In the final month of open enrollment for the federal and state-run health care exchanges, one of the architects of the Affordable Care Act (ACA) has published a new book thatoffers an inside look at health care reform.

In Reinventing American Healthcare: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System, Wharton health care management professor Ezekiel J. Emanuel, a special adviser on health care reform to the White House from 2009-2011, provides a history of the health care system, an examination of the ACA and an exploration of what the future holds for health care.

Recently, Hoag Levins, managing editor of digital publications at the Leonard Davis Institute of Health Economics (LDI) at the University of Pennsylvania, interviewed Emanuel for Knowledge@Wharton. In this discussion, Emanuel critiques the execution of the ACA, explains why many more changes will be needed and argues that ultimately, the ACA has been a big step in the right direction and is catalyzing positive change. (Read a review of Emanuels book on the LDI website.)

An edited transcript of the conversation follows.

Hoag Levins: The title of your book is Reinventing American Healthcare, and the subtitle is How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System. Were you at all concerned that the subtitle is too confrontational or absolute? Were you concerned that it might turn off some of the readers whom you would otherwise be able to influence?

Ezekiel Emanuel: I do think that the description there the complexity, the inefficiency, the expensive, error-prone system is well accepted. Before the Affordable Care Act, we did have the kind of system that was terribly expensive and inefficient. It had a lot of people uninsured. The Affordable Care Act is going to make a big dent in each one of those [issues,] and I make that argument in the book, although I should say the book is not just an argument about the Affordable Care Act. It tries to educate people about the health care system how various parties get paid, how insurance came about in the United States, all the efforts over a hundred years of trying to reform it, how the Affordable Care Act got passed and what is in the Affordable Care Act. Then I do make predictions about the future.

Levins: In the book, you take the Congressional Budget Office (CBO) to task. You talk about the tyranny of the CBO, and you say that although the CBO scores are objective and non-partisan, they are frequently wrong. You talk about the bias and how it can create real harm by [creating] roadblocks for important and worthy legislation, and you cite instances from three decades of wrong CBO estimates. How did the CBO scoring impede the ACA, and if there had not been CBO scoring, how would the ACA be different?

Emanuel: First of all, I also say that we need an umpire. I recognize that the role the CBO plays is absolutely essential. You have to have someone who is going to objectively assess a bill. But I also indicate, as you point out, that they have an institutional bias. They are always willing to, say, discount savings and assess higher costs than you might because if they are wrong if things do not cost as much or they save more than they anticipated they think there is no harm done to the system. Part of what I wanted to point out is that there is harm done to the system. [For] good ideas that might have saved, they say, No, it is really not going to save, or it is only going to save a little, or it might even cost. They may be wrong on that and inhibit a lot of good ideas from coming forward. I do cite three decades of cases from the 1980s, 1990s and the 2000s of major health care legislation where they simply have underestimated the savings that could be achieved.

The Part D Medicare drug benefit is an excellent example. Their cost estimate was 40% too high. That makes a very big difference in setting policy, especially when every politician is constantly asking, How does it score? which means, Does it save money? There are a lot of programs that we wanted to put in to the Affordable Care Act that didnt score or did not score as much as the CBO would say, and that means that when you are bargaining, you do not retain [those programs] for the bargain because you cannot get as much savings from them. I point out in the book that there are lots of [instances] where there is no precedence, so [the CBO] just guesses. Again, I did not want to fault them. I did want to just indicate how it creates a certain kind of mindset. Everyone thinks they have this model that really does predict the future. Well, they have a model. It does not predict the future terribly well, and to constantly be trying to guess what they are going to score [a program] inhibits a lot more creative policy thinking than we might otherwise get.

In a democracy, you cannot expect a perfect A+ bill. You are going to get compromises that policy makers would prefer not to be there.

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Ezekiel Emanuel on Reinventing American Health Care