- The Washington Times - Tuesday, March 24, 2009

Rahm Emanuel may be the most famous of the three Emanuel brothers, but he’s probably not the most intense.

Sitting next to his older brother, Rahm comes off as folksy, flashing Cheshire grins and cracking jokes as he did in a TV interview last year, while Dr. Ezekiel J. Emanuel radiates an almost nervous energy, leaning forward in his chair, earnestly waiting for the conversation to turn to health care reform.

It is that very issue that has brought Zeke Emanuel, as he is known, to the White House with his younger brother after two decades as an oncologist and nationally recognized bioethicist.

There is one complicating factor to all this: Dr. Emanuel, 51, has some very different ideas about health care reform than President Obama and some of his key advisers.

And he carries that same fire in the belly for which his younger brother is known. He has been known to challenge superiors during his time at the National Institutes of Health and elsewhere, colleagues say.

“He’s feisty. He’s not a milquetoast or a pushover,” says Victor R. Fuchs, a health policy and economics professor at Stanford University who worked with Dr. Emanuel over the past five years on a comprehensive health care reform proposal.

That infamous Emanuel feistiness — shared by the youngest brother, Ari, a Hollywood “superagent” — was on display recently when Dr. Emanuel helped moderate one of several small-group discussions between members of Congress and health care industry professionals.

“Can I throw out a challenge?” Dr. Emanuel asked nearly an hour into the session. Then he asked the group of about 20 to propose concrete ideas for how to “make” health care providers lower cost and increase the quality of care.

When a Pfizer Inc. executive praised an idea to collect and publicize infection rates among hospitals in an attempt to name and shame poor-performing institutions, Dr. Emanuel spun quickly to his left and placed his hand on the shoulder of Rep. Roy Blunt, Missouri Republican.

“Do you agree?” Dr. Emanuel asked pointedly.

“Yes,” said the startled Mr. Blunt, who is heading up a Republican health care working group.

Dr. Emanuel pounced quickly: “And do you think the government ought to pay to collect that information?”

Mr. Blunt hesitated, and before he could say anything, Dr. Emanuel raised his voice.

“Who ought to get that information?” he asked sharply. “It’s a public good. We know that we underinvest in the public good.”

Sen. Debbie Stabenow, Michigan Democrat, also was in the session.

“I was very impressed with him at that meeting,” she says days later during an interview. “He is intense.”

Dr. Emanuel, who is divorced and a father of three daughters, just last year published a 240-page book on health care reform — the product of his collaboration with Mr. Fuchs — based on his two decades of practicing medicine, researching bioethics issues and studying the intersection of policy and politics.

The differences between the Obama approach to health care reform and Dr. Emanuel’s plan is in the scope of change, not necessarily the direction.

Mr. Obama is pushing for universal and affordable coverage but does not want to take people off of their employer-based plans. His plan essentially offers a government-run alternative for those who do not have insurance, funded in part by increased taxes on those making $250,000 or more.

Dr. Emanuel thinks the best option would be to abolish the employer-based system and go to a voucher system providing all Americans with insurance paid for through a value-added tax.

Dr. Emanuel also proposes phasing out Medicare and Medicaid, arguing that the voucher system will cover the elderly and the poor sufficiently.

“There’s a part of Zeke’s thinking which is somewhat more in tune with what some conservatives have argued,” says Arthur L. Caplan, director of the Center for Bioethics at the University of Pennsylvania.

Mr. Caplan says he agrees with Dr. Emanuel that “the long-term reform should be to break health care insurance away from employment and make it more of a personal responsibility. You buy it, you get taxed for it, you have to have it, but it’s not something that has to go through your boss.”

Rahm Emanuel, for his part, has come down publicly on the side of the more politically cautious step of creating a government entity that is not mandated, an approach also advocated by key Democratic lawmakers such as Senate Finance Committee Chairman Max Baucus, Montana Democrat.

Dr. Emanuel is “an idea guy with strong principles about getting everybody affordable coverage,” says Judy Feder, a prominent health care reform expert at the Center for American Progress.

“He’s now part of a bigger political environment where other ideas are prominent,” she says.

Rahm Emanuel said last summer on “The Charlie Rose Show” that his older brother’s health care plan was “a game-changer” but that it is politically unfeasible because it would “scare a good portion of the American people.”

Dr. Emanuel is just one voice in an administration packed with health care reform devotees. In his official capacity, he is senior adviser to one of these other voices: Peter Orszag, director of the White House Office of Management and Budget.

Ken Baer, a spokesman for Mr. Orszag, did not want to make Dr. Emanuel available for an interview, saying he was “part of a much larger team of people who have expertise in different aspects of health policy.”

Rahm Emanuel’s cautious thinking reflects the general consensus of many in the Obama administration who still bear scars from trying unsuccessfully to help President Clinton pass health care reform in 1993.

“They’re very gun-shy,” said Jonathan Gruber, one of the nation’s top experts on health care economics and a professor at the Massachusetts Institute of Technology. “What we learned from the Clinton plan is that if you shake up the whole system, that dooms the whole thing to defeat.”

But Dr. Emanuel is no political novice. During his last two years of medical school at Harvard, he also obtained a doctorate in political philosophy.

In his book “Healthcare Guaranteed,” he says that “it is a big mistake to limit our thinking based on what we imagine is politically feasible.”

(Corrected paragraph:) Those who know Dr. Emanuel personally and professionally say he will subvert his personal preferences to serve the president’s agenda.

“He’s going to have to grit his teeth and probably make his point of view known, but I don’t think the Obama and Baucus plans are going to wind up looking like what Zeke favors,” Mr. Caplan says.

Yet he did add that the first step of creating a government alternative “will start to open the door for further change.”

Dr. Emanuel, Mr. Caplan says, is likely “hoping to start to get [his] ideas into place so they might be the object of further reform down the road.”

Henry Greely, a law professor at Stanford and a friend of Dr. Emanuel’s, says that while the eldest Emanuel is a “forceful, extroverted” personality, he’s “not so emotionally tied to his ideas that he views them as the only possible, sane alternative.”

“His role is to advance the administration’s position. He’ll advance the administration’s position,” Mr. Greely says. “He won’t go out and advance his own position. He’s a pro.”

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