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Cross-posted from Critical Condition on National Review Online.
There is widespread agreement that, in America, we don’t do enough to consider the consequences of modern medical miracles. Medicare pays for anything and everything: so the elderly have an incentive to seek aggressive treatment for diseases that weren’t even treatable a decade ago. The “unintended” consequence of this conundrum is exploding Medicare costs, costs that may literally wreck this country.
The Left’s solution is rationing: the government should determine when individuals are seeking care they don’t need, and prevent them from obtaining it. The Right’s solution is privatization: let individuals pay for the care they want, even if that means that some people are able to afford more care than others.
There are a lot of policy arguments to be made against rationing and in favor of privatization: for one, health care expenditures in socialized systems are increasing at rates that are equal to, or even higher, than those in the United States. But the reason why “death panels” have aroused so much passion is because they touch on something more personal and more ethical.
The news item is this: The Centers for Medicare and Medicaid Services, under the leadership of controversial recess appointment Donald Berwick, are set to enact a rule in which Medicare will reimburse doctors for end-of-life planning during the doctor’s initial interview of a patient. (Medicare calls these interviews IPPEs.) The rule was buried on page 74,306 of the Federal Register, Volume 75, Number 228, on November 29 (re-formatted and hyperlinked for clarity):Comment: We received a number of comments from physicians, health care providers, and others urging us to add voluntary advance care planning as an element to the definitions of both the “first annual wellness visit” and the “subsequent annual wellness visit.” They base their recommendation upon a number of recent research studies, and the inclusion by statute of a similar element in the existing initial preventive physical examination (IPPE) benefit.
One commenter noted that “the new wellness visit was wisely designed to build on the initial preventive physical exam, providing an ongoing, systematic focus on wellness and prevention by harmonizing Medicare services into a coordinated benefit.” Another commenter stated that “the AWV provides an appropriate setting for providers to initiate voluntary conversations about future care wishes, as they counsel beneficiaries on other aspects of their health and achieving their personal health goals.” The commenter added that the “care plans discussed in the ‘Welcome to Medicare visit’ should not be frozen in time, but revisited as an important component of patient wellness.”
Response: We agree that voluntary advance care planning should be added as an element of the definitions of both the “first annual wellness visit” and the “subsequent annual wellness visit” based on the evidence described below, and the inclusion of a similar element in the IPPE benefit (also referred to as the Welcome to Medicare visit), since January 1, 2009. We believe that this will help the physician to better align the personal prevention plan services with the patient’s personal priorities and goals.
Recently, Detering and colleagues (British Medical Journal 2010; 340:c1345) reported that “advance care planning improves end of life care and patient and family satisfaction and reduces stress, anxiety, and depression in surviving relatives.” Silveira and colleagues (New England Journal of Medicine 2010; 362:1211-8) reported that “data suggest that most elderly patients would welcome these discussions.” Lastly, a study by Fischer and colleagues (Journal of the American Geriatric Society 2010; 58:400-401) found “no evidence that these (advance directive) discussions or completing an advance directive lead to harm.”
Based on the available evidence and other relevant information, we are adding to the final regulation a definition of the term “voluntary advance care planning” to read as follows:
“Voluntary advance care planning” means, for purposes of this section, verbal or written information regarding the following areas:- An individual’s ability to prepare an advance directive in the case where an injury or illness causes the individual to be unable to make health care decisions.
- Whether or not the physician is willing to follow the individual’s wishes as expressed in an advance directive.
This definition is based on the definition of “end-of-life planning”, which is included as an element of the IPPE as described in section 1861(ww)(3) of the Act. Thus, the addition of “voluntary advance care planning” to the AWVs extends to those visits a similar element to the one already in the one-time IPPE.
We are also revising the definitions of the terms “First annual wellness visit” and “Subsequent annual wellness visit” by inserting a new element (ix) to the definition of the term “first annual wellness visit” and a new element (vii) to the definition of the term “subsequent annual wellness visit” in Sec. 410.15 (a) of the final regulation text that would read as follows: “Voluntary advance care planning as that term is defined in this section upon agreement with the individual.”
