President Barack Obama has nominated Donald Berwick, the founder of a Cambridge, Massachusetts-based think-tank, to head the Center for Medicare and Medicaid Services (CMS), America’s primary health care agency.
A leading Ivy League academic and technocrat, Berwick will have the opportunity to apply his sometimes-controversial ideas regarding rationing and the role of government in health care if confirmed for the powerful CMS position.
His nomination caps a lengthy vacancy in the leadership of the agency, which has remained unfilled since prior administrator Mark McClellan stepped down in late 2006.
‘Romantic’ About NHS
CMS provides health services to more than 98 million Americans and has a budget of approximately $800 billion. It is considered the world’s second largest insurance company after the United Kingdom’s National Health Service (NHS), for which Berwick served as a consultant under British Prime Minister Tony Blair.
In remarks at a speech celebrating an anniversary of the NHS in 2008, Berwick spoke openly about his belief in government-run health care and his strong support for the NHS system over American health care.
“I am romantic about the NHS; I love it. All I need to do to rediscover the romance is to look at health care in my own country,” Berwick said.
Berwick also detailed his opposition to consumer-focused solutions to health care problems, dismissing the “invisible hand of the market” as an “unaccountable system.”
“Any health care funding plan that is just, equitable, civilized, and humane must, must redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent health care is by definition redistributional,” Berwick said.
Favors Rationing, Single Payer
Berwick has attracted controversy as a strong supporter of single payer health care, particularly in an essay written with two colleagues and published in Health Affairs in 2008.
“With some risk, we note that the simplest way to establish many of these environmental conditions is a single-payer system,” Berwick and his colleagues wrote.
And in a 2009 interview on Comparative Effectiveness Research in Biotechnology Healthcare, Berwick focused on what he perceives as the benefits of the UK’s National Institute for Clinical Health and Excellence (NICE).
“NICE is extremely effective and a conscientious, valuable, and—importantly—knowledge-building system [which has] developed very good and very disciplined, scientifically grounded, policy-connected models for the evaluation of medical treatments from which we ought to learn,” Berwick said.
The interviewer pointed out, “Critics of CER have said that it will lead to the rationing of health care.”
Berwick responded, “We can make a sensible social decision and say, ‘Well, at this point, to have access to a particular additional benefit [new drug or treatment] is so expensive that our taxpayers have better use for those funds.’ The decision is not whether or not we will ration care—the decision is whether we will ration with our eyes open.”
Criticized by Senator
Sen. Pat Roberts (R-KS) has already become a public critic of Berwick, speaking on the Senate floor after Berwick’s nomination concerning his views on rationing and end of life care.
“The NHS utilizes an end-of-life pathway to death that many British doctors say leads to premature death in patients that could otherwise have recovered. Dr. Berwick’s ideas seem to mirror this death pathway,” Roberts said. “He has said that, ‘Most people who have serious pain do not need advanced methods; they just need the morphine and counseling that have been around for centuries.'”
Represents Administration’s Views
Dr. Robert Goldberg, cofounder of the Center for Medicine in the Public Interest in New York City, believes Berwick lacks the right credentials for the job of CMS administrator.
“I do not know if he is up to the job of administering not only Medicare but implementing many of the responsibilities the CMS director has: defining quality, conducting the studies,” Goldberg said. “There have been criticisms in the past about his work for the Institute, and whether the methods he used in assessing the quality of his pilot projects and whether those methods relied on very little scientific evidence to support the work that he has done.”
Dr. Scott Gottlieb, MD, a fellow at the American Enterprise Institute in Washington DC, said Berwick’s views are consistent with the Obama administration’s policy perspective.
“His views are widely shared in the administration, especially among the unelected appointees inside the Department of Health and Human Services who are calling significant shots on the regulations that implement the Obama plan,” Gottlieb said. “Dr. Berwick’s political mistake may have been candor.”
‘Ideology, Not Science’
Goldberg also expresses concerns about Berwick’s capacity to remain impartial given his past comments.
“The Medicare actuary anticipates significant revenue shortfalls under the new health care law. But that actuary would be reporting to the CMS Administrator, Dr. Berwick,” said Goldberg. “So what is [Berwick] going to do when these negative Medicare financial reports come? Is he going to stand up for his actuary and their reporting, or will he side with the Obama administration and fudge the data?
“Berwick makes these broad, provocative statements without evidence or scientific background, and unlike Dr. McClellan, who sought to evaluate fairly, Dr. Berwick has a specific agenda that is driven by ideology, not science,” Goldberg added. “It raises questions about President Obama’s campaign pledge to put transparency and science first.”
Roberts and others in the Senate are likely to raise questions about these statements in Berwick’s confirmation hearing, which has not yet been scheduled.
“Dr. Berwick is the perfect nominee for a president whose aim has always been to save money by rationing health care,” Roberts said.