Don Berwick Becomes Part of the Problem

According to the New York Times, a "recess appointment" will be used to install Don Berwick as the CMS Administrator. It seems this was the only way the Obama Administration could bypass those obstreperous Senate Republicans, who were apparently planning to abuse the confirmation process with toxic puffery, "gotcha" politics and other forms of unpleasantness.

There are plenty of good arguments in favor of the recess appointment, including fixing an obvious leadership vacuum at the worlds largest health insurer, accessing Dr. Berwick's considerable skills in implementing countless details of the Affordable Care Act (ACA) and capitalizing on his widespread support from the multiple corners of the health care industry. As my liberal colleagues like to point out here and here, this is also an opportunity for the Administration put its reasonable centrism on display while reminding its base of its commitment to health reform and simultaneously poking the eye of a bullying opposition.

While the non-liberal contrarian Disease Management Care Blog was among the first to endorse Dr. Berwick, it respectfully if naively disagrees with the strategy of a recess appointment. Here's why:

1. The Body Politic: While he's well known among physician and policy types, this was an opportunity to use a visible forum to introduce Dr. Berwick to other constituencies less familiar with him and his important ideas. Our nation's healthcare dialog did not end with the passage of ACA.

2. Transparency: Dr. Berwick's academic record, obvious leadership record and considerable rhetorical skills are more than a match for the Senate's scrutiny. Who is afraid of who?

3. Seizing the High Road (OK, it is the oxymoron of politics, but....): Republicans threatening to behave badly and remind Americans about their dysfunctions is a problem for the Democrats? In the few months until the election, it may be time for the Dems to start rolling the dice on acting honorably.

4. It stinks! Speaking of dysfunction, is the outcome of expediency worth short circuiting merits of a Senate supermajority? Will Dr. Berwick's credibility over the next two years be hampered by the recess appoointment? The Obama Administration is one-upping the opposition's political maneuvering with their own. The whole thing brings discredit to both parties.

5. Bloggery: The confirmation hearings promised to be a cornucopia of detailed analysis, second guessing and extreme wonkism. Darn.

Of course, even the DMCB isn't too sure that, if it were Dr. Berwick, it would have been able to resist the sure bet of a recess appointment in lieu of bruising Senate confirmation. There's something to be said, however, for the selfless heroism of the third option: respectfully declining the CMS post with the option of reconsidering when one of three things happen: 1) both sides get serious about putting the people's business over politics or 2) the bums get replaced by politicians who know how to compromise or 3) the Feds realize that intelligently centrally controlling health care is a myth.

Unfortunately, accepting the recess appointment continues business as usual.

As for things changing, the DMCB isn't holding its breath.

Coda: It didn't occur to the DMCB that the confirmation process posed election risks for some incumbent Democratic Senators. One small consolation is that at least Senator Baucus (D-MT) understands the bigger picture.

Six Reasons Why the Senate Republican Leadership Should Approve Dr. Berwick's Nomination to Lead CMS - An Open Letter

Dear Senate Republican Leadership:

You have the Disease Management Care Blog's sympathy. Despite your Verdun-style stand, Mr. Obama and his Democratic allies passed health reform and, to add insult to injury, convinced some voters that they may know how to govern after all. In the meantime, there's the toxic contamination of those wacky tea baggers, expensed soirees at clubs of dubious reputation, Sarah Palin’s unending media presence and generalized voter animus. Under these trying circumstances, who can blame you for planning to hunker down until the November election and lob filibustering daisy cutter neutron bombs that uniformly kill all Democratic-inspired appropriations, deals, legislation and nominees.

Yet, on the matter of Donald Berwick MD's apparent nomination to CMS Administrator, you may want to calibrate your scorched earth approach.* The DMCB is at your service with some unsolicited advice on three reasons why you may have no choice but to go along. Be of good cheer, however, because the DMCB says are three ways to turn this to your advantage.

No Choice

1. It's hard to underestimate St. Berwick's standing in the healthcare community. Don't be fooled by their faux-cooperation with the President, who is holding them hostage with the repugnant SGR threat and back-room deals. They don't like the Democrats but, if you block the nomination, they will be again reminded how little they like you.

2. You're trapped. Dr. Berwick's tireless advocacy on behalf of consumers is a David vs. Goliath story that will used by Mr. Axelrod et al to portray you as being on the wrong side of history. While letting the nomination go though may end up making you look feeble, the political calculus suggests you need to take the lesser of two evils.

