JULY 1, 2009
In 1995, John Gallin, the head of the clinical center at the National Institutes of Health (NIH), decided the nation's premier medical research facility should have a vibrant bioethics program. He embarked on a lengthy search, soliciting dozens of resumes and interviewing several candidates, before settling on a Harvard-trained M.D./Ph.D. named Ezekiel Emanuel to lead it. Emanuel, who goes by Zeke, was young (not yet 40) and relatively unknown outside the field of medical ethics. But, with his energy and a combination of clinical and scholarly credentials, he seemed uniquely suited to the task Gallin had set: Building the country's top bioethics department on a shoestring budget.
Gallin knew his prize recruit was unorthodox; precisely how unorthodox became clear shortly after Emanuel's arrival. In his first real act as department head, Emanuel opted to take Gallin's directive quite literally, trying his hand at interior design. As Emanuel recently explained it to me, Gallin had given him some 6,000 square feet to house the new program. But the space was a series of disconnected rooms--"basically a bunch of rabbit warrens"--divided by a cavernous, double-wide hallway. "I said to him, 'First, this sucks,'" Emanuel recalls. "'No one will be together. Second, you have all this dead space [the hallway].'"
And so, along with an architect friend who agreed to help, Emanuel set about turning the hallway into an enormous communal space, around which he reorganized the offices of his future faculty. The aesthetic that emerged was something you might call Museum of Natural History eclectic. Instead of store-bought desks, he affixed slabs of Formica onto file cabinets. On the walls, he hung African masks and Australian aboriginal drawings. "You know, you could put up some shitty Picasso poster, or you could get original aboriginal art at almost the same price," he told me.
Fortunately for both men, Emanuel would translate this same resourcefulness into building a team that would do Gallin proud. Over the decade-plus that he actively oversaw the department, Emanuel lured a healthy cadre of bioethics researchers to NIH from places like Brown, Princeton, and the University of Virginia. Together they churned out hundreds of articles in places like The New England Journal of Medicine and The Journal of the American Medical Association. Many now consider Emanuel among the most influential bioethicists in the country.
Which is perhaps why it's both surprising and quite fitting that Emanuel, the brother of the president's chief of staff, has turned up as a senior official at the Office of Management and Budget (OMB) under its director, Peter Orszag. Despite the agency's reputation for colorless bean-counting, Orszag has quietly assembled one of the most intellectually imaginative teams anywhere in the administration. In addition to Emanuel, there's Cass Sunstein, a renowned constitutional scholar (and longtime contributor to The New Republic), and Jeff Liebman, a Harvard economist and top Obama campaign adviser. Robert Gordon, a former Supreme Court clerk who was the policy guru behind John Edwards's 2004 presidential run, oversees education and labor issues. Xavier Briggs, an MIT urban planning professor, keeps an eye on everything from housing to homeland security. As his top communications aide, Orszag hired Kenneth Baer, who co-founded the policy journal Democracy in 2005.
The collective brainpower of the Orszag high command is beyond dispute. What's remarkable is the influence they exert over administration policy. In a town that's often run by political operatives and slick K Street lobbyists, the Orszag intellectuals are shaping everything from health care reform to climate-change legislation. And none quite epitomizes this model of administration praxis like the Emanuel brother who goes by "doctor."
Walk into the health care suite at OMB and you'll see a young assistant manning a standard-issue desk, on which rests a tray full of mini candy bars. Several paces behind her is the door to the imposing office of OMB associate director Keith Fontenot, the health care numbers whiz Orszag brought with him from the Congressional Budget Office. Just to the assistant's left, in a kind of glorified cubicle whose paper-thin walls don't quite extend to the ceiling, sits Zeke Emanuel. Most days Emanuel huddles over a cramped desk that is visible to pretty much anyone who drops by for chocolate.
