risk that hospitals will lose money ("If the N.S.A. is Big Brother, We're Big Mother"; see also Chris Mondie’s "The Hidden Dangers of Accountable Care Organizations").

Emanuel explains:

Since the doctors are paid one fee for the entire episode of care, regardless of how many tests and scans and drugs they order, they no longer have an incentive to provide unnecessary care for a few extra bucks. When implemented in hospital settings, bundled payments have been shown to encourage providers to improve efficiency and eliminate unnecessary procedures without stinting on care.

So on the one hand, doctors are the kind of swindlers who would “provide unnecessary care for a few extra bucks” – perhaps amputating a foot here and there, as Obama famously suggested.  On the other hand, if we take away those extra bucks, doctors will not “stint…on care.”  Are these a different set of doctors?

Although Emanuel later discusses malpractice reform, he never mentions that doctors often order “tests and scans and drugs” not out of greed, but out of fear of lawsuits.

2. Emanuel argues for an elimination of the “tax exclusion” for health care benefits – taxing health care benefits as income.  Emanuel says that this “is a major drag on the federal budget – lowering revenue by a whopping $250 billion a year.”  As if there’s ever any drag on the federal budget under Obama.  Wouldn’t those shysters love to get their fingers on a pile of cash like that?

Emanuel notes that in 2008, John McCain proposed eliminating the tax exclusion in return for a $5,000 tax credit to purchase health insurance.  In response, the “Obama campaign ran more than $100 million worth of ads pounding McCain, accusing the GOP nominee of ‘taxing health benefits for the first time ever.’"  Emanuel concludes:

Ultimately, Obama authorized a new tax-exclusion policy despite the heartburn he knew it would cause his political base – particularly labor unions. We proposed a tax on high-cost "Cadillac plans," which will begin in 2018. Reversing a campaign position took a lot of guts, but this was good policy, and the president showed leadership in endorsing it.

Where to start?  For one, Emanuel makes it no secret that Obama is in the pocket of labor unions.

Secondly, labor unions received an exemption from the Cadillac tax!  As the Wall Street Journal wrote in 2010, “[t]he 87% of Americans who don't belong to a union will now foot the bill for a $60 billion giveaway to those who do.”  So much for the gutsy Obama defying his base.

Third, when Obama trashed McCain for his tax exclusion and then “reversed his campaign position,” that was not “leadership.”  It’s called saying whatever is necessary to win the election and doing whatever you feel like after the election.  We could assemble a long list of these.  Evil Bush didn’t close Gitmo; gutsy Obama reversed his campaign position, etc.

3. Emanuel spoke to his brother about his third key issue: medical malpractice reform.  Zeke reports that Rahmbo “immediately cut [him] off: "Shut the f–  up! We are not doing malpractice. Period.”

Emanuel writes:

The president had already aggravated liberals by forgoing a "public option." He'd offended unions by limiting the tax exclusion. He wasn't going to antagonize trial lawyers, another core Democratic constituency, for no gain.

So the president is adroitly making deals, balancing the needs of his constituents, giving a little here to gain a little there.  How absurd.

Obama, Pelosi, and Reid pushed national health care through using every trick they could.  It was not a concession to conservatives to forgo the public option.  Those liberals who continue to push for the public option know full well that ObamaCare was a major victory for socialism.  As mentioned above, unions were hardly offended by the exemption granted them.

Conservatives might accuse Obama of steering clear of malpractice reform because he wants trial lawyers to sue doctors unnecessarily so they can donate a piece of their winnings to the Democratic Party.  Emanuel not only admits this – he tries to turn it into a positive.

According to Emanuel, “not a single Republican in Congress would even negotiate” on malpractice reform.  No, Zeke, not a single Republican voted for the abominable law.  Malpractice reform is a stated goal of the Republican Party.  From the 2012 Republican Party Platform:

Lawyers should not hold physicians hostage

A key step will be reform of malpractice law. In its current form, it encourages health care providers to conceal even innocent mistakes, lest they be subject to vilifying publicity through the trial lawyers.

Emanuel’s takeaway lesson: “it was heartening to learn that sometimes, sound policy can trump politics when politicians show leadership.”  Sound policy?  Caving into the trial lawyer lobby?

If Emanuel really believes any of this, he’s delusional.

Ezekiel Emanuel – brother of Rahm, with whom he shares a charm deficiency – shared his behind-the-scenes stories in the recent Wall Street Journal essay “Inside the Making of Obamacare.”  To my ear, Emanuel’s abrasiveness and arrogance in his radio and television appearances undermine his defense of ObamaCare,  and this piece of writing likewise does little to improve my opinion of President Obama or his signature law.