3. The Medicare Constituency. Most Americans couldn't care less about the filibustering or recess appointment of nominees for offices like the Under Vice-Secretary for Budgetary, Fiscal and Dress-Code Affairs at the Office for Import and Lavatory Safety and Integrity in the Deparment of Commerce. In fact, we think it might actually save money. Medicare, however, is different. Blocking a CMS Administrator may needlessly provoke the seniors who are paying attention.

Turn this to your advantage by.....

1. Being Clinonesque. Recall how your nemesis co-opted your ideas when "he took the center?" While Dr. Berwick is by no means a centrist (more on that below), announcing that Dr. Berwick's selection for CMS Administrator fits with your vision for America will help you regain the center. Mr. Obama will not be helped when you publicly congratulate him and his advisors for finally making a selection that fits with your conservative principles.

2. Considering it as a non-event? CMS is a huge bureaucracy and, thanks to the passage of health reform, has an impossibly unwieldy mandate. On top of that, Dr. Berwick has little experience in health insurance and will have an imperial boss. While the last confirmed CMS Adminstrator showed how powerful the office can be, it's possible that kicking Dr. Berwick upstairs into CMS bureaucracy will dilute any negative impact he might have. The DMCB doesnt think so, because it is......

3. Banking on Dr. Berwick being a greater long-term risk for the Administration. The DMCB says this with only the greatest respect. but there must be a reason why he had to start his own not-for-profit. Don't be fooled by the left's elitist ardor for him: this is an apolitical extremist maverick that is fed up with many of the same dysfunctions in the health system that also vex the Republicans. With his ascent into the head office at CMS, Dr. Berwick will undoubtedly discover much of the truth behind the The Gipper's famous quote. When he does, the DMCB suspects he'll be a bigger headache for his handlers than for you.

In fact, the DMCB thinks it's not unreasonable to believe that if we had a Republican Administration and majorities in both Houses of Congress, you could have just as easily nominated Dr. Berwick to the irritation of your Democratic opponents. Comfort yourselves by pretending it is so and cheer him on.

Oh, one more thing. Last but not least, politics aside, Dr. Berwick simply represents a right thing to for Medicare and Medicaid beneficiaries. If he lives up to his potential, we'll all be better off for it.

Sincerely yours,

The Disease Management Care Blog

*Hat Tip to Maggie's HealthBeatBlog

A Raw Political Analysis of the Nomination of Donald Berwick to Lead CMS

The Institute for Healthcare Improvement's Don Berwick MD has reportedly been tapped by the Obama Administration to be the Administrator for CMS. Like other denizens of the health policy bogmos (here, here and here), the Disease Management Care Blog is a big fan of Dr. Berwick's. Anyone who has done anything about health care quality, patient empowerment, systems of care, access disparities and health care value has certainly read his articles and heard him speak. He has been a tireless advocate on behalf of righting what is wrong with the system and the DMCB wishes him all the luck in the world.

He's really going to need it when it comes to his Senate confirmation.

The DMCB recalls this article suggesting that the White House seems to have two complimentary styles. On one side is the pragmatic Chief of Staff Emanuel Rahm, while on the other is the partisan top aide David Axelrod. While Mr. Rahm was urging caution on health reform following Republican Scott Brown's Senate victory, it was apparently Mr. Axelrod that successfully argued for a full court press. The rest is, as they say, history. Reform passed, leaving the Democrats resurgent and Mr. Axelrod's role intact.

In the meantime, the Republicans are in no mood to cooperate in any way. The DMCB agrees with the pundits who say the Republican game plan is to resist every Obama initiative until the November elections, hoping that's when they can capitalize on voter anger and further reduce the Democratic Senate majority and maybe even take control of the House of the Representatives.

Which leads us back to the iconoclastic and 'extremist' and outspoken Dr. Berwick. This is less about him and more about boxing in the Republican minority.

Which leads the DMCB to a prediction.

While Dr. Berwick is a genius, he may also be part of David Axelrod's purposeful political calculus that is now practically inviting the Senate Republicans to publicly stymie the able and widely admired Dr. Berwick's appointment to CMS. In fact, Harvard's Dr. Berwick has written and spoken so extensively that there should be little problem for some Senate staffers to find some juicy quotes to take out of context. This will prompt the usual D.C atmospherics that will leave both parties bloodied and each believing that the other lost more support. Scott Brown of Massachusetts may also be squeezed with some tough lose-lose decision-making. In the end, and assuming Dr. Berwick hangs in there, there'll be a recess appointment.

Until then, it will be business-as-usual at CMS. Unfortunately, it will also be business-as-usual in Congress.