The Tough Cost-Benefit Choices Facing Policymakers Regarding Coronavirus

Right now, the United States, like most of the rest of the world, faces two critical, yet diametrically opposed, priorities: Stopping a global pandemic without causing a global economic depression.

Balancing these two priorities presents tough choices—all else equal, revitalizing the economy will exacerbate the pandemic, and fighting the pandemic will worsen economic misery. Yet, as they navigate this Scylla and Charybdis, some policymakers have taken positions contrary to their prior instincts.

In his daily press briefing Tuesday, Gov. Andrew Cuomo (D-NY) discussed the false choice between the economy and public health. He made the following assertions:

My mother is not expendable, your mother is not expendable, and our brothers and sisters are not expendable, and we’re not going to accept the premise that human life is disposable, and we’re not going to put a dollar figure on human life. The first order of business is to save lives, period. Whatever it costs….

If you ask the American people to choose between public health and the economy then it’s no contest. No American is going to say accelerate the economy at the cost of human life because no American is going to say how much a life is worth.

On this count, Cuomo is flat wrong. Entities in both the United States and elsewhere—including within his own state government—put a dollar figure on human life on a regular basis.

Rationing on Cost Grounds Already Happens

Consider the below statement describing the National Institute of Health and Care Excellence (NICE), a British institution that determines coverage guidelines for the country’s National Health Service (NHS). NICE uses the quality-adjusted life year (QALY) formula, which puts a value on human life and then judges whether a new treatment exceeds its “worth” to society:

As a treatment approaches a cost of £20,000 [about $24,000 at current exchange rates] per QALY gained over existing best practice, NICE will scrutinize it closely. It will consider how robust the analysis relating to its cost- and clinical-effectiveness is, how innovative the treatment is, and other factors. As the cost rises above £30,000 [about $36,000] per QALY, NICE states that ‘an increasingly stronger case for supporting the technology as an effective use of NHS resources’ is necessary.

Entities in the United States undertake similar research. The Institute for Clinical and Economic Review (ICER) also performs cost-effectiveness research using the QALY metric. The organization’s website notes that “the state of New York has used [ICER] reports as an input into its Medicaid program of negotiating drug prices.” In other words, Cuomo’s own administration places a value on human life when determining what the state’s Medicaid program will and won’t pay for pharmaceuticals.

Cost-Effectiveness Thresholds

Cuomo represents but one example of the contradictions in the current coronavirus debate. Donald Berwick, an official in the Obama administration and recent advisor to the presidential campaign of Sen. Elizabeth Warren (D-MA), infamously discussed the need to “ration with our eyes open” While many liberals like him have traditionally endorsed rationing health care on cost grounds, few seem willing to prioritize economic growth over fighting the pandemic.

Conversely, conservatives often oppose rationing as an example of government harming the most vulnerable by placing an arbitrary value on human life. Nonetheless, the recent voices wanting to prioritize a return to economic activity over fighting the pandemic have come largely from the right.

The calls to reopen the economy came in part from an Imperial College London study examining outcomes from the pandemic. The paper concluded that an unmitigated epidemic (i.e., one where officials made no attempt to stop the virus’ spread) would cost approximately 2.2 million lives in the United States. Mitigation strategies like social distancing would reduce the virus’ impact and save lives, but would prolong the outbreak—and harm the economy—for more than a year.

The paper’s most interesting nugget lies at its end: “Even if all patients were able to be treated”—meaning hospitals would not get overwhelmed with a surge of patients when the pandemic peaks—“we predict there would still be in the order of…1.1-1.2 million [deaths] in the US.” Based on the Imperial College model, shutting down the economy so as not to let the virus run rampant would save approximately 1 million lives compared to the worst-case scenario.

A Cost of $1 Million Per Estimated Life Saved

Some crude economic math suggests the value a pandemic-inspired economic “pause” might place on human life. Based on a U.S. gross domestic product of approximately $21 trillion, a 5 percent reduction in GDP—which seems realistic, or perhaps even conservative, based on current worldwide projections—would erase roughly $1.05 trillion in economic growth. The Imperial College estimate that mitigation and social distancing measures would save roughly 1 million lives would therefore place the value of each life saved at approximately $1 million.

