With Mitt Romney’s recent victory here in the Illinois primary, it increasingly looks like the inventor of “RomneyCare” will square off against the creator of “ObamaCare” in the fall presidential election. And there’s little doubt that health care will be among the top issues discussed—given the ongoing rising costs faced by consumers and the GOP’s collective aversion to Obama’s health reform law. As I noted in my last blog, the debate over healthcare tends to slide into hyperbole and offer little in the way of insight (let alone appreciation of the underlying economic issues driving the debate in the first place).

During the HIMSS show, I spent one evening watching the Republican debate in Arizona—just a few weeks ago, the outcome of the Republican contest seemed uncertain. I recall Mitt Romney’s terse response to a question about containing health care costs. I’m paraphrasing now, but the former Massachusetts Governor said, essentially, we need to abandon Obama’s reform effort right away, a move which will save millions. The audience cheered wildly. Now I am not totally sold on the reform law’s ability to lower costs and drive quality—as I think the jury will be out a long time on it. Nor do I believe you can legislate your way out of the health care economic dilemma slowly engulfing our nation. But I don’t see how you can dismiss a law which has barely begun to take effect (and may be ultimately tossed out).

The GOP has an almost instinctive disdain for regulation—and it can play that card time and time again and undoubtedly draw cheers from its partisan base. What the anti-regulatory crowd conveniently forgets are the conditions that spawned the regulation in the first place. And in the health reform law, the condition was—and is—an industry beset with unsustainable cost inflation. Even if the law is tossed out by the Supreme Court on the premise that mandating the purchase of health insurance is unconstitutional, that pressing problem remains—as do the multitude of other “mandates” already resting squarely on the industry’s shoulders.

To his credit, Obama recognized the dire need for improved data sharing in a largely unconnected industry as a first step. Hence the “meaningful use” provisions of the HITECH Act. To date, I don’t recall anyone on the political stage challenging these emerging incentive payment regulations—even when the industry clamors for their simplification during the rules-making process. Supporting EHRs has been largely non-controversial.

The debate is just beginning however. And neither Obama nor Romney have a guaranteed audience when it comes to the topic of health care regulations—particularly those around the so-called “nanny state” of rules starting to emerge in response to obesity, other chronic diseases, and ill-advised health behaviors. According to a new Harris Interactive/HealthDay poll, most Americans remain ambivalent about the issue. They agree that policies that aim to protect public health and safety are sometimes necessary. At the same time, they believe that adults should take responsibility for their own actions, and consequences for health.

For example, Harris found that an overwhelming majority support a ban on texting while driving (91%), back mandatory vaccinations (86%), and favor banning smoking in public places (80%). But more than two-thirds said employers should not make hiring decisions based on nicotine consumption or weight. Even as they supported many individual initiatives aimed at protecting the public good, 81 percent of respondents agreed that individuals should take responsibility for their own actions and "be free to make their own decisions, even if they suffer as a result."

In other words, feel free to overeat, but be ready to bear the burden (so to speak). This notion strikes at the very heart of “accountable care,” which shifts compensation away from productivity to outcomes. It’s one of the key shifts underway now in federal health policy—and the private sector as well. I’ve had many a health care executive tell me that, while they concur that their delivery organizations should be on the hook for delivering better outcomes, they can’t accomplish this feat without the close participation of patients. And to that end, they’re feverishly building patient portals. Still they wonder: where is the accountability for the patient?

MU Stage 2 kicks the door wide open on this topic, with its proposed requirements around patient use of online information. The government is seeking feedback on its proposed requirement that at least 10 percent of patients view or download their health information maintained by a provider: “While this is a departure from most meaningful use measures, which are dependent solely on actions taken by the [provider], we believe that requiring a measurement of patient use ensures that the provider will promote the availability and active use of electronic health information by the patient or their authorized representatives. Furthermore, we believe that accountable care should extend to meaningful use objectives that encourage patient and family engagement.”

In other words, providers will be rewarded—if not penalized—for actions beyond their immediate control. And patients? Well, if you want to extend accountable care in a way to encourage their engagement, a portal is a great place to begin. Now, how about a premium reduction if they use it? What about an increase if they don’t?

If the Supreme Court tosses out the individual mandate, we could easily be facing a situation where consumers have little if any economic responsibility when it comes to financing their care. At the same time, unless the meaningful use provision is softened, health care providers will face a penalty if their patients don’t use the electronic tools at their disposal. The national ambivalence revealed in the Harris poll runs deep and wide.

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