Meet the Radical Technocrat Helping Democrats Sell Single-Payer

If anyone had doubts about the radical nature of Democrats’ health care agenda, they needn’t look further than the second name on the witness list for this Wednesday’s House Ways and Means Committee hearing on single-payer health care: Donald Berwick of the Institute for Healthcare Improvement.

If that name sounds familiar, it should. In summer 2010, right after Obamacare’s passage, President Obama gave Berwick a controversial recess appointment to head the Centers for Medicare and Medicaid Services (CMS). Democrats refused to consider Berwick’s nomination despite controlling 59 votes in the Senate at the time, and he had to resign as CMS administrator at the end of his recess appointment in late 2011.

Berwick’s History of Radical Writings

Even a cursory review of Berwick’s writings explains why Obama’s only option was to push him through with a recess appointment, and why Democrats refused to give Berwick so much as a nomination hearing. As someone who read just about everything he wrote until his nomination—thousands of pages of journal articles, books, and speeches—I know the radical nature of Berwick’s thinking all too well. He believes passionately in a society ruled by a technocratic elite, thinking that a core group of government planners can run the country’s health care system better than individual doctors and patients.

Here is what this doctor believes in, in his own words:

  • Socialized Medicine: “Cynics beware: I am romantic about the National Health Service; I love it. All I need to do to rediscover the romance is to look at health care in my own country.”
  • Control by Elites: “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.”
  • Wealth Redistribution: “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.”
  • Shutting Medical Facilities: “Reduce the total supply of high-technology medical and surgical care and consolidate high-technology services into regional and community-wide centers … 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.”
  • 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.”
  • Cost-Effectiveness Rationing of Care: “The decision is not whether or not we will ration care—the decision is whether we will ration with our eyes open.”
  • Doctors Putting “The System” over their Patients: “Doctors and other clinicians should be advocates for patients or the populations they service but should refrain from manipulating the system to obtain benefits for them to the substantial disadvantage of others.”
  • Standardized “Cookbook Medicine”: “I would place a commitment to excellence—standardization to the best-known method—above clinician autonomy as a rule for care.”

For those who want a fuller picture of Berwick’s views, in 2010-11 I compiled a nearly 30-page dossier featuring excerpts of his beliefs, based on my comprehensive review of his prior writings and speeches. That document is now available online here, and below.

Where’s the Political Accountability?

Some of Berwick’s greatest admiration is saved for Britain’s National Health Service on the grounds that it was ultimately politically accountable to patients. For instance, Berwick said his “rationing with our eyes open” quote was “distorted,” claiming 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.

When running for governor of Massachusetts in 2013, Berwick claimed he “regrets listening to White House orders to avoid reaching out to congressional Republicans.” But that doesn’t absolve the fact that Berwick went to great lengths to avoid the political accountability he previously claimed to embrace.

It also doesn’t answer the significant questions about why Obama waited until after Obamacare’s enactment to nominate Berwick—deliberately keeping the public in the dark about the radical nature of the person he wanted to administer vast swathes of the law.

Thankfully, however, Wednesday’s hearing provides a case of “better late than never.” Republicans will finally get a chance to ask Berwick about the extreme views expressed in his writings. They will also be able to raise questions about why Democrats decided to give him an official platform to talk about single payer (and who knows what else).

This post was originally published at The Federalist.

When CMS Director’s Post Opens–Again–Will Obama Step Up?

When Marilyn Tavenner steps down as head of the Centers for Medicare and Medicaid Services this month, one of the federal government’s most powerful positions will once again come open. History and President Barack Obama’s actions toward the post suggest that finding a replacement might prove difficult.

Before Ms. Tavenner was confirmed in May 2013, CMS had gone without a permanent, Senate-confirmed administrator for nearly seven years—since Mark McClellan left the agency in the fall of 2006. The Bush administration nominated Kerry Weems, a career civil servant, to replace Mr. McClellan; Mr. Weems received a polite hearing from the Senate Finance Committee in July 2007, but a CMS policy memo issued shortly afterward regarding the Children’s Health Insurance Program angered Senate Democrats. The committee’s chairman, Max Baucus (D., Mont.), refused to bring the nomination to a vote, and Mr. Weems served as acting administrator for the rest of the Bush administration.