Of course, these calculations depend in large part on inputs and assumptions—how quickly the virus spreads, whether large numbers of Americans have already become infected asymptomatically, whether already infected individuals gain immunity from future infection, how much the slowdown harms economic growth in both the short and long-term, and many, many more. Other assumptions could yield quite different results.

But if these types of calculations, particularly when performed with varying assumptions and inputs, replicate the results of the crude math above, policymakers likely will sit up and take notice. Given that Britain’s National Health Service makes coverage decisions by valuing life as worth tens of thousands of pounds, far less than millions of dollars, it seems contradictory to keep pursuing a pandemic strategy resulting in economic damage many multiples of that amount for every life saved.

Tough Cost-Benefit Analysis

Unfortunately, lawmakers the world over face awful choices, and can merely attempt to select the least-bad option based on the best evidence available to them at the time. Slogans like “Why put your job over your grandmother?” or “If you worry about the virus, just stay home” belie the very real consequences the country could face.

Consider possible scenarios if officials loosen economic restrictions while the pandemic persists. Some individuals with health conditions could face the prospect of returning to work in an environment they find potentially hazardous, or losing their jobs. Individuals who stay home to avoid the virus, yet develop medical conditions unrelated to the virus—a heart attack, for instance—could die due to their inability to access care, as hospitals become swarmed with coronavirus patients. And on and on.

The president said on Tuesday he would like to start reopening the economy by Easter, a timeline that seems highly optimistic, at best. If by that time the situation in New York City deteriorates to something resembling Italy’s coronavirus crisis—and well it could—both the president and the American people may take quite a different view towards reopening the economy immediately. (And governors, who have more direct power over their states, could decide to ignore Trump and keep state-based restrictions on economic activity in place regardless of what he says.)

Nonetheless, everyone understands that the economy cannot remain in suspended animation forever. Hopefully, better data, more rapid viral testing, and the emergence of potential treatments will allow the United States and the world to begin re-establishing some sense of normalcy, at the minimum possible cost to both human life and economic growth.

This post was originally published at The Federalist.

The “Other” Election Debate about Single-Payer Health Care

Stop me if you’ve heard this one before: There’s a national election going on, and single-payer health care is one of the prime points of contention. It’s not what you think.

Voters in Great Britain head to the polls on Dec. 12 in the country’s third general election in just more than four years. The ongoing Brexit debate, about whether or how Britain will leave the European Union, necessitated the early election. With his Brexit agreement with the European Union bogged down in Parliament, Conservative Prime Minister Boris Johnson felt the need to go to the country, to obtain a mandate to push the deal through.

But health care has also taken a prime place in the campaign. The Labour Party, led by Jeremy Corbyn, have raised the specter of the Conservatives “putting the National Health Service up for sale” to reach a post-Brexit trade agreement with the United States.

The issue of the NHS’s status in a U.S.-U.K. trade agreement came up during President Trump’s state visit to Britain in June. In a press conference with then-Prime Minister Theresa May, Trump originally said “everything with a trade deal is on the table,” only to walk those comments back one day later. With the president due back in London on Tuesday for a NATO summit, and Labour trailing in the polls only a week before election day, Corbyn will doubtless make the issue a focal point of Trump’s visit.

Drug Pricing Issues

Last week, a series of government documents leaked that summarized preliminary trade discussions between American and British negotiators. Corbyn waved around heavily edited versions of the documents at his first debate with Johnson earlier this month. Government officials had redacted large swathes of the documents, to preserve the sensitive nature of the trade talks, but those discussions escaped into public view via the unauthorized leak.

The leaked documents confirm that drug pricing remains a prime point of contention regarding a U.S.-U.K. trade deal. One document, summarizing a series of meetings held in July, includes a lengthy section entitled “Intellectual Property: Patents and Pharmaceuticals.”

Britain’s Channel Four reported in October that two linked issues drive the talks. First, American negotiators prefer the United States’s longer period of data exclusivity as part of any Anglo-American trade agreement. This policy would seek to preserve incentives for innovation, allowing manufacturers to maintain their exclusive intellectual property for longer periods of time.

