ACE (Adverse Childhood Experience) Scores: Part of the “Pay for Success” Plan?

A red flag for me in Gavin Newsom’s “child-friendly” proposed budget was the $45 million he allocated to screen children and adults in Medi-Cal for ACEs. I’m writing this post to express serious reservations I have about the process of developing ACE (Adverse Early Childhood Experiences) scores for people. ACEs are getting tremendous media exposure of late. While I believe this to be a crucial pubic health concern, my fear is that ACE prevention and mitigation interventions will become vehicles for “innovative” finance and will expand profiling of vulnerable populations.

I want to make it clear from the outset that I acknowledge childhood trauma does result in long-term negative health consequences for individuals. I’ve seen it in my own family. I also recognize that systems of structural racism have inflicted stress and violence on communities of color and indigenous peoples for generations, resulting in high rates of chronic illness that make them attractive targets for “social impact” schemes. People have a basic human right to treatment and care, which should not be conditioned on surveillance and having data harvested to line the pockets of social impact investors.

What concerns me about ACEs is the “scoring.”

Why should a standardized rubric developed under the auspices of one of the largest managed healthcare systems, Kaiser Permanente, label clients and structure the way a doctor, therapist, social worker, or educator can care for them? How did this tool come to have such a far reach, and whose interests will it ultimately serve?

Is a reliance on “scores” an intentionally-constructed framework that allows providers to limit their scope to “fixing” individuals and families rather than advancing a more radical approach whereby systemic causes of community trauma, trauma rooted in our country’s deep racist history, can be acknowledged, holistically assessed, and begin to be ameliorated?

And finally, will this “scoring” system be used to transform the treatment of childhood trauma into a machine for “pay for success” data speculation?

I believe it will.

A September-October, 2017 article for Academic Pediatrics, “Financing Mechanisms for Reducing Adversity and Enhancing Resilience Through Primary Prevention,” shows why ACE interventions will be an extremely attractive investment option for predatory social entrepreneurs. The authors note interventions that “prevent or mitigate the effects of ACEs can have impact across multiple sectors including: behavioral health, general health, child welfare, and “future criminal justice.” Every sector represents potential profit for investors. It appears there’s a lot of money in trauma remediation.

The paper references work done by the Washington State Institute on Public Policy (WSIPP) in which sophisticated cost/benefit models were created that estimate future cost savings across sectors so that the savings can be used to repay investors. WSIPP is one of eight data labs, operating under the purview of the NYU Gov Lab. Among the policy recommendations presented in this paper were: 1) setting “a conceptual framework to understand and account for outcomes across a broad range of public and private investment” 2) “validating metrics to estimate society costs and benefits” 3) adopting integrated budgets that combine health and social welfare finance and 4) disseminating information about innovative policies and finance mechanisms like “pay for success.”

The bottom line is that investors see children who have been harmed as potential sources of vast quantities of “impact” data, since the damage inflicted upon them extends across so many domains. The fact that the harm is so pervasive is, sickeningly, what makes so profitable. Interoperable databases are key to the program. All the data must be pooled in data lakes to claim the future cost offsets that enable the profit taking. WSIPP and its counterparts have been key collaborators in developing a national data architecture upon which impact investment markets will be built. More details in my post “Interoperable Data To Fuel Human Capital Hedge Funds.”

The ACE scoring system was developed under the auspices of one of the largest managed healthcare systems in the country, Kaiser Permanente in the mid 1990s, though the research began a decade earlier. The organization’s roots were providing managed healthcare to construction and defense workers in the 1940s and transitioned to managed care, with an emphasis on preventative care, in the post-war decades. It now has over twelve million subscribers, making it one of the largest providers in the country and very influential in public health policy.

Not only is Kaiser Permanente a healthcare provider, it is also a social impact investor. In May 2018, Kaiser Permanente announced the creation of a $200 million fund for affordable housing. They intend to generate both financial and social returns. In some ways this is consistent with their long-standing focus on preventative care and social determinants of health, but we are entering a new age where an individual’s compliance with preventative health protocols can be compelled through the imposition of wearable monitoring technologies and varied fee structures.

To say that healthcare delivery and insurance coverage in the United States are highly dysfunctional would be understating the calamity so many face attempting to access needed care without bankrupting their families. We cannot assume current systems will advance the good of the people over the interests of those directing $200 million investment funds. That simply isn’t logical, especially not in the Bay Area where Kaiser Permanente is based.

