Don Berwick Appointed to Drive Health-Care Changes, Sidestepping Congress

In a key step toward the implementation of his health-care reforms, President Obama has appointed Don Berwick to run the Centers for Medicare and Medicaid Services (CMS) today, sidestepping a bitter confirmation brawl with Congress.

The special recess appointment comes with senators on leave for two weeks. Berwick, a pediatrician, Harvard professor, and president of the Institute for Healthcare Improvement, had been nominated to the position in April. However, no confirmation hearings had yet been scheduled. In recent days, Republicans have blamed the Democratic majority for failing to bring the nomination forward. Meanwhile, Democrats were worried that Republicans would use Berwick's hearings—and in particular, the professor's previously expressed views on health-care rationing—to relitigate the merits of the historic but contentious health-care legislation passed earlier this year.

In his new role, Berwick faces a number of challenges: driving improvements in Medicare quality through programs that may eventually serve as templates nationwide, identifying inefficiency and waste, and working with Congress on the next so-called doc fix to retain reimbursements for doctors who treat Medicare patients.

Berwick's background, which includes stints as chair of the National Advisory Council of the Agency for Healthcare Research and Quality and on the governing council of the Institute of Medicine, indicates his qualifications for the role. Writing for The Washington Post, Ezra Klein describes the 64-year-old as neither liberal or conservative but a "zealot and an entrepreneur when it comes to quality improvement." He also enthuses, "You really could imagine the best young people in the field rushing to work with him, particularly when health care reform is just starting up."

Conservatives, however, have expressed concern about Berwick's views. In a speech in 2008, he admitted he was "in love" with Britain's National Health Service (although he also acknowledged the system contained "warts"). Then last year, in an interview with Biotechology Healthcare, Berwick was asked whether comparative-effectiveness research inevitably leads to rationing. He replied: "We can make a sensible social decision and say, 'Well, at this point, to have access to a particular additional benefit [such as a new drug or medical intervention] is so expensive that our taxpayers have better use for those funds.' We make those decisions all the time. The decision is not whether or not we will ration care—the decision is whether we will ration with our eyes open."

Despite what conservatives might claim, that statement isn't particularly earth-shattering. Rationing, by definition, occurs in any system where health-care resources are limited, regardless of whether that system is privately or publicly funded. Rationing occurs, for example, in Medicare today.

Yet Republicans still might have used the confirmation process to pin down Berwick further on the blurred line between cutting costs and determining when a patient is not worth expensive treatment. Republican Sen. John Barrasso today called the recourse to a recess appointment "an insult to the American people." Michelle Oddis of Human Events adds, "One wonders how breast cancer survivor Rep. Debbie Wasserman Schultz (D.-Fla.) or Sen. Frank Lautenberg (D.-N.J.), who has stomach cancer, feel about Berwick's stance on limiting preventative screening measures for cancer."

The big picture is that CMS has been without a head administrator since 2006. And the administration's health-care reforms, like them or not, are the law of the land. The sooner someone is in place to run them, the more likely they are to work. However, the GOP appears convinced that opposition to the reforms is a winning strategy in the lead-up to November's congressional elections. As Tom Scully, who ran the CMS under President George W. Bush, notes of Berwick's appointment, "You could nominate Gandhi to be head of CMS and that would be controversial right now."