Ezekiel Emanuel Quotes

In other words, path dependence means that the institutions and arrangements created before—often created haphazardly or as an expedient—now constrain and shape the changes that are possible today.

What the research shows is that the charge master and commercial insurance company prices for the same test or treatment will also vary substantially even at neighboring medical facilities where, presumably, basic input costs such as rent and wages do not vary substantially. Colonoscopies in New York City can vary fourfold—between $2,025 and $8,700—depending on the hospital. This variation in price is very hard to justify. Typically, neither patients nor physicians have access to the price, so they cannot shop around for lower prices. Imagine you were shopping for a new shirt but there was no price tag and you could not know until weeks after you bought it whether the shirt cost $25 or $200. This would make shopping a crazy experience.

Today 60% of workers in the private sector receive their insurance through their employer. I believe that by 2025 fewer than 20% of workers at private companies will continue to receive their health insurance through an employer-sponsored program. Nevertheless many will still receive an employer contribution, a so-called defined contribution toward the purchase of health insurance in the exchange. I believe the majority of private-sector workers will get their coverage through the exchanges.

Ezekiel and Linda Emanuel,

groggily

No. 1, when you ask who’s interested in this, the usual answer is, terminally ill people with excruciating pain. False. Factually not true. It tends to be a preoccupation of people who are depressed or hopeless for other reasons. No surprise, actually, if you look at what leads to suicide: hopelessness and depression. You have to look at euthanasia or assisted suicide as more like suicide than like a good death. Second, this notion that there’s no slippery slope, as advocates have long claimed? Totally wrong. Look at Belgium and the Netherlands: First, it’s accepted for adults who are competent and give consent. Then, it’s “We’re going to extend it to neonates with genetic defects, and adolescents.” Any time we do anything in medicine, it’s the same way: We develop an intervention for a narrow group of people, and once it’s well accepted, it gets expanded. I think it’s false to say, “We can hold the line here.” It doesn’t work that way. Third, people say this is a quick, reliable, painless intervention. No medical intervention in history is quick, reliable, painless and has no flaws. In the Netherlands, there’s about a 17 to 20 percent rate of problems, something screwing up. Initially, when the Oregon people published — “We have no problems. Every case went flawlessly!” — you knew the data was wrong. It had to be wrong. Either you’re not getting every case, so the denominator was wrong, or people are lying. There’s nobody who does a procedure, not even blood draws, and it’s perfect every time. So this idea that this is quick, reliable and painless is nonsense. And the last and most important point is: You want to legalize these interventions to improve end-of-life care in this country? That’s your motivation and this is your method? PS: I don’t think people argue that–— ZE: [interrupting] Oh, people do argue that! That is the justification for these procedures: It’s going to improve end-of-life care and give people control. The problem is, even in countries that have legalized it for a long time, at best 3 percent of people die this way in the Netherlands and Belgium. At best, 10 percent express interest in it. That is not a way to improve end-of-life care. You don’t focus lots of attention and effort on 3 percent. It’s the 97 percent, if you want to improve care. The typical response is, we can do both. Hmmm. Every system I’ve ever seen has a bandwidth problem: You can only do so much. We ought to focus our attention on the vast, vast majority, 97 percent of people, for whom this is not the right intervention and get that right — and we are far from that. I don’t think legalizing euthanasia and assisted suicide are the way to go. It’s a big, big distraction.

Conversely, there are other services in which Medicare is required to pay whatever it is charged. For instance, Medicare Part B pays oncologists for intravenous cancer chemotherapy drugs administered in the office. The

for exemptions for their outbreak investigations rather than quibble over whether such investigations are research or public health practice. There is nothing in an outbreak investigation that presents to the subjects risks as great as those presented by research on public benefit or service programs (particularly “possible changes in or alternatives to those programs”), a category that is already exempted at 45 CFR 46.101(b)(5) of the U.S. federal regulations.31

Nevertheless, by the 1980s and ’90s it was clear that immortality was not in fact around the corner and the assurances of the medical profession grew somewhat more modest. Most researchers no longer spoke of curing old age, but, instead, of “compressing” it: of shortening the natural period of ache and pain and disability and dementia that precedes active dying. The idea was that instead of experiencing long stretches of senescence, we could mobilize the forces of science and medicine to let us live our best lives until—snap. Our abrupt end. There was, Nuland wrote, “a nice Victorian reticence in denying the probability of a miserable prelude to mortality.” Today, even this compression of morbidity seems illusory. In truth, increases in life expectancy have been accompanied by more years of age-induced disability. Aging has slowed down, rather than sped up. Still, and in spite of evidence to the contrary, the heady promise of a curtailed old age endures in the popular imagination. “Compression of morbidity is a quintessentially American idea,” the physician and bioethicist Ezekiel Emanuel wrote, in a viral 2014 Atlantic essay called “Why I Hope to Die at 75.” “It promises a kind of fountain of youth until the ever-receding time of death.