Healthcare Guaranteed: A Simple, Secure Solution for America
By Ezekiel J. Emanuel, MD, Ph.D., with a foreword by Victor R. Fuchs, Ph.D., (New York: Public Affairs, 2008), 219 pages, $14.95
Here's an interesting little book that just might change our world. Ezekiel Emanuel, an oncologist with an additional doctorate in political philosophy, and Victor Fuchs, a healthcare economist, have been collaborating since 2003 on crafting a new model for the financing and delivery of healthcare in the United States. Emanuel has persuasively and provocatively argued the case for their proposed model — what they call the Guaranteed Healthcare Access Plan — in Healthcare, Guaranteed.
This is a relatively short book of eight chapters and written for the non-specialist. Chapter One begins with a brief, if familiar, review of the current healthcare system's woes. Chapter Two then outlines seven goals (elsewhere called "essential elements") for healthcare reform. These goals function later in the book as criteria by which his and other reform proposals are evaluated. The goals are worth listing here as they reveal Emanuel's thoughts (some might say biases) on what he believes a sustainable health system in a developed country such as ours should accomplish: guaranteed coverage for all citizens; effective cost controls; high-quality, coordinated care; choice; fair funding; reasonable dispute resolution mechanisms; and, interestingly, economic revitalization (by decoupling healthcare insurance and employment). Chapter Three briefly reviews how we got into the current "dysfunctional mess," and Chapter Four outlines Emanuel's and Fuchs' Guaranteed Healthcare Access Plan.
Under "Benefits and Coverage," the plan would:
1. Guarantee coverage to each American household through a voucher system that would allow the individual or family to enroll in a health plan of their choice.
2. Define a generous set of standard benefits that would be modeled on those currently available to members of Congress. Patients could choose their own physicians and hospitals.
3. Offer freedom of choice with regard to health plans. Plans would be required to accept enrollees, without regard for preexisting conditions, and to guarantee renewal each year.
4. Permit the purchase of additional services with after-tax dollars.
5. Eliminate employer-based health insurance, along with the $200 billion tax exemption that accompanies it.
6. Phase out Medicare, Medicaid, and SCHIP. No one would be forced out of these programs, but they would not accept new enrollees, and current enrollees would have the option of joining the Guaranteed Healthcare Access Plan.
Under "Oversight and Administration," the plan would:
7. Provide for oversight by a National Health Board and twelve Regional Health Boards, modeled on the Federal Reserve System. Funding for these boards will be independent of annual congressional appropriations and the boards would be insulated from lobbying efforts.
8. Direct each of the twelve Regional Health Boards to create a Center for Patient Safety and Dispute Resolution to receive and evaluate claims regarding patient injury, medical error, and physician concerns.
9. Monitor cost and quality control by creating an Institute for Technology and Outcomes Assessment.
Under "Financing," the plan would:
10. Fund healthcare vouchers or "certificates" through a dedicated value-added tax (VAT), initially of 10 percent, on purchases of goods and services. Revenue from the tax could not be diverted to other purposes and no other tax revenues could be used to fund the plan. Congress alone would have the power to increase the VAT rate.*
Chapters Five, Six, and Seven consider the other leading reform proposals. Emanuel argues these other proposals fall short in addressing the seven goals he outlined earlier. None of them, he argues, is sustainable. One of the principal benefits of Emanuel's model is that it is comprehensive. He claims that the other reform plans will not succeed primarily because they address only the financing side of healthcare. Unless a reform plan addresses both the financing and the delivery of healthcare, he argues, the steadily increasing costs of healthcare will always outstrip our ability to keep up with them. Thus, as we saw above, in addition to covering 100 percent of American citizens with the plan, he proposes an independent research institute to assess new technologies and to compare the cost and quality of competing treatments and treatment locations. Also, by allowing patient choice for health plans, physicians and hospitals, his plan introduces market incentives to encourage competition, more efficient organizations, and better coordinated care by health plans and providers. And, if patients want to buy additional benefits, they may do so, but only with their own, after-tax dollars.
Finally, in Chapter Eight, Emanuel the political philosopher considers what it might take to change the system we have currently to the one he is proposing. He does not discount the hurdles that must be overcome, but neither does he believe they are insurmountable. Nevertheless,
Healthcare, Guaranteed deliberately refrains from providing the details a policy specialist might like to see and, at the same time, from engaging in extensive speculation about the political feasibility of the model. Rather, it straightforwardly describes the Guaranteed Healthcare Access Plan and then argues why it is more likely to succeed than other proposals. His aim is to have a viable proposal ready when the pressures for reform coalesce, as he believes they eventually must.