Upon taking office, President Obama waited nearly 15 months—until his health-care legislation was passed—to nominate Don Berwick to run the agency that would oversee much of the law’s implementation. Mr. Berwick’s history of writings proved so inflammatory that Democrats, despite having an overwhelming Senate majority, refused to advance his nomination. Mr. Berwick received a controversial recess appointment from President Obama in July 2010 but was forced to leave CMS in December 2011 when his temporary appointment expired because the Senate had not voted on his confirmation.

While serving in the Senate in 2007-08, Mr. Obama stood by as Sen. Baucus and Majority Leader Harry Reid (D., Nev.) put Mr. Weems’s confirmation on ice. And as president, Mr. Obama failed to demand a vote from his fellow Democrats when they decided not to advance Mr. Berwick’s nomination, likely seeking to spare vulnerable incumbents from taking a position on a nominee with a controversial record. Given the president’s history of remaining quiet about a Democratic Senate not confirming CMS nominees, he has little standing to complain should the Republican-controlled Senate choose not to advance his choice to succeed Ms. Tavenner.

Even before Obamacare, the Centers for Medicare and Medicaid Services had a budget larger than that of the Pentagon; since the law passed, its subsidies, regulations, or both affect the insurance of basically every American with health coverage. The CMS administrator’s job is critical. But President Obama’s actions have contributed to a lack of permanent leadership in CMS for most of the past eight years. We’ll see whether that pattern persists after Ms. Tavenner departs.

This post was originally published at the Wall Street Journal Think Tank blog.

Donald Berwick’s Rationed Transparency

Dr. Donald Berwick is back in the public eye. The former administrator of the Centers for Medicare and Medicaid Services (CMS) has announced he will run for governor in Massachusetts.

Berwick first entered the public spotlight in April 2010, when President Obama nominated him for the CMS post. But Berwick never went through the regular confirmation process. Instead, the president granted him a surprise recess appointment that July.

The president renominated him in January 2011, but it became apparent that he could not garner enough votes for Senate confirmation. That December, Berwick resigned. Now, he is pursuing office as an elected, rather than an appointed, official.

Berwick’s short tenure at CMS was defined by a series of controversial statements he made before his appointment. He defended both Britain’s National Health Service and government rationing of health care. Most famously, in a June 2009 interview, he stated that “the decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open.”

After leaving CMS, Berwick said his comments were merely an attempt to argue for greater transparency in decision-making. “Someone, like your health-insurance company, is going to limit what you can get. That’s the way it’s set up,” he told the New York Times. “The government, unlike many private health-insurance plans, is working in the daylight,” he insisted. “That’s a strength.”

Unfortunately, Berwick himself, while head of CMS, went to great lengths to avoid transparency. He ducked reporters, in one instance even “exit[ing] behind a stage” to avoid press queries. Another time he went so far as to request a “security escort” to avoid questions.

Today, Berwick concedes his lack of transparency. According to a Politico report, he now “regrets listening to White House orders to avoid reaching out to congressional Republicans.”

The lack of transparency is endemic in the Obama administration. Case in point: the enactment of Obamacare. During his 2008 campaign, Barack Obama promised health-care negotiations televised on C-SPAN. Instead, we got a series of notorious backroom deals: the Cornhusker Kickback, the Louisiana Purchase, the Gator Aid.

“It’s an ugly process, and it looks like there are a bunch of backroom deals,” Obama feebly admitted in January 2010 — only to retreat again to the smoke-filled rooms two months later, where he cut the final deals to ram the legislation through Congress.

Obamacare is premised on the belief that government knows best. And those who share that belief all too often regard transparency and public accountability as inconveniences.

Consider the administration’s approach to regulating the proposed health-insurance “exchanges.” Obamacare requires state-based exchanges to “hold public meetings and input sessions,” but it fails to apply these same transparency standards to the federally run exchanges Washington will create in 33 states. The result: Many key questions remain unanswered.

Thus a law written in secret is being implemented in secret, with a maximum of opacity and a minimum of accountability from the administration.

This post was originally published at National Review.