Donald Berwick’s nomination to head CMS was controversial precisely because he is a passionate advocate of the British system, in which there are indeed death panels that prevent patients from receiving life-extending therapies for cancer, blindness, and other conditions. In his commentary above, Berwick cleverly cites several academic studies that show that end-of-life planning is a good thing: that it’s good for individuals and families to think ahead about what kind of care they want, in situations where they might only be able to live with the assistance of machines.
Yet there is no disagreement about the value of end-of-life planning. Where there is disagreement is as to the propriety of state involvement in the plan.
Earlier this year, I wrote a lengthy piece describing the concerns that many Americans have with state-sponsored end-of-life planning: concerns that Atul Gawande and others have dismissed as “demagogic.” The problem is, when the state pays for your health care, the state has an incentive to avoid paying for end-of-life care. When the government pays for end-of-life planning, it has a conflict of interest, because it has every incentive to encourage the elderly to “pull the plug” instead of encouraging them to fight to stay alive. This is why Britain has the system it has.
When Sarah Palin spoke out against death panels in August 2009, she wasn’t specifically referring to state-sponsored end-of-life planning. Nonetheless, the resulting furor caused House Democrats to pull Section 1233 of their health care bill, which would have allowed Medicare to reimburse physicians for conducting end-of-life conversations. “See?” said various Democrats. “We aren’t allowing the government to meddle in end-of-life care. Conservatives are just being paranoid.”
Unfortunately, while Obamacare did not explicitly grant Medicare the ability to fund end-of-life planning, it did transfer massive amounts of power to the Department of Health and Human Services, and under HHS, the Centers for Medicare and Medicaid Services (CMS). Donald Berwick, the CMS head, has wasted little time in using his powers to full effect. According to a Robert Pear article in the New York Times, advocates of the Berwick approach are keeping a low profile:Congressional supporters of the new policy, though pleased, have kept quiet. They fear provoking another furor like the one in 2009 when Republicans seized on the idea of end-of-life counseling to argue that the Democrats’ bill would allow the government to cut off care for the critically ill…
While the new law does not mention advance care planning, the Obama administration has been able to achieve its policy goal through the regulation-writing process, a strategy that could become more prevalent in the next two years as the president deals with a strengthened Republican opposition in Congress.
Rep. Earl Blumenauer (D., Ore.), the author of the original House legislation around state-sponsored end-of-life planning, was quite pleased with Berwick’s insertion:After learning of the administration’s decision, Mr. Blumenauer’s office celebrated “a quiet victory,” but urged supporters not to crow about it.
“While we are very happy with the result, we won’t be shouting it from the rooftops because we aren’t out of the woods yet,” Mr. Blumenauer’s office said in an e-mail in early November to people working with him on the issue. “This regulation could be modified or reversed, especially if Republican leaders try to use this small provision to perpetuate the ‘death panel’ myth.”
Moreover, the e-mail said: “We would ask that you not broadcast this accomplishment out to any of your lists, even if they are ‘supporters’ — e-mails can too easily be forwarded.”
The e-mail continued: “Thus far, it seems that no press or blogs have discovered it, but we will be keeping a close watch and may be calling on you if we need a rapid, targeted response. The longer this goes unnoticed, the better our chances of keeping it.”
Consider it noticed.
Cross-posted from Critical Condition on National Review Online.
This is the kind of math that requires three Harvard degrees to understand. Donald Berwick, head of the Centers for Medicare and Medicaid Services, is going to spend $10 billion on “Medicare innovation” over the next ten years…to save $1.3 billion. From the Boston Globe (h/t InsureBlog):Berwick is using a tool that Congress included in the new health care law: an innovation center with $10 billion to spend over the next decade in a quest for the best ways of improving care and reducing costs.
The launch of the test sites by the end of 2011 is just a first step in changing the fundamental ways the government pays physicians and hospitals. Over 10 years, the innovation center’s work is expected to save $1.3 billion on the $500 billion annual budget of the Centers for Medicare and Medicaid Services, the sprawling federal insurance bureaucracy Berwick now leads. Health care policy advocates had sought far more aggressive cost-control measures.
Berwick’s defenders argue that this $1.3 billion estimate is pessimistic, and/or that it is merely the short-term savings that Berwick will engineer, and that his ideas will save tens, if not hundreds, of billions of dollars in ensuing decades. There is little if no reason to believe this will be so. The history of Medicare is full of attempts to control costs by dancing around the periphery of the program, and none of these attempts has worked.
