“Rationing” is Back!

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If you’re still mourning the loss of the health care debate’s heated rhetoric, don’t despair. It’s about to get another lease on life thanks to the upcoming confirmation hearing for Donald Berwick, Obama pick to head the Centers for Medicare and Medicaid Services.

This is a powerful position within the Department of Health and Human Services under normal circumstances. But it’s even more important now because whoever holds the job will oversee the huge expansion of Medicaid, cuts in Medicare and cost-control pilot projects called for under the reform law. Republicans are gearing up for what promises to be a very contentious hearing. Yesterday, Senate Minority Leader Mitch McConnell said on the Senate floor that Berwick is “an expert on rationing.”

The reason? Berwick is, by all accounts, a huge fan of the National Health Service, Britain’s single-payer health care system. During the health reform debate, NHS was a dirty acronym associated with rationing and horror stories of patients denied needed care due to cost. The NHS is far from perfect, but it does, by World Health Organization measures, provide generally better overall care to the entire population of the UK than the U.S. system at a fraction of the per capita cost. (See a helpful list of FAQs about the NHS from my London-based colleague Eben Harrell here.)

The White House could have chosen to defend the NHS or explain major difference between it and the U.S. health care—the NHS is entirely government-run, for instance, while the U.S. system includes a gigantic web of private insurers, private hospitals and private doctors. Instead, the White House and Congressional Democrats generally avoided talking about the system at all. (Comparisons between the Democratic health plan and the NHS were based on the notion—pushed by the right—that reform was a stealthy first step toward a system modeled on the NHS.)

Well thanks to Berwick’s numerous endorsements of the NHS, the system could be front and center in his upcoming confirmation hearing before the Senate Finance Committee. (A date for the hearing has not yet been set.)

A memo from the Republican Policy Committee makes it clear that GOP Senators plan to associate Berwick with the NHS and, by extension, rationing and the redistribution of wealth. Berwick himself has said, “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 the less fortunate. Excellent health care is by definition redistributional.”


Fitting so neatly into the narrative that Obama is an ardent fan of redistribution—remember Joe the Plumber?—this quote is sure to be hashed and rehashed in the coming weeks.

But maybe with the old health reform debate a moot point—the bill is already law, after all—things will go differently than they did in 2009 and early 2010. Berwick, rather than shy away from an association with the NHS, has repeatedly and forcefully spoken about its virtues. A thorough piece by Philip Klein in the American Spectator today runs through a long list of instances Berwick has talked about the NHS, the per capita cost of care and paying providers for quality based on government standards. Berwick’s stance on these issues is no secret.

As he says in the video above, Berwick believes health care is a human right and systems—like taxation—are a valid means to ensure everyone gets it. He believes the NHS successfully delivers care to the UK, although it could be better. (In the speech excerpted above, Berwick also said “even at age 60, the NHS seems still immature, adolescent, searching.”) Berwick believes there is a tremendous amount of waste in the U.S. health care system that can be reduced through government policies, beginning with Medicare reform. At the same time, he believes patients should have more control over their medical destinies. Marrying these beliefs together into a philosophy that’s politically viable, morally defensible and fiscally responsible would be Berwick’s challenge as the head of CMS— if he can get through his confirmation hearing.

It should also be noted that Berwick, who works at Harvard Medical School, is widely respected in the health policy community. His stance that money can be saved and patients better served by rewarding performance over quantity is shared by most top policy experts consulted by the Administration in the ramp up to the vote on health reform. A community disagrees with Berwick’s methods for achieving this—including most Republicans and some health policy conservatives—but he is not a radical outlier. What he is is outspoken.