Democrats Afraid of Obamacare’s Shadow

Politico reported late last week that Finance Committee Chairman Baucus will not schedule a confirmation hearing for Acting CMS Administrator Marilyn Tavenner.  The article provided some hint as to the reasoning behind the Chairman’s position: “If she [Tavenner] did have a hearing, it would likely be dominated by controversial health reform politics.”  In other words, Chairman Baucus and Democrats are shelving confirmation proceedings for a major Administration post – again – because they don’t want to talk about Obamacare.

As noted above, this isn’t the first time that Democrats have attempted to avoid debating the controversial health care law.  With respect to Tavenner’s predecessor, Donald Berwick, Chairman Baucus could also have called a confirmation hearing any time he liked, but chose not to do so.  Even as liberals alleged that “Republicans refuse[d] to even have [sic] a hearing” about Dr. Berwick, the fact remains that Republicans have no power to block the Senate Finance Committee from moving forward on Berwick’s nomination, Tavenner’s nomination, or any other nomination.

Much as the White House may want to blame Republican obstruction for the delays in confirming a CMS Administrator, the Administration should take a closer look in the mirror at its own party’s actions.  While the White House alleged that Dr. Berwick’s nomination was blocked because senators “put political interests above the best interests of the American people,” it was Democrats who did not want to call a hearing, and were afraid to discuss either Berwick or Obamacare at any point during the second half of 2010, their huge Senate majorities notwithstanding.  Moreover, according to key Democrat staffers, the Administration wanted to appoint a CMS Administrator in 2009, but decided not to, perhaps because it did not want to tell the American people who would actually implement Obamacare prior to its enactment.

Some may find the irony that even as the Administration attempts to sell the unpopular law to the American people, Democrats in Congress appear to have settled on a “Don’t Mention the War” strategy towards the 2700-page legislative behemoth.  Regardless, the net effect will be that unconfirmed bureaucrats have been given control over every American’s health insurance, and a budget larger than the Pentagon’s, for four years without so much as a cursory hearing.

Correcting the Record on the Berwick Nomination

The end of Donald Berwick’s tenure as Centers for Medicare and Medicaid Services Administrator last week has resulted in several news stories, as well as points that need rebutting:

  • First, it is NOT correct to state that “Republicans refuse[d] to even have [sic] a hearing” on Berwick’s confirmation – for Republicans have no power to block the Senate Finance Committee from moving forward on Berwick’s nomination (or any other nomination).  Chairman Baucus could have called a confirmation hearing any time he liked, but chose not to do so.
  • Second, if the White House wants to claim that Berwick’s nomination was blocked because senators “put political interests above the best interests of the American people,” their criticisms should be focused on Democrats who did not want to call a hearing, and were afraid to discuss either Berwick or Obamacare at any point during the second half of 2010, their huge Senate majorities notwithstanding.  The White House should also look in the mirror – because according to key Democrat staffers, the Administration wanted to appoint Berwick in 2009, but decided not to, perhaps because it learned of his controversial views and did not want them publicized in the run-up to Obamacare’s passage.  Berwick had previously committed to delivering a public “point-by-point rebuttal” to his critics, but the New York Times noted this weekend that “for political reasons, the Administration did not want him [Berwick] to defend past statements” regarding rationing and British socialized medicine.  In other words, the White House censored Berwick, thereby playing politics with his nomination.
  • Third, the idea that Republican criticisms of Berwick were based on a “caricature” significantly understates the breadth and scope of Berwick’s comments regarding controversial issues.  In an interview with MSNBC’s Chris Hayes over the weekend, Hayes alleged that opposition to Berwick were based on one article about rationing and one speech about the NHS.  Berwick himself claimed his critics had “a lack of authenticity in inquiry.”  But in reality, the more one inquires into Berwick’s history, the more one finds controversial statements focused on a health system driven by government bureaucracy and centralized planning.  One publicly available document shows not just one article or one speech, but 158 separate quotes over 22 pages, and dozens of articles, highlighting Berwick’s troubling views – none of which have been publicly refuted.  Dr. Berwick wrote articles with such titles as “Cost-Effectiveness Analysis in Pediatric Practice,” which makes one wonder:  If these cost-effectiveness analyses were NOT designed with rationing health care in mind, then what exactly was the point of conducting the analysis in the first place?
  • Fourth, the notion that Republican concerns about Berwick were based upon gamesmanship, and that his nomination was merely “derailed by politics” understates the problematic nature of his nomination.  Berwick himself said this weekend that “I did not even know if I was fit for” the CMS post.  This concern about his managerial skills was shared by others in the health policy sphere, who “voiced concerns that Berwick lacked the administrative background for the position.”  Berwick in a 2006 interview admitted: “Inattention to detail is my biggest defect….I can create a mess.”  Couple his lack of managerial expertise with his controversial – and oft-repeated – views, and there were many substantive reasons, both practical and philosophical, for Republicans to question his nomination, not just a desire to score points.

