[Cross-posted at Corrente. -- lambert]
Let’s look at Obama’s two tech appointments. As it turns out, both are health care technocrats. Bloomberg:
Obama also named Aneesh Chopra, Virginia’s secretary of technology, as his chief technology officer to ”œhelp the country meet its goals from job creation, to reducing health care costs, to protecting the homeland.”
The good news on Chopra. TechPresident’s a little breathless:
A few quick observations about this choice. First, it looks like very good news for the transparency movement, as well as those of us looking for an open-minded leader willing to experiment with new forms of collaborative governance. For example, back in early 2007, under Chopra’s leadership, Virginia was one of the first states to move, with Google’s help, to make its state websites more searchable and thus more accessible to ordinary citizens. The state has also been in the forefront of efforts to create robust web services tracking the giant government stimulus spending package enacted by Obama, and as fed-watcher Christopher Dorobek points out, Chopra is well aware of and supportive of citizen-led watchdog efforts like Jerry Brito’s StimulusWatch.org. …
Under Chopra (and it must be mentioned, his boss Governor Tim Kaine), the state also launched a highly interactive website that collected more than 9000 suggestions from residents on how the stimulus monies might be spent. “Relative to calls and letters, it’s fairly safe to say this is probably a tenfold increase in civic participation by allowing people to click on a button, submit their ideas and engage with their governor,” Chopra told a local paper back in March.
I think Chopra’s got a big, big blind spot here, which I’ll get to in a moment. Now let’s look at Chopra on health care. Here’s a video (via The 463) of Chopra before the Congressional Internet Caucus conference in September 2008. The health care stuff starts at 24:00 minutes in:
Interestingly, Chopra begins with the story of his wife’s pregnancy where — as if he would have had to tell this story to any of us — “I had to fill out my insurance information three separate times.” For Chopra, as a good technocrat, the problem presents itself as one of interchange standards, and so if three insurance companies use one form, then problem solved! But why are there three insurance companies in the first place? (In other words, why not single payer, Medicare for all, or VA for all, for that matter?) Chopra’s technocratic mentalitÃ© dismisses that question tout court. Yet
Chopra had, as we saw above, the same technocratic blind spot in what he is pleased to call “civic participation.” Chopra seems to think that the appropriate metric for citizen engagement is a “ten-fold increase” in clicks — and for a technocrat, that’s not a wrong answer. However, for a citizen, that is the wrong answer: Citizens are at the institution’s site because they want to shove that institution in one direction or another; that is, to practice politics. If clicks were the right measure for effective citizen engagement, then marijuana would be legal today!
Here are my very rough notes (and if anyone want to improve on it, or find the complete transcript, please do):
[CHOPRA] “[A]t the heart of the matter we lack the basic data … [W]hat we want more than anything else, on a voluntary basis, is to create a platform much like the retailers have now [that tells us] … how do we access our health care system and let’s mine those actions to figure out how to intervene in a thoughtful way with patient permission. … [For example,] Someone on the data mining side could have known that my wife visited an OB-GYN, and had certain tests that were highly correlated with her being pregnant [so the system could tell her] “We think you might be pregnant, so you might want to look into this program.” Targeted, data-driven intervention is something that we lack today1.”
Chopra seems to regard the experience and business models of the retail industry as transferable to the health care sector. That may be appropriate, but I’d like some evidence to that effect. (Do people really shop for health care? Should they? Probably not.) Chopra seems to imagine that if only the medical system had the equivalent of retail’s loyalty card, they could market all kinds of keen stuff — sit down, Big Pharma, I know you’re excited, but let the nice man finish his talk! — to health care, er, consumers.
Blinder and blinder. Chopra talks a good game about the program being voluntary (like “opt in” for retail, I imagine), and about privacy (an implementation detail). But again, let’s supply the institutional context he conveniently omits: Can anyone imagine that employers won’t make opting into the program a condition of getting insurance? Can anyone imagine that insurance companies won’t? And the same deal for privacy, too. Let’s pick a less blubby example than Chopra did: Imagine you go to a treatment program, and then, a couple of days later, you’re in your cube and the following message appears in Outlook: “We think you might be
pregnant an alchoholic, so you might want to look into this program cancel your Cialis perscription.” Followed closely by a message from HR… So, due to institutional factors Chopra, because of his mindset, cannot address, there’s probably plenty of medical data that people will not wish to allow to be data-mined, and they’ll to what’s necessary to make sure it doesn’t. That means that as medical data, Chopra’s terabytes will end up being horribly skewed, although from a marketing or business model perspective, that may not matter.
I agree with Chopra that “targeted, data-driven intervention is something that we lack today,” but whether that’s a blessing or a curse depends on institutional factors that Chopra cannot see.
