Journalism in the Public Interest

Obamacare Q&A: ‘I Don’t Really Think You Could Stop This Law’

Donald Berwick, the president’s former Medicare and Medicaid administrator, says problems with the health reform rollout have masked benefits that millions of people are getting.

Then-Centers for Medicare and Medicaid Services Administrator Donald Berwick answers reporters' questions during a news conference in June 2011. (Chip Somodevilla/Getty Images)

Less than a month after President Obama signed the Affordable Care Act into law, he nominated Dr. Donald Berwick to lead its implementation as administrator of the Centers for Medicare and Medicaid Services. Months later, when Congress failed to act on the nomination, the president used a recess appointment to install Berwick in the post. Berwick resigned in late 2011 and is now running for governor of Massachusetts.

Berwick has positioned himself as a leader in the health reform effort, but he has tried to distance himself from the problem-plagued rollout of, the federal health insurance exchange. “Those were staff level functions,” he said in an interview last month with the Boston Globe. “My leadership investment was in the vision of CMS as a major force of improvement of care for the nation.”

I caught up with Berwick Friday as he was heading to the airport.

For many in the public, the disastrous rollout of has come to define the law itself. But Berwick emphasized — as other defenders of the law have — that its features extend well beyond the health insurance marketplaces.

Among other things, he said, the law provides free preventive care benefits to millions of Americans, allows young adults up to age 26 to remain on their parents’ health insurance policies, gives additional assistance to seniors with high medication bills, and improves oversight of insurance companies. He said the law also has many provisions to improve the quality of patient care and cited a recent drop in hospital readmissions.

Berwick said he hasn’t had much interaction with those responsible for the rollout because presidential appointees are barred from having substantive interactions with their former agencies for two years after they leave office.

The interview has been edited for clarity and length.

Q. How do you think things are going with the rollout?

A. I guess I answer in two tiers. I think for the law as a whole, things are going well. This implementation has after all been going on really since the law was passed. And there are many, many benefits that are in place — things that are much better for millions of people. The discussion of the exchange rollout tends to dominate the visual field when there’s so much else that’s going on under the law that I’m very familiar with, because that happened when I was there — much of it.

In terms of the rollout [of], it’s unfortunate for sure. Nobody’s happy with this. I don’t have much more information than an average newspaper reader has. But my general view is that this is a significant technical problem. It’s reminiscent of some of the Part D [prescription drug program] implementation problems, but it’s big and it’s unfortunate. I think it’s technical and therefore can be solved technically, and I assume will be. I can only guess the amount of resources that are now being put into an understanding of what’s wrong and fixing it. I’m confident that this is going to be behind us, but like everyone in the country, I’m sorry that it hasn’t gone well so far.

If we weren’t so polarized, if there weren’t people trying to shoot down the Affordable Care Act going way back to 2010, I think we’d have a different kind of national attitude, which would be, “Oh my goodness, that’s a problem. Let’s fix it.” Instead of “Oh this is proof this law doesn’t work and the government can’t do anything.” I mean that comes out of the political rhetoric, not out of the facts.

Q. How long do you think the administration has to fix the problems before it actually begins undercutting the law?

A. I don’t know. I think that the facts on the ground should favor the administration in some important ways because the benefit structure of the law as a whole is so widespread. Actually I don’t really think you could stop this law because the minute you tried to take it down, millions and millions of people would realize that they’re losing something right now, let alone in the future. Preexisting conditions applying to kids again, prevention benefits lost, drug access down. That should help. I’m not an actuary, and I don’t know how to calculate the actuarial consequences of the delay. I can make arguments on either side of the case. I will say that given the intensity of the commitment that I’m sure exists in the administration and the enormous technical competence of the nation, I think it will be fixed. I think it will be fixed in good enough time.

Q. As far as the whole issue of canceled plans, one of the things that’s bothered me in this discussion is that there has not been as much of a willingness to acknowledge that indeed there are people who had good plans and who will pay more. How many people like that do you think there are and is that a problem?

A. I don’t know how many people there are. Remember you’re talking to a newspaper reader and not an insider right now. A large portion of the change in plans does apply to people who have very, very substandard coverage, and most of them are going to turn out to get what they need. I take it from you and from what I read that there are some people who will lose plans that they would, fully informed, still have chosen. I don’t know the numbers there. I have no idea what the proportion is. I assume and believe that the president made his earlier presentations in good faith. He thought and hoped that the implementation process would allow people to keep all the coverage they wanted. That apparently is not the case now for some. I believe he apologized for it. Although I feel sympathetic to people who have coverage that they wish they could keep but cannot now, at the national level, the overall profile in the country will be far better coverage for so many people. This is an unfortunate thing for some but for the vast majority this will be an improvement in coverage.

Q. Do you think that the level of opposition has increased since the time that you were here?

A. Increased? I think there’s been a consistent, really perpetual series of assaults on the law with different rhetoric. There is a long-term plan here being carried out by the opponents of this law to try to make a law of the land that was upheld by the Supreme Court not the law of the land. That’s bad, but I think it’s consistent behavior. I wish they would settle down and try to make health care a human right in the country and get into the job of health-care reform, which is what this law can let us do.

Q. Is there anything that keeps you up at night now that you’re not there with respect to this law?

A. My hope and dream is that America can become a nation where health care is a human right for all and where the health-care system is evolving into the [system] of care that people really need — care of chronic illness, continuity of care, prevention-oriented, different from the care system we have. Much lower cost and much better at the same time. And the sooner we get there, the better. I just only lose sleep over tempo because people are still left out now.