Finally, it’s worth pointing out that in his New York Times interview, Berwick conceded the health care law remains unpopular: “It’s a complex, complicated law.  To explain it takes a while.  To understand it takes an investment that I’m not sure the man or woman in the street wants to make or ought to make….Somehow we have not put together that story in a way that’s compelling.”  That one of Obamacare’s key implementers, and biggest supporters, acknowledges the public continues to reject the law speaks volumes about the 2700-page measure.

Obama’s “Bait and Switch” on the Berwick Nomination

Late on Friday, John McDonough published a blog post in the Boston Globe entitled “Why Berwick Matters.”  He intended to use the posting as a means to attack Republicans – but in reality his revealing comments unwittingly serve as an indictment of Democrats, Obamacare, and Berwick for political gamesmanship over the nomination.

As many of you know, McDonough served as Sen. Kennedy’s point person on health “reform” through his senior post on the HELP Committee during 2009-10.  It is therefore with a strong insider perspective that McDonough’s post included the following bombshell:

It was a thrilling moment when it became clear that Berwick had been selected by President-elect Barack Obama and the new Secretary of Health & Human Services, Tom Daschle, to run the federal Centers for Medicare and Medicaid Services.  Finally, the key U.S. health agency would be headed by a physician thoroughly committed to fundamental quality and system improvement, as well as patient empowerment.  It was a heady — and short-lived — moment.

If you think the reference to HHS Secretary Daschle was a typo, it wasn’t; the piece continues:

In late January 2009, Daschle’s nomination blew up over his unpaid taxes.  Berwick’s nomination — which would have sailed through an easy confirmation in early 2009 — was held aside while a successor was recruited, and then the Administration began looking at other names.  The health reform legislative campaign provided another reason to delay, and so it was not until April, 2010 that the President nominated Berwick.

In other words, the White House intended to have Berwick head CMS all along – but delayed the nomination until AFTER Obamacare passed, because it knew how controversial he was.  What McDonough’s piece elides over is the fact that Daschle’s withdrawn nomination prompted the new Administration to engage in closer scrutiny of its nominees.  It’s likely that Berwick’s history of support for British socialized medicine – including his comments about the NHS being a “seductress” – emerged at that time.  At which point, according to McDonough’s account, the Administration scrapped the idea of nominating Berwick – at least until AFTER Obamacare passed.  All of which raises the question:  If Berwick was so unpopular that the Administration couldn’t bring itself to nominate Berwick in the light of day – i.e., to make a clear statement before Obamacare passed that Berwick would be the one to implement the law – why was ever he nominated at all?

McDonough concludes his blog post by saying that Senate Republicans engaged in “meaningful disrespect” of the nominee, a similar tone to the White House reaction that said “a small group of senators…[were] putting political interests above the best interests of the American people.”  In reality however, McDonough’s account makes clear that the real disrespect was being driven by the Obama Administration, which refused for political reasons to inform the American people before Obamacare’s enactment that the unpopular health care bill would be implemented by an even more unpopular and controversial appointed bureaucrat.

Donald Berwick’s Greatest Hits

Given Medicare Administrator Berwick’s resignation today, it’s worth remembering some of the highlights (or lowlights) of Berwick’s tenure.  Berwick spent most of his time in a virtual bunker since his controversial recess appointment last July – hiding from reporters’ questions, and going to great lengths to do so.

Recall also that Berwick never responded to substantive document requests related to his nomination either.  Berwick promised Sen. Grassley to release financial statements related to his tenure as the head of the Institute for Healthcare Improvement, only to renege on this promise once he accepted his recess appointment last year.  It remains unclear whether, or what, Berwick was attempting to hide by not disclosing these documents.

