A Serious Longevity Agenda Requires Habits, Social Ties, and System Reform

Ezekiel Emanuel has not retreated from the position that made him notorious in bioethics: his 2014 essay, published under the title “Why I Hope to Die at 75.” What he says he was arguing then, and is still arguing now, is narrower and more personal than the headline implied. He is not saying he would refuse all medical care after 75. If someone broke his hip on a ski mountain, he would repair it. If cataracts kept him from reading, he would treat them. If he had pain, he would take medication.

The line he draws is around medicine whose justification is life extension after 75. Emanuel’s fear is not death itself. It is living with a body that works while the mind is gone. “For me, hell is the body’s working great, and the mind isn’t there, and I have dementia,” he said. “I’d rather be dead.”

His argument rests on the shape of cognitive decline with age. Emanuel said that before 75, the rate of cognitive decline and dementia is “very, very low,” but then rises sharply. At 75, he said, roughly 30% of people have some cognitive decline: 20% with cognitive impairment and 10% with full-fledged dementia. By 80, he put the figure at 40%, including 15% with dementia and 25% with cognitive impairment. The line, he emphasized, keeps going up, and the medicines currently available do not meaningfully alter it.

That is the continuity between his essay and his book Eat Your Ice Cream. The book is not a conversion to maximal longevity. It is an attempt to identify what people can do to stay healthy as long as possible, especially cognitively intact, while separating evidence-backed practices from what Emanuel calls “nonsense” in the wellness market.

He repeatedly framed this as a philosophy rather than a universal prescription. The purpose of the 75 essay, he said, was to force readers to articulate their own view of aging and medical intervention, not to adopt his. The same personal edge runs through his account of his parents. His father died at 92 after a fall led to the discovery of a “lemon-sized” glioblastoma. Emanuel flew in, discussed treatment options, and agreed with his father that treatment was “pretty stupid”: it would not cure him, and removing a large portion of frontal lobe was not a route to a happy, healthy life. His father declined treatment, family came to visit, and he died 10 days later, without pain or other impairment.

His mother, also 92, is mentally sharp but deaf and largely housebound. Emanuel does not want that life either. He acknowledged that some 90-year-olds remain exceptional, but his caution is that outliers are rare by definition. Most people should assume they will be closer to the norm than to the exceptional case. He also said science now points to things he can do that his mother could not have done, and that he and his mother share some longevity genes. But genes and outliers do not overturn his central judgment: longer life is not the same as better life.

For Céline Gounder, one of the most striking findings in Emanuel’s book is that social relationships are a stronger predictor of a long, healthy life than diet, exercise, or sleep. She pointed to the Harvard Study of Adult Development and its 85 years of data, then asked why the wellness world mostly ignores social relationships.

Emanuel widened the critique. It is not just wellness influencers, he said. It is also most doctors. Patients are rarely asked how often they see close friends, what their conversations are like, or whether they have sustaining relationships. Gounder noted that infectious disease physicians take unusually thorough social histories, but Emanuel, an oncologist, said that is not the norm in his field.

His explanation for the neglect is partly conceptual. Social relationships are too often treated as “psychology,” as though they belong to an intangible mental realm. Emanuel rejects that separation. “The mind is between your two ears. It’s called the brain,” he said. Social relationships affect the brain, stress hormones, and gene expression. Those pathways matter, he said, for inflammation, cardiovascular risk, vaccine response, and other physical outcomes.

The wellness shorthand — eat well, exercise, sleep — is not wrong. Those are important enough to occupy major parts of the book. But when wellness is reduced to those three, it misses a large part of what keeps people healthy. Deep conversation, shared memory, and doing pleasurable things with friends are not just emotional luxuries in Emanuel’s framing. They are bodily events with physiological consequences.

Gounder asked whether social connection is ignored because it is hard to monetize. Emanuel conceded that “those wizards out there will monetize anything,” but he did not make monetization the primary explanation. The United States spends somewhere between $1 trillion and $2 trillion a year on wellness, depending on what is counted, he said. Yet the health care system is not getting rich from wellness and never will. That is part of why medical training and office visits do not spend much time on it. But the deeper blind spot, he argued, is the false distinction between mental and physical health.

The social point also shapes the book’s title. Emanuel had wanted to call it Don’t Be a Schmuck, a phrase from his father. His editor, Matt Weiland, told him he could not use that as the title. Emanuel said the manuscript folder still carried the old title, but Weiland persuaded him to change it. One of Emanuel’s agents came up with Eat Your Ice Cream, and Emanuel said he now thinks the title is “way, way better.” It is less negative than the original and, in his view, better captures the range of what he wanted to say.