Bernard Tyson, chairman and CEO of Kaiser Permanente, was named one of Time Magazine’s top 100 people for 2017 in the category of Titan. He was also tagged by Modern Healthcare as number two on a list of most the influential people in the field, recognized for disruption. He serves as chair of the Bay Area Council. Its board includes 160 people, many from the tech, finance, civic, and non-profit sectors who have direct interests in social impact investing. The council is a supporter of the Silicon Valley Community Foundation’s Center for Early Learning, which advances early childhood education and early literacy initiatives. Tyson also sits on the board of Salesforce, which has made investments in SocialSuite, a software dashboard program geared to provide metrics for government contracting and impact investors. SocialSuite partners with IXO Foundation, backer of Amply the social impact digital identity pre-k app being piloted in Cape Town, South Africa. Interactive map here.

Kaiser’s reach is international. In a climate of growing privatization, the UK National Health Service (NHS) has been in ongoing consultation with Kaiser Permanente to learn more about their managed care model. Initial connections were made around 2003, 2004. A 2010 article from BBC News described a three-day conference that was held to examine ways to make the NHS “more productive.” One of the key elements of the Kaiser Permanente program mentioned in the piece was the use of IT and remote monitoring to actively engage patients “managing in their day-to-day health.” The article noted that NHS expected to remain “in close contact” with Kaiser Permanente “to learn from their success.” Additional information on digital nudges in healthcare here.

After passage of the UK Health and Social Care Act of 2012, which advanced a market-based approach to healthcare, outsourcing services to private sector providers began to rise. According to a report from The King’s Fund, growth areas for outsourcing included community health and mental health services, both areas targeted for social impact investing by venture capitalist Sir Ronald Cohen and his cohort of hedge funders.

I correspond with a friend on the other side of the pond, and we’ve been comparing notes on pay for success contracting. In the UK the NHS (National Health Service) has begun to adopt “outcomes based contracting” and staggered payments to facilitate the outsourcing of a variety of services including mental health treatment. More information can be found in the report, “Better Outcomes, Better Value: The Evolution of Social Impact Bonds in the UK,” by Bridges Fund Management, Sir Ronald Cohen’s impact investing firm.

Social entrepreneurs have been putting the pieces in place to harvest profit from mental anguish caused by years of austerity and economic instability among large segments of the British population (cue Brexit). ARK (Absolute Return on Kids) is one of the most influential Academy chains (like charter schools) in the UK, funded by Paul Marshall who founded the Marshall Wace hedge fund. Several years back ARK developed an alt-cert training program for social workers called Frontline along the lines of Teach for America. They have been training harried, low-wage workers who are tasked with screening children and families and pushing them into portfolios of “impact” generating interventions to fuel the impact economy.

Such interventions are featured in the “Five Year Forward View for Mental Health” plan for Newham, a borough in East London with a sizable refugee population and high levels of poverty. In 2018, an agreement was made to deliver resilience training via headstart programs and parent academies and mental health services in schools and to young people in crisis. The services are financed through a social impact bond that requires clients be monitored for two years after they receive care in order to evaluate the “success” of the program. Treatment protocols include MST (Multi-Systemic Therapy for Juveniles). MST is a client of Steven Goldenberg of Caffeinated Capital who worked closely with Sir Ronald Cohen on developing social impact bonds while he served as Managing Director and Chief Counsel of Social Finance. This approach seems very much in keeping with the networks of services developed in Harlem Children’s Zone, which I wrote about here. Interactive map here.

The fiscal reasoning for the “pay for success” mental health outsourcing rests on research done by Sir Richard Layard, Director of the Centre for Economic Performance at the London School of Economics. Similar to James Heckman at the University of Chicago, Layard created an economic cost/benefit analysis that allowed the government to scale a vast expansion of mental health services through the NHS starting in 2006. By estimating the number of lost workdays associated with depression, anxiety, and addiction, the government was able to use the value of that labor as a cost off set to pay the impact investors.

As early as 2001, Layard developed the Wellbeing Programme at the Centre for Economic Performance where he sought to “establish happiness as a desirable and measurable goal of public policy in the UK and worldwide.” Early efforts included importing the Child Resilience Program that had been developed by Martin Seligman, Director of the Positive Psychology Center at the University of Pennsylvania. Of course Seligman and his collaborator Angela “grit” Duckworth were the ones who developed the “character framework” used by the emotionally brutal KIPP “no excuses” charter franchise.

The Wellbeing Programme’s most significant contribution was launching Improving Access to Psychological Therapy (IAPT). Under this program drop-in “Happiness Centres” were placed in low-income neighborhoods where Cognitive Behavioral Therapy (CBT) was offered, according to one Guardian article, as an “Ikea of the mind” where “the feel good factor was flat-packed for you to take home.” As cloud based computing began to take over the health-care industry, the pressure to digitize therapy grew more intense. In recent years the NHS’s National Institute for Health and Care Excellence (NICE) has been investigating “evidence-based” digital therapies, delivered online or by app for depression and anxiety. The claim is that these platforms make therapy more accessible, but they also generate vast amounts of data as all the online interactions are captured in digital transcripts. As with “personalized” online learning, this transformation aligns closely with the needs of the “what-works” “data-driven” service delivery model.

