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Illustration: Aïda Amer/Axios

Don Berwick, a physician and former head of Medicare and Medicaid during the Obama administration, wants the country to have a "rational" debate about "Medicare for All" — but says that will require a more rigorous comparison to the status quo.

What he's saying: This interview has been edited for brevity and clarity. It also took place before Sen. Elizabeth Warren released her Medicare for All financing plan, for which Berwick served as an adviser.

Q: You have been vocal lately in your support of Medicare for All, a stark contrast with other former and current administrators of the Centers for Medicare & Medicaid Services. Why?

DB: What I think I'm seeing is distortion and ambiguity about terms. One [misconception] is Medicare for All is a government takeover of health care delivery, which is absolutely not the case. I haven't seen anybody propose that.

Q: Many people may not know their employers cover 70% or more of their entire premium money that otherwise would go to their pay. Is this the main problem when talking about reforms?

DB: The basics are not that complicated. Every single dollar — every nickel spent on health care in this country — is coming from workers. There's no other source. But it’s coming through many different routes. We have to find a way to get those very complicated streams into one stream.

Q: Do you think hospitals and doctors have gotten a pass, considering their spending and influence?

DB: We have hospitals in markets, getting larger, become essentially oligopoly or monopoly players, that basically demand prices because there's not real competition. I don’t believe hospitals are ill-motivated. They're doing what they are there to do. It’s the way we set it up. But the pricing is out of control."

Q: If Congress is having this much trouble solving surprise hospital bills, why should there be confidence policymakers could tackle something as big as Medicare for All?

DB: There are opportunities that are immediately available and will need a much more progressive administration in the White House than we have now. Surprise billing is one. Site-neutral payments is another. I think Obamacare can be fixed a lot. We need to do more on antitrust enforcement, especially with hospital consolidation.

Q: Recently deceased health economist Uwe Reinhardt had said he didn't think single-payer would work in the U.S. because the political system is irresponsible and too easily manipulated by industry. Is he wrong?

DB: First, any proposal for change, including single-payer, should not be compared to a blank slate. It should be compared to a highly defective, existing system full of lobbying, full of self-interest.

Second, what if we begin to look at Medicare for All as a learning process, in which we would take the best shot we can? People are worried about rural or safety net hospitals — let's figure out what the policies that would help them out. People are worried about a big bureaucracy — what can we do to mitigate the bureaucratic obstacles so it's simpler?

Third, there's a tradeoff here between public accountability and private accountability. Right now, try to find out the nature of the contract between your insurer and the hospital. You literally can't. It's an opaque system. By not having a publicly accountable system, we are paying an enormous price in lack of transparency.

Q: Can you elaborate more on the improvements we can make to the system — especially when it comes to eliminating waste and improving care?

DB: "We need to wean ourselves from incentive structures that favor overuse. The straightest shot is population-based budgets. It's changing the payment system so there's an opportunity for doctors and hospitals to do the right thing instead of making money to do so much.

In my [JAMA] editorial, I point out the paradox. Everyone's fretting about costs. Everyone's wringing their hands. We have very strong scientific evidence that close to $1 trillion a year is absolute waste. You'd think that in any industry that had a brain, we'd be going after that money hard.

Go deeper

Toyota to build $1.3 billion U.S. battery plant in North Carolina

The all-electric Toyota bZ4X, the company's first battery-electric vehicle, at the Los Angeles Auto Show in Los Angeles, California on Nov. 17. Photo: Frederic J. Brown/AFP via Getty Images

Toyota announced Monday it's investing $1.3 billion to construct an electric vehicle battery "megasite" near Greensboro, North Carolina, set to open in 2025.

Why it matters: Toyota's Prius hybrid won environmental plaudits when it launched in 1997, but it has since lost ground to electric vehicle world leader Tesla, per Axios' Joann Muller. This battery plant will be the first to produce automotive batteries for Toyota in North America.

4 hours ago - Politics & Policy

Congress hunts for shortcut to pass defense funding, debt limit combo

Senate Majority Leader Chuck Schumer returned to his office Monday. Photo: Anna Moneymaker/Getty Images

The scramble in Congress to pass the National Defense Authorization Act is being complicated by an effort to tie it to a needed hike in the federal debt limit.

Why it matters: The House and Senate are rapidly coming up against a series of deadlines they must address before the end of the year — or risk disrupting crucial military funding and upending the economy. Congressional leaders are now hoping they can knock out both "must-pass" priorities in one, complex swoop.

Scoop: Inside Jake Sullivan's call with U.S. hostages' families

Photo: Jim Lo Scalzo/EPA/Bloomberg via Getty Images

National security adviser Jake Sullivan spoke last week with relatives of U.S. hostages and others wrongfully detained abroad, after more than two dozen families expressed frustrations about their inability to get a meeting with him or President Biden, Axios has learned.

Why it matters: Participants on the video call, which began at 7pm ET Friday and lasted more than an hour, told Axios they didn't get satisfactory answers to many of their questions. Nonetheless, they were encouraged by Sullivan's commitment to follow up and pledge to be personally available to them and others going forward.