When President Obama named Dr. Donald Berwick to head the Centers for Medicare and Medicaid (CMS) last March, I wrote this:

“Most who know Berwick describe him a ‘visionary’ and a ‘healer,’ a man able to survey the fragments of a broken health care system and imagine how they could be made whole.  He’s a revolutionary, but he doesn’t rattle cages. He’s not arrogant, and he’s not advocating a government takeover of U.S. health care.”

To understand what I meant, view these clips from the film, Money-Driven Medicine, where Berwick speaks about the need for healthcare reform. Soft-spoken and charismatic, Berwick is as passionate as he is original. His style is colloquial, intimate, and ultimately absolutely riveting. He draws you into his vision, moving your mind from where it was to where it could be.

And now, it appears that we are going to lose him. Thursday, 42 Senators delivered a letter to President Obama demanding that he withdraw his support for Berwick to head CMS. The Boston pediatrician and co-founder of the Institute for Health Care Improvement (IHI) had received a temporary appointment in July while Congress was on vacation. President Obama re-nominated him in January. But Berwick still needs to be confirmed by the Senate, or he will have to leave his post at the end of this year.

With 42 out of 100 Senators firmly opposed to him, it appears that Berwick’s supporters won’t be able to muster the 60 votes needed to clear the Senate floor. Reportedly, Senate liberals already have given up. According to Politico.com’s Brett Coughlin: “At a meeting with Senate staffers Friday, health care lobbyists and advocates were told that there will be no confirmation hearing and that they’ll soon be discussing ‘next steps’ for CMS.”    If this is true, Berwick is now a lame-duck CMS director without power—as of today.

 “Finance Committee Chairman Max Baucus has been mostly silent about the issue,” Coughlin added, “but he told Politico on Thursday that Berwick is Obama’s nominee and ‘it’s his choice.’”
Assuming that Berwick is ousted, Congress will have succeeded in ripping the heart out of health care reform. Can it be replaced? I don’t know. I cannot think of a truly qualified candidate who would take the job.

By “qualified” I mean someone who possesses the knowledge of what needs to be done, the integrity and strength of character to battle the opposition, and the patience, compassion and powers of persuasion to overcome the vitriolic politics of hate that have taken over our government. I am not suggesting that no one could replace Berwick, just that I have a hard time imagining someone in Berwick’s league who would choose to go to Washington, knowing that he will become the conservative’s punching bag.

Today, The New York Times suggested that “Dr. Berwick’s principal deputy, Marilyn B. Tavenner, has emerged as a candidate to succeed him. Lawmakers of both parties said Monday that Ms. Tavenner, a former Virginia secretary of health and human resources with extensive management experience, could probably be confirmed.” While Tavenner is an excellent deputy, she does not possess the strength to quarterback health care reform. This is why conservatives might vote for her. (Never a fan of Berwick, the Times has consistently failed to understand who he is, or the role he would play in health care reform.)

Regular readers know that I am not quick to give up. I was convinced that the Patient Protection and Affordable Care Act would pass. I predicted that Berwick would be appointed, even when things were looking dicey. When you’re fighting a revolution, pessimism is not productive. Cynicism is fatal.

Yet, here is the truth:  Without a powerful, persuasive leader, Medicare will go broke in a matter of years. And if Medicare does not lead the way in breaking the curve of health care inflation, we can forget about affordable health care for everyone. Indeed, we can give up any hope of affordable health care for the middle class and much of the upper-middle class.

But first, is there any way that Berwick can hang on? Today, Reid Cherlin, a White House spokesman, told the New York Times that the president would not withdraw the nomination. “The president nominated Don Berwick because he’s far and away the best person for the job, and he’s already doing stellar work at C.M.S.”  But, the Times added, “It is not clear whether the White House will fight for the nomination or press the Finance Committee to hold a confirmation hearing, which could provide Republicans another opportunity to criticize the new health law.”

Is there a chance that the administration might be able to rescue Berwick by persuading two honest Republicans to break with a lynch mob led by U.S. Senators Orrin Hatch (R-Utah), Ranking Member of the Senate Finance Committee, and Mike Enzi (R-Wyo), Ranking Member of the Senate Health, Education, Labor and Pensions Committee?

