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Photo: Garry Knight, CC-BY-2.0

Why neoliberals are pushing ‘Accountable Care’ worldwide


We’re constantly hearing from the media about the crisis in England’s National Health Service (NHS), but we rarely hear about the root cause of the problem – the process of creeping privatization.

Unlike the sell-off of British Telecom or British Rail, this privatization has been 30 years in the making. Politicians realize a visible, fast, wholesale sell-off would be political suicide.

This is a worldwide phenomenon, driven by capital rather than clinical need. Healthcare is a human right, but it is being trampled on by global capital’s ‘right’ to turn a profit

And so the current private sector strategy for gradually consolidating its grip on the NHS, assisted by the complicity of the government and NHS England, is the establishment of Accountable Care Organizations (ACOs) which are given responsibility for providing a defined package of health services to a list of patients. This is not just happening in England – this is a worldwide phenomenon, driven by capital rather than clinical need. Healthcare is a human right, but it is being trampled on by global capital’s ‘right’ to turn a profit.

ACOs are, at their heart, about restricting care through ‘demand management’. They are a model for limiting health care costs and extracting maximum profit. Currently, providers are largely paid per episode of treatment. ‘ACOs use per-head (‘capitated’) budgets which are likely to incentivize them to limit treatment, as providers can keep any profit made from keeping within budget.

ACOs originated in the US, and despite spending 17 per cent of GDP on healthcare (almost double that in the UK and much of Europe), millions in the US continue to go uninsured, even after Obama’s reforms. ‘Last-resort’ providers in the US such as Medicare frequently use the ACO model and still require co-payments – and insurers routinely deny clinically necessary treatments.

Simply put, ACOs risk damaging healthcare because the ‘accountability’ is ultimately to accountants, and not to patients’ clinical needs.

The Accountable Care Organization message is being spread on the global stage by such organizations as ‘Innovations in Healthcare’, which was founded by the World Economic Forum, management consultancy McKinsey and the US-based Duke Health, an offshoot of the private Duke University. Its Executive Director presented a paper on ACOs to the World Innovation Summit for Health (WISH) in 2016, detailing how ACOs are inserting themselves into widely divergent ‘markets’, from Germany to Singapore to Rwanda, with the assistance of global networks of ‘thought-leaders’ and ‘innovators’ with links to both governments and private healthcare.

No matter whether a country already has a universal, comprehensive system or is a middle or low-income economy where healthcare relies on some combination of insurance, out of pocket charging, charities, and NGOs – there’s an ACO to fit. The language used is carefully couched in terms of health goals, but a steady beat of driving down cost and ‘managing’ care pathways pulses throughout.

This model is part of a broader push by global organizations to make and remake health services along neoliberal lines. Stewart Player, co-author of privatization exposé The Plot Against the NHS, last year revealed how the NHS’s Five Year Forward View plan had been stage-managed to appear as if it had been written by front-line clinicians: it had in fact been drawn from two reports presented in Davos by the World Economic Forum, written with extensive help from McKinsey.

In these reports, global capital sets out the methods by which it can maximize the opportunities for transnational capital under the conditions of spiralling healthcare costs and fiscal pressures. Costs are to be kept low through using deskilled staff and telehealth technologies. Another way of keeping costs low are controversial ‘new models of care’ in which populations such as the frail elderly are cared for at home, leveraging maximum (unpaid) support from volunteers and family. ACOs embody these principles laid out at Davos.

A tangled web of subsidiaries, foundations and think-tanks is also tied up with the spread of ACOs. Ribera Salud, in Valencia, is 50 per cent owned by Centene, an established private sector player in American Medicare, and Centene UK are based in the offices of health think-tank The King’s Fund. Centene UK have been contracted to help develop Nottinghamshire’s nascent ACO, which also features in the WISH report.

Why this push to Accountable Care Organizations?

Low and middle income nations generally spend far less on healthcare as a percentage of GDP, making large sectoral growth possible.

Investors are only too happy to help nations meet the goals of the United Nations resolution on universal health coverage provided they can build a system that is attractive to private providers; one that maximizes profit margins and leaves the door open to top up insurance and co-payments – rather than a single provider, non-profit system like the NHS as originally founded. They are racing to do this in order to take advantage of the Trade in Services Agreement (TISA), a trade and investment agreement currently being negotiated by over 50 nations. If it is ratified, re-nationalizing public services will be legally impossible.

These factors make it imperative to act to oppose ACOs, TISA and the neoliberal health agenda now, before it is too late. Fortunately, battles are being won against ACOs. In Spain, Ribera Salud’s ACOs, which are highlighted in the WISH report, are being taken back into public management by the regional Partido Socialista/Podemos coalition in Valencia. This has happened in a context of escalating strikes and police charges of corruption against Ribera Salud.

Resistance to ACOs is also building in the UK. I am Chair of the campaigning organization ‘999 Call for the NHS’, and we are bringing a judicial review against Accountable Care Model contracts, challenging per-head capitated budgets. This is a rather dry legal point, but it goes to the heart of the matter of why ACOs are so potentially damaging.

In England’s deregulated system, with the Secretary of State’s responsibility to provide comprehensive healthcare removed, ‘per-head' budgets will result in restricted care – they impose a maximum spend. Private companies will also be able to both commission and provide services. Can’t access the treatment you need through your ‘NHS’ ACO? You’ll have to pay – or suffer.

The consequences of the spread of the private provision and organization of healthcare services in the name of ‘individual choice’ in the Global North and ‘development’ in the Global South stand to be devastating.

In the UK, life expectancies have failed to increase (some have described this as a fall in life expectancy) for the first time in 110 years, and public health academic Sir Michael Marmot has raised the possibility that this may be due to cuts in health and social care spending.

In England’s deregulated system, with the Secretary of State’s responsibility to provide comprehensive healthcare removed, ‘per-head' budgets will result in restricted care – they impose a maximum spend.

In the Global South, increased access to healthcare via extra spending on ACOs may initially increase life expectancies, but at the price of a system that locks nations into the principle of profit over people, limiting its potential to provide comprehensive healthcare. There is a better way. As developing nations foster universal health systems, it’s imperative that people stand up and say that a universal, comprehensive non-profit health service is a human right.

ACOs are about breaking up national health systems where they exist and preventing them from happening where they don’t. If you care about health as a human right, now is the time to join a group campaigning against privatization of health care, and against trade agreements such as TISA. Your health may depend on it.

You can find more information about the upcoming 999 Call for the NHS judicial review here.


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