Obama’s Chief Performance Office also has a health “care” focus:
As part of that effort, Obama said he was appointing Jeffrey Zients, former chairman and chief executive officer of the Advisory Board Co., a consulting and research firm, as his chief performance officer. Zients will help ”œstreamline processes, cut costs, and find best practices throughout our government,” Obama said.
[Jeffrey] Zients, who specialized in advising health-care companies on business practices, is Obama’s second choice for the chief performance officer job, which is new with his administration. Nancy Killefer, a director at management-consulting firm McKinsey & Co., withdrew her name from consideration Feb. 3, citing a personal tax issue.
Here’s The Advisory Board Company.2They have health care offerings (again, Zients’ area). One of their clients is California HealthCare Foundation, whose online news “digest” (see below) is “a service of The Advisory Board Company.”3 Fortunately, we have PNHP for the back story:
Understanding the origin of California HealthCare Foundation (CHCF) is important. During the decades that Blue Cross of California was a non-profit entity, it received favorable tax treatment not available to for-profit insurers. When Blue Cross of California converted to a for-profit entity, becoming a subsidiary of WellPoint, it was decided that the accrued value of the tax subsidy should not be granted gratis to the new shareholders of WellPoint, but should utilized for the benefit of Californians since this vested interest rightfully belonged to them. It was decided that this could be accomplished by establishing the California HealthCare Foundation and the California Endowment. The funds would then be used to improve the health care system in California, benefiting the underserved, and, in fact, benefiting all Californians by “improving the delivery and financing systems.”
Mark D. Smith, MD, MPH, President and Chief Executive Officer of California HealthCare Foundation, has infused foundation funds into research and reports on health plans, managed care, insurance markets, MediCal and other aspects of our current system. But he has often expressed his view that a single, universal health insurance program is not an option for reform. In spite of the California Health Care Options Project study that demonstrated that single payer reform could provide affordable, comprehensive coverage for all Californians (a goal of CHCF), he seems to continue to exclude that option from CHCF activities.
Yesterday we saw an interesting example of this apparent bias. The Kaiser Daily Health Policy Report sends out summaries of important policy issues, published by The Advisory Board Company. One item yesterday included reference to a New York Times article on employers’ concerns about health care costs, along with reference to the USA Today editorial debate on two views of controlling health care costs. It ended with my comment that we need to throw out the wasteful, ineffective health plans and spend the money on patients instead.
The items of national interest are often repeated in their entirety in California Healthline, a similar publication of the California HealthCare foundation, also published by The Advisory Board Company. The article above was no exception except for one remarkable difference [What's remarkable about it?]. The New York Times segment was carried, but the USA Today segment on controlling costs by replacing health plans with a public program was deleted and another USA Today story on reducing costs by exercising and eating well was substituted. Is it not unreasonable to ask what happened? Why was a statement highly unfavorable for health insurers such as Blue Cross deleted?
Gosh, I can’t imagine. Nice site, though. It really looks real!
Versailles always presents single payer as an experiment, as opposed to the “uniquely American” approach that is pragmatic, and based on what works. In fact, single payer is well proven in many other countries, and it’s a program — Obama’s innocously named “Electronic Medical Records” — of “targeted, data-driven intervention” in the process of medical care that’s the experiment. I would also add that scaling this approach to the entire country is an experiment — and a social experiment performed on the populace without their informed consent, which is about as unethical an act as can be performed in medicine.
We’re dealing with the ruling Money Democrat faction, here, so these are their priorities as I see them, suitably Rahm-ized:
0. Keep single payer off the fucking table.
1. Don’t fuck with the bond market; the investors who put their money into health insurance companies or Big Pharma have the right of first refusal for any “reform.”
2. Don’t fuck with the insurance companies. Leave their money flows in place, because some of that comes to the Party, but rationalize their cost structures — at public expense — with new IT. Insurance companies have refusal rights after the bond market.
3. Do reward IT, and in particular Google. Not only have they heavily backed the Party, a lot of “creative” [cough] “class” backers work there, whether delivering services over the web, or in what remains of the finance and insurance industries.
4. Do reward think tanks, lobbyists, pollsters, consultants, and marketers. The health care system is not about delivering health care to patients; the health care market is about delivering a product to consumers. We don’t want the simplicity of single payer; we want complexity we can collect fees for untangling. Remember: It’s all about designing a choice environment!
5. And do re-read Nudge.
1 Classy! The small caps remind me of the Obama campaign’s excellent design treatments.
3 And suppose we merged all the terabytes of medical data with all the NSA email and phone data we’re collected because Obama voted to gut the Fourth Amendment with FISA [cough] Reform! Just imagine the limitless possibilities!