Former White House health policy adviser Ezekiel Emanuel said in an interview on Bloomberg Television’s “Political Capital with Al Hunt,” airing this weekend, that the Internal Revenue Service will have a limited function in administering President Barack Obama’s health-care law, and that concerns about the agency’s role are “a tempest in a teapot.”
(This is not a legal transcript. Bloomberg LP cannot guarantee its accuracy.)
AL HUNT: We begin the show with Dr. Ezekiel Emanuel, vice provost at the University of Pennsylvania and former top health-policy adviser to the Obama administration, and the most-educated of the fabled -- the fabled Emanuel brothers.
Let’s talk about the affordable health care. The key to the rollout Oct. 1, you have said all along, is how many healthy young people sign up for the exchanges. What should the administration be doing it’s not doing now to make -- to produce a better outcome?
DR. EZEKIEL EMANUEL: Well, I think we have to get the country talking about the exchanges, people being aware of it, and getting people to understand that they can go in and shop, and that there will be good prices. It does look -- HHS released some information yesterday about the number of insurance companies coming in. And their reports suggest that a lot of new companies are coming in to offer products, that, in fact, 90 percent of the people who they anticipate will shop on the exchange will have more than five alternatives to choose from, which is, I think, good.
HUNT: But that’s all good. They have a good website. But my 24-year-old daughter, I said, in a year from now, you’ve got to sign up. Oh, come on, I’m healthy. I mean, she doesn’t -- she doesn’t even seem to be aware of it.
EMANUEL: Exactly. And I think we have to boost the awareness. You know, in Massachusetts, when they did this, one of my favorite anecdotes from Massachusetts is they had Fenway days related to the exchanges.
HUNT: That’s the Red Sox -
EMANUEL: Exactly. You’ve got to target -
HUNT: So what should they be doing now? What kind of stuff are they not doing that the administration should be doing?
EMANUEL: Well, I think everyone needs to begin talking about it. I think they need to direct people to the Massachusetts experience, if you want to see what it’s going to be like. I think one of their hesitations is, if you jazz up everyone and you get them excited, they can’t shop yet. They can’t shop until Oct. 1. And so it’s a bit of a chicken-and-egg problem, which is, do we talk a lot about it, even though people can’t act on it at this moment?
I still think you need to build awareness, but that obviously is a marketing issue, and you’re not talking to a guy who’s a professor of marketing at Wharton. So, you know, that’s the problem.
HUNT: All right, Zeke, let me ask you this. This is obviously the president’s signature priority.
HUNT: But he also has to talk about taxes and the budget and Syria and terrorism. Should there be a point person, a publicly visible point person with knowledge of this who is out there in these critical next four months promoting this?
EMANUEL: I think that -- you have to have someone. This isn’t the president’s full-time job, as you well know. I think it’s not just a person. I think they probably need a bunch of doctors and nurses, people who the American public trust.
HUNT: But shouldn’t it be a public face that really can sell this thing?
EMANUEL: Again, you’re not talking to the marketing genius, but -
HUNT: No, I know. But you know -- you know how difficult it is.
EMANUEL: Yes, and I think we have to explain to the American public -- and you need to explain over and over -- wasn’t it Richard Nixon who said something like, you say it once, you say it twice, you say it seven times, and then the American people is just hearing it?
HUNT: Who would you like to see -- who would you like to see more involved in this?
EMANUEL: Anyone who can be articulate on the issue and inform the public.
HUNT: Give me a suggestion or two.
EMANUEL: I’m not a personnel person. Al, you’re asking me all the wrong questions, marketing, personnel.
HUNT: I’m sorry.
EMANUEL: I’m just policy guy.
HUNT: All right. All right. All right, I’ll get back to one policy concern, then, and that is the IRS is going to play a critical role in the implementation of this? They’re -- it’s a very controversial agency now because of this. Does that undermine the IRS --
EMANUEL: No. All the IRS is doing in this situation is certifying how much -- someone’s income and how much subsidy they’re entitled to. They’re not releasing any information. They’re not snooping around. I think that is just a tempest in a teapot that is unrelated to the Affordable Care Act.
HUNT: So it won’t have any effect on their role?
EMANUEL: It should -- it should not have any effect, and no person of the American public should be worried that somehow the IRS is going to get anything -- more information that they don’t already know on people or release it in any way. So that I don’t think is a relevant issue.
HUNT: Let me go back to one -- what I think is a policy question. Did you have any estimate on how many young people have to sign up in that first year for it to really be -- to work, to be feasible?