Britain Wants to Keep Rationing Health Care

Second, the American side “want[s] to remove the UK’s ability to block American drugs not deemed ‘value for money.’” The BBC notes that Britain’s National Health Service relies on the National Institute for Health and Care Excellence (NICE) “on what offers the best benefits for patients balanced against value for money:”

The NICE regime, introduced 20 years ago, is seen as a great success in helping the NHS strike realistic pricing deals. A recent deal for the cystic fibrosis drug Orkambi was hailed by health leaders in England as a big win for the system, with the American manufacturer Vertex, having initially refused to bring down its price, eventually signing up.

However, the BBC neglected to mention that, as part of its “negotiations” with the manufacturer Vertex, NICE denied thousands of British patients access to Orkambi for more than three years, because the drug exceeded cost limits set by the government body.

It seems somewhat ironic that in October, a spokesman for Britain’s Department for International Trade told Channel Four that the British government “could not agree to any proposals on medicines pricing” that would “reduce clinician and patient choice.” For the past three years, patients had no choice for accessing Orkambi—bureaucrats called the drug too expensive, therefore British cystic fibrosis patients could not receive it.

End Foreign Freeloading

Britain’s drug pricing policies cost American and British patients alike. British patients pay when they cannot get access to treatments the government deems too expensive, and their health suffers as a result. And American patients pay when Britain, like other European nations, free rides on American innovation—allowing U.S. consumers to pay far more for pharmaceuticals, absorbing a disproportionate share of drugs’ research and development costs.

U.S. House Speaker Pelosi and others have suggested importing socialist-style price controls to the United States to “solve” the free-rider problem—a variation of the “If you can’t beat them, join them” approach. But a better solution would involve American negotiators taking up the issue of foreign freeloading with other governments as part of trade talks—the exact policy pursued as part of the U.S.-U.K. discussions.

Trump’s visit to London so close to Britain’s election has prompted speculation about its political ramifications. Johnson has warned Trump not to endorse his re-election bid, fearing it may only encourage Britons to vote for his Labour opponents instead.

But on policy, the United States absolutely should work to stop foreign free-riding over pharmaceutical prices. Moreover, we would do the British people no small favor if, in the process of ending that free-riding, we could stop that country’s health care system from denying patients access to life-saving treatments that a government board deems too costly.

This post was originally published at The Federalist.

Note to Britain: You Can Have Your NHS

As expected, the American press has heavily covered President Trump’s visit to Europe, including his time spent in Great Britain. But a row (that’s British for “argument”) that has gone under-reported on this side of the Atlantic also holds major implications for American patients.

Based on comments the President made earlier in the week, British politicians now believe they need to protect the country’s National Health Service (NHS) from “privatization” at the hands of American corporations. But even as they do so, another controversy—about the ways in which Britain denies life-saving treatments to patients, solely on cost grounds—illustrates the problems with socialized medicine, which the left wants to export to the United States.

Concern about Trade Agreements

During a press conference in London Tuesday, a British reporter questioned Trump about a post-Brexit trade deal between the U.S. and Britain. The reporter specifically asked whether “the entire economy needs to be on the table” in those discussions, “including the NHS.” Trump responded that “everything with a trade deal is on the table.”

Those comments—which Trump later attempted to walk back—prompted outrage that Britain’s “beloved” NHS was at risk. British politicians across parties raised concern that American companies could receive NHS contracts (even though subsidiaries of U.S. corporations have already done so), or that a free trade agreement could supersede legislative efforts by Parliament to prohibit additional private contracting within the health service.

The Health Secretary, Matt Hancock—an announced candidate in the race to succeed Theresa May as Conservative Party leader and Prime Minister—epitomized the sentiments, claiming that “the NHS

NHS Denying Patients Care

The controversy continued at Prime Minister’s Questions in the House of Commons Wednesday. In that hourlong session, no fewer than five questions asked whether the NHS was “for sale,” or some variation thereof. But the sixth NHS-related question, by Labour MP Karl Turner, proved the most revealing:

Twelve months ago, the Prime Minister told this House that she wanted a speedy resolution to the funding row between NHS England and Vertex regarding the drug Orkambi to treat cystic fibrosis. My seven-year-old constituent Oliver Ward wrote to the Prime Minister recently asking what progress she has made. Could the Minister please give Oliver some good news and tell him that he need not get up every day worrying about this terrible injustice?

