Pigs will never grow wings no matter how advantageous it might be for them to learn to fly. This is because the Triassic ancestors of pigs were small and best at hiding, crawling and scurrying for cover in the underbrush. Meanwhile the lizards that would become dinosaurs and later birds were small but better at racing away from danger. One group got slinky and flexible and used all four legs. the other got rather stiff and tended to lift its forelegs off the ground. the rest is history.

Generally mammals do not fly, with the small exception of the bats. No matter how many pigs you drop off the barn you will not get one up in the air. Too much history of adaptation to ground life.

Which brings us back to health care. Because in our health care debates we have a similar kind of ahistorical argument being made. We need to cut medical costs - Wonks Anonymous will grant this - and the best way to do this is to open insurance markets to competition while putting pressure on consumers and businesses to spend less on health insurance and health care.

This is the essence of Senator Wyden's proposals. Tax insurance policies that the folks in Washington think are too expensive and, at the same time, let everyone shop for cheap private policies on insurance exchanges.

Insurance companies will produce cheaper policies. Individuals might pay more for health care but this will force them to take responsibility for keeping health costs in line. Meanwhile, somehow, insurance companies will also design innovative wellness programs and pioneer new compensation schemes for medical providers which will break away from the fee for service payment system.

Except that this is not what insurance companies know how to do. They take money from consumers and then try not to pay for medical care. The easiest way that they have to do this is to require that consumers pay most of their own medical bills. This requires no fundamentally new payment system or organization of medical care.

In fact any Accountable Care Organization that might exist in this environment would be forced to adapt to the industry standard - that would be fee for service medicine - in order to compete.

An Accountable Care Organization might reasonably offer complete medical care services to consumers for a flat fee but if, these services were at all complete, the organization could not offer a price comparable to the cost of a high deductible policy. The flat fee would have to cover average medical costs for everyone. The sellers of the deductible policy could deduct the first $5,000 or so from expenses because this would be paid by the consumer or health care providers.

The only way that an Accountable Care Organization could offer policies at deductible prices is if it were able to bill consumers for the first $5,000 of care.

Which would mean that it needed to adopt the whole mechanism of fee for service medicine. the thick codebooks and the professional coders, multiple charges for each part of the procedure and each professional consultation and the obsession with procedures and technical minutiae.

But after this change the Accountable Care Organization becomes just another flavor of fee for service medicine with lots of procedures and plenty of complex bills. This leaves consumers trying to make sense of medicine on their own with providers who make their money by selling treatments.

So Wonks Anonymous wants to know just why we are trying to reinforce a system that does not work.