The core problem of Medicare is that retirees have no incentive to think about cost or value when they obtain medical services. Nothing in Obamacare, and nothing that Berwick envisions, will do anything to change that.
Cross-posted from Critical Condition on National Review Online.
Liberals find it odd, and perhaps slightly irrational, that Americans so heavily criticize the British National Health Service. This has been of particular relevance in light of Donald Berwick’s “love affair” with the agency.
The Conservative Prime Minister of the United Kingdom, after all, often talks “of how proud we in Britain are of the NHS.” Just as with Medicare in the U.S., British politicians who talk of dismantling the NHS get hammered in the polls. (Despite Her Majesty’s Government’s surprise announcement this week of incremental market-oriented reforms to the program, the Tories under David Cameron have repeatedly pledged to preserve its funding.)
But describing the NHS as “popular” with British voters is a bit like describing cocaine as “popular” with crack addicts. Once people become dependent on heavy state subsidies, it is natural for them to feel insecure at the thought of losing them. Tocqueville long ago articulated how this problem inevitably arises from majoritarian democracies. And people who live under a single-payer regime have no way, short of moving abroad, of appreciating that there are better alternatives.
Having said that, Britons are frustrated by the indifference and inhumanity of the National Health Service. Its problems are covered widely in the British press. Here are some examples (and readers are welcome to provide others):
- NHS doctors routinely conceal from patients information about innovative new therapies that the NHS doesn’t pay for, so as to not “distress, upset or confuse” them.
- Terminally ill patients are incorrectly classified as “close to death” so as to allow the withdrawal of expensive life support.
- NHS expert guidelines on the management of high cholesterol are intentionally out-of-date, putting patients at serious risk, in order to save money.
- When the government approved an innovative new treatment for elderly blindness, the NHS initially decided to reimburse for the treatment only after patients were already blind in one eye—using the logic that a person blind in one eye can still see, and is therefore not that badly off.
- While most NHS patients expect to wait five months for a hip operation or knee surgery, leaving them immobile and disabled in the meantime, the actual waiting times are even worse: 11 months for hips and 12 months for knees. (This compares to a wait of 3 to 4 weeks for such procedures in the United States.)
- One in four Britons with cancer is denied treatment with the latest drugs proven to extend life.
- Those who seek to pay for such drugs on their own are expelled from the NHS system, for making the government look bad, and are forced to pay for the entirety of their own care for the rest of their lives.
- Britons diagnosed with cancer or heart attacks are more likely to die, and more quickly, than those of most other developed nations. Britain’s survival rates for these diseases are “little better than [those] of former Communist countries.”
These problems are not an accidental side effect of socialized medicine—they are inherent to socialized medicine. Liberals who believe that technocratic experts can rationally allocate health care resources ignore the real-world examples, like Britain’s, of how that model fails in practice.
The American health care system has its flaws, and real reform is urgently needed. But the reason why Obamacare is so unpopular is that most people would never trade our approach, warts and all, for that of Donald Berwick’s NHS.
Cross-posted from Critical Condition on National Review Online.
Jonathan Cohn of The New Republic, in a post entitled “Obama (and Cohn) Wrong on Berwick,” appears to have been persuaded by Tevi Troy’s argument that Berwick would have benefited from a full hearing:Several of my readers, particularly conservative ones, wrote back to say they disagreed. Among them was Tevi Troy, a former deputy secretary at HHS who is now a visiting senior fellow at the Hudson Institute. I always take Tevi’s arguments seriously and advise readers to do the same.
Cohn goes on to cite Troy’s correspondence:I am also not averse to recess appointments in cases where the Senate is clearly dragging its feet or tripping someone up via rotating anonymous holds. In this case, however, I think the White House was unfair to both Berwick and CMS by recess appointing him before he could have a hearing.
Being a confirmed appointee really makes a difference at the agencies, and it is worth taking some political hits to give your nominees that important blessing.
There is another reason for thoughtful (and philosophically consistent) liberals to oppose Berwick’s recess appointment: There won’t always be a Democrat in the White House.
UPDATE: Ezra Klein disagrees.
In which we discuss the “four P’s” of healthcare policy.