Ice cream also fits the argument because it is pleasure, moderation, and often social experience. In London, Emanuel said, he spent hours in an ice cream shop as part of a book promotion and noticed that very few people came in alone. Ice cream, in that setting, was a group activity.

When asked for one thing people could do immediately to lead a healthier life, Emanuel did not say buy a supplement, start tracking sleep, or adopt a diet. He said: throw a dinner party.

His reasoning was deliberately practical. A dinner party involves cooking good food, learning or using a recipe, cognitive effort, friendship, conversation, and, if done his way, a walk afterward once the dishes are put away. He called it “wellness stacking.”

Emanuel’s critique of “Big Wellness,” as Gounder called it, is not that all nonmedical health advice is useless. It is that much of the market promotes interventions without evidence, or treats biology as if more of a supposedly good thing must always be better.

Gounder raised Casey Means in pointed terms, describing her as someone who went from wellness influencer to U.S. surgeon general nominee and promoted gummies, algae supplements, and “immunity stacks.” Emanuel immediately disputed part of that frame: Means was not surgeon general, he said, and was not going to become surgeon general. Gounder added that other nominees had been “in the same vein.” Emanuel’s criticism of the recommendations Gounder had raised was straightforward: he said there is no data behind much of that advice. The book, he said, includes a lot of studies because data should drive decisions.

He applied the same mixed judgment to the MAHA movement. On vaccines, he was blunt: “total nonsense.” He said several vaccines can reduce the risk of dementia and should be taken, naming shingles, pneumococcal, annual flu, and DPT vaccines. Not taking them, especially the shingles vaccine, he called “a big mistake.” On food, though, he said the movement is “probably 80, 85% right.” Its concern about pesticides also has merit, he said, and he noted frustration among some MAHA adherents that the current administration was not acting on pesticides and was, in his view, making some of them easier to use.

That distinction matters because Emanuel does not place every dissident wellness claim in one bucket. His complaint is not that establishment medicine has nothing to learn. It is that claims should be separated by evidence.

The same frame informs his argument against diets. Wellness, he said, is not like “Alcohol-Free January.” If someone is serious about health, they have to sustain changes for years and decades. Willpower cannot carry a person through decades of behavior they dislike. Emanuel cited studies showing that willpower fatigues easily and may take days to regenerate. Diets fail, he argued, because they are generally organized around deprivation: “Don’t eat this, don’t eat that.” People can keep that up briefly, not as a life.

His preferred language is habit formation. A healthy eating pattern has to include pleasure and be something a person can repeat. He used his own baking as the example. His mother’s cheesecake — made with three full-fat cream cheeses and six eggs — is not on any wellness diet. He makes it every three or four months, savors it, associates it with his mother, and shares it with people who like it. That is not a failure of wellness. It is the point: moderation is more biologically sensible than purity.

This is where he attacks “maxing.” Protein maxing is his example. Emanuel told the audience that everyone in the room was getting enough protein. The American diet’s problem is not insufficient protein, he said; the average American eats about 12 ounces of meat a day, while something closer to 12 ounces a week would be more appropriate. The nutrient most Americans should worry about, he said, is fiber: about 93% of Americans do not get enough because they do not eat the right mix of fruits, vegetables, nuts, and beans.

Gounder also raised GLP-1 drugs such as Ozempic and Mounjaro, noting that more than half of people stop taking them within a year and that the resulting weight cycling may be worse for health than remaining heavy. Emanuel did not give a detailed drug-specific analysis in the exchange. He pivoted to the broader principle that wellness has to be sustainable over years and decades. The issue, as he framed it, is not whether a short-term result can be produced. It is whether the behavior or treatment can support a long life without depending on exhausted willpower or cycles of stopping and starting.

He recommends not trying to change everything at once. People do not have enough willpower to overhaul eating, exercise, sleep, and friendship simultaneously. Emanuel invoked Benjamin Franklin, who focused on one virtue at a time for two weeks and scored himself before moving on. The principle is incremental habit formation, not maximal self-optimization.

Gounder pressed Emanuel on whether individual wellness advice is a retreat from the systems work that has defined much of his career, including the Affordable Care Act and the food plate. Emanuel accepted the premise conditionally: if individual advice were all he were doing, the criticism would be right. But he argued that the U.S. “health system,” not just the health care system, is broken and must be fixed at the environmental level.

