IT may have been the most influential magazine article of the past decade. In June of 2009, the doctor and writer Atul Gawande published a piece in The New Yorker called “The Cost Conundrum,” which examined why the small border city of McAllen, Tex., was the most expensive place for health care in the United States. The article became mandatory reading in the White House. President Obama convened an Oval Office meeting to discuss its key finding that the high cost of health care in the country was directly tied to a system that rewarded the overuse of care. Five years later, the situation has changed. Where McAllen once illustrated the problem of American health care, the city is now showing us how the problem can be solved, largely because of the Affordable Care Act that Mr. Obama signed into law in 2010.
The problem was that doctors in McAllen were responding to reimbursement incentives in the American health care system that rewarded activity rather than value. The more procedures and visits a doctor billed, the more he got paid. The Affordable Care Act was designed to change that. One of its provisions created the Medicare Shared Savings Program, which rewards doctors for keeping their patients healthy. Participation in the program requires primary care doctors to create networks, called accountable care organizations, or A.C.O.s, to better coordinate patient care. These networks are reimbursed for delivering high-quality care below a baseline of historical Medicare costs. In 2012, doctors in McAllen formed the Rio Grande Valley Accountable Care Organization Health Providers, and signed up for this experiment. The early results are in, and they are stunning: From April 2012 to the end of 2013, the Rio Grande Valley A.C.O. saved more than $20 million from its Medicare baseline. These changes didn’t just save money; they also improved patients’ health. From 2012 to 2013, the number of patients achieving control of their diabetes rose 11.8 percentage points. The number receiving vaccinations rose 12.2 percentage points.
President Barack Obama holds the baby daughter of former staff members Darienne Page Rakestraw and London Rakestraw in the Ground Floor Corridor of the White House, July 1, 2014. (Official White House Photo by Pete Souza)
First Lady Michelle Obama hugs Braeden Mannering, the 2013 Kids’ State Dinner winner from Delaware, after he introduced her at the Kids’ State Dinner in the East Room of the White House, July 18, 2014. (Official White House Photo by Amanda Lucidon)
President Barack Obama greets audience members after he delivered remarks on the economy at the Georgetown Waterfront Park in Washington, D.C., July 1, 2014. (Official White House Photo by Pete Souza)
President Barack Obama and First Lady Michelle Obama talk with Ken Burns as part of an interview for a PBS documentary about Jackie Robinson, in the White House Library, July 3, 2014. (Official White House Photo by Lawrence Jackson)
President Barack Obama greets Airman First Class Karen Mae Manalo with other citizenship candidates in the Blue Room prior to a naturalization ceremony for active duty military, military dependents, reservists and veterans at the White House, July 4, 2014. (Official White House Photo by Pete Souza)
New behind-the-scenes photos from July, now posted on Flickr: bit.ly/1nNCmAs
President Barack Obama greets a young girl after he delivered remarks on the economy at Cheesman Park in Denver, Colo., July 9, 2014. (Official White House Photo by Pete Souza)
First Lady Michelle Obama discusses Millennium Development Goals with students during a visit to Global Kids, Inc. in New York, N.Y., July 10, 2014. (Official White House Photo by Amanda Lucidon)
President Barack Obama jokes with Mattina Falco, 19-year-old Make-A-Wish recipient from Worchester, Mass., as she sits at the Resolute Desk in the Oval Office, July 17, 2014. (Official White House Photo by Chuck Kennedy)
First Lady Michelle Obama and Jennifer Lopez pose for a selfie before the 85th Annual League of United Latin American Citizens (LULAC) National Convention and Exposition in New York, N.Y., July 10, 2014. (Official White House Photo by Amanda Lucidon)
Vice President Joe Biden talks with Chief of Staff Denis McDonough in the Oval Office, July 2, 2014. (Official White House Photo by Pete Souza)
President Barack Obama greets audience members after he delivers remarks on the economy at the Paramount Theatre in Austin, Texas, July 10, 2014. (Official White House Photo by Pete Souza)
