Reinventing American Health Care: How the Affordable Care Act will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System

This is a well-written and well-organized book with interesting information. The beginning part of the book starts out with the history of medical care and attempts at medical reform in the history of the United States. It points out that as many as 98,0000 people die in hospitals each year as a result of preventable medical errors. The book also points out the following information: Half the American population hardly uses any services. 10% of Americans use nearly 2/3rds of all health care services. The mandate reduces adverse selection. 55% of those earning less than 100% of the Federal Poverty line were not offered Health Insurance from their employers. 51% of the uninsured have been uninsured for three years or more. Of course, these figures are as of the end of last year before the Affordable Care Act went into effect. Before ACA went into effect, at least 15% Americans were uninsured. One out of 7 Americans lacked health insurance in the richest country of the world. Not having health insurance can cost you your life. Being uninsured means your chance of dying in a car accident is 40% higher than that of a privately insured person. The author of the book feels that the mandate is the only way insurance companies can offer to all-including those with pre-existing conditions. The mandate is to balance the sick and the healthy. The drawback of this book is that it does not mention the fact that in California for Medi-Cal as of the present time this review is written, the Government can seek recovery (reimbursement) from the estate of anyone 55 or over who died for all health insurance premiums that were paid into it. Some people feel that this is unjust because it allows people with higher income levels to get subsidized health insurance through the new health insurance exchange and not have to pay back any of it. There is a bill that could be signed or vetoed by California Governor Brown by the end of September 2014 that could still retain this or change it. Some people feel that it is Orwellian to have to choose between having health protection and your estate.

Well, this book was one that had me underlining and calling friends and rereading and wondering why we didn't know this before. It is hard for me to know how many others would find this book as fascinating as I did. First I was a front line clinician until I retired last year. In the course of my education I was fortunate enough to take a course in health care economics. I loved it and it helped me understand why this is so hard. You also have to understand that many clinicians are going to hate this because it changes things. Others will love it for the same reason. This book explains were we have been, what the Affordable care Act really is, and tries to guess where things will go from here. We need this kind of information to intelligently debate and evaluate what is happening and to understand some of the whys. Is it perfect? The ACA, I mean. Of course not, but it is a huge accomplishment. It does make me really wonder about those who so vehemently oppose the whole idea of health care for all and how that group made this bill less than it could have been. But nothing is perfect and I am just so happy to know that we have come this far. I would love to be in on the part of the process that will be doing research on how to fix the system. And do not be surprised when those who benefit from the present system send up a hue and cry about how terrible it is. Just think about the money and where it is going and what we are getting for it. I loved this book. It is important and well written. One question for all of those who hate it and rail against it. Do they know what it is about....really? Are they heavily invested in the status quo? Are they willing to try to make it better and be rational in the defense of their criticisms? It makes me happy to know that people are trying to do this right and not just "give stuff away". There are opportunities to make it a good thing for our population. Not just the people who stand to profit. Not perfect but a step in the right direction.

This is a good primer on the Affordable Care Act. It goes into sufficient detail to leave the reader with a basic understanding of the law. The book emphasizes the ACA goes well beyond its headline attracting features like the individual and employer mandate and includes many provisions that will fundamentally change the health care industry. One of the Act's main objectives the author notes is to tame rising health care costs for all Americans, which, since the 1970's, has outpaced the growth of the economy. The author also points out that the Act is structured to provide incentives and penalties, particularly for hospitals, intended not only to lower costs, but to improve the quality of health care as well. As one of those intimately involved in passage of the ACA, the author is sometimes defensive about the events surrounding passage, but overall does a very good job of explaining - in neutral terms - the details of the law and how they are intended to effect health care in the United States. For those wishing to learn about the specifics of the law beyond partisan interpretation, this book will fill the bill.

This is truly a really good book that has a lot of depth to it. There are so many laws that are cited and what the ramifications are of each of them. It is really a good read that keeps you interested throughout the book. If I have to select a negative remark, it would have to be that the book is dated. The author tell us what will (or supposed to) happen in 2014, 2015... Some of it became true and other items did not make it but do not let that hold you back from reading this book. I purchased the audio companion version and it is read by the author. To close, I would pair this book with Remedy and Reaction by Paul Starr.

Wow, what a wonderful book this is! Like most physicians, before reading this book, I knew only a few of the provisions in the Accountable Care Act like the elimination of "previous conditions" when choosing one's health insurance and the ability of young adults to stay on their parents' plan until age 27. I knew the act encouraged the formation of Accountable Cost Organizations with with which I had passing experience prior to retirement. (I was amazed at how quickly costs dropped when an ACO identified the "at risk patients" and managed their care with case workers rather than allowing them to use the most expensive and cost ineffective services, ie. the local emergency room.) But I had no idea how extensively the ACA changes the way health care is to be delivered in the future. I think Emanuel is right on in his assessment of the current health care delivery system and it's inherent flaws where physicians are rewarded for doing more whether or not it benefits the patient. Bundled payments and ACO's turn that equation on its head. Thank goodness! The one thing the ACA doesn't adequately address is the shortage of primary care physicians. The probable solution will be the substitution of professionals meant to be "physicians extenders" in the inappropriate role of initial diagnosis and triage. This is a nuance good physicians will recognize as "bad medicine" when triage is performed not by your best trained clinicians but delegated to those with less training. Errors at the beginning of care tend to be perpetuated and with some illnesses, if you don't get it right at the outset, the patient suffers and potentially may not recover from that initial error. Nothing in the ACA does much to change the incentives to go into primary care except for a puny increase in reimbursements that only apply to the first two years of the plan and some loan forgiveness. Unless ACO's embrace the value of good primary care physicians and their importance to the success of delivering truly patient centered quality care, the result will be far less than ideal. But, most folks won't notice....just the ones who are misdiagnosed and mistreated. Wonderful comprehensive book.....and I think Emanuel is spot on in his predictions about how this legislation will be regarded in the future. This will be Obama's legacy to the nation and it is nothing to sneeze at.