On Friday, I spoke with Ben Domenech, Managing Editor of the Heartland Institute’s Health Care News, about President Obama’s controversial usage of the recess appointment procedure to install Donald Berwick atop the Centers for Medicare and Medicaid Services (CMS). I believe I was the first person to raise questions about Berwick’s nomination in a major journal, and you can review my extensive coverage of his nomination and appointment on this website. Here is the full audio of my 18-minute conversation with Domenech (performance by browser may vary):
The Heartland Institute’s health care subsidiary, Consumers for Health Care Choices, does a nice weekly podcast on health care policy, to which you can subscribe via iTunes.
Because it's that important.
I realize that this is my third post on Donald Berwick today. This time, I share with you the best of the day’s commentary on this issue—because anyone who is interested in health care policy needs to learn as much as possible about Berwick and the future of Medicare and Medicaid.
Ben Domenech of the New Ledger, who has been following the Berwick controversy from the beginning, does a nice job summarizing the early reaction to Berwick’s recess appointment (replete with videos of his controversial speech to the British National Health Service). He adds in a follow-up post that the recess appointment allows Berwick to avoid standard disclosures about who his financial backers are.
Tevi Troy, a deputy secretary of Health and Human Services in the Bush administration, gives a nice insider’s take as to why the CMS Administrator is important, and why he is disappointed by the President’s maneuver. In a similar vein, Keith Hennessey goes through the inside baseball of Senate confirmation hearings, and explains why the Berwick recess appointment was so unusual.
Joe Rago of the Wall Street Journal gets past the sound bites and digs into the real problem with the Berwick appointment: his affection for centrally planned health care systems, and the fundamental flaws of that approach.
The progressive end of the blogosphere is puzzled as to why conservatives are so exercised about Berwick’s fondness for the British National Health Service. Conn Carroll of the Heritage Foundation cites one of NHS’ cruelest features: if the NHS denies you an expensive drug, and you try to pay for it yourself, the NHS bans you from future NHS support, driving you into bankruptcy or death. This is the same NHS to which Dr. Berwick professes a “love affair.”
Cross-posted from The Agenda on National Review Online.
Washington Post blogger Ezra Klein wonders why conservatives are opposed to the appointment of Donald Berwick to head the Centers for Medicare and Medicaid Services (CMS):Conservatives are making a serious mistake by forcing the administration to rely on a recess appointment for Berwick. Ultimately, what weakens Berwick weakens them, as Berwick, whether they know it or not, is one of the best friends they could have in the administration. That’s because insofar as Berwick is a radical, he’s a radical in favor of a patient-centered health-care system — a position that has traditionally been associated with conservatives, not liberals.
This has escaped notice because political activists don’t pay much attention to questions of delivery-system reform.
I agree with Klein that Berwick and conservatives have some areas of common ground. Here is what I wrote about Berwick in April:While [Berwick] was a big supporter of Obamacare, [he] acknowledges its core failing; in an October lecture, he said, “Health-care reform without attention to the nature and nurture of health care as a system is doomed. It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is, care as our patients, their families, and their communities experience it.” Indeed, if you put Berwick in a room with a leading market-oriented health-care analyst, the two would find broad areas of agreement as to where our health-care system fails patients.
But they would diverge on the most important questions of all: can, and should, the state provide quality health care for all? Can enlightened, public-minded experts effectively manage one-sixth of the U.S. economy?
It is possible for conservatives and liberals to find agreement on certain aspects of health care: for example, the use of checklists in reducing surgical errors and hospital-borne infections. Such questions are ideologically neutral, and Berwick has spent a great deal of productive time considering these kinds of questions.
Where conservatives take issue with Berwick is in his sweeping confidence in the ability of politicians and technocrats to manage something as complex as our health care system. They also take issue with the idea that NHS-style bureaucrats should decide what treatments are appropriate for them. (To give one of many troubling examples, NHS initially refused to pay for a blindness drug until patients were already blind in one eye.)
Klein is right to point out that Berwick acknowledges some of the flaws of Britain’s approach in his speech to the NHS. But Berwick’s criticisms miss the point: poor quality is the inevitable consequence of the NHS approach. And that is where Berwick goes tragically wrong.
Cross-posted from Critical Condition on National Review Online.
