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The Agenda

NRO’s domestic-policy blog, by Reihan Salam.

Ezra Klein on Donald Berwick



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Ezra Klein wonders why conservatives are opposed to the appointment of Donald Berwick to head the Centers for Medicare and Medicaid Services (CMS):

Conservatives are making a serious mistake by forcing the administration to rely on a recess appointment for Berwick. Ultimately, what weakens Berwick weakens them, as Berwick, whether they know it or not, is one of the best friends they could have in the administration. That’s because insofar as Berwick is a radical, he’s a radical in favor of a patient-centered health-care system — a position that has traditionally been associated with conservatives, not liberals.

This has escaped notice because political activists don’t pay much attention to questions of delivery-system reform.

I agree with Klein that Berwick and conservatives have some areas of common ground. Here is what I wrote about Berwick in April:

While [Berwick] was a big supporter of Obamacare, [he] acknowledges its core failing; in an October lecture, he said, “Health-care reform without attention to the nature and nurture of health care as a system is doomed. It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is, care as our patients, their families, and their communities experience it.” Indeed, if you put Berwick in a room with a leading market-oriented health-care analyst, the two would find broad areas of agreement as to where our health-care system fails patients.

But they would diverge on the most important questions of all: can, and should, the state provide quality health care for all? Can enlightened, public-minded experts effectively manage one-sixth of the U.S. economy?

It is possible for conservatives and liberals to find agreement on certain aspects of health care: for example, the use of checklists in reducing surgical errors and hospital-borne infections. Such questions are ideologically neutral, and Berwick has spent a great deal of productive time considering these kinds of questions.

Where conservatives take issue with Berwick is in his sweeping confidence in the ability of politicians and technocrats to manage something as complex as our health care system. They also take issue with the idea that NHS-style bureaucrats should decide what treatments are appropriate for them. (To give one of many troubling examples, NHS initially refused to pay for a blindness drug until patients were already blind in one eye.)

Klein is right to point out that Berwick acknowledges some of the flaws of Britain’s approach in his speech to the NHS. But Berwick’s criticisms miss the point: poor quality is the inevitable consequence of the NHS approach. And that is where Berwick goes tragically wrong.



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