During last Thursday's GOP presidential debate, Herman Cain told the audience that he'd be dead if Obamacare had been in effect when he was diagnosed with colon and liver cancer in the spring of 2006. Cain has often made this statement on the campaign trail, so the moderator asked him to elaborate. Cain answered by pointing out that "from March 2006 all the way to the end of 2006, for that number of months, I was able to get the necessary CT scans, go to the necessary doctors, get a second opinion, get chemotherapy… go to get surgery, recuperate from surgery, get more chemotherapy in a span of nine months." He went on to suggest that, under Obamacare and its bureaucratic red tape, his diagnosis and treatment would have unfolded far more slowly and that probably would have been fatal.
This provoked a predictable flood of fact-free derision from numerous progressive pundits. Steve Benen's response was typically snide: "What Cain is peddling is little more than 'death panel' garbage without the literal phrase." More surprising was the skepticism with which some critics of Obamacare responded. David Whelan at Forbes, for example, wrote that Cain was overstating his case: "ObamaCare's main feature is throwing money into the current system. There's very little change to how care is delivered." This is particularly naïve coming from a writer whose bio says he has "a job in hospital finance." A key feature of Obamacare is the Accountable Care Organization (ACO), and it will affect the delivery of care more profoundly than any development since Medicare introduced the Prospective Payment System (PPS).
For readers sensible enough to have avoided careers in health care finance, PPS is a price control scheme whereby Medicare began paying hospitals a fixed fee based on diagnosis rather than the patient's length of stay or cost of treatment. Within a decade of its implementation during the early 1980s, a tectonic shift occurred in the way care was delivered. Because PPS applied only to patients who spent at least one night in the hospital, it created a powerful incentive to treat patients on an outpatient basis whenever possible. And, as any health care economist would have predicted, the number of outpatient surgery procedures skyrocketed. As the New York Times reported a decade after the introduction of PPS, "The shift… to outpatient surgery accelerated in the 1980's, growing at a rate of more than 10 percent a year."
ACOs will affect patient care in an equally dramatic fashion. However, instead of merely shifting the setting of care, they will slow down the speed at which it is delivered. How? As with the PPS system, it's all about the incentives. The ostensible purpose of an ACO is to achieve high quality and efficient care by encouraging a group of hospitals, physicians, and other providers to work closely together on a particular population of patients. But, under the ACO rules proposed by Donald Berwick and his fellow bureaucrats at the Department of Health and Human Services (HHS), "quality" and "efficiency" will be measured in terms of money. "If the ACO is not successful it… is at risk of having to pay money back to CMS, and its participating providers may find that their own Medicare reimbursement is subject to recoupment by CMS."
Dr. Paul Hsieh, of Freedom and Individual Rights in Medicine, recently phrased it thus: "Under the ACO system, patients basically become cost centers for hospitals and doctors." In other words, a system purportedly designed to promote quality and efficiency actually creates disincentives that discourage physicians from pursuing those goals. As Hsieh goes on to ask, "If his patient has chest pain and needs to see a cardiologist, should the physician recommend the better but more-expensive expert across town -- or steer him towards the cheaper but not-quite-as-good cardiologist in the same ACO?" Obviously, this puts the physician in an awkward ethical position. Obama's HHS apparatchiks have fashioned a system that will sometimes force him to choose between his financial wellbeing and the health of the patient.
And if you're thinking you can avoid the clinical dithering and ethical ambiguity that will inevitably result from the incentives HHS has built into their system, think again. Another distinctive feature of Obamacare's ACO system is "blind assignment." Unless someone imposes some sanity on the proposed rules, it is entirely possible that you could be retroactively assigned to an ACO without even knowing it. This means, in theory at least, that your doctor could be prescribing care according financial imperatives of his ACO rather than your best interests. Will he hesitate to send you to a pricey specialist or think twice before sending you to the hospital for an expensive diagnostic test, like an MRI or a CT scan? Will your doctor temporize if your symptoms are ambiguous, as they often are for patients with colon cancer?
If Herman Cain's doctor had been beset by such concerns, and had succumbed to them, we would probably be referring to him as "the late CEO of Godfather's Pizza." The man's chances of surviving his colon cancer were, according to his physician, about 30 percent. As to the tumors on his liver, which she didn't know about until she saw the results of his CT scan, she broke it to him thus: "I'm not sure what I'm going to do about those until after I open you up." So, despite the snide remarks of DNC shills in the blogosphere, the skepticism of media "fact-checkers," and even the doubts of more serious critics of Obamacare, Cain was absolutely right when he said, "I'm here five years cancer free because I could do it on my timetable and not on a bureaucrat's timetable."
The good news is that the ACO rules proposed by Donald Berwick and his minions at CMS, like the bleak prognosis provided to Herman Cain in March of 2006, are not the final word. Obamacare has been metastasizing at a rapid pace, but it isn't too late to stop the disease in its tracks. If the voters are willing to endure a harsh course of therapy that will often leave us nauseated, tired, and depressed, the cancer can be eradicated from the body politic. And it may well be that the specialist we need to call in is Herman Cain himself.