The passing of healthcare legislation in the US was a ‘world historic event,’ says this bioethics scholar. In India, too, a solution to universal healthcare should not be hard to find
When he walks into The Deck, India Habitat Centre’s airy poolside restaurant, Ezekiel (“Zeke”) Emanuel reminds me of someone, though I only figure out who towards the end of the meal, says Kanika Datta. It’s not his younger brother Rahm Emanuel, former White House chief of staff and current mayor of Chicago. He doesn’t resemble his brother much I tell him later, to which he replies, “Well, you’d better say I’m better looking or I shall be offended.”
At any rate, Rahm may be the name with the stronger recall but it’s Zeke who may be of greater relevance to India, given his former and current jobs and India’s emerging public discourse on health and higher education. He was, till late last year, special advisor for health policy to the White House (that is, he was part of the team that shaped Obama’s healthcare reform programme) and is currently Vice Provost for Global Initiatives at the University of Pennsylvania (UPenn).
Interestingly, too, Emanuel is a leading scholar of bioethics and a strong opponent of euthanasia. He’s followed with interest the case of Aruna Shanbaug and I feebly argue that withdrawal of care (which he says “has been around since Socrates”) and euthanasia aren’t that different, to which he puts up a vigorous defence.
Since his qualifications (he’s an oncologist and holds a PhD in political philosophy from Harvard) far outstrip my outstandingly modest ones, I struggle to sustain the argument and am pathetically grateful that the waiter arrives to take our orders. Emanuel has scoured the menu rapidly, decides (unilaterally) that we’d share a vegetarian mezze platter as a starter and selects a Moroccan Lamb Ossobuc for his main course, to be washed down with Gingerale. I choose a Roast Chicken Supreme and a Darjeeling tea.
Two days before this lunch, he’d delivered a lecture at the Public Health Foundation of India (PHFI) on American healthcare reforms. The issues there are very different from India, I tell him, where the Cabinet was beginning to consider a proposal for universal healthcare legislation. From what he says, it could be a long-drawn process. “One of the points I made at PHFI is that it took us 100 years to pass healthcare in America. The first national debates started in 1912. Five or six presidents tried to pass comprehensive healthcare — all failed.”
Emanuel sees the passing of healthcare reform legislation by Obama as a “world historical event” that will have a huge impact on other countries. In the two years since the Bill was passed, he adds, healthcare inflation has been lower and he anticipates that costs will fall further. I say although India needs urgent action to improve its sub-Saharan-level health indicators, the fate of European welfare economies suggest that the costs of universal healthcare will eventually become unsustainable.
He points out that it is a question of the system you adopt. “If you have a welfare state that is unlimited and you take more out — that is not sustainable. For instance, in Greece, people are retiring at 50 and living till their eighties. If you spend more than half your working life on public assistance — that’s pretty crazy. That is clearly not a model.”
So how is the American system different? Because, he replies, it does not rely on the government to provide the infrastructure — “we have a private system”. But the new laws have a default option for the government-subsidised insurance, which could amount to the same thing, I persist. It doesn’t, Emanuel says, though the answer is complicated.
First, he says, 50 per cent of the US population gets its insurance through employers and another five per cent through buying insurance themselves. “So currently you’ve got 16 per cent uninsured and you have 35 per cent already getting government-provided insurance.” Second, “it is true that more people will get subsidies but no one knows how companies are going to react to the new system. A lot depends on whether the exchanges – that is where people buy insurance – work well.”
Since those will be set up by the states, I suggest the progress could be iffy. “That is one of the problems,” he admits, adding, “I was a strong advocate for a national exchange because they’re complicated to run and not all states have the necessary skills to do it. Ironically the complication is partly a nod to the Republicans because they always want things done by the states.”
He does concede, however, that the American “employer-pay” system is “terribly designed” for reasons ranging from keeping wages down to creating inefficiencies in the system (he details six reasons in an email later) but it’s something they’ll have to live with. “Undoing the system would be an even bigger transformation,” he says, as the starters are served.
Unlike many lunch guests, Emanuel manages to answer my questions and eat with business-like speed. I ask what a “vice-provost” does.
He laughs at the naivety of the question but answers good-naturedly: “I am responsible for what we’re going to do globally in terms of students, researchers and so on.” So will we see a UPenn outpost in India soon, since this seems to be the model in vogue? “We’re not going to be like NYU [New York University] and set up an institution in, say, Abu Dhabi.” Instead, the university was looking at centres that would facilitate research and collaboration with institutions in India, including exchange programmes for students.
Bioethics, for instance, is an issue that he found resonated in India as did food security, for which UPenn had one of the world’s leading experts. Healthcare alone could be a rich subject of research given that “India can offer first-world care at very cheap prices”. Which most Indians can’t afford, I counter. He agrees and says he visited the All India Institute of Medical Science on this trip.
What did he think? He hesitates. “It clearly has incredible talent and is also incredibly badly organised — it’s a facility that’s being asked to do way too much on its budget. So, if you are a health policy guy like I am, one of the questions you ask is, can you change the incentive structure to dramatically improve service and maintenance?”
One possible answer is an experiment he saw in Ethiopia, which has a big state provision for free healthcare. The state hospitals have been allowed to see patients after hours for a charge. “It’s not commercial in the following sense. All that money can do two things — a third of it goes towards paying the doctors and nurses who were providing the care after hours so they are incentivised to be there.” The other two-thirds goes to improving the facility (building, say, a maternity ward or HIV clinic, getting new lab equipment and so on).
It’s interesting, he adds, because the community has to decide how to spend the hospital money. “You look at that and say, wow, that really looked dramatically better from everyone’s perspective. So that’s something you might look at.”
In any case, he thinks, a solution shouldn’t be hard to find since India has “very smart and talented people”. This is “not a poor developing country, you have much more capacity than, say, Mali and probably have more intellectual capacity than Greece”.
When the main course arrives, Emanuel appears to enjoy the lamb but I pick at a chicken that is overcooked and dry. We’re chatting about politics – Iran, Israel, the Presidential election – though he’s emphatic that it’s his brother who is the politician, not him. This is his third trip to India but, he assures me, it won’t be his last.
For dessert, Emanuel has chosen what looks like a banana split. What did he do to relax? The answer is unexpected. He liked to cook, mostly desserts. Before he left for India, he had had a party and made blueberry crisp and biscotti. From scratch, I ask incredulously. Of course, he replies indignantly.
Just as I’m about to ask how he stays so lean with such a calorific hobby, he tells me he’s also a marathon runner. Now, the penny drops; in build and energetic manner he bears a passing, albeit younger, resemblance to another well-known marathon runner, WTO Director General Pascal Lamy. It also explains the racy sports watch teamed with a conservative grey suit.
He’d followed one brother in government service. Since another brother, Ari, was a well-known Hollywood talent agent, did he consider a career in movies or TV? No, he laughs, though he did consult for HBO for the medical TV series. In any case, he didn’t own a TV. “I don’t like to waste my time — there are other ways of getting the news,” he says by way of explanation.
But what about sports, I persist, then joke that it didn’t matter since Americans didn’t follow “real” sports like football and cricket. Ah, cricket. He did learn to bowl when he was at Oxford but, laughs, “I was not talented.” The bill arrives and I turn off the recorder. “Don’t you want to hear my views on cricket?” he asks with mock hurt. Sadly, we are out of time but those views would surely have been unique.