Observations Yankee Doodling

The rise and likely fall of Don Berwick

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1640 (Published 14 March 2011) Cite this as: BMJ 2011;342:d1640
  1. Douglas Kamerow, chief scientist, RTI International, and associate editor, BMJ
  1. dkamerow{at}rti.org

Failure to reappoint the Medicare chief will be a disappointment. What can be learnt?

Democrats have given up hope of saving Donald Berwick, the current director of the influential and costly US Medicare and Medicaid health insurance programmes. He is now likely to lose his job at the end of the year. It is a disturbing and discouraging development, worth reviewing for possible lessons learnt.

The Centers for Medicare and Medicaid Services (officially abbreviated, incorrectly, as CMS) is the proverbial 800 pound gorilla of US healthcare. Its Medicare programme pays for care for Americans aged 65 or older, and its state based Medicaid programme covers uninsured poor people. More than 100 million US citizens have CMS administered insurance. The administration asked Congress for just under $850bn (£530bn; €615bn) to fund CMS next year, and its programmes are growing as the United States ages and more poor people are covered under the health reform’s Affordable Care Act.

In addition to its direct role in paying hospitals and doctors for care, CMS has a huge influence on private sector insurance as well. Because of its size, CMS sets standards for coverage policies and payment levels that are almost universally adopted (or at least adapted) by private health plans and insurance companies. So the head of CMS (in government speak, the administrator) is an important position indeed.

Soon after his election in 2008 President Barack Obama made many key appointments in the health sector, but he chose not to appoint a CMS administrator. Once health reform was passed by Congress last March it became even more vital to have someone running CMS. Finally, a month later, President Obama nominated Berwick to be CMS administrator.

It is hard to imagine a more inspiring, exciting, and forward looking nominee than Don Berwick. His experience in improving quality and safety in hospitals and medical practices would seem to be exactly what the huge federal systems needed, not to mention his charismatic leadership style. Berwick is a paediatrician who has spent much of his career focusing on improving the quality and safety of healthcare. I first met and worked with Don in the early 1990s, when he was vice chairman of the US Preventive Services Task Force. It was clear then that he was a brilliant thinker and a dynamic, even inspirational, leader. He went on to found and lead the Institute for Healthcare Improvement, a private, not for profit organisation that works with hospitals, health systems, and practices to find measurable ways to improve quality and safety and cut waste and needless expense. He also coauthored two hugely influential reports from the US Institute of Medicine, To Err is Human and Crossing the Quality Chasm.

Senate confirmation is required for appointments at this level, but the necessary hearings for Berwick were never scheduled. The administration blamed Congress, saying that it had delayed considering the appointment for political reasons. Not at all, responded Congress, in turn blaming the administration and Berwick for dragging their feet in providing necessary background information. The nomination went nowhere.

In July, tired of waiting, the president bypassed the Senate’s confirmation powers by using a mechanism called a “recess appointment” to install Berwick as CMS administrator unilaterally. This loophole, roundly condemned and yet widely used by all presidents, was designed to keep the government running during long periods in which the Congress was not in session. President Obama appointed Berwick during the week long 4 July break, hardly meeting the intent of a recess appointment.

Republicans were incensed, and many Democrats were disappointed that they did not have a chance to question Berwick before he took office. It is easy to find quotations from Berwick’s long career that upset conservative, free market Republicans, including discussions of how the US already rations healthcare and praise for the many accomplishments of the UK’s National Health Service.

Recess appointments expire with the end of a two year congressional session, in this case December 2011. Presumably the administration hoped that Berwick could mend fences with enough Republicans to allow him to be renominated and (this time) properly confirmed by the Senate before then. It hasn’t happened. On 1 March, 42 Republican Senators wrote to Obama to urge him to withdraw Berwick’s renomination because of the way in which he was appointed the first time, the now expanded role of CMS under health reform, and his “lack of experience” and prior “controversial statements.”

How could this have happened? A visionary nominee, thought by many to be one of Obama’s best appointments, who was endorsed by medical organisations, public health leaders, hospitals, and virtually everyone else in organised healthcare, is going to be scuttled after 18 months in office.

Perhaps it couldn’t have been avoided, as the poisonous atmosphere between Republicans and Democrats seems to intrude at every level, especially where healthcare reform is concerned and given the many new Tea Party members of Congress. But maybe the president should not have waited until reform had passed to name his CMS leader, and maybe he should not have used the recess appointment to install him without hearings. It may have taken longer to get him into office, but perhaps Berwick would have ended up with more time—more than the 18 months he will likely have—to make the changes he needs and wants to make in the US healthcare system.

As the Washington Post pundit Ezra Klein said, Berwick and the Medicare and Medicaid recipients he could have helped deserved better than this.


Cite this as: BMJ 2011;342:d1640

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