After all, five Republicans refused to join the attack on Berwick: Senator Scott Brown, (who supposedly was elected from Massachusetts because of his opposition to the health care law), Maine’s Olympia Snowe and Susan Collins, and Republicans Lisa Murkowski of Alaska and Rob Portman of Ohio all declined to sign the letter. (For a list of those who signed, see the end of this post.)

Could the White House Save Berwick?  “You Know You Can’t Quote Me”

Yesterday, I talked to someone from the administration’s inner circle who knows Berwick and the opposition very well.  When I asked these questions, he laughed (not a happy laugh), and replied:  “You know you can’t quote me.”

This is what he went on to say:

“I don’t think he’s going to stay. The Congressional conservatives think they got screwed in the sense that he was a ‘recess appointment’ and they didn’t have a chance to vote on him. . . . I think the administration doesn’t want it to look as if they are abandoning him, but  . . .”  If Berwick’s backers in the Senate don’t have 60 votes, the White House may not have a choice.

As for my hope that President Obama could talk just two senators into splitting from the Gang of 42, my source—who knows beltway.gang politics far better than I—replied:

“What you don’t realize is that the retribution these guys exact is very high— especially against their own.” Far-right conservatives rely on fear as their weapon of choice—whether striking terror in the hearts of seniors or disciplining their own party members. “Look at Olympia Snowe and the health care bill,” said my source. “She voted for it in committee, but they brought all hell down on her to make sure she voted against it on the floor.”  (Given that experience, it is to Snowe’s great credit that she refused to sign the letter.  At the risk of appearing prejudiced in favor of my gender, I cannot help but note that three of the five who broke ranks with 42 of their colleagues were women. Maybe we need more women in the Senate?)

The law does provide one loophole that might let Berwick remain at CMS. “In reality, Berwick can stay on as acting administrator if he was once again a recess appointee — he just could not be paid for the position, thanks to a 2009 Omnibus Appropriations law,” points out Benjamin Domenech at “Don Berwick Online: Tracking the Controversy.”

But would an unpaid recess appointee have the power to do the job at the Centers for Medicare and Medicaid (CMS).  “He wouldn’t have any authority,” my source said flatly. “They’d skewer him.”
“The most worrisome part” of all of this, he continued, “is that we’re going have serious problems implementing reform through the Centers for Medicare and Medicaid. It’s a bureaucracy that doesn’t like big bold leaps. Housed in Baltimore, it’s not an innovative place. It is very, very cautious. And if you look at things that need to be done, they need to be bold.” This is why I very much doubt that Tavenner would be able to do the job that needs to be done.

    The Back Story: Why Conservatives Want to Oust Berwick

When President Obama first put Berwick’s name forward shortly after passage of the Affordable Care Act last spring, conservatives were bitter over the passage of   reform legislation, and they poured their fury into blocking the appointment—postponing Berwick’s confirmation hearing, while simultaneously spreading lies about him. (For examples of how both conservatives and the media have cherry-pickied what Berwick has said and written, grossly distorting his views, see this post.)

As I wrote at the time, Berwick was highly respected by virtually everyone who knew him—including Republicans:

“He enjoys support that ranges from the AARP to three former directors of the Centers for Medicare and Medicaid (CMS) who served under Republican presidents. ‘This is not really about Don Berwick,’ John Rother, executive vice president for policy and strategy at the AARP told McClatchy Newspapers. ‘In ordinary times, the nomination of somebody with Don's record and standing in the field would not be controversial.’ Thomas Scully, who led the CMS under President George W. Bush agrees: ‘He's universally regarded and a thoughtful guy who is not partisan. I think it's more about … the health care bill. You could nominate Gandhi to be head of CMS and that would be controversial right now.’” (For a profile of Berwick, see this post.) 

As I noted, the American Association of Family Physicians, the American Medical Association, and the American Hospital Association” also offered warm endorsements. . . .  But I added, “The conservatives will do their best to postpone the confirmation hearing. And the longer they defer the hearing, the more time they will have to try to demonize Berwick.” This is precisely what they did.

