This is an important book by an important American health policy player. It is not just a very readable and useful account of the US health system, its dysfunctions and its reforms. It is also a very readable and useful account of how contemporary American health policy analysts tend to think.

Part of the reason is Emanuel himself, who is no ordinary academic. An oncologist by training, he is a Professor, Vice-Provost and department chair at the Ivy League University of Pennsylvania who has a host of other academic accomplishments and positions ‒ including the ultimate academic status symbol of a MOOC. His brother was White House Chief of Staff in Obama's first term (when health reform passed), he was involved in the health reform at high levels, he writes for the New York Times regularly, and he even had the distinction of being attacked by Republicans as a proponent of ‘death panels’. The bibliographic essay, which frustratingly stands in for references, is a virtual ‘greatest hits’ collection of the works that shape the current Democratic style of thinking. Even his list of acknowledgements is a list of some of the United States’ greatest health economists and political theorists. It is hard to imagine a more exemplary American health policy writer in 2014. We should expect a book by such a writer to be very good, and to reflect the thinking and assumptions of that policy community.

That is emphatically the case. For those who need to understand how most American health policy analysts view the United States health care system, this book is the answer. It is a coherent presentation of the dominant, politically and economically sophisticated, Democratic, understanding of the US system and its potential for reform (Republican alternatives are rare and often trivial).

Approximately the first third of the book is a readable and teachable account of how the US health system operates, and another third mixes political analysis with the contents of the Affordable Care Act, aka the Patient Protection and Affordable Care Act, aka Obamacare. These parts are simply and lucidly written, with superb graphics. They make the complex American system, and the complex reforms, as accessible as they can be. It would very much be worth assigning to university students. It also has practitioners’ advice on how to do politics, and some interesting new legislative history.

Read by a practitioner of political analysis, it is simultaneously a case study of how American politics works ‒ notably, the plethora of veto points that empower marginal interests ‒ and of how people within a system adjust their assumptions to it. It is about the ACA as the best health system that could be legislated in the US, rather than about the ACA as the best possible system. For example, he shares the characteristic American focus on payment systems, which makes sense in a system with relatively weak hierarchical policy tools, limited government purchasing power and diffuse regulation. Policy tools that would be second nature in other health systems, such as price controls, let alone an instrument like NICE, are just not in the American repertoire.

Attention to assumptions is especially rewarding in a chapter at the end titled ‘Six Megatrends’. Here he makes a number of dramatic predictions: the death of insurance companies as Americans know (and detest) them, to be replaced by integrated provider systems; the generalisation of ‘VIP care’ for the chronically ill; the ‘emergence of digital medicine and closure of hospitals’, by which he means at least a thousand US hospitals will close; the end of employer-sponsored health insurance as the ACA's marketplaces find their footing; the end of health care inflation; and the transformation of medical education so it is shorter, has less research and is more team-based. Each megatrend has a date (digital medicine and the cull of hospitals will take place by 2020).

What stands out across them, and unites them, is faith in technology and management. The ‘technological solutionism’ long associated with American medicine applies as much to IT as to drugs or surgery. Over and over again, he mentions in passing that this or that reform in the ACA will only work if the USA has far better data and is far better at analyzing it. This faith is not obviously well placed. Health IT has not been very impressive in far more integrated systems than the United States (e.g., the English NHS), and the United States has weak technical standard-setting, poor data protection law and a host of actors who prefer that information be proprietary so they can sell it on or use it to retain patients. How many of his managerial innovations, or forms of digital medicine or concierge care, depend on IT that doesn't work, isn't interoperable, or is owned by businesses that do not want to share?

Second, the book is cheerfully managerialist. Emanuel puts a great deal of faith not just in data and IT, but also in managers of big systems (and in doctors as managers). Somebody, such as hospital systems or Accountable Care Organisations, will be able to manage the different professionals, problems and procedures better than ostensibly procedure-oriented doctors. So, for example, his call for a shorter medical school education is partly justified by the fact that most doctors need no research training. Research training, though, is not just for those who produce research. It is also an effective way to train future consumers of research. If doctors are further removed from the ability to decide on treatments, are we really so sure that the combination of health services researchers and managers is an adequate replacement? The answer is left implicit: if the payment systems are set up correctly, then managers will have incentives to respond to guidelines put out by leaders of academic medicine. People with less faith in the managers, the incentives or the guidelines might wonder at the apparent sidelining of classic professional virtues and the figure of a personal doctor who could be a patient's advocate.

That is not to say that Emanuel's megatrends are wrong; they might very well all be accurate. What is less sure is that they will be good things or work as intended. Emanuel's faith in management and technology is once again representative of elite American health policy debate, but one wonders if we should all share it.