Testimony by Donald M. Berwick, M.D., M.P.P.
U.S. House of Representatives, Ways and Means Committee, June 12, 2019
Serving as CMS Administrator was the greatest privilege of my professional career. My duties included helping to implement the coverage expansions, quality improvement, and program integrity provisions of the Affordable Care Act, which was passed three months before my arrival.
In effect, I had the honor to help lead “Medicare for Some,” and the successes and potential of that program have given me confidence that a wise choice for this nation would be Medicare for All.
If anyone can show me a payment model that beats Medicare for All in achieving the Triple Aim and universal coverage, I am all ears. But I have as yet seen none. And the nation’s experience with Medicare for Some – as it exists now, and as endorsed by the overwhelming popularity of Medicare in our nation – suggests that we may, indeed, already have an answer in our hands.
I do not wish to minimize or disregard the many obstacles and objections to Medicare for All as a pathway for our nation. But, whereas some others find the obstacles to be insurmountable, I do not. I believe that we have the wits, experience, wealth, and agility to overcome every one, as we have for Medicare as we know it today. To be specific, here are some of the objections:
- That Medicare for All is unaffordable. I think the opposite may be true; that is, without Medicare for All, health care in our nation may be bound to head, as it is now heading, for true unaffordability. Medicare for All is a positive way out. As I noted above, the level of waste in our health care system is enormous. A publicly accountable, transparent, and mission-oriented payer would offer us as a nation leverage against wasteful health care expenditures that is not achievable in the current, chaotic payment environment.
- That Medicare for All is a governmental takeover of health care. It is not. Not one single bill that I know of proposes under any form of expanded governmental coverage that government should become the provider of health care for all Americans. Medicare for All is about paying for care – consolidating payment in a public program. It is not about providing care. Care provision, through today’s array of hospitals, clinicians, nursing homes, and so on, would remain as it is – largely private sector and entrepreneurial.
- That Medicare for All would severely underpay hospitals and clinicians. That would be neither wise nor inevitable. When government becomes the payer for any good or service, and is subject to oversight from Congress, it is and should be held accountable for responsible practices. That is how Medicare works today; and it is how Medicare for All should and would work in the future.
- That Medicare for All implies a financially unrealistic package of health care services. Any insurer – government or commercial – has to end up implementing a defined benefit package, and the content and comprehensiveness of that coverage will always be subject to debate and negotiation. What Medicare for All does do is to move that dialogue into daylight, as we can consider as a nation what we wish to include in universal coverage and what not. That is exactly what happened, for example, when the ACA extended coverage for clinical prevention services, and when Congress took steps toward assuring mental health care parity. The current commercial insurance system does the same – deciding what is and is not covered – but it does that largely out of sight and without any real form of pubic accountability.
- That Medicare for All would unacceptably disrupt people’s current relationships with their health care insurers. Indeed, Medicare for All would give every American not now covered by Medicare a new insurer – a public insurer. Whether this threat to existing bonds between people and commercial insurers in fact troubles Americans I find doubtful. I suspect that what most Americans value is their bond with clinicians, not with insurers.
- That the tax increases implied by Medicare for All are massive. This represents a negative framing of a positive result. Yes, indeed, the fund flows for health care under Medicare for All would become public, as opposed to the private payment now channeled through payroll check deductions and employer contributions to commercial health insurance. These are existing fees – “taxes” really – through private channels. What the American worker cares most about financially is how much he or she takes home at the end of the day. Under Medicare for All, properly designed, that amount – take home pay – goes up, not down.
I end where I began: Medicare for All is not an end in itself. It is a means to achieve what we care about: better care, better health, lower cost, and leaving no one out. I am open to considering any proposal that moves our nation fast and well toward those goals. Compared with Medicare for All, I see none better.
Ways and Means Hearing:
By Don McCanne, M.D.
For much of his career, Donald Berwick has been an outspoken supporter of improving quality in health care and, more recently, a supporter of Medicare for All. Until we can enact Medicare for All he does support making improvements in the Affordable Care Act. He supports accountable care organizations (ACOs) and value-based care (VBC) as he believes that they are a means to improve quality.
Because of uncertainties about the benefits and deficiencies of ACOs and VBC, some fear that he may have strayed as a supporter of single payer Medicare for All as he pursues these dubious solutions. His testimony before the House Ways and Means Committee should allay those fears. We can continue our efforts to educate our colleagues and the public on the refinements of an ideal single payer model, such as excluding ACOs, but the fundamentals are solid – comprehensive, high quality, affordable, equitable health care for all – and Donald Berwick clearly supports that.
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