Another element that feeds into the social impact scheme is the growing practice of “social prescribing,” in which health professionals recommend patients pursue non-clinical services in community-based settings. The city of London is a big booster of the concept, aiming for every resident to have a social prescription by 2028. Such “prescriptions” are coordinated by community navigators. A recent example is a 1.7 million pound social impact bond to be implemented in Devon where a social prescribing service will be brought to scale to reduce dependency on health care. The SIB is one of 22 announced in 2018, financed through the “Life Chances Fund,” which is managed by The Big Lottery Fund on behalf of the UK Department of Digital, Media, Culture, and Sport. While the thought of coordinated services is appealing, its underlying financial structure means it can never truly serve the best interests of the clients. The goal is to track people in such a way that they will be denied future services. That is the model for impact investing-that public expenditures be redirected away from the public good.

In a 2013 discussion paper titled, “Mental Health: The New Frontier for Labor Economics,” Layard discusses the role mental health interventions play in national economic productivity. Layard chaired the World Economic Forum’s Council on Health and Wellbeing from 2010-2011, and during that time he, at the request of then Prime Minister David Cameron, developed a series of metrics of “national well-being and progress.” It is the framework Layard developed that will be used to scale financialized approaches to mental health treatment globally. To bring these programs to scale, services like tele-therapy and text therapy will be prioritized, because they deliver the data. Not coincidentally they also generate vast quantities of information about the mental health of populations that could be fed into machine learning systems to inform the decision making of governments, financiers, and multi-national corporations.

In the remainder of this post I will address digital “brain-training” mental health treatments that are being devised to sell app-ified “solutions” that supposedly develop “resiliency” and “executive function” in children identified as “slow,” “troubled,” or “delinquent.” Sounds a lot like what we see coming out of KIPP, doesn’t it? Of particular interest to the impact investors are children with high ACEs scores. When implemented with “fidelity,” the pitchmen for these software systems say their “evidence-based” interventions reduce addiction, unemployment, crime, and mental illness thereby relieving pressure on already burdened public services. I have a strong feeling Betsy DeVos’s financial interest in the discredited Neurocore, ADHD treatment protocol, had everything to do with planned growth in the digital “pay for success” brain-training market.

My UK colleague shared an experience attending a professional development program where supposedly “progressive” educators touted programs designed to “train” the brains and “enhance” the executive function of children with high ACEs scores. Remember the joint effort announced by the Gates Foundation and the Chan Zuckerberg Initiative to create an R&D program to improve executive function in children facing “adverse life situations?” If you don’t, it was all about “innovation” that could be scaled cheaply with demonstrated impact; see image below. Yes, this is about moving the data around on the dashboard for benefit of the hedge fund speculators.

If this sounding like a set up for a tech-driven social impact bonds, you’d be right! The school in question was Seven Sisters Primary School located in Tottenham, which according to a New York Times feature is one of London’s most diverse and deprived communities with a sizable immigrant population. The school has a “pastoral team” of ten staff members in addition to a handful of “Children’s Wellbeing Practitioners.” The online bio for the school’s health mentor notes that Seven Sisters is implementing two software behavior programs: My Cognition and Stronger Brains. See the screen shot below from the Stronger Brains website.

The company’s director, Wendy Haigh, trained at Harvard and Stanford and previously worked at the Benevolent Society where she advanced one of Australia’s first two social benefit bonds. She is deputy chair of the Capital Working Group of Impact Investing Australia.

Michael Merenzich is the research half of the pair. An emeritus professor of neuroscience at the University of San Francisco (UCSF), Merenzich started the company Scientific Learning whose flagship product is Fast ForWord, language and reading skills software used in schools across United States, Canada, and Australia. A 2011 meta-analyses of research on the program published in the Journal of Child Psychology, Psychiatry, and Allied Disciplines, indicated NO evidence that the program was “effective as a treatment.” He then went on to establish Posit Science that sells a cognitive training program called BrainHQ, which is being pushed via the 2019 Medicare Advantage Plan in twenty-four states. I imagine that’s a lucrative contract.