Emanuel had gotten to know Orszag in recent years thanks to their shared interest in health care reform. The day the White House named Orszag budget director, Emanuel e-mailed his future boss and asked, half-joking, if he needed a doctor on his team. Orszag replied that the two of them should talk and, that evening, called to ask when Emanuel would be joining him. This is where the cubicle comes in. "Basically, I said, 'I'd love to come over, but I want to be in the building, near your office,'" Emanuel told me. Let it not be said that the Emanuel brothers don't appreciate the way power flows through Washington.
Emanuel is officially "Special Advisor for Health Policy," and his ambiguous place in (or, rather, outside) the OMB bureaucracy can create minor strains. His memos don't always swim through the normal channels, but they have a knack for finding Orszag's desk. (One memo, about the administration's global health initiative, triggered a small shift in new funding toward child and maternal health, to the dismay of activists who sought more money for HIV.) On a recent Sunday in Chicago, I saw Emanuel speak to a group of Albert Schweitzer Fellows--students in health-related fields whose mission is to serve struggling populations. The fellows shared their frustrations with the current health care system--not enough incentives to practice primary care rather than specialize, not enough time with patients. Emanuel listened intently and, at the end of the session, announced that he'd jotted down four or five key points, which he'd be "sending e-mails [to colleagues] about tomorrow morning." It did not sound like idle talk.
Whatever the organizational implications, this model of intellectual activism seems to have been what Orszag had in mind when he staffed his department this winter. "This sort of alignment doesn't happen by accident," Orszag recently told me, flashing a conspiratorial grin. Other government agencies also have their share of academic types, of course. But OMB's may be unique in their range of interests. Sunstein, who will be the government's "regulatory czar" pending Senate confirmation, has written about everything from law and economics to the Internet and democracy to Moneyball. Liebman, who is OMB's fourth-ranking official, is part of the health care team and spends considerable mental energy helping incorporate behavioral economics into administration policy. (He recently convened an in-house seminar on the subject. ) This collection of personnel can sometimes make OMB feel more like the RAND Corporation than the administration's in-house budget scold.
For all its big ideas, though, Orszag's group is mostly preoccupied with notching victories. The OMB intellectuals pride themselves on mixing easily with bureaucratic doers like Fontenot and deputy OMB director Rob Nabors, a former congressional staffer who was critical in crafting the stimulus bill. When I posited the think-tank conceit to Orszag, he conceded the point but pushed back at the characterization. "I don't want OMB to be driven just by a very narrow focus without ideas coming into play. But you can't let it just be an academic debating society either," he said. "If you're too theoretical, you don't actually execute."
The evidence that OMB excels at execution is not hard to find. In addition to the budget and the stimulus bill, on which OMB left a large institutional imprint, the agency has also seized a leading role on health care--one aided by the fact that Orszag was up and running with personnel when Tom Daschle's bid to be health secretary ran aground. Of the ten officials from half a dozen agencies who meet almost daily to hash out the administration's reform efforts, no fewer than three--Emanuel, Liebman, and Fontenot--reside at OMB.
And it's not just health care. Earlier this spring, I happened to meet two administration officials working with OMB on a multi-agency initiative that was about to be unveiled. The two officials were anxious that, despite assurances to the contrary, OMB would charge ahead and announce its portion prematurely, relegating the rest to an afterthought in the media. The officials were especially concerned about details trickling out on OMB's blog. "We do try to make sure we don't surprise people," Orszag says. "But I do think that if we--and we're not there--if we got into the practice of excessively delaying something like a blog post ... you start to stifle the intellectual energy that generates ideas."
The Saturday night before his talk with the Schweitzer Fellows, I joined Emanuel for dinner at Charlie Trotter's, one of his favorite restaurants in Chicago. While waiting for him to pick me up at my hotel, I Googled the restaurant and discovered that it was more than a khakis-and-blazer affair. This made me slightly self-conscious standing outside in my khakis and blazer. All the more so when Emanuel showed up in a sleek blue suit.