Yesterday, White House Communications Director Dan Pfeiffer announced that President Obama will take advantage of Congress’ brief Fourth of July break to make a recess appointment of Donald Berwick as Administrator of the Centers for Medicare and Medicaid Services (CMS). Pfeiffer’s defense of this extraordinary action—that Republicans “were going to stall the nomination as long as they could, solely to score political points”—is laughable. Let me count the ways:
1. Using a recess appointment to avoid a Congressional hearing? Presidents Bush and Clinton used recess appointments, over the complaints of the opposition, to appoint nominees who were actually being stalled, by filibusters or Senate holds. No one was stalling Berwick’s nomination; instead, Senators were looking forward to airing out his views in a public setting. If Bush had done something like this (Democrats refused to confirm Bush's CMS nominee from 2006-2009), we can be certain that many people would be up in arms.
2. We are not talking about some mid-level government functionary. The government funds half of all U.S. health expenditures—over $1 trillion. Hence, the policies of CMS affect the provision of health care for every American. Medicare and Medicaid dump costs onto individuals with private insurance; they subsidize certain types of procedures over others; they enact health-care standards that affect how all doctors must practice medicine. In addition, Berwick will be responsible for implementing most of the new provisions of Obamacare, including the $500 billion cut in Medicare Advantage. Using a recess appointment to place Berwick atop CMS is like using a recess appointment to put Elena Kagan on the Supreme Court.
3. If Republican obstruction is the problem, why not prove it on live television? The White House’s argument that a recess appointment is justified by GOP partisanship is self-evidently misleading. If Republican opposition to Berwick was simply partisan—that is, merely because he is an Obama appointment rather than on substantive grounds—that would be obvious by the kinds of questions they asked in Senate hearings. Indeed, the White House’s action is being taken to protect Democrats, some of whom won’t support Berwick, and don’t want to be forced to take an uncomfortable public vote months before an election.
4. Berwick is an advocate of socialized, government-controlled health care. As we and others have documented, Berwick is “starry-eyed” about Britain’s National Health Service, in which government owns the insurers, the hospitals, and the doctors’ offices. He is a highly intelligent and articulate defender of that position. Liberals claim that Republicans are taking his views out of context. If that is true, why not give Berwick a public platform to explain himself? The answer is clear: Berwick would only generate more controversy if he aired his views in Congress. And we’re not talking “controversy” in the mountain-out-of-a-molehill sense: we’re talking about the basic philosophy of whether or not we should have a free or centrally-planned health care system. The American public, and more importantly, the American idea, are not on Berwick’s side.
Cross-posted from The Agenda on National Review Online.
Health Wonk Review is a traveling, biweekly compilation of interesting posts from the health care policy blogosphere. The latest edition, hosted by David Williams of Health Business Blog, highlights articles from 23 blogs on the left, right, and center. Much of the focus this time around is on the provision in the Patient Protection and Affordable Care Act that requires insurers to spend 80-85% of their premium revenues on patient medical expenses (the “medical loss ratio” in industry parlance).
Austin Frakt of the Incidental Economist argues that increasing competition among insurers, by allowing people to buy insurance across state lines, for example, can lead to increased costs, because health care providers (hospitals, doctors, etc.) also play a role in determining the price of healthcare. While I partially agree with him on that front, his favored solution—converting insurers into utilities via medical loss ratio mandates—will make the problem worse, not better. As David Williams observes, “it is foolish to look at medical costs as good and administrative costs as bad,” because MLR mandates incentivize insurers to “drive premiums up over the long term so that relatively fixed administrative costs (like executive salaries) decline as a percentage of premiums.”
Jaan Sidorov of the Disease Management Care Blog summarizes the MLR debate as one between “constructionists,” who understand that insurance is strictly about pooling risk, and “activists,” who seek to so “enable the betterment of needed health care services” via insurance regulation. (I would quibble with the term “betterment.”) Sidorov notes that “the activist view of Medicare may underlie the nomination of [Donald] Berwick to lead the [Centers for Medicare and Medicaid Services].”
Louise Norris of the Colorado Health Insurance Insider analyzes a new report from the National Center for Health Statistics, which points out that most of the people who visit emergency rooms already have health insurance, debunking the myth that individual mandates are necessary to fix this problem.