Merenzich maintains ties with UCSF, where there is considerable brain training neuroscience research underway. UCSF is home to Adam Gazzaley’s Neuroscape program, whose spin-off, Boston-based Akili, is in the process of developing a range of prescription video game therapies to treat ADHD, depression, and anxiety. The company slogan is “It’s time to play your medicine.” Seriously. Akili is backed by a dozen international companies, evenly split between pharmaceutical and tech-start up venture capital firms. For the past three years Gazzaley has been piloting executive function training games with Melina Uncapher in San Jose Schools. I’ve written about that project here and here.

MyCognition is another program being foisted on the young students of Seven Sisters Primary. The company’s website states the platform provides assessment, “tailored insights” and “coaching.” But the coaching program is actually a video game called Aquasnap that can be used either at home or to cognitively train entire schools on laptops or tablets. They claim that embedded in the video game are “training tasks” “calibrated” to each student based on a preliminary assessment. Completing the tasks supposedly improves attention, working memory, episodic memory, executive function and processing speed.

The website includes an extensive overview of data being collected via the platform and how it is shared, but I wonder for a school that serves a largely poor, immigrant community how many parents are informed of their rights regarding this data before their children are signed up for the program? I wonder if they have a right to refuse this gamified cognitive “training?” Right on the homepage it states that the app supports the following sectors: medical, military, education, sport, corporate, and consumer. Tell me why primary school children should have their personal data fed into ANY of these systems? The only reason is to fill data lakes whose contents can be used to fabricate profits for impact investors and profile children to groom them to submit to corporatized government and consumer culture.

Now, back to our side of the pond. The state of Tennessee recently launched a massive “Building Strong Brains” campaign to raise awareness around ACEs and child mental health. It built off a summit hosted in 2018 by the Tennessee Commission on Children and Youth. Note the language featured in the screenshot below. It was taken from a video documenting a display board from the conference: “What about it works?” “Evidence-based Practice,” and “Can you measure impact?” The commission hired Frameworks, the same organization that developed the Digital Media and Learning program for the MacArthur Foundation, to create a tool kit for this campaign. Included were trigger videos, reframing cards, talking points, and FAQs to help lobbyists “stay on message in the face of tough questions.”

Al Race from Harvard’s Center on the Developing Child presented, as did Donald Schwarz of the Robert Woods Johnson Foundation, a member of Living Cities. Harvard’s Center on the Developing Child launched in 2006. The initiative manages a “Frontiers of Innovation” research and development platform to improve “life outcomes” for children facing adversity. The focus is on science-based interventions addressing such topics as: toxic stress, brain architecture, resilience, and executive function. The center’s top tier of “investors” at $1 million + features a who’s who of tech and social impact investors: Bezos Family Foundation, Buffet Early Childhood Fund, Chan Zuckerberg Initiative (via their Silicon Valley Community Foundation Donor Advised Fund), Pritzker Children’s Initiative, Omidyar Network and the Annie E. Casey Foundation. Interactive map here.

Results for America, one of the major groups that lobbied for the adoption of Pay for Success enabling legislation, last summer identified Tennessee along with Colorado, Minnesota, Oregon, and Washington as states that were “leading the way with their data-driven and evidence-based examples. Former Governor Bill Haslam is featured as one of their “All Stars” along with Gina Raimondo, Jay Inslee, and John Hickenlooper. Tennessee has been on the leading edge of the so-called “community school” roll out. According to the Tennessee Communities in Schools website, their branch of the national network, came to the state during the 2012-13 school year and services 10,000+ students in Nashville and Memphis. The privatized wrap around services offered through the community school model will be used to fill the data lakes for the impact investors.

ACE scores are key part of Pay for Success infrastructure. Rather than getting the humane care they deserve, people who have experienced trauma will become targets for predatory mental health and brain-training interventions. The “treatments” offered will largely be digital, using online games and wearable technologies, that generate data to prove the programs “work.” Coordinated efforts are underway in the US, the UK, and Australia.

With the passage of Foundations for Evidence Based Policy Making Act some states are forging ahead with “What Works” “Moneyball for Government” initiatives to advance this investment program. We are seeing new legislation and budget appropriations for home visits and ACE screenings. I know of this happening in California, Tennessee, and Washington State. To create this market, the government needs baseline data, and they also have to set up data agreements and unique identifiers to track the children through the system. What can we do to ensure those who have experienced childhood trauma get the care they deserve and are not sucked into this awful machine of digital brain engineering? We absolutely must push back on the scoring system now, before the pay for success agreements are embedded into everything. I welcome your thoughts.

As an addendum I want to add a few items that have come to my attention via Twitter from folks in the UK who are reading this post. Thanks!

Research into use of machine learning in child social care by the What Works Centre. Source

Dartington Social Research Unit, Louise Morpeth’s 2016 presentation on working on Big Lottery funded social programs in Scotland. References involvement of Annie E. Casey foundation. Source