I agree with Ezekiel J. Emanuel, MD, PhD

Some of us have been saying from the start that expanding coverage before addressing the underlying cost of health care is a mistake.  Of course, some of us do not have a number of letters attached at the end of our name and thus we are going on gut instinct, in some cases such as mine accompanied by several decades of working with health benefits and the people who provide and use them.  I recall during the Clinton health care initiative going to a

"Free"  healthcare available here
"Free" healthcare available here

public hearing and seeing one person after the other give horror stories about their medical care and the failure of their benefits to cover it all in full, but I heard not one word about the cost of the care of why a certain amount was charged for this or that service. 

White House advisor Ezekiel Emanuel has taken a lot of flak recently over the bogus flap about death panels, but if you read some of his past writings, you may take heart in his assessment of health care and its costs.  It is, however, very unfortunate that the politicians pushing their version of “reform” do not pay attention to the advice he is giving. 

Here are the first few words from an article he wrote in the Journal of the American Medical Association in February 2008 (even I could have written this): 

The Cost-Coverage Trade-off

“It’s Health Care Costs, Stupid”

Ezekiel J. Emanuel, MD, PhD

JAMA. 2008;299(8):947-949.

“According to recent polls, many Americans consider health care reform the No. 1 domestic issue.1 Presidential candidates, other politicians, health policy experts, labor leaders, business groups, and others have responded with numerous reform proposals. And somehow in the clamoring, health care reform has become equated exclusively with expanding coverage to the 47 million uninsured Americans.

This is a mistake. As serious as it is, the problems of the uninsured and lack of coverage are symptoms, not the underlying problem. Focusing on them is like treating a fever without addressing the causal infection. Instead, the diagnosis and treatment need to focus on health care costs. The fundamental problem arises because of a cost-coverage trade-off. Without controlling health care costs, any attempt at universal coverage will be transient. Sustainable expansion of coverage to all Americans requires credible changes in the rate of health care inflation—the slope of . . . “

He also wrote, “Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records and improving quality of care are merely ‘lipstick’ cost control, more for show and public relations than for true change.”

Those among us who tell Americans that controlling health care costs will come about without fundamental change in the way we think about, delivery and reimburse for health care are dreamers or liars. Americans who want cost control should look at what it takes in other countries to achieve that.  Only then should we expand coverage to all Americans and by then hopefully Americans will understand they can’t have everything they want, when they want it and the cost be damned and along with that they may understand that high cost does not guarantee high quality.


  1. Good article and those that are paying for coverage like employers know this is the biggest issue. we should outlaw any plan that provides 100% coverage and move to HSA 100% the only way to control cost is when the person has to pay out of pocket.


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