A hearing would have turned into a Kangaroo Court. Meanwhile, Medicare needed to begin the work of reform as quickly as possible. . President Obama had little choice but to do an end-run around Berwick’s opponents by making a temporary appointment in July while Congress was on vacation. Presumably the hope was that by 2011, the opposition’s anger over the passage of health care reform would have faded. But hell hath no fury like that of right wing extremists scorned. They believe that they represent what is Right and True, and thus, should always win.

Now, Senator Enzin, one of the leaders of the group that  sent a letter to President Obama last week, has  made it clear that they will not even consider Berwick as a nominee. In the past, skeptics claimed that they simply wanted Berwick to answer their questions. But at this point, they say that they will only entertain a candidate who agrees to “compromise” with them: “The President should start with a clean slate and send the Senate a nominee who is willing to answer our questions and seek our bipartisan support as he or she leads CMS in implementing the new health care law.”

Translation: President Obama should send us someone willing to reform Medicare Our Way.

      Why Medicare Reform is Essential to Health Care Reform

The consensus among healthcare reformers is that one-third of Medicare dollars are squandered on procedures and products that provide little or no benefit for the  patient.  In our hospitals, preventable medical errors and acccidents add to the waste.  And it doesn't matter whether Medicare or a private insurers is payingthe bills:  health care spending in the private sector is no more efficient. The cost of care has been spiraling at roughly the same rate, both in the public sector and in the private sector for the past twenty years. Medicare desperately needs to change how it pays for care and what it pays for. If CMS takes the lead, and provides political cover, private sector insurers have said that they will follow. This is the only way that we, as a nation, can hope to make health care affordable.

Government now covers well over 50 percent of all doctors’ bills, hospital charges, prescription drugs and other health care expenses in this country. As a result, only the Centers for Medicare and Medicaid (CMS) enjoy the market clout to insist on value for our health care dollars. Even the largest private insurer does not possess comparable power.

No hospital could stay open without Medicare patients. No drug company could turn a profit without reimbursements from CMS. A relatively small number of doctors might be able to refuse Medicare and thrive by offering concierge medicine to  affluent younger patients.  But what would happen when their patients needed to be admitted to the hospital?

Without reform, a concierge doctor’s patients would be exposed to the same high rates of errors, infections and accidents that threaten all hospital patients today. As one specialist who cares for the very wealthy (and does not accept insurance), said to me not too long ago: “It doesn’t matter who you are—or how much money you have—you don’t want to be in any of Manhattan’s hospitals.” 

Nevertheless, conservatives are dead set against reining in health care inflation by excising waste and errors from our health care system because that would mean cutting into the incomes of the many industry lobbyists who feed at the trough of overtreatment. They argue that “more care is always better care. We can’t spend too much on health care. If we trim spending, we’ll stifle innovation.”

Rather than cutting Medicare spending, conservatives would prefer to shift the cost of Medicare to seniors, raising their co-pays and deductibles, while continuing to over-pay for diagnostic tests,  surgeries and treatments that put patiients at risk without benefit.  This would means that many middle-class Medicare patients who live on roughly $20,000 a year (median income for seniors, including Social Security and all other sources of income), wouldn'tt e able to use Medicare: they couldn’t afford to cover the out-of-pocket payments.

In the end, many of Berwick’s opponents would like to simply privatize Medicare, turning it over to private-sector insurers who would offer “bait and switch policies” as they have in the past. Then, for-profit insurance companies  would decide how much care seniors deserve and how much they should pay, while they  made their own side deals with drug-makers, device-makers, medical equipment makers, and brand-name hospitals, agreeing to pay many of them lavishly, without regard to quality, just as they do today.

                                Looking Ahead

I may be discouraged, but of course, I am not giving up.

There is still a slim possibility that the administration might figure out a way to keep Berwick. And I hold out some hope that another extraordinarily talented and committed reformer will step forward to fill the slot.

But no one who believes in reform wants to “compromise” with conservatives when, by their lights, “bipartisan co-operation” means folding on everything that counts. And few would choose to preside over the demise of Medicare. Yet, without thoroughgoing reform, I am quite certain that Medicare is heading for a wall.

I don’t think most people recognize what the loss of Berwick would mean. They aren’t familiar with the details of the Affordable Care Act and so don’t realize how much of it pivots on Medicare changing the way it does business. As I have argued, Medicare reform is the only engine with the power to drive health care reform.  (For evidence, see this HealthBeat post.)

