And if the purpose of the stimulus is to be a jobs bill, obviously enlisting private industry would hopefully multiply the effect of this money.

Exactly, exactly. For most of the stuff in the recovery act, you could at least say that it provided some reasonably quick stimulus. Health IT was one of the items that at the time they weren't even sure they could say that with a straight face. But it turns out that the prospect of all this money out there did create a real boom in the industry. I'm not sure that they gamed that out in advance.

Talk about meaningful use. At first it was too stringent. When even the Mayo Clinics and Kaisers of the world say they can't meet the mandates, you know it's probably too strict.

There was a fight inside the White House. My sense is that the strongest advocate for "stringent" was Zeke Emanuel, Rahm's brother, who was at the Office of Management and Budget, and really felt that this is the time: If you're going to have it, you've got to use it, and this is such an opportunity. Let's force people to do the right thing. They're going to get all this money [in incentive payments], let's get them to do everything.

And Blumenthal, the analogy he always used was the escalator: If we can get people onto the escalator, then they'll sort of naturally ramp up. But there has to be some use. We don't want them to just buy this stuff to have it sit in the corner gathering dust. But if we can get them doing some stuff with it, gradually over time we can get them to be more comfortable and they'll ramp up that way.

And I think the first draft, although they claim it was not just a negotiating position, it was, as you said, really draconian. Even Blumenthal's old boss at Partners was complaining about it in the New York Times. I think there was the sense that they had to go back to something a little less stringent – well, a lot less stringent.

But it's still, I think most people would say, "meaningful" use. You've got to be using this stuff. I think reasonable people can disagree about whether it's meaningful enough. But I think there's a real belief, I think if you're going to spend $27 billion on this stuff you'd better have this belief – that as doctors start to use it they're going to find it useful. There will certainly be some bitching now, especially among older doctors, but my sister is bitching about it too. She's a doctor and she's 39. But like Obama always says about decisions that reach his desk: if it was easy, somebody would have done it already.

And I think the fact that that first draft of meaningful use regs was so harsh, I think if they came out with what they eventually settled on first, people might have howled about that too.

I found it interesting that, beyond the practical considerations of toning the rule down, there was a political calculus, too. They didn't want to pick a fight with the healthcare industry – and give red meat to the Tea Party – as they were starting to to do health reform.

I don't remember if I put this in the book, but during the Obamacare debate, comparative effectiveness had become this big kind of crazy political football…

Not as bipartisan as health IT, to say the least.

Yeah, it's like rationing and "death panels" and Zeke Emanuel was "Dr. Death," all this crazy stuff. And you can see as the drug industry and particularly the medical device industry – to get a drug approved you just have to prove it's better than a placebo, and to get a device approved you basically just have to prove it won't hurt you – you don't have to prove your stuff is good, or at least better than any other treatment.

They had that [former Calif. Rep.] Tony Coehlo patients' group [the Partnership to Improve Patient Care] – it's not fair to say it's just a front, because it's a real patients group, but it sure does get its money from the device and drug people. Who have really extracted their pound of flesh for this stuff. And have tried to make sure: "You can have your comparative effectiveness research, as long as you don't use it."

But during Obamacare, this almost scuttled the bill. Democrats were behind the scenes screaming about it, and Rahm almost got in a huge fight with Zeke about it. Rahm just wanted to ditch it, and it was Zeke's baby. Rahm actually forced Zeke to write a new version of the bill without comparative effectiveness. This was when they were putting together PCORI [Patient-Centered Outcomes Research Institute]. It was real Emanuel brothers fireworks.

I'm sure there was some salty language exchanged…

I would think it was probably not like, 'Well, Ezekiel, I would suggest that perhaps we should…" Or, "My dear Rahm, I must dissent."

(Continued on next page.)