Nov 6, 2019

Don Berwick: The Medicare for All debate is distorted

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.

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