Without fierce leadership at CMS, I see only one alternative: Perhaps our last, best hope is that Berwick leaves the Beltway, returns to the Institute for Health Care Improvement, and helps lead reform from within the medical community, as he has in the past. He would not be alone.

On the ground, an amazing number of health care providers possess what Berwick has described as the “will to excellence,” and they have been turning health care around in communities across the nation, lowering costs, without impairing the quality of care. Often, patient outcomes are better. (See this Healthbeat post.)

Admittedly, reform from within will be a slow and patchy process. If we rely on a revolution that enjoys little support from Washington, it will not happen nationwide, certainly not anytime soon. Nevertheless, I believe Berwick when he argues that that there are enough like-minded people within the health care professions to eventually transform our health care system:

“The will to excellence is present everywhere in Health care,” Berwick told an audience at the National Forum on Quality Improvement in Health Care— these are natural capital, human traits. Not of all human nature, not all of the time, but enough, plenty enough. We can waste them and deplete them,” he adds, referring to low morale in many parts of our health care system. “But the will to have pride in work is not scarce; it is everywhere abundant.”

Time and again, Berwick has seen IHI’s pilot projects work –without any financial incentives for the medical professionals involved. Hospital workers want change. Many are horribly frustrated to find themselves laboring in a system where the left hand and the right hand often fail to communicate, making much of their work seem redundant or even pointless. Berwick recognizes that these professionals would like nothing more than to turn their hospitals into efficient workplaces. Such an opportunity might well be worth more than a 2 percent raise. 

At the same time, Berwick is not naïve. He understands, all too well, the role that money plays in our highly-competitive for-profit system. At one of IHI’s National Forums, Berwick recalled phoning a hospital in Houston to learn about its reportedly successful innovations in pneumonia care. He was told that “the gains are enormous but the methods cannot be reported to the public—excellent pneumonia care offered the hospital local competitive advantage.”

Berwick was stunned. “The enemy is disease,” he told his audience. The competition that matters is against disease, not one another. The purpose is healing.” Yet “in the storm of the health care crisis,” Berwick acknowledged “it is so easy to forget why we trouble ourselves in the first place. It is so easy—frighteningly easy—to become trapped in the sterile thesis  . . . that our true, deep purpose is to gain and preserve market share in a vacant terrain of others whose purpose is precisely the same.” In other words, it is so easy to forget the patients.

If Berwick leaves Washington, I hope he will continue to lead the vanguard for meaningful reform.

In the meantime, what can the rest of us do? If the Senator who represents you signed the letter to President Obama, you might want to drop him or her an e-mail, indicating that voters also can “exact retribution.” Here’s the list: Lamar Alexander (R-Tenn.), Kelly Ayotte (R-N.H.), John Barrasso (R-Wyo.), Roy Blunt (R-Mo.), John Boozman (R-Ark.), Richard Burr (R-N.C.), Saxby Chambliss (R-Ga.), Dan Coats (R-Ind.), Tom Coburn (R-Okla.), Thad Cochran (R-Miss.), Bob Corker (R-Tenn.), John Cornyn (R-Texas), Mike Crapo (R-Idaho), Jim DeMint (R-S.C.), John Ensign (R-Nev.), Lindsey Graham (R-S.C.), Chuck Grassley (R-Iowa), John Hoeven (R-N.D.), Kay Bailey Hutchison (R-Texas), Jim Inhofe (R-Okla.), Johnny Isakson (R-Ga), Mike Johanns (R-Neb.), Ron Johnson (R-Wis.), Mark Kirk (R-Ill.), Jon Kyl (R-Ariz.), Mike Lee (R-Utah), Dick Lugar (R-Ind.), John McCain (R-Ariz.), Mitch McConnell (R-Ky.), Jim Moran (R-Kan.), Ron Paul (R-Ky), John Risch (R-Idaho), Pat Roberts (R-Kan.), Marco Rubio (R-Fla.), Jeff Sessions (R-Ala.), Richard Shelby (R-Ala.), John Thune (R-S.D.), Pat Toomey (R-Pa.), David Vitter (R-La.), and Roger Wicker (R-Miss.).