'If the N.S.A. is Big Brother, We're Big Mother'

When President Obama said, ObamaCare is "not just a website," unfortunately he was right. The disastrous launch of the ObamaCare exchanges is only part of the transformation of the U.S. healthcare system that has been going on since 2009. One prominent example: the Center For Medicare And Medicaid Innovation was established by the Affordable Care Act (ACA) with an appropriation of "$10,000,000,000 for the activities initiated under this section for the period of fiscal years 2011 through 2019," or $1.1 billion per year for nine years.

The main thrust of the Innovation Center, which is under the umbrella of the Center for Medicare/Medicaid Services (CMS), is to move American health care from "fee-based service" to "value based healthcare" through the creation of what are known as Accountable Care Organizations, or ACOs.

This represents a big bet on an approach to medical care that might fail, and will certainly infringe on individual liberties.

The management consulting firm Oliver Wyman reports:

One of the most striking features of healthcare reform in the United States is the explosive growth of accountable care organizations (ACOs). ACOs take responsibility for the overall health of their patients -- not just treating their diseases -- and are paid based on their success in controlling costs.

According to Wyman, "25 to 31 million Americans already receive their care through ACOs," around 14% of Americans.

An example of the approach arrived in the mail this week from my doctor, who recently joined an ACO: a glossy pamphlet with DVD titled, "Is a PSA Test Right for You?" The material suggests gently that there's no reason to test for prostate cancer if you don't plan to treat it -- sensible advice, which coincidentally will benefit the ACO's bottom line.

Bill Keller, former editor of the New York Times, praises the new ACOs in a recent op-ed:

The accountable care organizations have become the Silicon Valley of preventive care, laboratories of invention driven by the entrepreneurial energy of start-ups...

Irony of ironies, the people who ought to be most vigorously applauding this success story are Republicans, because it is being done not by government decree but almost entirely with market incentives.

Keller is seriously confused here. It's not a free market when the "market incentives," both carrots and sticks, come from a behemoth government agency with expected outlays in 2014 of $936.6 billion.

Oliver Wyman elaborates:

ACOs have the advantage that the government is investing Medicare dollars to lure providers into making the switch...

With almost 50 percent of the nation's healthcare buying power, CMS is the only funding source with the regulatory authority and economic clout to change the game... Providers make the switch to participate in one of the Medicare programs, but then they eventually switch the rest of their patients over to an ACO model as well. Overall, there are only about 2.4 million Medicare patients covered through ACOs. But those same ACOs serve an additional 15 million non-Medicare patients. There's a real multiplier effect...

Wyman notes the high start-up costs for ACOs -- someone has to produce those PSA brochures and DVDs. He concludes: "We've seen a few organizations try to operate fee-for-service and value-based models side by side. It doesn't work in the long term. The two models are simply incompatible."

Many of our top health care providers are gambling that the ACO approach will improve care and save money. Once the ACA's transitional funding ends, however, it's not clear that how profitable the ACOs will be. Wyman (in a link provided by Keller!) describes the guidance from HHS as: "'Take our vague but promising idea for a rocket ship, build one, and fly it to the moon.' We'll see some crashes, but we really need that rocket."

Keller admits that "the reform of health care will produce some losers. Not all of the new organizations will make a go of it." He disingenuously describes this as free market "creative destruction." It's closer to the crony capitalism that gave us failures like Solyndra.

ACOs gamble that preventative measures will reduce major expenses that might bankrupt them. A 2009 study by the Robert Wood Johnson Foundation however concludes: "Given that so few preventive services save money and that these services are already in wide use, it is unlikely that prevention can reduce health care spending." The faith in government to mold human nature and create a "new man," who in this case eats well and takes his medication, has an unhappy history, and these efforts are likely to be thwarted byhuman weakness and the stubborn genetic reality of disease.

A second concern about the ACO model is the threat to individual freedom. Here's how Bill Keller describes these "Silicon Valleys of preventative care":

These organizations have invested heavily in information technology so they can crunch patient records to identify those most at risk, those who are overdue for checkups, those who have not been filling their prescriptions and presumably have not been taking their meds. They then deploy new medical SWAT teams -- including not just doctors but health coaches, care coordinators, nurse practitioners -- to intervene and encourage patients to live healthier lives.... patients with a history of congestive heart failure get a daily phone call from a nurse asking them to step on a scale and report their weight, the best early indicator of an impending emergency. The next stage, Grace Terrell, the president of Cornerstone, told me, will be to give these patients scales that automatically transmit their weight directly to the nurse. ("If the N.S.A. is Big Brother, we're Big Mother," Terrell says of the weight surveillance program.)

This passage is strikingly tone-deaf. Can Keller imagine that Americans will be reassured by the idea of Big Mother "crunching our records" and "deploy[ing] new medical SWAT teams" after we just witnessed our friendly Smokey the Bear National Park Service Police morph into the Gestapo?

Imagine how badly this could go wrong. Scales installed in your house monitored daily by subcontractors of the federal government? What's next: a breathalyzer that detects cheeseburger consumption? Tobacco smoke detectors? Cameras to monitor safe sex practices? We're not far from Big Brother's "telescreen" that watched every home in Orwell's 1984, and its proponents refer to it fondly as Big Mother?

And what if you don't follow the recommendations of Big Mother? Health experts can be wrong, and often change their recommendations. Will this be grounds for the IPAB death panels to refuse care? Or if I follow the recommendation to forego a PSA test, might this be used to deny treatment for prostate cancer? What if the money spent on accountability doesn't generate enough savings? Won't this necessarily lead to rationing care?

In a free society we're not "accountable" to the government for our health. The trade-off is that we can't demand that government take care of us when our irresponsible actions have consequences. Alcoholics don't have a Constitutional right to a liver transplant.

Accountable care inverts this relationship. Government taking care of us -- until the money runs out -- gives Big Mother the right to demand compliance with healthy living dictates from Kathleen Sebelius and Michelle Obama. When Big Mother tells you to eat your peas, you better listen up. 

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