July 11, 2010

July 11, 2010 | Commentary on Medicare, Medicaid/SCHIP

Medicare Chief Favors Rationing

There's a new sheriff in charge of the Centers for Medicare and Medicaid Services: Dr. Donald Berwick.

A former clinical professor of pediatrics and health care policy at Harvard Medical School, Berwick was nominated for post way back in April.

But the Senate never approved the nomination. Indeed, the Democratic-controlled Senate never even scheduled a hearing to discuss President Obama's nomination. Instead, while Congress was away on Fourth of July recess, the president simply appointed Berwick to the post without congressional review and consent.

President Obama justified the action by implying that GOP stonewalling had left him no recourse. "It's unfortunate that at a time when our nation is facing enormous challenges, many in Congress have decided to delay critical nominations for political purposes," he said.

But, as ABC's Jake Tapper pointed out, "Republicans were not delaying or stalling Berwick's nomination. Indeed, they were eager for his hearing, hoping to assail Berwick's past statements about health care rationing and his praise for the British health care system."

What is it about Dr. Berwick that Republicans are eager to discuss and Democrats wish to avoid raising in hearings? For starters, the good doctor has gone on the record -- several times -- as a passionate supporter of socialized medicine, including the cost-containment decisions that come with it. Whether to allow the government to ration or allow individuals to make their health choices isn't even a question for Berwick -- he claims that "the decision is not whether or not we will ration care -- the decision is whether we will ration with our eyes open."

It's not the sound bites that are important here; it's the vision for the U.S. health care system that Berwick has articulated in numerous writings and interviews. In a 2009 interview, Berwick outlined the three most important levels of knowledge to guide medical decision-making. First: whether a health intervention is effective at all. Second, whether it is more or less effective than comparable treatments. And third, whether the benefits of a more effective treatment outweigh additional cost.

None of this is exceptional. There are limited resources, and ordinary Americans realize that there must be trade-offs and tough decisions. But those decisions should be made by patients and their families, in consultation with their physicians -- not by government officials.

Most ordinary Americans are not in favor of denying care to the sick because of the cost of providing it. This was abundantly evident with the public outcry against government rationing which arose while Congress was considering earlier versions of the massive health reform bill passed this March. While the final bill contains significant safeguards against overt rationing, it also created the Patient-Centered Outcomes Research Institute, charged with conducting comparative effectiveness research (CER). Because of that provision, the issue remains unsettled.

The reason: the limitations are not sufficient to ensure the correct use of CER. CER alone would address the second tier of Berwick's decision-making scheme: determining which among several treatments for an illness are most effective. This information would provide a useful tool for care providers to offer better care to their patients.

But the inclusion of cost information could open the door to denying coverage based on cost. Indeed, Sec. 6302 of the health bill claims that the limitations put on the Patient-Centered Outcomes Research Institute "shall not be construed to ... limit the application of differential copayments under [Medicare] based on factors such as cost or type of service ... "

And that brings us back to Berwick. With him at the helm of the two largest public health programs, Medicare and Medicaid, the likelihood of CER being used to deny coverage based on cost becomes ever more worrisome. In his own words, the United States may one day find itself making health decisions based on the question of whether a health intervention "is so expensive that our taxpayers have better use for those funds."

In June of 2009, President Obama told the American Medical Association that "identifying what works is not about dictating what kind of care should be provided." Moreover, the president has assured the public time and again that the government will not get between patients and their doctors. His nomination of Don Berwick for director of CMS, however, tells a different story.

Berwick's nomination was not just fodder for partisan politics. It was about who will fill a critical post that will soon determine the direction of health care of millions of Americans.

Senate conservatives had hoped nomination hearings would provide an opportunity to gain assurances that Dr. Berwick would pursue creation of a health care system that lets patients and doctors decide on the best course of treatment -- case by case -- rather than one in which bureaucrats determine what treatment will be most cost effective in most cases. By making the recess appointment, President Obama has made sure that discussion doesn't take place.

Kathryn Nix is a research assistant in The Heritage Foundation's Center for Health Policy Studies.

About the Author

Kathryn Nix Policy Analyst
Center for Health Policy Studies

First appeared in the Daily Herald