The View From 1776

Read Daniel Henninger’s editorial:

Berwick: Bigger Than Kagan

If the American people want the health-care world Dr. Berwick wishes to give them, that’s their choice. But they must be given that choice.

Barack Obama’s incredible “recess appointment” of Dr. Donald Berwick to head the Centers for Medicare and Medicaid Services (CMS) is probably the most significant domestic-policy personnel decision in a generation. It is more important to the direction of the country than Elena Kagan’s nomination to the Supreme Court.

The court’s decisions are subject to the tempering influence of nine competing minds. Dr. Berwick would direct an agency that has a budget bigger than the Pentagon. Decisions by the CMS shape American medicine.

Dr. Berwick’s ideas on the design and purpose of the U.S. system of medicine aren’t merely about “change.” They would be revolutionary.

One may agree with these views or not, but for the president to tell the American people they have to simply accept this through anything so flaccid as a recess appointment is beyond outrageous. It isn’t acceptable.

The Democratic chairman of the Senate Finance Committee, Max Baucus, was taken aback at the end-around: “Senate confirmation of presidential appointees is an essential process prescribed by the Constitution that serves as a check on executive power.”

Let’s look, then, at what President Obama won’t let the American electorate hear Dr. Berwick say in front of a committee of Congress. These excerpts are from past speeches and articles by Dr. Berwick:

“I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.”

“You cap your health care budget, and you make the political and economic choices you need to make to keep affordability within reach.”

“Please don’t put your faith in market forces. It’s a popular idea: that Adam Smith’s invisible hand would do a better job of designing care than leaders with plans can.”

“Indeed, the Holy Grail of universal coverage in the United States may remain out of reach unless, through rational collective action overriding some individual self-interest, we can reduce per capita costs.”

“It may therefore be necessary to set a legislative target for the growth of spending at 1.5 percentage points below currently projected increases and to grant the federal government the authority to reduce updates in Medicare fees if the target is exceeded.”

“About 8% of GDP is plenty for ‘best known’ care.”

“A progressive policy regime will control and rationalize financing—control supply.”

“The unaided human mind, and the acts of the individual, cannot assure excellence. Health care is a system, and its performance is a systemic property.”

“Health care is a common good—single payer, speaking and buying for the common good.”

“And it’s important also to make health a human right because the main health determinants are not health care but sanitation, nutrition, housing, social justice, employment, and the like.”

“Hence, those working in health care delivery may be faced with situations in which it seems that the best course is to manipulate the flawed system for the benefit of a specific patient or segment of the population, rather than to work to improve the delivery of care for all. Such manipulation produces more flaws, and the downward spiral continues.”

“For-profit, entrepreneurial providers of medical imaging, renal dialysis, and outpatient surgery, for example, may find their business opportunities constrained.”

“One over-demanded service is prevention: annual physicals, screening tests, and other measures that supposedly help catch diseases early.”

“I would place a commitment to excellence—standardization to the best-known method—above clinician autonomy as a rule for care.”

“Health care has taken a century to learn how badly we need the best of Frederick Taylor [the father of scientific management]. If we can’t standardize appropriate parts of our processes to absolute reliability, we cannot approach perfection.”

“Young doctors and nurses should emerge from training understanding the values of standardization and the risks of too great an emphasis on individual autonomy.”

“Political leaders in the Labour Government have become more enamored of the use of market forces and choice as an engine for change, rather than planned, centrally coordinated technical support.”

“The U.K has people in charge of its health care—people with the clear duty and much of the authority to take on the challenge of changing the system as a whole. The U.S. does not.”

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There is no need to rehearse the analogies in literature and social thought that Dr. Berwick’s ideas summon. That the Obama White House would try to push this past public scrutiny with a recess appointment says more about Barack Obama than it does Dr. Berwick.

Vilifying Dr. Berwick alone for his views is in a way beside the point. Within Mr. Obama’s circle they all think like this. Defeat Dr. Berwick, and they will send up 50 more who would pursue the same goals.

If the American people want the world Dr. Berwick wishes to give them, that’s their choice. But they must be given that choice with full, televised confirmation hearings.

Barack Obama, Donald Berwick and the rest may fancy themselves philosopher kings who know what we need without the need to inform or persuade us first. That’s not how it works here. That is Sen. Baucus’s point.

It should be clear why Berwick is bigger than Kagan. We need a large public debate over these views, over what Mr. Obama has said his health plan would and would not do. We need to find out if every Democrat in Congress and every Democrat writing newspaper columns and blogs agrees with Dr. Berwick about clinical and individual autonomy and about leaders with plans.

Then we need to build an election around whether we want to go down the road Dr. Berwick has planned for us, or start dismantling the one that President Obama paved through Congress on a partisan vote.