What should I ask Ezekiel J. Emanuel?

I will be doing a Conversations with Tyler with him, no associated public event.  So what should I ask him?  Here is his Wikipedia page.


Why is insulin so expensive?

the demand curve slopes upward?

so emrs that was harvard
& drgs that was princeton
or is it vica versa?

do you like old guitars & dark guitar jokes?

now please tell to us the drg code for burned by flaming water skies?
answer- v91.07

The obvious question to ask is if he agrees with you that there will be no significant advances in medicine until at least 2030. And then you could ask if he will still refuse any advances in cancer treatment, heart or other organ rejuvenation or dementia treatment after he turns 75 in 2033 or so.

With brainshaping pills and nanobots in the horizon, we are increasingly pushed to ask tough questions about health insurance spending. AZ Medicaid already has deaths on its hands due to refusal of basic hearing aids in the $500-2,000 range, so I think it’s fair to ask how and when cancer treatments with low success rates costing over $100,000 can Be afforded.

As a big supporter of free health care is it his intent to give free health care to all non-citizens too?

Of course, old white people will get the Leon Klinghoffer treatment.

Good! Serves 'em right. But probably just the old white men.

When Dr. Emanuel said that people should kick the bucket at age 75, was he thinking of people in general or of his brother, the mayor of Chicago, or of his other brother, the Hollywood agent on "Entourage," or of his dad, the old terrorist?

Actually, what he said was that he would stop diagnostics and life-prolonging medical treatments once he reaches age 75: "At 75 and beyond, I will need a good reason to even visit the doctor and take any medical test or treatment, no matter how routine and painless. And that good reason is not “It will prolong your life.” I will stop getting any regular preventive tests, screenings, or interventions. I will accept only palliative—not curative—treatments if I am suffering pain or other disability." https://www.theatlantic.com/magazine/archive/2014/10/why-i-hope-to-die-at-75/379329/

I think about this as adopting hospice protocols - palliative treatment only, no curative . I've structured my medical directives to implement this. My motivation isn't concern for Medicare spending, but rather to avoid living with dementia or other catastrophic infirmity.

One could argue about the cut-off age, but 75 is in the ballpark. The risk of dementia before death for a 70 year old is about 1 in 3. That's a fate to be avoided.

But when Emanual turns 70 in 2028, the risk of dementia before death won't be close to as high as 1 in 3. He has assumed essentially no important changes in medicine for 20 years when he wrote his article, just as Cowen stated in 2010.

Not clear risk will be reduced. Alzheimer’s is the leading cause of dementia, with essentially no progress. Vascular is next, which might be impacted by better BP control, but not a lot of general population success with “exercise, don’t be fat” medical advice to date.

There are some suggestions that Alzheimer’s may be due to an infection, which might hold out hope for a truly effective treatment. We’ll see.

There has been a lot of progress in Alzheimer's research over the past 15 years and some leading researchers like Rudy Tanzi are convinced that Alzheimer's will at least be preventable by 2025.

Stem cell therapy will have revolutionized heart disease by 2025 and the vitamin B3 compound, NR, has had a profound effect on mice with heart failure. Human trial results will be published next year. A small human trial last year showed that NR reduced non obese people with pre-hypertension's systolic blood pressure by 10 points (a heart attack reduction of 25%) while not changing those with normal blood pressure. There are now over 20 human NR trials in progress for acute kidney disease, cognitive function, vascular health, stamina, etc.

Alzheimer’s is already preventable in most people. The APO4 gene creates a higher risk, but this gene is most common in Nigeria where there are much lower rates than in the US because they eat a mostly whole food plant-based diet. Alzheimer’s is a chronic disease caused by the same chronic inflammation of the arteries as heart disease. The challenge for medical science is to develop a drug that overcomes the chronic inflammation caused by the standard American diet comprised mostly of artery inflaming animal products and refined oil from plant food. They may make some progress, but I doubt they will accomplish much mopping up the floor when the spigot is flowing freely.

Kind of clunky way to show that you read the wiki. What are you trying to prove with that comment, Steve?

Has chemotherapy improved at all in the past 20 years? What tangible progress has cancer research made in the past 20 years? Have mortality rates gone down for reasons other than early screening?

