Rationing Debate

The case for and against President Obama's newest health care administrator.


If government-run health care is such a bad thing—at once too expensive, too impersonal, and too ineffective—shouldn't those who oppose it want to see the government's major health care payment systems run by someone who has single-mindedly devoted himself to cutting costs, focusing on patients, and improving health outcomes?

Dr. Donald Berwick, President Obama's appointee to run the Centers for Medicare and Medicaid Services (CMS), is, judging by his record, just such an individual. And yet his appointment generated enough early opposition, mainly from those who favor a limited role for the government in health care, that the White House took the controversial step of nominating him during a congressional recess. That means Berwick gets to serve for a year without the Senate's vote of approval—and, perhaps more importantly, without a public hearing. Yes, there are legitimate reasons to be concerned about Berwick's appointment and the signals sent by the White House's decision to avoid public debate. But within the bounds of political possibility, there are also reasons to think that he might be just the man for the job.

A Harvard triple-graduate, Berwick helped pioneer the study of health care delivery system reforms and has earned a reputation as a driven, outspoken wonk. Since the 1980s, he has made cutting waste from health care systems—and in particular, cutting costs without diminishing quality of care—a central goal in his professional life. In a July 2008 speech about Britain's National Health Service (NHS), he declared that health providers should make it a priority to "[customize] care literally to the level of the individual." In an op-ed for The Boston Globe, he rejected the idea of reducing expenditures through mindless cuts to service, writing that "[making] care less expensive and worse at the same time…is neither necessary nor worthy of us."

Berwick, though, has run into trouble largely because he's spoken highly of the National Health Service, Britain's socialized medical system. But it's to be expected that a Democratic president would pick a fan of government health care to oversee the nation's biggest government health care programs. As head of CMS, it will be Berwick's responsibility to prepare Medicare and Medicaid for the massive changes called for by the recent federal health care overhaul, including more than $400 billion in cuts to the former and the addition of an estimated 16 million new enrollees to the latter. Given the fiscal stakes riding on the future of these programs—according to the Congressional Budget Office, health care costs are the chief contributor to our fiscal woes—isn't it preferable to have them led by someone whose stated goal is to keep them running efficiently, and for less money?

Like it or not, Medicare and Medicaid aren't going anywhere. As long as that's true, we may as well have a devoted cost-cutter and health optimizer like Berwick at the reins. Far better that than the alternative—a political panderer with little actual interest in containing the health system's bloat or addressing its inadequate health outcomes.

No, if there's a reason to worry about Berwick, it's that although he's expressed a preference for limiting the resources consumed by government health care systems, he's also stated a strong desire to expand their reach and scope. A professed single-payer advocate, he's also a foe of markets and private decision-making. In his speech to the NHS, he declared that he finds "little evidence anywhere that market forces, bluntly used, that is, consumer choice among an array of products with competitors' fighting it out, leads to the health care system you want and need."  And in 1996, as The Wall Street Journal pointed out in a recent editorial, he and Troyenn A. Brennan wrote that health policy should seek "to constrain decentralized, individual decision making" and "to weigh public welfare against the choices of private consumers." Berwick is not merely an advocate of publicly funded health care systems; he believes that it is the purpose of those systems to exercise a controlling influence on private markets.

Still, arguably the most worrying thing about Berwick's nomination is not the philosophy he professes, but the method by which he was installed. The White House argued that a recess appointment was necessary to avoid partisan sniping, and to make for a speedy appointment. But the real effect was to stifle debate. Berwick's belief in the power of benevolent bureaucrats to cure our health system's woes represents a significant strain of thinking in American health policy circles. It is not, however, the only strain. Yet, as happened so often throughout last year's health care debate, President Obama has decided not only to ignore opposing ideas about health care, but to effectively pretend that they do not exist. Like Berwick, he has decided that the best way to govern is to make people's choices for them.

Will the American public eventually come to agree with Berwick's ideas about rationing care? Maybe, maybe not. But either way, they ought to be given the opportunity to hear about them first.

Peter Suderman is an associate editor at Reason magazine.