John Goodman wrote an outstanding piece on his outstanding blog about why the problem of rescissions—when an insurer cancels someone’s policy because he had misrepresented his preexisting conditions—is overrated. (In sum, rescissions are very rare, and abuse of the procedure is already illegal.)
Bob Vineyard of InsureBlog notes that the latest episode of the Massachusetts health care soap opera involves the state legislature forcing wealthy hospitals to make a “one-time $100 million contribution”—a sentence in which possibly every word is factually inaccurate—to keep the Bay State’s health care system from falling apart. “Some politicians just don’t learn,” he writes.
Roy Poses at Health Care Renewal notes a Pittsburgh Tribune-Review article that shows that the University of Pittsburgh Medical Center paid $5.16 million to CEO Jeffrey Romoff in 2009, and millions to other top executives, puncturing the illusion that it’s only at for-profit entities that senior management is well-paid.
Brad Flansbaum at the Hospitalist Leader is pessimistic about the fiscally sane options for dealing with the “doc fix.” As he concludes: “‘Physicians, you will be making less money, the good time days of the last forty years are coming to a close.’ What is waste, what we can afford, who will take the hit…they are all up for debate, and it is going to get ugly.” Indeed.
Cross-posted from Critical Condition on National Review Online.
Bob Goldberg, vice president of the Center for Medicine in the Public Interest, has an excellent blog entry over at The American Spectator on Donald Berwick, President Obama’s nominee to head the Centers for Medicare and Medicaid Services. You should read the whole thing, but here are some excerpts:
Berwick not only has a role model picked out for a role that sounds a lot like what he would be doing at CMS, he has a soulmate: For the past 15 years he has consulted for — or, in his words, been “starry-eyed” over — Britain’s National Health Service. In 2008, at a 60th anniversary celebration of the creation [of the] NHS, he told a UK crowd, “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 complained the American health system runs in the “darkness of private enterprise,” unlike Britain’s “politically accountable system.” The NHS is “universal, accessible, excellent, and free at the point of care — a health system that is, at its core, like the world we wish we had: generous, hopeful, confident, joyous, and just”; America’s health system is “toxic,” “fragmented,” because of its dependence on consumer choice. He told his UK audience: “I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.”
While most European health-care systems involve government-run health insurance, the British actually go farther than most in that the state also runs the nation’s hospitals and primary care centers. In essence, Britain is the model of what Berwick would call “integrated care”: the idea that, by centralizing control of both the funding and the provision of health-care services in the hands of government technocrats, we can achieve the best health outcomes. Unfortunately, OECD statistics and other landmark studies show that Britain ranks near-to-dead last in the developed world on many metrics of health quality, such as cancer survival rates and hospital wait times. Goldberg concludes:
Berwick described how NHS rations care this way: “you plan the supply; you aim a bit low; historically, you prefer slightly too little of a technology or service to much too much; and thenyou search for care bottlenecks, and try to relieve them.” Relieve them? In 2008 the system Berwick believes is an example for healthcare worldwide denied cutting edge cancer drugs to 4,000 people, forcing thousands to remortgage their homes to pay for treatment. Love is blind. With regard to Dr. Berwick’s devotion to the NHS, it’s deaf and dumb as well.
UPDATE: Health Affairs, helpfully, has made Berwick's contributions to the journal freely accessible on its web site, for those who want to learn more.
Cross-posted from Critical Condition on National Review Online.
On Monday, the White House announced that President Obama was nominating Donald Berwick to run the Centers for Medicare and Medicaid Services (CMS), the most important subsidiary of the Department of Health and Human Services. CMS oversees around $800 billion dollars of annual U.S. health-care expenditures, affecting the lives not only of Medicare and Medicaid recipients but of all Americans, since we all use the same hospitals and doctors.
If confirmed, Berwick will lay the groundwork for Obamacare’s most fiscally consequential elements: its massive expansion of Medicaid and its elimination of Medicare Advantage subsidies. So it’s worth asking: Who is Donald Berwick, and what would a Berwick-run CMS look like?
Berwick, a decorated triple-graduate of Harvard with faculty appointments both at Harvard Medical School and the Harvard School of Public Health, embodies the technocratic element of the president’s governing philosophy. As with any decent technocrat, Berwick’s nomination has a good side and a bad side.
