Ezekiel Emanuel

Chair, Department of Bioethics, National Institutes of Health (since 1996)

Why He Matters

Health policy expert "Zeke" Emanuel was drafted to the White House health-reform team in February 2009 to advise then-Office of Management and Budget (OMB) Director Peter Orszag, himself something of a health-financing wonk, on overhauling America's health-care system. It was an opportunity to work with his younger brother, former Obama Chief of Staff Rahm Emanuel.

Trained as an oncologist, Emanuel took leave from his job heading the medical ethics department at the National Institutes of Health to advise the OMB on anything that fell within his areas of expertise, with health-care reform high on his agenda.

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Background

At a Glance

Career History: Special Health Adviser to Director, Office of Management and Budget ( February 2009 to January 2011) Chair, Department of Bioethics, National Institutes of Health (1996 to 2009); Associate Professor, Dana-Farber Cancer Center, Harvard University (1992 to 1996)
Hometown: Wilmette, Ill.
Alma Mater: Amherst College, B.S. (chemistry), 1979; Oxford University M.Sc. (biochemistry); Harvard Medical School, M.D.; Harvard University, Ph.D. (political theory)

Religion: Jewish
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Path to Power

Emanuel is the oldest son of Benjamin Emanuel, who was born in Jerusalem before the creation of the state of Israel, and worked with Irgun, a Jewish underground movement, before moving to Chicago. There he became a pediatrician and met the woman who would become his wife, Marsha, an X-ray technician and civil- rights activist.

"Politics and the civil rights movement were very much a part of our family life," Zeke told the Washington Post. "We went on Martin Luther King's march on Cicero [a neighborhood in Chicago] with my mom."

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Zeke, along with younger brothers Rahm and Ari, and their younger sister Shoshana, grew up in the wealthy northern Chicago suburb of Wilmette, Ill., and attended well-regarded New Trier high school. The brothers also spent some summers in Israel.

The eldest Emanuel was an outstanding student from the beginning. "Ari and I had to swim in Zeke's wake," Rahm said of their youth.

Emanuel attended Amherst College in western Massachusetts, where he majored in chemistry, graduating in 1979.

After Amherst, he took a research masters in biochemistry from Oxford, studying at Exeter College.

Emanuel went on to do a combined M.D.-Ph.D. program at Harvard. He began at the medical school in 1981 and completed his M.D. in 1988. At the same time he was doing doctoral work in political philosophy, which he began in 1984 and completed in 1989. His doctoral dissertation won an award for the finest in political science that year.

From 1987 to 1988, he was a fellow at Harvard's Kennedy School of Government in the program in ethics and professions.

In 1988, Emanuel developed the Medical Directive, a living will to help people plan important medical decisions in case they were incapacitated when the time came to do so. Emanuel's version has been endorsed by the New York Times, Wall Street Journal and the Boston Globe, among others.

From 1988 to 1990, Emanuel did a medical internship and residency at Boston's Beth Israel Hospital. His residency was slightly shorter than usual because Emanuel planned to become an academic.

From 1990 to 1992, he did a fellowship in oncology at Boston's renowned Dana-Farber Cancer Institute, which is associated with Harvard Medical School. Once he completed his fellowship, he stayed on at the Dana-Farber, becoming an assistant professor and specializing in breast cancer.

In 1993, he was a member of the Health-Care Task Force in the new Clinton White House, where brother Rahm was a top aide. On the task force, Dr. Emanuel's focus was biomedical ethics.

After the Clinton health-reform effort failed, Emanuel returned to Dana-Farber, eventually becoming an associate professor before leaving in 1997.

National Institutes of Health

Returning to Washington, D.C., Emanuel became chair of the newly-created department of bioethics at the Clinical Center of the National Institutes of Health in Bethesda, Md. He spent the next dozen years investigating the ethics of managed care, the doctor-patient relationship, euthanasia and end-of-life issues, publishing in most of the country's top medical journals.

He trained people in the ethics of medical research using human test subjects. He also focused on the ethics of allocating limited medical resources. In other words, rationing.

Emanuel also wrote on the issue of health-care reform, including his 2008 book "Healthcare, Guaranteed," which proposed a health-care voucher system that would cover all Americans.

In his work on health-care reform, Emanuel came across Orszag, then the director of the Congressional Budget Office, who famously had an interest in how to pay for universal health care. Emanuel and Orszag had been featured on health-care panels before and "had come to see that we had a similar world view," Emanuel said.

In December 2008, the Obama administration announced they wanted Orszag to head its OMB. "I emailed[Orszag] and said, 'Do you need a doctor?'" Emanuel remembered, "and he called that evening."

In December 2008, the Obama team announced Emanuel would be assigned out from the NIH to work as a senior counselor on health policy at the OMB.

Emanuel is also an avid baker who writes a food blog for The Atlantic and likes to bring baked goods in to his OMB co-workers.

Hollywood

Rahm is not the only brother with whom Zeke has common professional interests. He's also developing a new TV show for HBO about medical ethics with his youngest brother, Ari. Emanuel described the premise as, "The hospital of the future: the kinds of things we might see and might create issues."

