Don Berwick on Defense

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If Don Berwick’s first appearance before a hostile congressional committee is any indication, there is no way the Medicare/Medicaid chief will ever earn the support of enough Republicans to be confirmed by the U.S. Senate.

Berwick, installed via recess appointment last July, gave testimony and took questions from members of the GOP-controlled House Ways & Means committee on Thursday. It was his second trip to the hill; a few months ago, he took questions from members of the Senate Finance Committee, where Democrats are in the majority. Thursday’s hearing was contentious from the very first lines of inquiry from new Chairman Rep. Dave Camp. Is Britain’s National Health Service (NHS) – a single payer system with a reputation for rationing – a good model for the U.S.? Is Berwick still “in love” with the NHS, as he has said in the past? Is competition in health care a bad thing?

Berwick answered none of these questions directly. While he may be an innovative health care policy wonk, there was nothing innovative about his strategy for getting through Thursday’s hearing. In fact, the episode was reminiscent of many such Capitol Hill grillings – it was tiresome political theater in which no one really landed any blows. Berwick deflected and sidestepped most of the grenades lobbed at him by Republican members of the committee. Camp and some other GOP members demanded “yes or no answers,” but Berwick ignored them. When asked about the NHS, for instance, Berwick said, “America needs and American solution…There are strengths and weaknesses in every country’s system…we’re on the route to a system that fits our country.”

In reality, Berwick does admire the NHS – for its efficiency and ability to manage and analyze data, in particular. But he wouldn’t admit this Thursday. Instead, he repeatedly stressed his desire to foster “public private partnerships” – essentially the heart of the U.S. health care system.

To be fair, Republican Ways & Means committee members wanted Berwick to defend past quotes and statements, but provided no context. Asked to explain a quote or written statement he supposedly made about preventive medicine being “over-demanded,” Berwick responded, “I’m a pediatrician. I’ve spent my life in prevention.” When his questioner asked again if he stood by his past statement, Berwick responded, “I don’t recognize your quote. I’m telling you what I think.” Rep. Tom Pricetold Berwick, “I think you missed your calling. I think you would have made a great lawyer.”

Read through Berwick’s speeches and journal papers – as I have – and it quickly becomes clear that he’s not a man of absolutes. The NHS has many admirable qualities, but it isn’t right for the U.S. Competition and free market principles are good when they can drive down prices – like for durable medical equipment – but these forces can also put profit ahead of patient care. Some preventive care can save lives and money, but other preventive care is wasteful and unnecessary. These are the kinds of arguments Berwick typically makes, but which apparently had no place before the Ways & Means committee Thursday. Berwick’s goal appeared to be to get through the day without saying anything that could be used against him in a later confirmation hearing. He made a point, in fact, to say, “I abhor rationing. My entire life has been spent opposing rationing.”

(Berwick was recently appointed by the Obama Administration and presumably will be put through the formal confirmation process before his recess appointment expires at the end of the year.)

Democrats on the committee tossed Berwick softballs that he handled easily. Minority members thanked him for his “candor” and asked him to explain the virtues of the Affordable Care Act. When it came time for Rep. Charlie Rangel to ask questions, he said, “I want to thank the Republican majority for giving us an opportunity to not only defend the bill…but to point out in the short and long run this is best for our nation.” Rep. John Lewis said, he “loved” Berwick’s testimony and asked the Medicare/Medicaid administrator how the ACA will help poor people.