Berwick had some “achievements” while at CMS – for instance, a preliminary rule for accountable care organizations so onerous and bureaucratic virtually every health care provider group imaginable promised not to participate.  But it’s worth asking:  If a Medicare Administrator has to go to such seemingly absurd lengths to avoid scrutiny of his own record, did he EVER belong in that role in the first place?  And how does the “most transparent and accountable Administration” justify such conduct?

Donald Berwick’s Tenure Rationed With Our Eyes Open

In a holiday edition of “Take Out the Trash Day,” the Administration announced this afternoon that Medicare Administrator Donald Berwick was resigning effective December 2 (next Friday).  Deputy Administrator Marilyn Tavenner has been nominated to succeed Berwick, whose statements in support of the British single-payer system and “rationing with our eyes open” sparked widespread controversy.

It is of course ironic that given the Administration’s mantra of “We Can’t Wait,” the White House took three years to nominate a Medicare chief who might actually be confirmable.  Recall reports from earlier this year suggesting that even Senate Democrats did not want Berwick’s confirmation to go ahead, as Finance Committee Chairman Baucus refused to schedule a hearing on Berwick’s appointment.

On this day before Thanksgiving, all Americans should give thanks that the Obama Administration finally gave in to political and constitutional realities, and submitted the nomination of a new Medicare Administrator to the Senate.  However, many may still be concerned at the circumstances by which an unconfirmed bureaucrat was given control over every American’s health insurance, and a budget larger than the Pentagon’s, for nearly a year and a half without so much as a cursory confirmation hearing.

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.

Obama’s Next CMS Administrator?

Press reports over the past several months have indicated that Senate Democrats are unlikely to act on the controversial nomination of Dr. Donald Berwick for a full-time appointment as CMS Administrator – in which case Dr. Berwick’s term in office would end with the expiration of his recess appointment next year.  However, the Administration may have found one possible replacement in an unlikely source late last week, when Paul Krugman wrote a column on health care, patients as consumers, and the inevitability of government rationing.  This column should be a must-read for critics of the House Republican budget, as it sets out the only alternative vision developed by Democrats to date – one built around arbitrary rationing by government bureaucrats.  As the below spreadsheet shows, Dr. Krugman’s vision for health care as an outside observer closely aligns with the views of Dr. Berwick, the chief implementer of Democrats’ health care law:

  Paul Krugman Donald Berwick
Patients as Feeble-Minded Consumers “There’s something terribly wrong with the whole notion of patients as ‘consumers’ and health care as simply a financial transaction….Making [health care] decisions intelligently requires a vast amount of specialized knowledge.” “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.”
Need to Enact Caps on Government Health Spending “The point is that choices must be made; one way or another, government spending on health care must be limited.” “The social budget is limited—we have a limited resource pool.”
Bureaucrats Rationing Care “We have to do something about health care costs, which means that we have to find a way to start saying no.” “The decision is not whether or not we will ration care—the decision is whether we will ration with our eyes open.”

Krugman’s broader point is that bureaucrats will have to ration care because patients are incapable of functioning as health care consumers due to the technical nature of health care decisions, many of which are made in emergencies.  A response would go something like this: Of course patients will not function as pure consumers in all circumstances – the heart attack patient will obviously go to whichever emergency room an ambulance takes him.  But as Regina Herzlinger and others have pointed out, a small vanguard of the population functioning as educated consumers can drive important changes within the entire health care system – just as early adopters help spread technological innovations.  Put another way: You may not know the details of how a car works – I sure don’t – but a small percentage of educated consumers, and a ruthlessly competitive marketplace, can easily drive innovation while penalizing firms with lax attention to quality control.  (If Dr. Krugman cares to take issue with that comparison, I would be happy to provide him a copy of the latest innovation in government-run automobile manufacturing, to provide an illustration of what happens when bureaucrats micro-manage car companies, just as he would have bureaucrats micro-manage Medicare.)

The central debate around entitlement reform is whether patients or government bureaucrats will make the critical decisions in health care.  By setting out a vision closely mirroring the Administration’s, in language starker than the President himself has dared to use, Dr. Krugman has helpfully clarified the stakes for patients – and illustrated the fact that the Administration’s version of health “reform” will be far more costly to patients than the President would have most Americans believe.