A policy wonk is derailed by politics

There are two legacies to Don Berwick’s time as the leader of the Medicare program — one in policy, the other political.

Berwick left the Centers for Medicare and Medicaid Services (CMS) at the end of the week, closing out a period that combined barbed partisanship with a deeply wonky focus on the way healthcare is delivered.

Berwick came to the job with a passion for delivery-system reform, and in roughly 18 months as CMS administrator he oversaw an aggressive push to implement pieces of healthcare reform that matched his vision. Though many of those policy goals have some measure of bipartisan support, Berwick remained a lightning rod for congressional Republicans.

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“It is time for him to go,” Sen. John Barrasso (R-Wyo.) told The Hill as Berwick was on his way out last week.

President Obama nominated Berwick to lead CMS just a month after signing healthcare reform into law. Republicans at once seized on positive comments he had made about the British healthcare system and accused him of wanting to ration care.

“He had made some speeches that caused great concern for people of all ages, but specifically to people on Medicare, and yet he never came forward to tell the American people really where he stood with regard to the healthcare law and the implications of that law,” Barrasso said.

With the GOP united against Berwick, Obama resorted to a recess appointment a few months after submitting his nomination — a move that rankled even some Senate Democrats. The political cloud never dissipated. Earlier this year, Rep. Phil Gingrey (R-Ga.) compared Berwick to Don Corleone, a fictional Mafia godfather.

“It’s unfortunate; he’s a nice guy and did a very good job,” said Thomas Scully, who led CMS under President Bush and is now senior counsel at Alston and Bird.

Any Obama nominee for a healthcare post would have been defeated at that time, Scully said. But he supports Berwick’s work on policies like accountable care organizations, or ACOs — new, integrated health systems created by the healthcare reform law.

“This is a missed opportunity to have someone who really understands the healthcare system, who understands quality of care rather than volume of care, which has been his hallmark,” Sen. Tom Harkin (D-Iowa) said. “I'm just so sorry to see this end like this."

Berwick’s push to transform the delivery system was hardly seamless. Hospitals, doctors and other providers balked at the first proposals for creating ACOs, which sidelined some policy considerations in pursuit of higher savings estimates. But CMS answered most of those complaints in its second attempt.

“I think the career people think very highly of him and think he’s a very decent human being and did a good job with a lot of integrity,” Scully said.

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Berwick got the ball rolling on policies like ACOs and the new Center for Medicare and Medicaid Innovation. But it will be up to the agency’s career staff and its new acting administrator, Marilyn Tavenner, to see them through.

Harkin, who chairs the Senate health committee, said he expects those programs to survive, but that Berwick was uniquely qualified to lead them.

“They won't be administered as well, maybe, without him,” Harkin said. “I don't know. I don't know who this new person is that's taking over."

Stuart Guterman, who studies healthcare payment systems at the Commonwealth Foundation, was more optimistic about the post-Berwick era. Berwick wasn’t the first CMS administrator to focus on patients and coordinated care, he said, but rather was the right person to take the first steps on policies included in the healthcare law.

“He had a tremendous challenge in this role and he brought to it a tremendous amount of leadership ability,” Guterman said. “This was a special time, because we have a pretty broad, intricate and controversial health reform law to put in place, and the agency needed someone who could play a leadership role.”