In a town where power is often measured in dollars controlled, Donald Berwick, MD, should be a rock star. CMS has a budget larger than the defense department and with the implementation of the Affordable Care Act, Berwick as the CMS administrator (at least for now) could influence healthcare policy for years to come. So why is his nomination being stonewalled?
The simple reason is probably because he will have money and power. But it is more complicated than that. Here is the lowdown on arguments swirling the beltway as to whether Berwick should stay or go.
It's politics. Tom Scully probably put it best. The former CMS director and Berwick supporter is widely quoted as saying, “You could nominate Gandhi to be head of CMS and that would controversial right now." Congressional Republicans were still licking their wounds from passage of the ACA when the White House nominated Berwick in April 2010. The GOP pounced and promised to make Berwick a poster child for everything wrong with the reform effort.
Congressional Democrats, worried that their ACA support would be an election issue, did not push for confirmation hearings. It looked like the nomination was dead until the Obama administration installed Berwick as a recess appointment.
This month 42 Republican senators signed a letter to Pres. Obama telling him that they will not support Berwick. That leaves 58 senators who may support the acting CMS chief, but rules require 60 votes for confirmation.
- Why he should stay: CMS has had five administrators since 2000 and only two, Scully and Mark McClellan, were confirmed by the Senate. CMS is the agency Congress loves to hate. It has a lot of power, affects the lives of more than 100 million Americans and is a key player in the implementation of ACA. Opposition to Berwick looks like an effort to reignite the reform debate.
- Why he should go: The White House waited for more than a month after passage of healthcare reform to nominate Berwick and then they tucked him away from the press and Congress. Instead of being proactive, the Obama administration has allowed Berwick opponents to set the tone and tenor of the argument. It makes you wonder if they really want the guy.
Throughout his lengthy career Berwick has made a lot of comments and some of them are coming back to haunt him. According to his critics, Berwick is a radical proponent of healthcare rationing, so-called “death panels” and the British system of healthcare.
- Why he should stay: Healthcare is too important to allow the level of discourse to fall so low.
- Why he should go: In the era of the 24-hour news cycle, Berwick makes great theater. The soundbite rules so his speeches and writings are mined for controversy. Yes, the statements are often used out of context but as long as Berwick remains the nominee it will be hard for the healthcare reform debate to move beyond emotion-laden words like “rationing” and “death panels.”
Berwick's Qualifications
Don Berwick is a Harvard-educated pediatrician who has spent much of his career as a policy analyst. HealthLeaders Media wrote about him last year: "Berwick's record as a healthcare shepherd is unassailable. Through the Institute for Healthcare Improvement he founded, Berwick and his team cleverly hooked into the healthcare industry's untapped desire to improve with catchy, actionable programs like the 100,000 Lives Campaign. His critics worry that at CMS, what Berwick envisions would be less like feel-good voluntary programs and more toward British-style universal care of which he has spoken fondly."
- Why he should stay: His specialty is examining how a healthcare system can improve patient care while holding down costs. That is exactly what everyone says should happen.
- Why he should go: One ongoing criticism of Berwick is that he lacks experience in management and with health plans.
The White House has released a seven-page, single-spaced document that lists more than 200 organizations that support Berwick’s nomination. Here are some of the ones that really matter: AARP, AMA, AHA, AHIP, Medical Group Management Association and the American Public Health Association. When was the last time they all agreed on anything?
Why he should stay: It looks like Berwick can get everyone to the table and that is vitally important as ACA moves to implementation.
Why he should go: No downside here.
Why it may not matter: Berwick can stay right where he is until the end of 2011. By then he will have filled his management positions with people who pretty much think like him. Marilyn Tavenner, who is now second in charge at CMS, would probably become the acting director. Also, the Obama administration has tucked the Office of Consumer Information and Insurance Oversight into a safe place within the mammoth CMS. It is a preemptive move to counter legislative efforts to defund the office, which is charged with developing healthcare reform rules and regs. Steve Larsen, the widely respected and consumer-friendly former Maryland insurance commissioner, heads that office and has already issued a first round of rules.
Why it does matter: His supporters consider Berwick a visionary and an innovator in terms of patient-centered quality healthcare. As the head of CMS he will have the final say over what pilot projects are funded through the new Center for Medicare and Medicaid Innovation. That is important because much of the heavy lifting in terms of policy development will be formed around the successful pilots.
Berwick's chances for confirmation depend more on politics than anything else.