Emanuel is a trim man of average height with slightly thinning grey hair. It was only when he got out of the car that I felt a twinge of relief. On his feet was a pair of beige suede shoes that might be charitably described as risky. I was reminded of something his longtime friend Greg Keating had told me. "Ari"--the third Emanuel brother, whose career as a Hollywood agent has been chronicled in the HBO series "Entourage"--"is extremely suave. When he goes to dinner ... he's the most polished person in the room," Keating had said. "Zeke couldn't care less about it. Ari winces at his complete indifference."
Of course, Zeke is not exactly a monk. It took us more than three hours to make our way through an eight-course tasting menu. (His favorite: red shiso sorbet with mango--"Clarifying. Like a waterfall or something." Among his least favorite: the sea urchin "amuse-guele"--"Better than the last sea urchin I had. ... It has a slight turpentine taste if it sits around for any length of time. ") Later, on our way back from the restaurant, he couldn't get over a high-tech oven we'd seen while touring the kitchen. The oven combined two heating mechanisms--microwave and high-speed convection--and could cook a whole turkey in under 45 minutes. "I know I'm obsessing about this oven," he told me, contemplating whether it would be gauche to buy one.
Still, one could hardly accuse Zeke Emanuel of leading a shallow existence. He earned his Ph.D. in 1989, and, in 1991, Harvard University Press published his dissertation as a book called The Ends of Human Life. In the book, Emanuel argues that the kind of liberal political philosophy associated with thinkers like John Rawls--in which the state is scrupulously neutral between different value systems--is incapable of resolving our thorniest questions of medical ethics. There's simply no way to decide, say, when to pull the plug on a comatose patient without injecting one's own values. (If, for example, you let the family decide, you're implicitly elevating its importance as an institution. ) Emanuel's alternative was to allow different communities to arrive at different answers to these agonizing questions based on their own "conceptions of the good life."
But the book is interesting for another reason. To put it simply, Emanuel seemed to use his dissertation to grapple with his ambivalence about his own identity. On the one hand, he writes, community gives meaning to a person's life; participation in a community allows us to "transcend [our] mortality." On the other hand, community can imprison us. "If I wasn't born into a particular kind of Jewish family at a particular moment in history, would I have been a doctor? No chance," he says. "It obviously is the fact that my father"--also a doctor--"is pushing me very, very hard." Emanuel hated medical school so much that, after his first year, he fled to TNR for a summer internship. He eventually came to philosophy after his third year as a kind of compromise. "I did this Ph.D. thing to at least do medicine my own way if I was going to do it, " he says.
And yet, wherever he went, he wore his identity on his sleeve. His undergraduate days at Amherst were miserable: "It was a culture clash. I came to this WASP institution, and I was a very aggressive Jewish kid from Chicago." While doing a master's degree in England, he participated in a kind of proto-reality show on the BBC, in which students and farmers and businessmen from Oxford and Cambridge performed a variety of (often menial) tasks. He remembers the review in a local publication proclaiming him "the worst of all things--a pain in the ear." But it was Harvard that was most oppressive. "I mean, medical school is the worst. You know, the hierarchy--the low guys never challenge the top guys." When Emanuel got rejected from a residency at the prestigious Brigham and Women's Hospital, the dean of students explained that "they didn't think they could tolerate you."
One thing you notice if you spend more than a few minutes around Emanuel is his indifference--outright hostility, actually--to authority. A friend from college told me Emanuel had once been pulled over by a cop while driving back to Amherst with an African American classmate. Emanuel accused the cop of racial profiling; I asked how the cop had taken it. "They never react well," he told me. "What landed me in prison in Oxford is precisely this kind of stuff." Wait, prison? "I was bicycling home after my mentor's son's bar mitzvah." It was about midnight and a cop flagged him down inexplicably. "He says, 'Are you drunk?' And I said, 'No, I'm not drunk.' Because I don't drink. And, uh, I blew in his face to prove it."
