Donald Berwick, Transparency, and Rationing

In his first interview since leaving government service over the weekend, Donald Berwick made a series of revealing comments that reinforced just how and why Republicans and Democrats disagree on health care.  Asked by MSNBC’s Chris Hayes about his infamous “rationing with our eyes open” quote, Berwick talked about his daughter’s experience being denied a lab test by her insurer:

I called them and I said what do you mean, it’s not covered?  Who’s accountable?  Who made that decision, that that test is rationed to her, and you can’t even get a number or a name.  And what I said is, we need the lights on – we need that kind of decision-making to be done in daylight….So the quotes are nearly totally out of context.

Berwick’s television comments echo a print quote given to the New York Times, in which he said the point of his rationing comments was “that someone, like your health insurance company, is going to limit what you can get.  That’s the way it’s set up.  The government, unlike many private health insurance plans, is working in the daylight.  That’s a strength.”  So essentially, Berwick’s position is that someone has to tell a patient “No,” and that a government agency is better to serve this function than a private insurer, because the former is more transparent than the letter.  There are several problems with that line of thinking:

  • First is that when several private insurers participate in a marketplace, patients have choices – if they don’t like one carrier’s policies, they can buy a policy with another insurer.  (True, portability among insurers currently has some gaps, but some Republicans support solutions that could remedy this problem.)  Under a government-run system, individuals have no other place to turn if they don’t like the government’s decision-making processes.  And lest there be any doubt, Berwick didn’t just write about a single-payer system in Britain – his famous “Triple Aim” journal article said that a single-payer system in the United States was the best way to achieve his stated goals.
  • Second, Obamacare actually DECREASES transparency and accountability within the government-run health system.  Most notably, its new IPAB board of unelected bureaucrats, established in Section 3403 of the statute, will have the power to make binding rulings regarding Medicare policy.  And Obamacare includes NO requirement for public comment prior to IPAB issuing its recommendations.  Moreover, IPAB is definitely NOT accountable – unlike insurers, whom customers can sue for denying covered treatments, the decisions of IPAB’s unelected bureaucrats are not subject to judicial review.  So this new IPAB – which will make many of the key choices regarding Medicare – is neither open nor accountable to the American people.
  • Third, the way Obamacare was enacted was far from a paragon of transparency.  Candidate Obama promised to televise all health care negotiations on C-SPAN, but the process leading up to Obamacare was plagued with notorious backroom deals – so much so that Speaker Pelosi thought candidate Obama’s promise was a big joke.  And Berwick himself spent most of his time in a figurative bunker while at CMS – he held closed-door meetings with lobbyists and other industry executives, went so far as to call the police to avoid reporters’ questions, and admitted over the weekend that he was effectively muzzled by the Administration, being told by his “minders” not to explain his positions on rationing or other controversial issues for political reasons.

It’s telling that Donald Berwick claimed that government can be a transparent arbiter – if not explicit rationer – of health care resources, even as he admitted in the very same interview that he couldn’t be transparent about his viewpoints and writings while serving in the Obama Administration.  If that’s not an indictment of Berwick’s own philosophy, I don’t know what is.