Food is the clearest example. Emanuel said 60% of the calories American adults eat come from ultra-processed foods. He traced that in part to 1970s agricultural policy under Earl Butz, Secretary of Agriculture under Richard Nixon, who pushed subsidies for corn, soybeans, rice, and wheat — the ingredients that make ultra-processed foods cheaper and calorically dense. For people on low or fixed incomes, these foods fill them up for less money. The result, as Emanuel framed it, is a food ecosystem that encourages and even addicts people to unhealthy food, followed by a medical system that pays the bills for obesity, diabetes, hypertension, kidney disease, and cardiac disease.

A serious wellness policy, in his view, must address the food ecosystem: subsidies, school lunches, food stamps, and the incentives that shape what people can afford and learn to eat. He credited parts of MAHA for focusing on that ecosystem and said that gives him some encouragement.

The same systems logic applies to sleep and friendship. It is hard to sleep if work schedules keep changing. It is hard to make friends without institutions and spaces that bring people together: churches, libraries, reading groups, and other social activities. Wellness cannot be reduced to personal responsibility when the environment makes healthy behavior difficult.

Emanuel also argued for reviving home economics. He sees a basic skills gap in young adults, including highly educated ones. His example was Vincent, a research assistant who had graduated from Cornell with a 4.0 and later went to medical school at Mount Sinai. Emanuel noticed Vincent getting fast-casual food delivered every day and wondered whether he was overpaying him or whether something else was wrong. It turned out, Emanuel said, that Vincent did not know how to cook.

Emanuel gave him what he called the easiest nutritious recipe he knew: roast chicken with root vegetables. The first obstacle was that Vincent did not have a roasting pan. Emanuel told him to buy a disposable aluminum one. A week later, Vincent reported that he had bought a chicken cut into eight pieces. The story was funny, but the point was structural. A country that does not teach people how to cook leaves them dependent on the food environment it has created.

This is also how Emanuel answered a critique from bioethicist Art Caplan, whom Gounder quoted as saying that mainstream wellness advice applies to a “narrow subset of affluent folks” who are not divorced, working two jobs, caring for an aging parent, and grabbing fast food during a joyless commute. Emanuel said that may be true of supplement sellers, tests, facilities, and expensive wellness programs. But he said he tried to write a book whose recommendations generally do not require money.

He is against wearables, despite assuming that much of the Aspen audience uses Oura rings, Fitbits, or Apple Watches. He does not think they contribute to wellness, though they may contribute to anxiety. In the exercise chapter, he said, most suggestions require little or no money. He also argued that many Americans, not just affluent ones, want their doctors to help them stay healthy and treat illness without medication when possible. For hypertension, he said, the DASH diet can be “as good as one drug” for control. Eating, exercising, sleeping, and maintaining social ties can, in some cases, save money rather than require it.

Asked how Covid changed his thinking about wellness, Emanuel identified two failures. The first was the insufficient attention paid to the social costs of isolation. His emblematic memory was a playground near his home in Washington, D.C., which fed into Rock Creek Park. About two weeks into lockdown, city workers wrapped the play structure in yellow tape so no one could use it. Emanuel called that “pretty moronic.” The structure was outdoors; play and social interaction carried much lower risk outside than inside. Blocking it, he said, showed how poorly that decision weighed the social costs of restrictions.

His point was proportionality. He did not say outdoor transmission was impossible; he said the risk was “so much reduced,” while the loss of play and social interaction was substantial. He also said the CDC got transmission wrong, creating a chain of problems around masking and other guidance.

The second missed opportunity was indoor air quality. Emanuel argued that the issue extends well beyond Covid. Better air quality in schools improves test scores, reduces asthma attacks, and has other health benefits, he said. The country spent hundreds of billions of dollars during the pandemic but did not refit every school and office building with better air quality. He called that a “huge missed opportunity” and a chance for generational health improvement.

Gounder agreed, noting that she had written with Joe Allen on what she described as essentially the same theme: a once-in-a-generation opportunity for schools that was not used, and that could also have mitigated risks from wildfires and climate change. Emanuel added that policymakers did not put social, educational, and family-harmony costs at the center of reopening calculations. The health costs were visible. The broader costs were not treated as front and center.