Despite $Billions spent, overall mortality has hardly moved (less than 2%) and the incidence is higher. The cause is the standard American diet (SAD). There’s very little chance these stats will improve in an environment that encourages treatment (chem, drugs, medical procedures) over prevention (diet). The irony is that the hope of a cure tragically prevents many people from changing their diet in hopes of a “cure”. The system we have will never encourage meaningful change as long as all the money is in treatment.

Dr. Emanuel is a foodie, so he and Cowen should share some food stories. He wrote an article for The Atlantic about why Aspen had no good restaurants. It was true back then (when I would visit) but I don't know now. Back then the most popular restaurant in Aspen was Mezzaluna. My son and I ate there several times not for the food but the history of the restaurant with the same name in Brentwood, California. https://www.theatlantic.com/health/archive/2010/07/why-are-the-restaurants-so-bad-in-aspen/60530/

Here is the link to the many food articles Dr. Emanuel has written for The Atlantic (make sure you go to the More Stories at the bottom of the page): https://www.theatlantic.com/author/ezekiel-j-emanuel/

The fact that Emmanuel hoisted Obamacare on the US population with no cost constraints, then dines on high end animal products and other foods that cause uncontrollable chronic disease in the US population is disgraceful. His arrogance and elitist attitude are disgusting and reprehensible. This proves his primary goal is power, not solving America’s real problems.

1. We tend to have an inconsistent approach to applying cost/benefit calculations. If we are serious about the idea of QALY/$ spent, shouldn’t this be applied to all government programs? What is the $/QALY of the department of agriculture?

2. As a society we spend $30+B on video games. Why doesn’t this suggest we have lots more money to spend on heath care?

3. Certain very expensive drugs are also very effective (e.g., the #1 drug in the world, the anti-TNFa antibody Humira). Is this drug worth it?

4. How would he reduce HC expenditures from physician services and hospital costs?

5. Should we use in vitro genetic testing to select away from the birth of children likely to have high life time HC costs?

"2. As a society we spend $30+B on video games. Why doesn’t this suggest we have lots more money to spend on heath care?"

It suggests to me that you may not be in accord with where people actually want to spend money. Be sure to avoid government jobs in the future.

P.S. I don't spend money on video games, and I, as a seventy-year old who is spending more and more time and money on the medical provider racket, think this mindless spending has got to stop.

What is the single biggest policy mistake he has made in the last 20 years? When and how did he recognize his error?

I suppose Cowen must ask Dr. Emanuel about health care. Anyway, here is the link to his latest thinking about Medicare for all and variations of it (alert: he opposes the elimination of private insurers): https://www.theatlantic.com/ideas/archive/2019/03/bernie-sanders-thinks-he-can-beat-insurers-hes-wrong/584731/

I agree with Emanuel on the desire and need to avoid medical treatment after a certain age.

But can we bump that age up to say, 78?

At the end of the article Emanual says he could always change his mind, and he will when he sees what therapies will be able to do in 2033.

A “therapy” already exists to prevent most chronic diseases. It’s called a whole food plant-based program and diet designed by Dr. Ornish and approved by Medicare. Dr. Caldwell Esselstyn has also proven in clinical trials that such a diet can reverse heart disease. Ornish proved it can reverse heart disease and prostate cancer. The problem, of course, is that people love to hear good news about their bad habits and there is none worse than the standard American diet. Spending $Bs so people can avoid changing their diet is insane, but will continue until we’re bankrupt because of the addiction to our food choices. Addicts rarely change their habits until they’re forced to do so. Simple.

"there is none worse than the standard American diet."
otoh we gonna take the positon that
the venezualan diet where venezualans starve to death is
gonna be a lot worse than the standard american diet

LOL... Mao had a version of that “diet” back in the 60s that killed over 10million Chinese. Stalin killed millions with his “diet” plans too. I’ll go with the Mao version as the worst all-time. So, I’ll qualify by adding, “without calorie restriction” next time I post!

Is the right to die included in his approach to healthcare?

What does he think of the idea of taking out of the estate of the deceased the last six months of medical care paid for by Medicare as an estate tax applicable to everyone. There would be a deferral if there were a surviving spouse.

This would give an incentive for the kids to manage care of their parents at the end of life to avoid extraordinary and expensive efforts at futile care which is now paid for by Medicare.

It would also not only be a way to reduce medical costs, but would raise revenue for the government. If the heirs wished to protect against the loss of money from the estate, they could, or their parents could, purchase a six month tail health care coverage to cover the last six months cost of medical care.