First, the good. Berwick is a serious and credible health-care analyst. In his capacities both as a Harvard professor and as founder and CEO of a Cambridge-based think-tank called the Institute for Healthcare Improvement, he has written extensively about health-care policy in all of the leading scholarly journals. His focus, in most of these writings, is on the quality and efficiency of health care: things like avoiding medical errors and unnecessary spending. He was granted an honorary knighthood by Queen Elizabeth for his role in shaping Tony Blair’s (mostly futile) attempts to modernize Britain’s National Health Service.
While he was a big supporter of Obamacare, Sir Donald acknowledges its core failing; in an October lecture, he said, “Health-care reform without attention to the nature and nurture of health care as a system is doomed. It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is, care as our patients, their families, and their communities experience it.” Indeed, if you put Berwick in a room with a leading market-oriented health-care analyst, the two would find broad areas of agreement as to where our health-care system fails patients.
But they would diverge on the most important questions of all: can, and should, the state provide quality health care for all? Can enlightened, public-minded experts effectively manage one-sixth of the U.S. economy? Consider this excerpt from a recent piece Berwick and two colleagues wrote for Health Affairs:If we could ever find the political nerve, we strongly suspect that financing and competitive dynamics such as the following, purveyed by governments and payers, would accelerate interest in [our policy ideal] and progress toward it: (1) global budget caps on total health care spending for designated populations, (2) measurement of and fixed accountability for the health status and health needs of designated populations, (3) improved standardized measures of care and per capita costs across sites and through time that are transparent, (4) changes in payment such that the financial gains from reduction of per capita costs are shared among those who pay for care and those who can and should invest in further improvements, and (5) changes in professional education accreditation to ensure that clinicians are capable of changing and improving their processes of care. With some risk, we note that the simplest way to establish many of these environmental conditions is a single-payer system, hiring integrators with prospective, global budgets to take care of the health needs of a defined population, without permission to exclude any member of the population.
Ideologues on the left favor a single-payer system for, well, ideological reasons of material egalitarianism. But for technocrats like Berwick, who shape the liberal policy consensus, the single-payer system is the most efficient way to manage health care. Top-down control, in their minds, ensures that every participant in the system serves the broader public good: hospitals and doctors only perform the tests and procedures they need to; private companies make enough money to get by, without excessive profits; and “integrators” mandate best practices for all parties based on the best available evidence.
But the technocratic approach has fatal flaws. First off, as William Schambra observed in National Affairs, it assumes that politicians — and politics — play no role in forming health-care policy. Even if you believe that technocrats could better organize our health-care system, Berwick’s approach only works if the narrow interests of Congressmen, labor unions, general hospitals, the AARP, etc., have no influence on the writing of law. No one who watched Democrats make the Obamacare sausage can harbor any illusions on this score.
Secondly, as Friedrich Hayek pointed out back in 1945, the command approach is doomed to fail because its commanders do not gain accurate information about what is happening on the ground. Technocrats may believe they can marshal statistics and analysis to optimize the health-care system, but they are not omniscient. Their analyses rely on too many assumptions and on unreliable data. This is why government programs always result in colossal amounts of waste, fraud, and abuse. On the other hand, a truly free market for health insurance could efficiently allocate health-care resources to those therapies and tests that patients and doctors most need.
Conservatives have persuaded a majority of the public that Obamacare is fiscally and morally flawed. But they would be unwise to ignore the technocratic arguments for socialized medicine. Just imagine how Berwick’s confirmation hearing could go: Berwick will make his case for top-down management of the nation’s health-care system; Senate Republicans, unable to challenge him intellectually, will praise his Harvard degrees, ask him easy questions in an angry voice, and move on to the next order of business.
And then imagine the same confirmation hearing in an alternate scenario, one in which Senate Republicans go toe-to-toe with one of liberal wonkery’s leading lights. They highlight Berwick’s own critiques of Obamacare; they ask him how his “integrators” are doing in Britain. They ask him what procedures Medicare pays for that he thinks the Independent Payment Advisory Board should eliminate. They take on his advocacy of the technocratic approach, with facts and analysis, and win. By doing so, they meaningfully build the case for repeal.
In short, the Berwick nomination is Republicans’ first opportunity in Congress, since the passage of the Affordable Care Act, to show that they have better solutions for the nation’s health-care problems. Will they seize it?
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