In the end, there are many questions we might like to press on Emanuel. He anticipates some of them in Chapters Five, Six, and Seven when critiquing the proposed reforms of others. Is not incremental reform a better way forward, especially in the light of the Clinton failure? Should we not give state mandates a chance to work before completely overhauling the entire system? And would not a single-payer system be more efficient in the long run? He does address these questions, if only briefly. But as I said above, he also is provocative. The Guaranteed Healthcare Access Plan is not overly complex and, in theory at least, is no more expensive than we are currently paying for much less than this plan promises. It addresses both the financing and the delivery side of healthcare, and it purports to bring together the best of government oversight and private competition. Emanuel has proposed a plan that might actually work, and it is worth giving his book serious attention.
Jan C. Heller, Ph.D.
System Director, Ethics and Theology, Providence Health & Services, Seattle
The views and opinions expressed in this review are those of the reviewer and do not represent Providence Health & Services.
* Emanuel,
Healthcare, Guaranteed, pp. 83-84.
Narrative Medicine: Honoring the Stories of Illness
By Rita Charon, (New York: Oxford University Press, 2006), 258 pages
Narrative Medicine advances the line of argument developed over the past twenty to thirty years regarding narrative ethics. This rich discussion has focused on the healing narratives of care givers and the illness narratives of patients. In terms of health care ethics this literature has highlighted the ethical task to be one of hermeneutics, the duty of the ethicist to discern the meaning and significance of events contained within the narratives of both care givers and patients. Narrative ethics has tended to focus on ethical responsibilities as the by-product of relationships between care givers and patients. The hermeneutical and relational foci of narrative ethics have been emphasized to distinguish this approach from the dominant approach to health care ethics in recent years, principalism.
Charon's Narrative Medicine is an outgrowth of narrative ethics and the general characteristics of narrative ethics are woven deeply throughout her text. Her unique contribution is the manner in which she demonstrates that the traits associated with narrative ethics and literary theory should underlie medicine as a practice, a praxis in the sense articulated by Alasdair MacIntyre. "My hypothesis in this work," writes Charon, " is that what medicine lacks today — in singularity, humility, accountability, empathy — can, in part, be provided through intensive narrative training. Literary studies and narrative theory, on the other hand, seek practical ways to transduce their conceptual knowledge into palpable influence in the world, and a connection with health care can do that." (p. viii). Although her hypothesis stresses both the impact of literary studies on medicine and the contribution of medicine to literary studies, to the mind of this reader, the former is given much more emphasis throughout her text than the latter.
Rita Charon is a practicing physician with her own private practice who also shares some responsibility for the training of residents. Among the many interesting highlights of her text is the manner in which she distinguishes between the subjective, experiential narration of a patient at the time that he or she presents to the physician. On the other hand there is the objective, clinical, scientific narration contained in the physician's chart of the patient. Although this is not a point developed by Charon, many ethics consultations could be construed as efforts to interpret and integrate the levels of meaning latent in these two narrative accounts of the same case.
What is truly innovative in Charon's work is what she refers to as the "parallel chart." The parallel chart is a brief one page narration of the resident's or attending physician's account of their experience, their emotions, feelings, anxieties, and moral distress that stem from caring for a patient. She provides numerous examples of parallel charts authored by her students that are poetic, deeply sensitive to the vulnerability of patients, and the moral and emotional distress frequently associated with the care of hospitalized patients. At a seminar each week, each student is asked to read his or her parallel chart and it is then discussed by the group. The purpose of these seminars is not to provide group therapy, they are neither support groups nor venting sessions. Rather the goals of these sessions "are to enable them (i.e. the residents) to recognize more fully what their patients endure and to examine explicitly their own journeys through medicine." (p. 156) The practicum of the parallel chart, a narrative crafted by residents, becomes a vehicle through which the medical practices of these future physicians will hopefully be infused with singularity, humility, accountability and empathy.
Narrative Medicine is a very sophisticated text that reveals the author's knowledge of medicine, philosophy, literary theory and ethics. This book should be required reading for anyone engaged in medical or nursing education. Health care ethicists, of either a philosophical or theological bent, will find in Charon's book an innovative and insightful approach to engaging patient care issues at a deeper, more sensitive, level.
John A. Gallagher, Ph.D.
Corporate Director, Ethics
Catholic Healthcare Partners
Copyright © 2008 CHA. Permission granted to CHA-member organizations and Saint Louis University to copy and distribute for educational purposes. For reprint permission, contact Betty Crosby or call (314) 253-3490.