Book Review

Healthcare, Guaranteed: A Simple, Secure Solution for America

N Engl J Med 2008; 359:874-875August 21, 2008

Article

Healthcare, Guaranteed: A Simple, Secure Solution for America
By Ezekiel J. Emanuel. 219 pp. New York, PublicAffairs, 2008. $14.95. ISBN: 978-1-58648-662-4

In 2007, spending on health care represented 16% of the U.S. economy — a much greater percentage than that spent in nations with universal access to health care services — while at the same time nearly 50 million Americans were uninsured. These imbalances affect not only those without health insurance but also the federal budget, our entire health care system, and Medicare in particular. Unlike the potential “fixes” that are available to solve the expected shortfalls in the Social Security pension system, there are no ready solutions to shore up Medicare financing. Over and above these issues are concerns about the availability and quality of health care.

Healthcare, Guaranteed is a broad discussion of pervasive problems in our health care system, and it lays out a comprehensive plan to remedy them. The author, Ezekiel Emanuel, is a physician, and his collaborator, Victor Fuchs, who wrote the foreword, is an economist; together they present a plan designed to ensure universal access, with economic fairness, a higher quality of care, and greater efficiency.

In contrast with the health plans offered by the leading 2008 presidential candidates — each calling for incremental changes — Emanuel and Fuchs advocate total reform. From one perspective, the design of their plan is elegant in its simplicity, as it puts an end to problems that plague employer-based and public-sector health insurance. From another perspective, the plan is fraught with obstacles — it puts an end to well-liked programs such as Medicare and the Federal Employees Health Benefits Program as well as the health benefits hard-won by unions.

The plan is straightforward. Everyone in the United States would be given a certificate (or voucher) that entitles an individual person or a family to enroll in a health plan of choice. Employer-based health insurance would no longer be needed. Similarly, public-sector programs such as Medicare, Medicaid, and the State Children's Health Insurance Program would no longer be needed; Medicare enrollees could continue to use the program, but there would be no new enrollees.

Health plans would be required to accept all applicants; no one could be rejected on the basis of a preexisting condition or denied renewal. Payments to plans would be risk-adjusted to eliminate the incentive to avoid the sick. Every plan would be required to cover a standard set of benefits (modeled on the benefits that members of Congress now receive), with no premiums or deductibles and with only minimal copayments. Plans would arrange for services through a network of physicians, hospitals, and other providers. Those who wish for more amenities and additional services could buy a “platinum” plan at their own expense.

Financing would take place through a value-added tax dedicated solely to health care; to cover the 257 million Americans not receiving Medicare, it is estimated that the value-added tax would be about 10% on the purchase of goods and services. Administration and oversight would be managed by a national health board with 12 regional boards (modeled on the Federal Reserve System), with assistance from centers for patient safety and dispute resolution and an institute for technology and outcomes assessment.

My only quarrel with this book is the unbridled optimism of its author, who seems convinced that this plan would achieve all its goals. Emanuel writes that “the Guaranteed Healthcare Access Plan sets the stage for free enterprise to deliver on its promise that competition will drive quality up while driving prices down” and that implementing the plan would result in “obvious improvements to the nation's health.” Readers familiar with the wide-ranging research and demonstration projects undertaken in traditional Medicare and in managed care to control costs and improve quality and efficiency may be skeptical that this plan will achieve these same goals. Nonetheless, if health care in America were to be reimagined from scratch, this book would provide an important service in drawing attention to two critical issues.

The first issue is a matter of principle. Should the system guarantee every American the right to choose among health insurers and plans (as advocated in this book), or should it guarantee everyone the right to choose a physician and other health care providers while prohibiting private insurance that duplicates public coverage (as is the case with traditional Medicare and as advocated by the Physicians' Working Group for Single-Payer National Health Insurance)? Some argue that Americans will demand a choice of plans, whereas others believe that a system built on marketplace competition will result in a two-tiered health care system that may exacerbate existing disparities in health by race and socioeconomic status. The second critical issue is financing. Although a value-added tax is part of the mixed revenue-producing schemes used in many European countries, its adoption would introduce major changes to U.S. tax policies.

This book is especially timely. A new study by the Commonwealth Fund, published in June in Health Affairs, found that among U.S. adults aged 19 to 64 years, 25 million were underinsured for health care, a 60% increase over the past 4 years. If this number is added to the 50 million people who are without health insurance, approximately 75 million Americans — or 42% of 19-to-64-year-olds — are at risk for relatively high out-of-pocket expenses, and possibly financial ruin, if they suffer a serious illness. Policymakers and all Americans troubled by these injustices will find Healthcare, Guaranteed a valuable resource for considering solutions to our health care dilemmas.

Marian E. Gornick
3704 N. Charles St., Baltimore, MD 21218
mgornick@aol.com