Emanuel is often called the “the architect of ObamaCare.”  Although no one person put together the Rube Goldberg contraption of a law, Emanuel was certainly a key player.  He describes his role in the Journal:

As a White House special adviser on health policy, I was party to many of the internal debates that shaped the Affordable Care Act. Looking back, I believe that three key issues were emblematic of the sometimes tortured interplay of policy and politics in crafting Obamacare.

His three key issues are as follows:

1. Emanuel pushed for a “bundled payment” system to replace “fee-for-service,” but “the Medicare bureaucracy wouldn't budge.”  I expressed my doubts in an earlier AT article about bundled payments, currently being implemented by the new Accountable Care Organizations – the invasion of patient privacy, the probability that care will be rationed, and the risk that hospitals will lose money ("If the N.S.A. is Big Brother, We're Big Mother"; see also Chris Mondie’s "The Hidden Dangers of Accountable Care Organizations").

Emanuel explains:

Since the doctors are paid one fee for the entire episode of care, regardless of how many tests and scans and drugs they order, they no longer have an incentive to provide unnecessary care for a few extra bucks. When implemented in hospital settings, bundled payments have been shown to encourage providers to improve efficiency and eliminate unnecessary procedures without stinting on care.

So on the one hand, doctors are the kind of swindlers who would “provide unnecessary care for a few extra bucks” – perhaps amputating a foot here and there, as Obama famously suggested.  On the other hand, if we take away those extra bucks, doctors will not “stint…on care.”  Are these a different set of doctors?

Although Emanuel later discusses malpractice reform, he never mentions that doctors often order “tests and scans and drugs” not out of greed, but out of fear of lawsuits.

2. Emanuel argues for an elimination of the “tax exclusion” for health care benefits – taxing health care benefits as income.  Emanuel says that this “is a major drag on the federal budget – lowering revenue by a whopping $250 billion a year.”  As if there’s ever any drag on the federal budget under Obama.  Wouldn’t those shysters love to get their fingers on a pile of cash like that?

Emanuel notes that in 2008, John McCain proposed eliminating the tax exclusion in return for a $5,000 tax credit to purchase health insurance.  In response, the “Obama campaign ran more than $100 million worth of ads pounding McCain, accusing the GOP nominee of ‘taxing health benefits for the first time ever.’"  Emanuel concludes:

Ultimately, Obama authorized a new tax-exclusion policy despite the heartburn he knew it would cause his political base – particularly labor unions. We proposed a tax on high-cost "Cadillac plans," which will begin in 2018. Reversing a campaign position took a lot of guts, but this was good policy, and the president showed leadership in endorsing it.

Where to start?  For one, Emanuel makes it no secret that Obama is in the pocket of labor unions.

Secondly, labor unions received an exemption from the Cadillac tax!  As the Wall Street Journal wrote in 2010, “[t]he 87% of Americans who don't belong to a union will now foot the bill for a $60 billion giveaway to those who do.”  So much for the gutsy Obama defying his base.

Third, when Obama trashed McCain for his tax exclusion and then “reversed his campaign position,” that was not “leadership.”  It’s called saying whatever is necessary to win the election and doing whatever you feel like after the election.  We could assemble a long list of these.  Evil Bush didn’t close Gitmo; gutsy Obama reversed his campaign position, etc.

3. Emanuel spoke to his brother about his third key issue: medical malpractice reform.  Zeke reports that Rahmbo “immediately cut [him] off: "Shut the f–  up! We are not doing malpractice. Period.”

Emanuel writes:

The president had already aggravated liberals by forgoing a "public option." He'd offended unions by limiting the tax exclusion. He wasn't going to antagonize trial lawyers, another core Democratic constituency, for no gain.

So the president is adroitly making deals, balancing the needs of his constituents, giving a little here to gain a little there.  How absurd.

Obama, Pelosi, and Reid pushed national health care through using every trick they could.  It was not a concession to conservatives to forgo the public option.  Those liberals who continue to push for the public option know full well that ObamaCare was a major victory for socialism.  As mentioned above, unions were hardly offended by the exemption granted them.

Conservatives might accuse Obama of steering clear of malpractice reform because he wants trial lawyers to sue doctors unnecessarily so they can donate a piece of their winnings to the Democratic Party.  Emanuel not only admits this – he tries to turn it into a positive.

According to Emanuel, “not a single Republican in Congress would even negotiate” on malpractice reform.  No, Zeke, not a single Republican voted for the abominable law.  Malpractice reform is a stated goal of the Republican Party.  From the 2012 Republican Party Platform:

Lawyers should not hold physicians hostage

A key step will be reform of malpractice law. In its current form, it encourages health care providers to conceal even innocent mistakes, lest they be subject to vilifying publicity through the trial lawyers.

Emanuel’s takeaway lesson: “it was heartening to learn that sometimes, sound policy can trump politics when politicians show leadership.”  Sound policy?  Caving into the trial lawyer lobby?

If Emanuel really believes any of this, he’s delusional.