Gounder pressed Emanuel on whether public anger at the U.S. health system could be channeled into reform rather than destruction. Emanuel answered with John Kingdon’s framework for major change: a recognized problem, a vetted plan with a plausible chance of addressing it, and a political opportunity. The first condition exists, he said. People are worried about affordability, surprise bills, and the difficulty of navigating the health care system. The third condition may emerge through elections or other political openings. The missing element is the plan.

He argued that big plans take time to become legislation. Medicare was proposed in 1957 and passed in 1965. The Affordable Care Act drew on components adopted in Massachusetts in 2005 before becoming federal legislation in 2009 and 2010. What exists now, he said, is anger without a vetted plan. The health policy community, which might normally produce one, is “a little depressed, a lot depressed.” Washington also has fewer politicians and long-serving staff with deep health system knowledge than it once did.

Emanuel defended the ACA’s achievements as substantial. He said it gave tens of millions of people insurance, controlled costs for 15 years in a way he said had not happened in the United States after World War II, and saved the government $4 trillion on Medicare alone. Democrats, he said, get no credit for that, which creates a political problem: if a party saves trillions and receives no credit, next time it may not bother.

But he also said the ACA made some structural problems worse. The American insurance system was already fragmented: employer-sponsored insurance, Medicare, Medicaid, the VA, the Indian Health Service, and, within employer-sponsored coverage, roughly a thousand insurance companies operating 350,000 different plans. The ACA added exchanges. Emanuel called that added complexity a mistake, though one with a politically understandable rationale: middle-class people were not going to be asked to enroll in Medicaid at a time when Medicaid had a poor reputation.

The core structural problem is administrative spending. Emanuel said the United States spends $5.6 trillion a year on health care, of which $1.25 trillion is administration. A hospital bill may cost about $215 to process for surgery, and a regular doctor visit about $30, he said; a credit card charge costs under a dollar, often pennies. Much of the difference, he argued, comes from a lack of standardization in health care billing and processing.

In response to an audience question, Emanuel clarified that he was not claiming $1.4 trillion in billing waste. He meant $1.25 trillion in administrative costs overall, with hundreds of billions in potential savings across billing and related processes. Coding and billing require large staffs; he said hospitals have almost two people assigned to coding and billing for each bed. The United States has thousands of codes, while Europe has about 400, he said. Each insurer uses different billing rules. Prior authorization adds another layer.

The solution, in his view, is standardization, digitization, and simplification — not as slogans, but as enforceable administrative reform. He acknowledged a failure of his own: the ACA included an “administrative simplification” provision that he helped put there. “I fucked up,” he said, because he did not assign responsibility to a specific official, set deadlines, allocate money, require reports, or create accountability. The government itself does not capture much of the savings from administrative simplification; insurers and providers do. That weakened the incentive to pursue it.

Emanuel’s current reform concept begins by leaving employer-sponsored insurance largely in place for the roughly 165 million Americans who have it. He criticized employers as having been “AWOL” and “idiotic” on cost management, saying they complain about prices but do not take the steps necessary to control costs. Still, many people like employer coverage, and employers see it as “golden handcuffs” for employees. Emanuel’s view is pragmatic: let employers keep doing what they do, while giving them a better alternative they can opt into if they choose.

The major change would be for everyone else — roughly 175 million people, including those on Medicare, Medicaid, exchanges, the uninsured, veterans, and others — to move into a consolidated system with six plans. One would be a public option, a modernized Medicare-like plan. The others would be managed care insurance alternatives. Employers could opt into the public option and subsidize premiums.

The reason to pool the non-employer population is leverage and signal clarity. Hospitals and doctors respond to payment incentives. In a fragmented system, no single signal is strong enough to change behavior. Pooling creates a large enough payment stream to align incentives. Emanuel called incentive alignment a “magic phrase,” and said the current diversity and fragmentation make it nearly impossible.

He also wants to reduce choice, not eliminate it. Drawing on behavioral economics, he argued that too much choice leads people to make worse and more irrational decisions, spend more, and become less satisfied. Six plans, in his view, are enough to preserve meaningful choice while avoiding the chaos of unlimited variation.

The plans would offer the same standardized comprehensive benefits, so people are not tricked by small irrelevant differences or harmed by hidden exclusions. Emanuel criticized Medicare’s current structure — separate hospital, outpatient physician, and drug benefits — as outdated for modern medicine. He would also keep people in their plan for five years. Annual churn from United to Aetna to a local Blue Cross Blue Shield plan creates administrative expense and undermines prevention. If an insurer invests in prevention today but the patient moves to another insurer next year, the investing insurer may not capture the benefit. A five-year enrollment period would give plans a stronger reason to invest in keeping people healthy.

