WASHINGTON — Pro-life groups and other critics who are worried about the specter of health-care rationing attacked the recess appointment of Dr. Donald Berwick, a Harvard professor and pediatrician who was sworn in July 13 as the head of the Centers for Medicare and Medicaid Services of the federal government’s Department of Health and Human Services.
While Berwick’s crusade to improve hospital services has earned national recognition, his past statements of support for health-care rationing and Britain’s government-run system have sparked controversy.
The National Right to Life Committee led the charge against Berwick’s appointment, calling the Harvard physician a “one-man death panel.”
“Dr. Berwick has a long history of advocating governmental rationing of health care, including life-saving medical treatment,” said Burke Balch, director of the Powell Center for Medical Ethics at the National Right to Life Committee. “We are deeply concerned that, in an effort to impose cost controls, he will follow the pattern set by the National Institute for Clinical Excellence in Great Britain [the agency responsible for selecting services covered by the public system] of which he is an avid admirer.”
“The fundamental problem is that the provision of life-saving medical treatment — especially innovative new treatment — is something Dr. Berwick is very skeptical about,” added Balch.
Asked whether Berwick’s previous comments of support for health-care rationing could signal future problems — such as limited access to health services for the elderly, disabled and other vulnerable groups — White House spokesman Reid Cherlin said, “Don Berwick believes deeply in putting the patient first. But the fact is, that isn’t what’s happening in our health-care system today. Right now, it’s the insurance companies that decide what kind of care you can get — and it’s based on what’s best for their bottom line, not what’s best for you.”
Cherlin said that Berwick has “dedicated his career to making the system work better for patients and their families.”
As a recess appointee, Berwick can serve until the end of the 111th Congress this coming January. Obama on July 19 resubmitted his nomination to the Senate, hoping that he will be confirmed permanently.
Berwick’s controversial public record includes this passage from a 1994 article published in the Journal of the American Medical Association: “Most metropolitan areas in the United States should reduce the number of centers engaging in cardiac surgery, high-risk obstetrics, neonatal intensive care, organ transplantation, tertiary cancer care, high-level trauma care, and high-technology imaging.”
In the June 2009 issue of Biotechnology Healthcare, Berwick stated, “The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open.”
The National Catholic Bioethics Center doesn’t comment on political appointments and did not issue a statement regarding Berwick. But Marie Hilliard, its director of bioethics and public policy, underscored the center’s concerns regarding rationed care.
“We have a strong position on rationing: Rationing violates the Hippocratic Oath. Decisions regarding what treatments will be available must remain with the patient. That is what the sacrosanct Hippocratic principles of autonomy and consent are all about,” said Hilliard.
“Granted, there are times when patients might choose things that are not in their best interests, and they can’t expect health-care providers to be entrepreneurs who will address any and every demand,” added Hilliard. “The patient-provider relationship is a covenant relationship in which a dialogue needs to occur regarding beneficial versus burdensome treatment.”
Sister Carol Keehan
The U.S. Conference of Catholic Bishops did not release a formal response to Berwick’s appointment. “We don’t comment on federal appointments,” said spokeswoman Sister Mary Ann Walsh.
During the health-care debate on Capitol Hill, the bishops did not speak out about rationing. In a recent statement, they said that they were “clear in calling for health-care reform as a moral imperative and urgent national priority.”
“We called for reform that would make health coverage affordable for the poor and needy, moving our society substantially toward the goal of universal coverage,” the statement read. “We were equally clear in stating that this must be done in accord with the dignity of each and every human person, showing full respect for the life, health and conscience of all.”
But the bishops set a higher priority on conscience protections and an ironclad ban on federal funding of abortion. When these concerns were excluded from the bill’s final language, they announced, with clear regret, that they would oppose passage of the health bill.
But while the bishops’ conference stayed on the sidelines of the debate fueled by Berwick’s appointment, Daughter of Charity Sister Carol Keehan, president of the Catholic Health Association, publicly applauded his selection.
This spring, Sister Carol antagonized conference leadership when she backed the health bill during the final week of the bruising legislative battle. Pro-life groups quickly attacked her endorsement of Berwick.
But Sister Carol insisted that Berwick’s critics soon would learn to trust his judgment, and she applauded his record of helping hospitals reduce infections and improve the quality of their services.
“When it comes to Berwick’s commitment to the quality of care — when he says that every patient/physician encounter should be of high, consistent quality — that’s pro-life,” said Sister Carol.
She contended that critics who worried about health-care rationing ignored the brutal reality of American health care.
“We have the worst rationing of health care of any industrialized nation: When you get told you need surgery, you have to ask your insurance company, ‘May I?’ And if you don’t have insurance, you need to find a program for the poor. We have terrible rationing right now.”
But other experts argued that the vulnerable fare much better in America’s multipayer health-care system, despite its limitations.
“One of the biggest problems with the ‘single-payer system’ is that it will quickly move into issuing mandates for participation. We have to consider the vulnerability of Catholic health care: What will be the implications for participation?” asked Marie Hilliard of the National Catholic Bioethics Center.
Berwick now directs an annual budget that exceeds $800 billion and covers more than 90 million people. He possesses broad authority to interpret the new bill’s complex guidelines and mandated goals, from the inclusion of 16 million additional Medicaid enrollees to the reduction of $500 billion in Medicare payments within 10 years.
The recess appointment allowed President Obama to avoid the spectacle of contentious Senate confirmation hearings. Republicans had signaled they would fight the physician’s confirmation, and the Senate’s minority leader, Mitch McConnell, labeled Berwick as an “expert on rationing.”
The White House, in turn, had accused the GOP of unnecessary obstructionism, and noted that almost 200 nominees still await Senate confirmation. But when the recess appointment was announced, Sen. Max Baucus, D-Mont., the Finance Committee chairman, signaled his displeasure with the move.
Critics of the new health-care bill have argued that uniform rationed care will be an inevitable outcome of government-controlled mandates. During the long debate on Capitol Hill, the White House disputed this prediction.
Now, Berwick’s appointment has reignited those concerns. In a 2008 speech delivered in Britain, he lauded its health-care system and criticized America’s approach as fragmented and lacking accountability.
“Trust transparency; trust the wisdom of the informed public; but, do not trust market forces to give you the system you need,” he said. “I favor expanding choices. But 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.”
This is the kind of talk that worries opponents of government-rationed care and single-payer systems. Now that Berwick is securely in place — at least through 2010 — critics see no immediate opportunity to challenge a vision of health care that will reshape the American landscape.
“They are trying to avoid a debate on how to handle these very difficult issues around cost,” contended James Capretta, who worked on health-care issues in the George W. Bush administration and now serves as a fellow for the Ethics and Public Policy Center in Washington, D.C.
“They have a distinct point of view, and Berwick perfectly represents it,” Capretta said. “The federal government has the capacity and responsibility to manage cost reduction.”
Joan Frawley Desmond
writes from Washington.