Zeke is unquestionably an Emanuel, in other words. The subject of the brothers has become a bona fide pastime in Washington of late, as the three men have ascended to the top of their respective fields. But, for all of the fascination with Rahm, it's the relationship between Zeke and Ari that may be most intriguing. Whereas Rahm, the middle son, displays elements of both his brothers--some of Zeke's wonkiness, some of Ari's instincts for deal-making--one sometimes struggles to see how the eldest (Zeke) and youngest Emanuel siblings relate to one another. For example, while Ari is an HBO icon, Zeke rarely even watches television. When I brought this up at dinner, Emanuel initially protested. "You shouldn't sell Ari short," he said. "He's very committed to the environment--very keen and knowledgeable. He's also quite keen and knowledgeable about health issues." But he conceded that even here the two men differ in sensibility. "Ari's a bit of a hypochondriac," he said. "I went for like fifteen years without ever seeing the doctor."
If Orszag wasn't aware of it beforehand, he has surely learned you could do worse than to have an Emanuel at your side in a fight. Despite Rahm's reputation, Zeke says he reflects the family's shortest-distance-between-two-points ethos even more so than his politician brother. ("Ironically, I'm more brute force than he is. I have nowhere near the talent he does for seeing what other people are feeling.") Certainly, his ideas about health care are direct and unadorned. In a book he published last year laying out a model for reform, Emanuel dwelled at length on the irrationality of the employer-based system--which creates huge administrative costs and saddles small companies with enormous expenses--and the practice of compensating physicians and hospitals for services rendered rather than the outcomes achieved, leading to a proliferation of unnecessary (and pricey) procedures.
Emanuel insisted that fixing these structural defects, along with a handful of other ideas like collecting data on the effectiveness of treatments, was the only way to bring down costs. He criticized the kind of "mandate" plan the administration and congressional Democrats are now weighing, which builds on the employer-based system. "Mandate plans do not exclude the possibility of having ... initiatives to address cost control and quality," he wrote. "But at best these would be 'lipstick' initiatives--put on for show." Most economists and health wonks agreed that the employer-based system was dysfunctional, but many argued that the political obstacles to a wholesale junking were insurmountable.
These days, some of these same people praise Emanuel's pragmatism. "Zeke is taking the president's plan and trying to think through how you would structure it, make it work most effectively," says an administration official involved in the health care effort. "It's not like he sits in meetings trying to shape the Obama plan to be his own."
But, perhaps not surprisingly, Emanuel digs deepest into his healthy reserve of enthusiasm for the parts of the plan that dovetail with his own ideas. At the top of this list is a so-called insurance exchange--a regulated market in which people who lack coverage through their employer (and maybe people who work at small companies, though that's still being negotiated) could choose from a variety of private plans, which would offer at least a minimum level of benefits and could not discriminate by health status. "He's a key thinker on the exchange. How it operates. How it interacts with insurance market reform," says the administration official.
On the one hand, the exchange is absolutely central to the Obama plan--it's how the uninsured get covered. So it's worth having Emanuel's considerable brainpower on the problem. On the other hand, one can imagine a future in which the employer-based system gradually withers away, leaving everyone to purchase insurance on the exchange. Though Emanuel scrupulously avoids such discussions, it's hard to believe the thought has never occurred to him.
In the meantime, expect to see more of Zeke Emanuel as the health care battle intensifies. The weekend we spoke, The New York Times Magazine had published a long piece about White House legislative strategy on health care. I asked who from the administration was likely to hammer out the final shape of the package on Capitol Hill. Rahm and Phil Schiliro, the chief White House congressional lobbyist, seemed like a lock, I said. So did Orszag and Nancy-Ann DeParle, the health care czar. Emanuel would only say that, "There are things we care about. You have to keep your eye on the ball, otherwise the ball could escape." In that case, it may be worth asking again if the White House needs a doctor on the team.
Noam Scheiber is a senior editor at The New Republic.