Obamacare architect shares recommendations for a new system

Dr. Ezekiel Emanuel
Dr. Ezekiel Emanuel speaks about the Affordable Care Act while being interviewed at the Top Coast Festival at the McNamara Alumni Center at the University of Minnesota, Minneapolis, Minn., on Sunday, June 1, 2014. Currently vice provost for global initiatives, chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania and a columnist for The New York Times, Emanuel has written and edited nine books, most recently 'Reinventing American Health Care.'
Tom Baker/For MPR News

When asked for just one recommendation for the Trump administration on the subject of repealing and replacing Obamacare, Dr. Ezekiel Emanuel focused in on the potential danger of destabilizing the health insurance exchange.

All of the proposals currently offered up by Republicans take away the exchanges and attempt to retain subsidies in the form of refundable tax credits, which would result in a substantial cost shift from the government to the people when it comes to buying insurance, said Emanuel, an oncologist and key architect of the Affordable Care Act.

"If you are trying to get affordability for the American public and you're reducing the subsidies, that seems like a contradiction to me," he said. "And it does mean if you went that route, fewer people would actually buy insurance."

Republicans are also pushing for incentives rather than mandates in their plans, but in order for that to work you would need what Emanuel calls compulsion.

"I like to say there are only four ways of getting everyone in," Emanuel said. "A mandate with a penalty, higher rates or a penalty of higher rates if you don't actually buy the insurance and want to come in later. Continuous coverage, that means you have to have insurance all the time except for a month or two between jobs — again not a great mechanism. And the last one is: we give it to you. You don't have to buy it; we give it to you. Or we give you something."

As many Americans have experienced, it isn't so much insurance that is expensive, but the medical care itself. High quality and low cost should go together, but in the U.S. the medical delivery system is very expensive and the quality is incredibly inconsistent, Emanuel said.

In order to consistently improve their quality and reduce their costs health care providers need good leadership to anticipate the changes, data on how they're spending they're money; and they may also need a financial crisis — which, sometimes, is the only motivator that works to induce change, Emanuel said.

"It also helps to have a culture that's willing to try new things," Emanuel said.

Emanuel spoke January 11, 2017 at the Commonwealth Club of California with moderator, Mark Zitter of The Zetema Project.

To listen to their entire discussion, click the audio player above.

Further reading

• More: Repeal of health law could mean women pay more for less

• How it could affect you: 6 lesser-known Obamacare provisions that could evaporate

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