President Barack Obama greets patrons at the Charcoal Pit restaurant in Wilmington, Del., July 17, 2014. (Official White House Photo by Pete Souza)
First Lady Michelle Obama joins the cast of Disney’s “The Lion King” onstage after their performance at the Kids’ State Dinner in the East Room of the White House, July 18, 2014. (Official White House Photo by Lawrence Jackson)
President Barack Obama greets patrons at Canter’s Delicatessen in Los Angeles, Calif., July 24, 2014. (Official White House Photo by Pete Souza)
President Barack Obama greets HUD staff following remarks at the Department of Housing and Urban Development in Washington, D.C., July 31, 2014. (Official White House Photo by Pete Souza)
President Barack Obama and Vice President Joe Biden share a laugh in the Oval Office July 21, 2014. (Official White House Photo by Pete Souza)
Consider the photographs above of events that happened this year less than six months apart? There is no comparison. That is the point. They all involve American citizens in protest over perceived affront to their rights. But can the people in those photographs be interchanged with the same outcomes? Can the Ferguson MO black residents stage their protest armed like the Bundy-ranch militias or the open-carry ammosexuals flaunting their AR-15s in stores in public? Would they be covered by the media with fawning deference as we saw during the standoff in Nevada or in the narratives spun about open-carry advocates?
Of course no. It is not hyperbole to say the streets there would already have been littered with many more black bodies being gunned down by platoons of SWAT teams pouring in to maintain “law and order.” They would not be retreating like the BLM and law enforcement did outside the Bundy ranch in Nevada in order to safeguard “public peace” and NOT escalating the potential for violence. The media would have whipped up the fear factor to the rafters, not the love-in we saw when the Bundy ranch militias had federal officials locked in their gunsights and bragged they were ready to “water the tree of liberty”.
Likewise, the language of inherent criminality being used now to describe Ferguson’s black residents’ protests would not be invoked in similar actions by white protestors. It is like clockwork, the types of thesauri with stock phrasing that get whipped out to describe public behavior of American citizens depending on their race and class. White Militias are “patriots” defending the “constitution”, not “lawbreakers, or thugs, or looters.” White youths’ public misbehavior and even serious felonies are given benefit of the doubt as “feisty pranks” or aberrant “lone wolves” or “mentally challenged” individuals.
Blacks and Latinos are described as criminals-in-the-making and bearers of regressive group cultural traits who should be “feared” and removed from civilized society. There is an insistence that their citizenship can only rest on approval of their morality, something that is not required of any other groups. The statistics from our criminal justice system glaringly show the disparities in who gets convicted for similar crimes and who gets slapped on the wrist.
Therein lies the dirty underbelly of American creed of “Freedom” and “justice”. It was always a lie, from the nation’s founding. But it was a powerful lie that sewed together a nation populated by peoples of disparate backgrounds ever re-making themselves anew with infinite optimism in this vast land. City on a Hill, it was. Even if built on the blood of shackled slaves. Frederick Douglass described this foundational hypocrisy so astutely in his famous speech “What to the Slave is the Fourth of July?”
Question is why the lie? Other societies don’t bother to broadcast “Freedom” for all. Don’t pretend to want equality for all. For a nation that prided itself on throwing off the yoke of calcified monarchies, and hewing to the creed — “all men are created equal”, why does this country keep insisting on universal “freedom”? I argue that “freedom” is a useful cover that keeps a tight lid on fissures cracking apart a deeply unequal society. It is a release valve in the same way that maintaining an underclass that can be scapegoated for society’s ills. That way we don’t have to deal with crushing class inequality.
And what the wielders of power bet on is that the eruptions be it in Ferguson or Nevada, will inure to their benefit. The Fearful buy more weapons, and disenfranchised minorities get slaughtered in the street, or fill profit-making private prisons!