June 3, 2009 — -- Dr. Ezekiel "Zeke" Emanuel, special health adviser to the president's budget director, has emerged as a key behind-the-scenes player for what could be the biggest overhaul of the nation's health care system in the past two decades.
With lawmakers working in earnest this week to craft health care legislation, Emanuel admits he often thinks about what could go wrong.
"What scares me is we get it wrong and we don't create something that's going to be sustainable, that has some major defects in it," Emanuel said recently in an exclusive interview with ABC News. "Establishing an exchange that is unstable, creating a more Byzantine bureaucracy, not actually ending up getting costs under control and just fueling health care inflation. Those things would be disastrous."
Even worse, Emanuel said, would be to do nothing about a health care system he calls 'unsustainable" and "really, really dangerous."
Emanuel is the eldest brother of White House chief of staff Rahm Emanuel, 49, and Hollywood talent agent Ari Emanuel,48, no strangers to the media spotlight.
But when Zeke Emanuel, 51, was tapped by the Obama administration to be special health adviser to budget director Peter Orszag in February, the renowned medical ethicist, oncologist and policy wonk became the go-to guy for stakeholders who want a say in the Obama administration's effort to reform the nation's health care system.
He works closely with Orszag and Nancy-Ann DeParle, director of the White House Office of Health Reform, who is coordinating legislative efforts on Capitol Hill.
When the president held a White House meeting last month with the major health care players -- including many of the people who had worked to scuttle former President Bill Clinton's reform efforts -- medical establishment representatives rushed up to Emanuel afterwards to remind him how they knew him.
It doesn't hurt that he also has the ear of his chief of staff brother.
"Working with Rahm is great," Emanuel said. "He can tell me directly, unlike anyone else, when I screw up and when I'm being stupid. And also he knows he can ask me questions he can't ask everyone and get an unvarnished answer."
Emanuel on Working With Rahm: 'Zero Awkwardness'
Emanuel, who is on extended leave from the Clinical Bioethics Department at the U.S. National Institutes of Health, insists there is "absolutely zero awkwardness" in working on health care matters with Rahm, even though he once called his big brother's health plan "a game-changer."
Emanuel has advocated scrapping employer-based health care coverage, outlining his plan in his 2008 book "Healthcare, Guaranteed: A Simple, Secure Solution for America."
Under Emanuel's plan, Medicare and Medicaid would be phased out, and all Americans would be given a voucher that could be exchanged for medical coverage, funded by a value-added tax.
It's a plan that goes much farther than anything advocated by President Obama, who has proposed a more incremental approach, setting aside $634 billion as a down payment toward universal coverage and expanding subsidies to make coverage more affordable.
Even Emanuel's friends concede the guaranteed health care access plan couldn't get passed by Congress.
"It's not politically feasible," said Victor Fuchs, economist at Stanford University who wrote the foreword to Emanuel's book and has co-authored several papers with him. "There is a huge chasm between what is needed and what is possible."
Fuchs argued that the political system works against the kind of fundamental health care changes advocated by Emanuel. "There are too many individuals and organizations who don't want any significant change," Fuchs said.
But, sitting in the Old Executive Office Building at the White House, Emanuel insisted he is practical about achieving a politically viable plan.
"Not every good policy is achievable in practice and, you know, you have to make compromises and there are trade-offs," Emanuel said. "You can't be stuck to the ideal and let that torpedo making substantial improvements."
After the health care stakeholders meeting at the White House last month, Emanuel said he was convinced there is some common ground.
"Some of those groups were dead set against what Clinton did, ran advertisements against it and now they're at the table, wanting to be a part of it," Emanuel said, citing the TV commercial that aired in opposition to Clinton's proposals in the 1990s.
"Look, the guy who developed the 'Harry and Louise' ads, [Federation of American Hospitals President] Chip Kahn is now gung-ho, pro-reform. I mean, that says it all in some fundamental way."
Health Care Reform's High Strategy and Tactics
Working with his brother Rahm -- who once sent a dead fish to a pollster who displeased him -- has given him new insight into why Rahm has been successful in politics.
"He's incredibly perceptive, not just in articulating the strategic question but in identifying the tactical moves that need to be made to realize it," Emanuel said. "That combination, high strategy and tactics is not something everyone has."
Emanuel is also working with his youngest brother, Ari Emanuel, the inspiration for Hollywood superagent Ari Gold's character in the HBO series "Entourage." They are developing a new television show for HBO about medical ethical issues.
"I've worked with both brothers, the Hollywood brother and Rahm," Emanuel said, "and while you're growing up and you love your brothers and know they're both at the top of their field, sometimes you wonder what makes them good. I don't know Hollywood. I didn't know politics at all. But once you see them in action, I really understand what makes them so, so, so successful."
While not as well known as his brothers outside of medical and academic circles, Zeke Emanuel, who has degrees from Amherst, Oxford and Harvard Medical School, is every bit as intense and driven.
He said he puts in a minimum 12 hours a day at the White House, carries four cell phones, hasn't owned a television since college, and is at work by 7:45 a.m., in time for a daily senior staff meeting run by budget director Orszag, who Emanuel said is "one of the smartest people I've ever met."
Emanuel also has a black belt in Taekwondo, recently completed his first half marathon in 1:40:06 and runs long distances every weekend in Washington's Rock Creek Park.
"You can sort of forget the world, think about big issues," Emanuel said.
Something few people know about Emanuel: his love of dessert. He writes a regular column for The Atlantic Food blog and often brings in baked treats for his colleagues at the Office of Management and Budget.
"I like to make desserts, cheesecakes, apple pies, Linzer tortes, banana cake, cookies," he said.
'Chance to Make a Difference'
Health care reform is only one aspect of his job. Emanuel is also putting his background as a bioethicist to use.
"We're going to have to make some priority decisions about the flu, if in fact, it comes back in the fall, that involve fundamental ethical choices and global health aid," he said, as a copy of the president's initiative on scientific integrity throughout the executive branch sat on his desk.
"The needs are just so enormous that we can't satisfy all of them, so there're fundamental questions about what should get priority in terms of funding."
Emanuel is also working on how to implement any health care legislation that is passed by Congress.
The Obama administration is pushing Congress to enact sweeping health legislation this year, arguing that providing health coverage for 50 million uninsured Americans is the key to economic recovery.
"Just passing a bill, while it will be a world historical event, is only the first part of actually making this thing work," Emanuel said. "Making sure everyone really does get affordable, high quality health care that is sustainable over time is the really big challenge."
But even with its complexities, Emanuel said, the opportunity to be at the center of the Obama administration's health care push is irresistible.
"The chance to make a difference is, I think, what drives us," he said, "and the opportunity to have health care reform enacted and be a part of that process, since it's an area I've worked on for a long time, is pretty powerful."