Turner’s question referred to Orkambi, a drug that could help thousands of British patients currently suffering from cystic fibrosis. But the NHS refuses to pay for the drug—not because it does not work, but because it does not meet cost thresholds that government bureaucrats have set.

Britain’s National Institute for Health and Clinical Excellence decided in 2016 that the NHS would not pay for Orkambi at the price set by its manufacturer. For the three years since, British patients have not found that decision very NICE at all.

A Precursor of an American Single-Payer System?

Unfortunately, however, liberals want to export the British model of rationing health care on cost grounds to the United States. Recall President Obama’s comments about the issue a decade ago:

The chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here….There is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place.

Months after those comments, the New York Times ran an article, entitled “Why We Must Ration Health Care,” that argued for bringing a British-style rationing model to our shores.

This prevailing mentality among intellectual elites explains why neither the House nor Senate single-payer bills prohibit a government-run health plan from implementing cost-effectiveness research. In fact, the House bill explicitly provides for cost-effectiveness research as a method of determining drug prices, because most liberals believe that bureaucrats can and should have the power to restrict access to care on cost grounds. Most Americans, on the other hand, would strongly object to this rationing of care.

As for British politicians saying the NHS “isn’t for sale,” I could not care less—I wouldn’t want to buy it even if it were. The American health care system has its flaws, to be sure, but I have little interest in creating a system where government bureaucrats have near-total control over patients’ medical decisions, and use that power to deny access to life-saving care. I think most Americans would agree.

This post was originally published at The Federalist.

Key Democrat Calls for Cost-Effectiveness Research in Medicare

In case you weren’t watching the HELP Committee hearing on FDA, Chairman Harkin just commented that while the Food and Drug Administration analyzes the safety of pharmaceuticals, it’s the role of the Centers for Medicare and Medicaid Services to analyze the “cost-effectiveness” of these treatments.  In other words, Sen. Harkin said he wants Medicare bureaucrats to analyze treatments based on their cost – the implication being that those deemed “too expensive” by federal bureaucrats should be denied to patients.

Unfortunately, these views are far from a minority opinion among Obamacare supporters.  Just last week, the liberal Commonwealth Fund hosted a briefing with the CEO of Britain’s National Institute for Health and Clinical Excellence (NICE).  Its acronym notwithstanding, NICE has proven to be anything but for British patients – denying access to important life-saving, and life-extending, treatments based solely or primarily on their cost.  A series of examples can be found in this one-pager.

Similarly, CMS Administrator Donald Berwick – whose controversial views about “rationing with our eyes open” have made Democrats afraid to even consider his nomination – has also asserted that NICE and other similar bodies conducting cost-effectiveness research “have created benchmarks of best practices that we could learn from and adapt in this country.”

Obamacare created a new board of 15 unaccountable bureaucrats with the power to make binding rulings about Medicare policy.  Today’s comments by Chairman Harkin about Medicare conducting cost-effectiveness research once again illustrate why Democrats set up such an unelected board:  To have bureaucrats deny “expensive” treatments to Medicare patients.

Rationing Comes to Capitol Hill

Later today, the Alliance for Health Reform hosts a briefing with the CEO of Britain’s National Institute for Health and Clinical Excellence (NICE).  Its acronym notwithstanding, NICE has proven to be anything but for British patients – denying access to important life-saving, and life-extending, treatments based solely or primarily on their cost.  (A series of examples can be found in this one-pager.)

Today’s briefing is being sponsored by the prominent liberal think-tank the Commonwealth Fund.  In providing intellectual support for Obamacare’s big-government approach to changing the health care system, Commonwealth has published a series of papers on “Realizing Health Reform’s Potential.”  Apparently Commonwealth may also believe that realizing the potential of health “reform” also involves denying treatments to sick patients because government bureaucrats deem them too expensive.

It’s also worth noting that un-confirmed CMS Administrator Donald Berwick – whose controversial views about “rationing with our eyes open” have made Democrats afraid to even consider his nomination – has also asserted that NICE and other similar rationing bodies

… are functioning very well and are well respected by clinicians, and they are making their populations healthier and better off.  Nor are their policies resulting in injury to patients in any way like what is being speculated here in the United States.  These organizations have created benchmarks of best practices that we could learn from and adapt in this country.