His test for any comprehensive plan is demanding: it should guarantee universal coverage, improve quality, and remain affordable without raising health spending as a share of GDP. Emanuel said his plan would have roughly $14,000 per insured person available across all ages. By comparison, he said, Medicare currently spends about $16,000 per Medicare patient on average, even though Medicare patients are among the most intensive users of care. His conclusion is that universal coverage and affordability are possible at current spending levels if the system becomes simpler, more standardized, and more disciplined.

Céline Gounder raised a prior exchange between Emanuel and Brian Blase, a Trump health adviser, at a Penn LDI event. They agreed that hospitals are the number one driver of U.S. health system costs. Emanuel said that is not merely opinion: “It’s just a fact.”

He found the agreement notable because it suggests there are hospital-cost policies that people on the right and left can support. He also said there are drug-pricing policies with bipartisan potential. The agreement has limits. Emanuel said Blase is intensely focused on fraud in Medicaid and insurance exchanges, which Emanuel called “total bunk” as a major explanation. Any program has some fraud, he said, but the large fraud is not on the patient side. It is on the provider side or among large companies selling into the system.

Why, Gounder asked, is the public more focused on Big Pharma and perhaps pharmacy benefit managers than on big health systems? Emanuel’s answer was experiential and reputational. People feel drug costs at the pharmacy counter, through copays that can be outrageously high. Drug companies also make an obvious target because they are seen as rapacious and, in Emanuel’s words, making 25% returns and benefiting from special sweetheart deals.

Hospitals, by contrast, have long had an aura. People think of them as places that heal: you go in sick and come out better. Hospitals are also major employers in towns. Emanuel argued that this should not shield them. Hospitals exist to make people better, not to serve as employment programs. Some should be closed, he said, because some places are over-bedded while others are under-bedded.

Since 2000, Emanuel said, hospital prices have risen more than costs in other sectors, including physician salaries and university tuition. Hospitals have consolidated to gain bargaining power over insurers and extract higher payments that do not necessarily go to patients. The public, he said, is beginning to sour as debt collectors pursue patients for hospital bills.

The middlemen problem, in Emanuel’s account, is a direct consequence of fragmentation. Complexity creates opportunities to game the system. Someone can discover a billing trick, a rebate arrangement, or a fee structure and make billions. In health care, he said, nothing is in millions; it is always in billions. Reducing those opportunities requires simplifying and standardizing the system itself.

Emanuel’s answer to a health policy professional in the audience was that every major stakeholder will have to give something up, including patients. The political case for comprehensive reform, he said, is that most people would also get something more valuable back: universal coverage, more affordable care, and deductibles that function like insurance rather than, in his phrase, “some extortion racket.” Incremental reform cannot do that balancing, because the upsides and losses have to be visible together.

An audience member, age 92, challenged the group on dementia, describing the scale of the problem and asking why prevention is not more central. Ezekiel Emanuel answered by drawing a careful boundary. Dementia has a major genetic component, he said, and as of now there is no way to solve that. That component is not trivial.

There are, however, ways to postpone decline. A good education does not prevent dementia, he said; it pushes cognitive decline later. He said serious cognitive decline begins far earlier than many assume: fluid cognitive functioning peaks in the 30s or 40s and then declines slowly, though faster for some. Exercise helps. The four vaccines he named earlier help. Continuing to challenge oneself and adopt new things can help maintain or create neural connections.

But brain plasticity declines with age, except in rare outliers. Emanuel again used Benjamin Franklin as his model of exceptional aging. Franklin was 81 at the Constitutional Convention in 1787, and Emanuel said reports describe him as having the brain power of a 25-year-old: cognitively sharp and engaged. But that is precisely the point. Franklin was an outlier. Most people cannot build their expectations around becoming Franklin.

Emanuel’s caution was blunt: people can prevent some things, but they cannot currently prevent dementia. They can postpone cognitive decline and push it out by years. That is valuable, but it is not the same as a cure or prevention. Many people who eat well, exercise, and live healthy lives still develop dementia.

This boundary is central to his whole argument about longevity. The goal is not to promise control over aging. It is to identify actions that plausibly improve the odds of more healthy years, while resisting the fantasy that enough optimization can make people exceptions to biology.