EMANUEL: So the -- the total estimate is that we need 7 million to 9 million -- they’re expecting 7 million to 9 million people in the first year, and I think you need about half of them to be young people. That’s not -
HUNT: And hopefully mostly healthy young people.
EMANUEL: Yeah, that’s not a huge number. On the other hand, you do have to have them come out and you have to have -- a lot of them are going to be people who aren’t -- don’t have current insurance, either because their parents don’t, so they’re likely to be lower educated, minority people, and that’s a -- you know, a tough demographic to go after, and we have to go after them.
I will say that Rahm, my brother, who actually knows something about marketing and political sales, has, you know, a really good important point on this is that you really have to go after their mothers, because their mothers want them to have coverage, their mothers want to protect them, and they’ll listen to their mothers. And I think that’s probably a good suggestion, too.
HUNT: I’ll tell my wife, because my daughter is not listening to me so far. She may -
Tell me this. We’ve talked a lot about enrollment. As this law takes effect, what else worries you? What else causes your blood pressure to rise?
EMANUEL: Well, I think it’s -- look, like everything else, the -- in my opinion, the big issue over the long term is, can we transform how we deliver care to the American public to make it higher quality and lower cost? And that really requires doctors to get in and transform what they’re doing, and they need to buy in and think that the system is going to support them in that transformation, reengineer how they deliver care.
HUNT: Are you encouraged that they are doing that? Or are you worried that they’re not doing that?
EMANUEL: I’m encouraged that they’re doing that. And so the problem that I was going to point to is that we’re saying, listen, redesign how you’re doing care, focus on quality, and -- and getting things efficient, and yet we’re not paying them to do that. And that misalignment, payment is not reinforcing the requested improved quality, I think is a big problem. And so what I really want to see Congress and the administration, as well as private insurers tackle is paying people more to keep people healthy and keep them out of the hospital.
That’s going to be the key over the long haul. So once we’ve got people in the system, we want the system to perform well, and the key to that performing well is how we pay doctors.
HUNT: Measure success. What -- say, a year-and-a-half from now, what -- what -- you know, as far as premiums are concerned, the effect on hospitals, enrollees, what will be -- what can we say, all right, it’s working?
EMANUEL: So I think the issue is, do we have enrollment expanding? And is the buzz around the exchanges, I got -- I have good choice, they’re easy to navigate, and the subsidies are good? I think if that’s the buzz, we’re going to see a lot of people wanting to come into the exchange, including people who normally get their insurance from their employers.
I think what you really want to see is 10 million to 15 million people by the end of the second year in the exchanges, and I think you want premiums to stay flat for a couple of years.
HUNT: Stay flat, right.
EMANUEL: And I think those things are good. But here, Al, I think a year-and-a-half is too early to really make a good assessment. I -- when I go around talking around the country, I say the real measure is going to be 2020, because that’ll be a decade for implementation -
HUNT: To see -- to see how it works?
EMANUEL: To see how -- how stable the exchanges are. Are people really in the system? Is the system reformed how we deliver care? And so I like to keep my eye on 2020.
HUNT: One other controversy, Lamar Alexander, no right-wing ideologue, says the secretary of HHS may be breaking the law by soliciting private-party funds to help Enroll America. I don’t know if she’s breaking the law, but isn’t that sort of an appearance problem, it just is something that distracts from what you need to do?
EMANUEL: Well, it does sound like a distraction. I would actually remind people, when we started Medicare in this country, we actually hired thousands of people to knock on the doors of elderly individuals in this country to get them to sign up and to inform them. And I think that kind of rollout is important. It was also controversial in 1966, when the law went into effect, and I think we’re going to have the same controversy now.
HUNT: Final quick question -
EMANUEL: But, remember, whatever the controversy is right around the rollout, over time, the American public learns what they need to learn about this system and ends up liking these programs.
HUNT: Final quick question. Does the Medicare Trust Fund report that was out on Friday say anything about this whole issue?
EMANUEL: Yes, the trust fund report shows that Medicare is going to be solvent for an additional two years compared to last year, and when we were debating the Affordable Care Act, we’ve improved the solvency a decade, 10 years. So I think part of all the -- as I’ve commented before -- one of the things that’s been lost in all the conversation is the fact that medical inflation has actually been moderating over the last few years, and that translates into lower spending by Medicare, and means that the trust fund will last longer.
That’s very good news for the country. We obviously have to moderate it more. We can’t take our focus off of it. We’re still growing more than the growth in the economy. We have to get down to where health care is just growing with the economy.
HUNT: Dr. Zeke Emanuel, thank you so much for being with us.
EMANUEL: Thank you, Al.
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