Here are some examples of NICE’s “best practices” in action.  While reading them, it’s worth taking a minute to stop and consider that one of Washington’s most prominent liberal think-tanks wants to hear more about this model of cost-based rationing – and that an unaccountable and unconfirmed bureaucrat managing a budget bigger than the Pentagon’s has stated he wants to make this model of rationing a reality for American patients.

Will Obama Learn from Cameron on Health Care?

The President arrived in London last night, on the longest leg of his trip to Europe.  His British visit will continue tomorrow with a speech to both Houses of Parliament in Westminster Hall. (No word yet on whether the President will take questions from MPs.)

It is unclear whether health care will be on the agenda for the Anglo-American summit – but perhaps it should be.  As we’ve previously reported, the British Government is attempting a “radical reorganization” intended to promote efficiency by eliminating bureaucracy – bureaucracies that are often used to deny care to patients.  As the New York Times noted: “Currently, how and where patients are treated, and by whom, is largely determined by decisions made by 150 entities known as primary care trusts — all of which would be abolished under the plan, with some of those choices going to patients.”  In other words, the Cameron government is attempting to put patients and doctors, not bureaucrats, at the center of the health care conversation.

Compare that to the Obama Administration, which signed a law creating 159 new boards, bureaucracies, and programs to “improve” health care.  Its approach to accountable care organizations (ACOs) has turned into an historic flop, with multiple letters coming from the provider community about the mass of regulations and mandates placed on ACOs in the Administration proposal.  In fact, several Republican senators wrote to the Administration today asking for a U-turn on ACOs and a withdrawal of the proposed rule.

And yet the Administration not only wants to continue with its top-down, government-centric approach to health care, it wants to increase government control over health care.  The only Democrat idea to “reform” Medicare is the President’s proposal to give even more power to an unelected board of 15 bureaucrats to make rulings on how Medicare should operate.  Such a board could come to resemble Britain’s National Institute for Health and Clinical Excellence (NICE) – and while CMS Administrator Berwick has expressed his strong support for NICE’s policy of “ration[ing] with our eyes open,” British patients have been far from keen about NICE’s arbitrary rationing.

So, whilst the President is in London this week, he would do well to talk with Prime Minister Cameron about true health care reform – and for that matter, visit with some British patients who have had life-saving treatments denied to them by government bureaucrats.  America’s health care system could be the better for it.

Why Rationing Is Not NICE

The Wall Street Journal reports on a preliminary decision made late last week by Britain’s National Institute for Health and Clinical Excellence (NICE) to deny the use of several new drugs used to treat chronic leukemia patients.  Here’s how NICE explained its decision: “When we recommend the use of very expensive treatments, we need to be confident that they bring sufficient benefit to justify their cost.”  The article goes on to summarize how NICE operates in Britain:

NICE has rejected a number of pricey drugs for cancer and other diseases in the past…Sometimes NICE rejects drugs for all patients with the disease, and sometimes just for patients with a specific form of the disease, where the efficacy doesn’t appear to justify the price.  NICE’s decisions often anger patients, their families, and drug companies.

President Obama and Democrats in Congress borrowed from the NICE model when creating the health care law’s Independent Payment Advisory Board, a board of bureaucrat “experts” who will have wide-ranging powers to make binding rulings on Medicare policy.  While the President claims his board will help reduce the deficit, the latest decision by NICE in Britain illustrates the likely way such deficit savings will be achieved – as well as the impact on patient care of putting unaccountable bureaucrats, rather than physicians and patients, at the heart of health “reform.”

Friday Quiz: Rationing in the UK and the US

From Britain yesterday came word that the National Institute for Health and Clinical Excellence (NICE) refused National Health Service (NHS) funding for the life-extending drug Avastin, due largely to its expense.  (Also of note: The FDA is still considering its own separate review of Avastin for treating breast cancer; a previous Washington Post article noted that the review should not consider cost issues – but if the FDA revokes its approval, Medicare will stop paying for the drug.)  This story seemed eerily similar to reports in the Washington Post on Monday that Medicare may refuse to pay for the prostate cancer drug Provenge due to its cost.