In the Medicaid states that are not expanding [coverage under the Affordable Care Act], it’s really terrible. People reeling and very much in poverty are going to be denied access to coverage, and I just think that’s bad news. Can’t we please get about the job of making health care a right and organizing around the proper, just, compassionate and excellent care that this law intends? It’s just loss of time. I’m sorry about it.

Q. Some have said that the big problem here if you take a look at it from a policy perspective, the health-care system in this country is so disjointed that you really can’t right it with a law short of going toward single payer. Do you agree?

A. It’s not a binary thing. This is about progress. There’s no question in my mind that the policy environment in the Affordable Care Act was a better environment. It’s more sensible payment, more accountability and transparency, more orientation toward continuity of care, more investment in prevention, more investment in innovation. All of that is progress. I don’t see it the same way as the people who say it’s all or none. We did choose as a nation a pluralistic payment system under this law. That does add complexity. It adds political and administrative complexity. This law does permit states to try a simpler payment system, including single payer. It looks like Vermont may go that way and I think we might learn a ton from states that choose that pathway about whether that is indeed as much simpler and better and easier to manage as some believe it is.

Here’s what worries me most about Obamacare:

“People respond to incentives, although not necessarily in ways that are predictable or manifest. Therefore, one of the most powerful laws in the universe is the law of unintended consequences.” -From the book “SuperFreakonomics”

With that in mind, see:

“Obamacare: Making a bad situation worse”

How could giving 40 million additional American people healthcare make a bad situation worse? Stop the right-wing propaganda and get a life.

Health care is NOT a right.  Period.

Health care IS a right is almost every other industrialized nation. The Affordable Care Act finally at least makes it so that people who are covered cannot be denied care or have their policies cancelled because they get sick. It’s about time we start treat our peoples’ health in a civilized way.

I totally agree with Jon that healthcare is a right and demanded so by over 70% of adult population. We the people of USA determine what is a right and NOT our political ideologues!  United States of America is the ONLY Western civilized nation on the planet without mandatory healthcare for it’s citizens….it’s shameful!

Spaghetti Cat

Nov. 11, 2013, 5:43 p.m.

“Remember you’re talking to a newspaper reader and not an insider right now.”

Investigative journalism at its lowest. Our side talking to our side about how we can’t be stopped - after we quit and moved on to more glamorous opportunities.

“Those were staff level functions,”  Really. If this guy thinks it’s not his responsibility for make sure the program he’s responsible for actually works, he’s not fit to run for dogcatcher, let alone governor.  One of the Obama admin’s chronic problems is people who like Berwick - or the president - who think they’re above mere management.

Diane Lindgren

Nov. 11, 2013, 6:28 p.m.

Reading comments responding to articles in ProPublica, I keep wondering why the majority of readers, e.g responders are so extremely right wing. Makes me step back and look again at ProPublica.


“How could giving 40 million additional American people healthcare make a bad situation worse?”

By adding $2.5 trillion MORE do your children’s debt.  Have you no conscience?

Diane: Re,  ” ....,I keep wondering why the majority of readers, e.g responders are so extremely right wing.”, it’s all a matter of perspective.  We, on your perceived “extreme right wing” only appear that way to you because you may be on the far, far left.

Some of us have been a little late to the game, but are now on to your Saul Alinsky methodologies so deftly employed over the last 4 of 5 years.  You will lose this time.  The jig is up. 

The House this week will vote on a measure called the Keep Your Health Plan Act. It aims to do what the president promised years ago: If you like your healthcare plan, you can stay on it. Senate Republicans are pushing for a vote in their chamber. That measure has already attracted Democratic support.

Obama admitted on NBC News that he broke the promise he made repeatedly in the lead-up to the vote on DemoCrapCare: “If you like your healthcare plan, you’ll be able to keep your healthcare plan.”

“I am sorry that they are finding themselves in this situation based on assurances they got from me,” he said.

Boehner has seized on the apology to challenge Obama to support the GOP bill.

“An apology is certainly in order, but what Americans want to hear is that the president is going to keep his promise. ... If the president is sincerely sorry that he misled the American people, the very least he can do is support this bipartisan effort. Otherwise, this apology doesn’t amount to anything,” Boehner said.

The bill serves as a legislative “slap in the face,” according to Pitney, who noted that both parties would be well served to support the measure.

Imagina(tion) re: “How could giving 40 million additional American people healthcare make a bad situation worse?”

Nobody “gave” anybody healthcare. People were required to buy insurance that included such things as maternity care and pediatric dental care - regardless their age—whether they wanted it or not.

The number of uninsured pre-mandatory insurance was 48 million. Best estimates of post-mandatory-insurance numbers is that 35 million will remain uninsured. At best, 13 million who were previously uninsured will be covered. That’s a far cry from 40 million.

@Diane Lindgrenn Re: “I keep wondering why the majority of readers, e.g responders are so extremely right wing.”

Since when does criticizing left-wing policies make one right wing? Have you considered that some people criticize both side? Or does the left now embrace the “if-not-for-us-their-against-us” doctrine?

lamajia, from my perspective, the problem is that insurance isn’t care.  Health insurance doesn’t make a person healthier.  If a lack of health insurance is blocking people from care (the explanation I’ve been given), then maybe that problem should be solved instead of being enshrined in law.

I mean, when a criminal runs a protection racket, the cops don’t say, “well, it’s a shame you can’t afford their rates.”  They bust the creep.

The government can (and should) help people get the care they need without enriching parasites along the way.

This article is part of an ongoing investigation:
Obamacare and You

Obamacare and You

The Rollout of the Affordable Care Act has been marred by glitches and political opposition.

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