Zeke is a great explainer and story teller on the US health system and reform. The organization is clear and logical given the complex mish mash Zeke hopes to explain. I like that this book concisely covers so many so angles on US healthcare: the history, policy making, politics, economics, and behavioral psychology. Additionally, Zeke is comprehensive in analyzing relevant stakeholders: patients, providers, manufacturers, suppliers, commercial insurers, government payers, politicians, constituents, special interests, bureaucrats - it's all here. It's a lot to take in but Zeke writes in a digestible style and format. I really appreciate that this book exists, because I learned a great deal.

Ezekiel Emanuel just published an important book with a great title, "Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System." In it, he describes the history of health care reform in the US, gives an overview of the Affordable Care Act (ACA), and speculates about future trends in American health care. The concluding chapter of Emanuel's book is entitled, "Six Megatrends in Health Care: The Long-Term Impact of the ACA." I will devote this review to discussing his six "megatrends." Megatrend 1) The End of Insurance Companies as We Know Them Emanuel argues that health insurance companies will "shift their business to focus on offering services they have expertise in, particularly analytics, actuarial modeling, risk management, and other management services...." or "transform themselves into integrated delivery systems," or they will go out of business. This seems quite plausible. However, I think it will depend on how the ACA implementation goes over the next several years. If insurance companies raise their rates, there could be major political fallout. Megatrend 2) VIP Care for the Chronically and Mentally Ill Emanuel argues that "tertiary prevention" for chronically ill people with diabetes, heart disease, cancer, etc, and mental health care for people with depression/anxiety, will become an increasing focus of our health care system. I agree. I've taken care of many patients with chronic diseases and mental illness who cycle in and out of the hospital. The question is if our fragmented health system can provide coordinated, community-based care for these vulnerable people. Doctors and nurses must learn to use a biosocial approach when taking care of marginalized patients with chronic disease and mental illness. Megatrend 3) The Emergence of Digital Medicine and the Closing of Hospitals Emanuel writes: "Digital medicine will allow physicians to monitor patients remotely anywhere they are, get labs and many imaging tests done, and perform interventions once done exclusively in the hospital." I agree - sort of. We are rapidly headed into a digital era. More health care will be provided in the community, and digital devices will continue to proliferate. But will these digital devices provide value for money? Or will the hype outpace their effectiveness? Unfortunately, so far, the hype is winning. Megatrend 4) The End of Employer-Sponsored Insurance This controversial megatrend was analyzed in yesterday's front-page New York Times article. I think this megatrend is very difficult to predict. It depends on a number of political and economic factors. Will America's health insurance system remain constant, or will it move 1) towards a Republican system based on tax credits, or 2) towards a single payer system based on universal health coverage, or 3) a Kaiser-like group model? The latter is the most likely. Megatrend 5) The End of Health Care Inflation I'm definitely not an economist, but I'm not sure I agree with Emmanuel that the ACA will succeed at controlling the growth in health care costs. In his book, Emanuel admits that the ACA didn't go far enough on payment reform, and that there remains "a serious misalignment between what we want physicians and hospitals to do in terms of improving value, efficiency, and reducing unnecessary care and how insurance companies, Medicare, Medicaid, and others pay them." As long as our fee-for-service system is around, and Medicare payments and RVUs are biased towards specialists, the growth of health care costs won't be controlled. Megatrend 6) The Transformation of Medical Schools I agree with Emanuel. Medical schools must change, and become much more team-oriented, community health oriented, and digital medicine oriented. The problem is that medical school curricula are very difficult to change. Can they begin to change rapidly? I'm not sure. If they can, it will require a major awakening of medical students and faculty. With the enormous amount of material for physicians to learn, does reducing the length of medical school from 4 years to 3 years really make sense? I don't think so. I think it would be preferable to keep medical school at 4 years and subsidize medical school tuition, or provide 100% debt forgiveness for medical students who enter primary care careers. The National Health Service Corps is a good program, but it doesn't go nearly far enough. If medical school is reduced to 3 years, will the training physicians receive really be sufficient?

You might think a book about the history and future of health care would be dry as the Sahara (or a California winter) -- but you would be wrong. I am actually taking this book with me to the gym, as my elliptical read. (Yes I know, when I'm on the elliptical, I should be moving my arms more, rather than just turning pages.) But it is well written, entertaining and enlightening. I definitely recommend it to anyone who is interested in looking at how we got to where we are, in terms of the US health care system, and what it will take to untangle it.