Which brings us to this morning’s quiz.  I’ve attached below a series of quotes from the BBC article on NHS rationing and the Post piece on Medicare’s cost-effectiveness review.  Can you tell which series of quotes refer to Medicare’s decision-making, and which relate to the NICE-imposed system of cost-based rationing…?  (Answer is below.)

This development comes a few days before Dr. Donald Berwick is scheduled to testify before the Senate Finance Committee in his first appearance before Congress since his controversial recess appointment.  Dr. Berwick has previously stated that “we could learn from and adapt” the British model of cost-based rationing – and given the series of quotes below, some may wonder whether that process has already begun.

Country A Country B
“The treatment costs $93,000 a patient and has been shown to extend patients’ lives by about four months.” “Research shows the drug can give an extra six weeks of life.”
“To charge $90,000 for four months, which comes out to $270,000 for a year of life, I think that’s too expensive.” “At a cost of nearly $21,000 per patient, the drug is just too expensive.”
“I’d like to think cost doesn’t need to come up when it’s a slam dunk….But when it’s a close call like this, it certainly has to be a factor.  That’s $100,000 [we] can’t spend elsewhere.” “The independent committee that makes the final decision needs to be certain that the benefits offered justify the cost.”
Oncologists’ reaction: “Firing a shot across the bow like this is not the way to have an intelligent and meaningful discussion about how we start to address the complex issue of drug costs.” Cancer group’s reaction: “We believe that all treatment options should be ruled in, regardless of cost, giving doctors and their patients the freedom to choose the treatments that are right for them.”



Answer to the quiz:  Country A is the United States, based on Monday’s Washington Post story about Medicare’s cost-based review of Provenge; Country B is Great Britain, based on yesterday’s BBC story about NHS coverage of Avastin.  Quotes have been edited lightly above to disguise the country being discussed.

More Cost-Effectiveness Rationing in Britain’s NHS

From Britain today came word that the National Institute for Health and Clinical Excellence (NICE) has rejected the use of the cancer drug Avastin for use in bowel cancers within Britain’s National Health Service (NHS), because “the cost…at about £21,000 per patient, does not justify its benefits.”  As a result of this decision by unelected bureaucrats, an estimated 6,500 affected patients in the UK will not obtain NHS funding for their treatment.  Here’s what one bowel cancer patient had to say about the ruling: “It seems immoral to me that, as a result of negative NICE decisions like this one, people’s choice of living or dying depends on whether they can afford a drug, because it isn’t available to them on the NHS.”

Avastin is subject to a separate controversy here in the States, regarding whether or not the drug will remain approved for treatment of breast cancer.  That decision, still awaiting final disposition, lies with the Food and Drug Administration (FDA), which, as the Washington Post noted, “is not supposed to consider costs in its decisions.”

But in Britain, cost remains of paramount concern in determining whether or not bureaucrats will grant approval to pay for a drug – as government officials readily admit.  NICE’s chief executive today noted that “we have to be confident that the benefits justify the considerable cost of the drug.”  That quote sounds eerily similar to Dr. Donald Berwick, head of the Centers for Medicare and Medicaid Services (CMS), who said last year that “The social budget is limited—we have a limited resource pool….The decision is not whether or not we will ration care—the decision is whether we will ration with our eyes open.”

It is perhaps small wonder then that Dr. Berwick has expressed his “romance” regarding Britain’s single-payer health care system, and supported NICE’s use of cost-effectiveness research to deny patients care.  The bigger question is whether and how Dr. Berwick plans to impose such a system in the United States, and what the American people would say about federal bureaucrats preventing patients from obtaining access to life-saving treatments on cost grounds.

Donald Berwick In His Own Words

Last week President Obama bypassed the Senate and public hearings to appoint Dr. Donald Berwick as Administrator for the Centers for Medicare and Medicaid Services (CMS). Even though the President previously admitted that “an ugly process” surrounding the health care legislation “legitimately raised concerns…that [the American people] just don’t know what’s going on,”[i] his recess appointment means that Dr. Berwick did not face any public scrutiny before assuming control of an agency that provides care to 100 million seniors, children, and low-income and disabled individuals[ii] with an annual budget exceeding $800 billion.[iii]

However, the quotes below highlighting his views on health care—along with another highlighting his self-described greatest defect—provide troubling indications about the policies Dr. Berwick may attempt to impose when running the vast agency now under his control:

Berwick on rationing: “The decision is not whether or not we will ration care—the decision is whether we will ration with our eyes open.”[iv]

Berwick on redistributing wealth: “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 less fortunate.”[v]

Berwick on Britain’s government-run National Health Service: “I fell in love with the NHS…to an American observer, the NHS is such a seductress.”[vi]

Berwick on extending coverage: “At $5,000 per person per year, we leave 45 million souls without health insurance. At under $3,000 per person per year, the United Kingdom leaves no one out—no one—not even illegal immigrants.”[vii]

Berwick on individual choice in health care: “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.”[viii]

Berwick on single payer health care: “I admit to my own devotion to a single-payer mechanism as the only sensible approach to health care finance I can think of.”[ix]

Berwick on closing health facilities: “Most metropolitan areas in the United States should reduce the number of centers engaging in cardiac surgery, high-risk obstetrics, neonatal intensive care, organ transplantation, tertiary cancer care, high-level trauma care, and high-technology imaging.”[x]

Berwick on end-of-life care: “Most people who have serious pain do not need advanced methods; they just need the morphine and counseling that have been available for centuries.”[xi]

Berwick on ultrasound treatments: “As many as 80 percent of hysterectomies are scientifically unnecessary. So are more than a quarter of the drugs used for ear infections, most of the ultrasound tests done in normal pregnancies, and almost half of the cesarean sections in the United States. Isn’t this, with all due respect, some form of assault and battery, however unintended?”[xii]

Berwick on access to new technology: “The need to balance effectiveness against cost has shifted the burden of proof onto the shoulders of those who use or propose to use expensive technologies.”[xiii]

Berwick on Berwick: “I don’t feel like a leader, so it’s very hard for me to project myself into that situation. But inattention to detail is my biggest defect. I’m always leaning forward into something new. I can create a mess. Luckily, I have people who are willing to create the detail around the idea or, if they’re really smart, know which ideas to ignore.”[xiv]

These quotes—a small sampling of Dr. Berwick’s extensive writings over the last several decades—reveal views on issues from ultrasound use in pregnancies to hospital consolidation to single-payer health care that many may find disconcerting. The American people deserve a full explanation regarding his comments and a thorough examination of how his long-held views will influence his critical role in implementing Democrats’ massive new 2,700 page health care law.


[i] Full interview transcript available at

[ii] Brief Summaries of Medicare and Medicaid, Centers for Medicare and Medicaid Services Office of the Actuary, November 2009,

[iii] Centers for Medicare and Medicaid Services Fiscal Year 2010 Budget Justification,, p. 2

[iv] “Rethinking Comparative Effectiveness Research,” An Interview with Dr. Donald Berwick, Biotechnology Healthcare June 2009,

[v] “A Transatlantic View of the NHS at 60” by Donald Berwick, speech at NHS Live, July 1, 2008; Emphasis original

[vi] “Celebrating Quality 1998-2008” by Donald Berwick, speech at London Science Museum, September 30, 2008

[vii] “Plenty,” speech to 14th annual National Forum on Quality Improvement in Health Care, December 2002, in Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), pp. 293-94

[viii] “A Transatlantic View of the NHS at 60” by Donald Berwick, speech at NHS Live, July 1, 2008

[ix] Foreword to Quality in the Veterans Health Administration: Lessons from People Who Changed the System (Jossey-Bass, 1996) by Donald Berwick, p. xi

[x] “Buckling Down to Change,” speech to 5th annual National Forum on Quality Improvement in Health Care, December 1993, in Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), pp. 28-29

[xi] “Reforming Care for Persons Near the End of Life: The Promise of Quality Improvement” by Joanne Lynn, Donald Berwick, et al., Annals of Internal Medicine July 16, 2002, p. E-118

[xii] “Why the Vasa Sank,” speech to 9th annual National Forum on Quality Improvement in Health Care, December 1997, in Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), pp. 129-130

[xiii] “Techniques for Assessing the Impact of New Technologies in the Neonatal Intensive Care Unit” by Donald Berwick, Respiratory Care June 1986, p. 524

[xiv] “Seeding a Simple Dream: Do No Harm” by Avery Comarow, US News October 30, 2006,