Opinion Column

The Donald Berwick Predicament

Dr. Donald Berwick runs the Centers for Medicare & Medicaid Services. He now serves under a recess appointment that will expire at the end of this year. And, although the president could take the politically risky step of extending his tenure with another recess appointment, officially naming him to run the agency for the long haul would require Senate confirmation. News reports suggest that this won’t happen. Berwick may not even receive a hearing.

We can’t evaluate the backstage politics, but one thing is certain. Both Democrats and Republicans should be dismayed at the sight of a partisan campaign driving yet another distinguished figure out of American government.

In a recent letter, 42 Republican senators harshly urged that Berwick’s permanent nomination by withdrawn, citing his “lack of experience in the areas of health plan operations and insurance regulation” as well as “his record of controversial statements and general lack of experience managing an organization as large and complex as CMS.” Because 42 votes is enough to block his approval, Berwick has been described by some as a bureaucratic dead man walking. As one supporter told the New York Times: “Everybody here admires Don and the work he’s done, but he is not going to be confirmed. That’s inevitable. … There’s not a lot of optimism that the White House can do anything about it.”

You might think there is some genuine issue regarding Berwick’s professional stature, his experience, his integrity or his job performance. There isn’t - any more than there is such an issue regarding whether Federal Reserve Board nominee (and Nobel Prize-winning economist) Peter Diamond has sufficient experience in monetary policy.

Berwick has greater management experience than many previous CMS administrators. Few have matched his knowledge of the American health care system or his high standing within the medical profession. He is one of the world’s leading experts in patient safety and quality improvement. A pediatrician and health policy researcher, he has authored hundreds of scholarly articles. He has spent decades in the trenches of the American health care system seeking to improve it.

In 1999, he co-founded the Institute for Healthcare Improvement, which has provided guidance in the U.S. and abroad regarding strategies to improve health outcomes. Most famous is the 100,000 lives campaign, which disseminates best practices to prevent hospital-acquired infections and avoidable deaths.

He is intimately familiar with many of the nation’s best (and worst) health care organizations. The new federal health law finances critical demonstration projects to expand coverage, improve chronic disease management and to improve care quality. He has virtually unique credibility among physicians, hospital leaders and health services researchers in leading these efforts.

He is exactly the type of health policy wonk who, if circumstances were different, might have been appointed to the same job under a Republican administration. Thomas Scully, CMS administrator under President George W. Bush, got to the nub of things: “He’s universally regarded and a thoughtful guy who is not partisan. … You could nominate Gandhi to be head of CMS and that would be controversial right now.” Berwick’s nomination was supported by Gail Wilensky and Mark McClellan, two prominent Republicans who ran CMS in two Bush administrations.

But, like every seasoned and serious health policy researcher, he has provided a few sound bites that political operatives can spin in a systemic campaign to depict him as a left-wing figure. For example, Berwick recommended that physicians “reduce the use of unwanted and ineffective medical procedures at the end of life.” One can present such statements as supporting death panels. In fact, these comments reflect a sensible and humane perspective shared by most physicians who provide end-of-life care.

President Barack Obama’s adversaries are pursuing Berwick because he provides a valuable political scalp in attacking the health law. Last year, opponents of the measure waged a deliberate campaign against him immediately following its passage. In this climate, the most likely outcome of Berwick’s nomination would have been for it to linger for months and then to finally die under a filibuster. Rather than see this happen and to waste months in the implementation of one of the most complicated policy reforms in American history, Obama gave Berwick a recess appointment.

Though not ideal, this was the proper response to escalating, bluntly partisan abuses of the Senate confirmation process. The proper purpose of the confirmation process is to scrutinize nominees, to question them and then to approve or reject them through an up-or-down vote. If senators continue to exploit ossified procedures to simply obstruct opposing administrations, presidents of both parties will pursue recess appointments with greater frequency.

They will be right to do so. Berwick serves a Democratic administration, but you can bet that policy experts in the next Republican administration will receive similar rough handling. Imagine what skilled Democratic operatives could do to any Republican nominee who had genuine private-sector “experience in the areas of health plan operations and insurance regulation,” say because they worked for an insurer or an HMO.

Imagine what would happen if Democrats were to pursue the same sound-bite fishing expedition that was pursued against Berwick. He stands accused of praising Britain’s National Institute for Health and Clinical Excellence (NICE), which examines which therapies the National Health Service should finance based on efficacy and cost-effectiveness. McClellan praised NICE’s approach in rather similar terms in addressing America’s escalating medical expenditures.

Does this mean that McClellan supports death panels and rationing? No. Virtually any policy expert who has had the courage to discuss delicate issues of financing, palliative care or cost control has said something that can be ripped out of context and used to politically embarrass or destroy them.

Politics is a rough business. Some rough and tumble personal criticisms come with the territory. Still, the long-run consequences of blocking a highly-qualified official such as Berwick are quite damaging - especially at this critical point in time.

As the new health reform law is implemented, it will require many adjustments and fixes along the way. Much public attention is focused on ideological differences between Democrats and Republicans regarding expanded coverage, the accompanying taxation, and more. Alongside the ideological divide, it also poses technical challenges that are less ideological but no less difficult to resolve.

The Obama administration will need to work with the states and with both parties in Congress to implement health insurance exchanges, to regulate insurers, to expand Medicaid and more. This won’t be easy. It will require good faith collaboration in a very difficult and polarized national moment. This task will also require public managers and policy experts on both sides of the table who have the experiences, the professional standing and the expertise to get the work done.

Our worst fear is that the people best-equipped to do these jobs will view Berwick’s predicament and decide: It just isn’t worth it. After all, people at Berwick’s or McClellan’s level can pursue many other lucrative and challenging opportunities that bring a lot less trouble and stress. For government to succeed, we need such experts who can do their work at least somewhat shielded from the immediate partisan fray.

Our cable-TV political culture provides too little space for this. If we don’t fix this, we will all come to regret it.