Maybe Zeke will finally get his own TV character, after all.

The Issues

"I have more or less carte blanche by [Orszag] to work on things related to health," Emanuel said in 2009.

As an M.D. among economists, Emanuel has worked on everything from the administration's response to the H1N1 "swine flu" epidemic and resulting Global Health Initiative to planning a wellness program aimed at disease-prevention.

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Health-Care Reform

Though health-care reform was hashed out in Congress, President Obama wanted to make sure certain proposals made it into the final legislation.

"There was an outline before I arrived here," Emanuel said of the administration's health-reform priorities, which included sweeping changes such as creating a government-funded health insurance option and a national health insurance exchange. The former didn't make it into the final legislation, but the latter did.

"There are lots of ways to get to the goal of coverage and cost-control and high-quality medicine," Emanuel said in June 2009. "In this case the most important objective by far is to get something done."

Emanuel had his wish granted when, after more than a year of legislative wrangling, the House passed the Senate version of health-care reform on March 21, 2010, clearing the way for the Senate to approve a package of amendments insisted on by the lower chamber with a simple majority (using a process known as reconciliation).

The $940 billion bill required most Americans to carry health insurance and required insurance companies to cover them, regardless of pre-existing conditions. It established a national insurance exchange allowing Americans to compare and purchase insurance plans. The bill was financed by increasing taxes on well-off Medicare recipients and by taxing premium insurance plans. By the end of the bill's 10-year roll-out, 32 million uninsured Americans would have health coverage and the deficit would be $138 billion lower, the Congressional Budget Office estimated.

Health-Care Financing

One of the primary goals of health reform was always decreasing skyrocketing health costs. But that sort of overhaul required a huge initial investment, nearly a trillion dollars.

"We're gonna have some cuts, and we're gonna have some revenues," Emanuel said.

The administration proposed streamlining the health-care system. That meant reducing fraud and abuse as well as eliminating wasteful spending by determining which medical treatments are most effective. Emanuel himself had often advocated better preventive medicine including lower co-payments for preventive care, and the final bill made preventive care visits free.

The administration hoped that the big investment would pay off in the long-term. As Emanuel wrote in 2008, "Expanding coverage the right way generates savings."

Taxing Health Benefits

The employee health-benefits paid for by employers have traditionally been tax-exempt. "Thus, $1 in health insurance, which was not taxed, became worth more than $1 in income, which was taxed," Emanuel wrote in October 2008. "The result is that today's health care system relies on employers to provide coverage and encourages more and more health insurance and spending."

Emanuel proposed ending or limiting the tax exemption, but insisted "every dollar collected . . . must be directly linked to providing health coverage for the 47 million uninsured Americans."

In June 2009, President Obama said he would consider taxing health benefits in order to fund health reform.

Universal Health-Care Vouchers

Obama's overhaul wasn't Emanuel's first time at the health-reform dance. In his 2008 book, "Healthcare, Guaranteed: A Simple, Secure Solution for America," he advocated giving all Americans vouchers for medical care. The voucher program would be paid for by a value-added tax, and coverage would no longer be connected to employment. Emanuel also outlined the voucher idea in a paper for the liberal Brookings Institution.

Emanuel proposed phasing out government-sponsored Medicare and Medicaid and replacing them with the voucher program.

But many, including Emanuel's allies, admit the plan isn't politically feasible. "Not every good policy is achievable in practice and, you know, you have to make compromises and there are trade-offs, he told ABC News. "You can't be stuck to the ideal and let that torpedo making substantial improvements."

According to Zeke, his chief of staff brother Rahm described the plan using one word: "wacko."

Obama's 'Deadly Doctor'?

In July 2009, Emanuel found himself as a target in attacks on the administration's health-reform plan. In a New York Post article, conservative scholar Betsy McCaughey listed him along with HHS official David Blumenthal as "Deadly Doctors," who wanted to ration care.

McCaughey quoted scholarly articles Emanuel had written as a medical ethicist, before his White House appointment, saying, "He [Emanuel] says medical care should be reserved for the non-disabled, not given to those 'who are irreversibly prevented from being or becoming participating citizens . . . An obvious example is not guaranteeing health services to patients with dementia' (Hastings Center Report, Nov.-Dec. '96)."

"It would only get worse," TIME magazine reported. "Within days, the Post article, with selective and misleading quotes from Emanuel's 200 or so published academic papers, went viral."

Soon after, Rep. Michele Bachmann (R-Minn.) read the New York Post article aloud on the House floor.

Former Alaska Governor Sarah Palin (R) referenced Bachmann's speech in an August 2009 Facebook post, which famously accused Obama's health-care plan of creating "death panels." Her post on the social-networking site went on to mention Emanuel specifically, calling his thinking "Orwellian."

Emanuel responded, telling TIME Magazine his quotes had been taken out of context. "No one who has read what I have done for 25 years would come to the conclusions that have been put out there," he said.

The Network

Emanuel's brother, Rahm Emanuel, is Barack Obama's chief of staff.

At the Office of Management and Budget, Emanuel reports to director Peter Orszag. He also works with health economist Jeffrey Liebman, and Keith Fontenot, head of the OMB health desk.

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