Did he support a "public option" when the ACA was being developed? If a "public option" like those 50+ being able to buy into Medicare had been included, what impact would it have had on the program's marketplace, total coverage numbers, outcomes, and the popularity of the ACA?

Ask him what he thinks about his Wikipedia biography

What are the top three outcomes from the ACA that either disappointed or surprised you?
Have you read my book: A Crisis Wasted?

In what decade or century does he anticipate the emergence of "quantum medicine"?

In what domain might "quantum medicine" first emerge: oncology, say, or brain physiology? genetics? virology?

Might "quantum medicine" find more utility in diagnostics or in therapeutics?

Why is ACA set up so the subsidized potion of the pool is mainly paid for by the unsubsidized portion of the pool (smalll businnes people usually) instead of society as a whol;e?

What advice would you give medical students?

How might we improve the system whereby conflicting incentives pull doctors in many different directions, resulting in suboptimal care, high costs, and unfulfilled doctors?

I would ask him why Medicare only pays for about $55k a year for hospice care, half the market rate.

I would ask him if he has ever read the quote "The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design", and if the years after Obamacare have been humbling at all.

Taxpayers currently spend around $35 billion a year providing dialysis and other services to end-stage renal disease patients through Medicare. There are about 700,000 of these patients a year. At what price per live kidney donation could the government subsidize a kidney market and break even, and is this higher or lower than the price that would clear the market?

Most kidney patients, who often have diabetes, die of heart disease. We’re headed down a path where organ replacement is the only meaningful cure except for a change to a whole food plant-based diet. We all know Americans would rather undergo organ replacement and bypass surgery rather than change their diet, so the better question would be “how do we get Americans to change their diet”? The answer to that question would rank as the greatest accomplishment to western medicine, with the possible exceptions of antibiotics and vaccines. It would certainly save more money than all of those prior accomplishments combined.

Ask him why academic MDs have a tendency to overlook research that demonstrates how non-MDs can improve access, provide similar or higher quality care, and cost less than MDs.

Ask him how the MD-heavy composition of editorial boards at clinical journals restricts and selects knowledge. (If he says it doesn't, let him know that editors and reviewers at top journals have actively censored authors who refer to this line of research.)

And ask him why he's still such a bully despite his claims to the contrary, and whether he thinks intellectual arrogance is necessary for academic success.

Ask him if they know why they put nails in coffins? (To keep the oncologists out.) A more fun way to ask about end of life care.


Ask him if he has an idea about how much health care is not being paid for by insurers due to the administrative roadblocks, billing errors, patient high co-insurances etc, i.e. how much the insurers/patients are keeping even tho service was delivered?

Given the public checkered history of Rhoads leading to the invention of chemotherapy, what is your view of the balance between innovation and medical ethics? If more liberal human trials of treatments can advance cures, is there any ethical dilemma to offer on a voluntary basis for the terminally ill? What’s the balance here and where do you stand?

Do you think all children should have dancing lessons? Is it more important for the boys? What benefits has dance instruction provided for your later life?

Two Questions:

1 Do you still intend to refuse medical treatment after the age of 75 that would extend your life? Please summarize your current reasoning for this position.
2. What would be the economic effect on the health care system if US subsidies to animal and refined food products ended and instead a tax was imposed that reflected the overall environmental and health care costs of those products? At the same time, assume that the tax imposed was reallocated in the form of a subsidy for whole plant-based foods and the distribution system necessary to get those foods to the poor.

1. What portion of the decline in the growth in healthcare spending is due to the ACA and which changes specifically does he think had the largest impact?
2. Based on the Oregon experiment is that it seems like Medicaid doesn't improve health outcomes but definitely relieves financial stress. Is that the best we can hope for from coverage expansion? Or is there a medical equilibrium where providing insurance improves medical outcomes?

This is what I asked him:


Along the vein of 'raising aspirations of others is important' - what can parents do to instill higher aspirations in their children? Or to what does he credit the high aspirations/achievement of all three Emanuel brothers?

One more:

-the top ten drugs by Rx in the US are generic multisource, and cost pennies. the top ten drugs by sales in the US will at some point be multisource. So why isn't a high price for 10-15 years 'worth it' to generate an armory of free drugs for the rest of human history?
-And if his answer is "but complex biologics don't go generic in the same way as small molecules" the response is to fix biosimilar legislation and regulation, not to remove the incentive for innovative medicines development

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