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NRL News
Page 32
June 2010
Volume 37
Issue 6

Rationing Advocate Is Obama’s Nominee to
Oversee Implementation of New Health Care Law

By Burke J. Balch, J.D.

Dr. Donald Berwick

President Obama has nominated Dr. Donald Berwick, president and chief executive officer of the Institute of Healthcare Improvement, to direct the Center for Medicare and Medicaid Services. This massive bureaucracy within the federal Department of Health and Human Services will have the largest role in implementing the Obama Health Care Rationing Law enacted earlier this year.

Given the content of that law, Berwick is an apt choice. He is on record as an open advocate of rationing health care. For example, in a June 2009 interview with the journal Biotechnology Healthcare, Berwick maintained, “The decision is not whether or not we will ration care—the decision is whether we will ration with our eyes open. ... We can make a sensible social decision and say, ‘Well, at this point, to have access to a particular [new drug or medical intervention] is so expensive that our taxpayers have better use for those funds.’”

Berwick favors strong government limits on the implementation of lifesaving medical technology, especially new health care technology. He believes that the highest objective should be preventing some individuals from being able to obtain better health care than others do.

In an article in the May/June 2008 issue of Health Affairs, Berwick advocated imposing “balance” through “specified policy constraints, such as decisions about how much to spend on health care or what coverage to provide and to whom. The most important of all such constraints ... should be the promise of equity; the gain in health in one subpopulation ought not to be achieved at the expense of another subpopulation. ... [I]mproving care for individuals can raise costs if the improvements are associated with new, effective, but costly technologies or drugs.” Through “rational collective action overriding some individual self-interest,” Berwick wrote, “we can reduce per capita costs.”

Calling for “global budget caps on total health care spending for designated populations” (that is, limits imposed not just on what government spends on health care, but also on what private individuals and groups are allowed to spend on their own health care), Berwick emphasized the importance of replacing the free market with a command economy in health care through the use of what he called an “integrator”:

The important function of linking organizations across the continuum requires that the integrator be a single organization (not just a market dynamic) that can induce coordinative behavior among health service suppliers to work as a system for the defined population. ... An effective integrator would work persistently to change the ‘more-is-better’ culture ... . Today’s individual health care processes are designed to respond to the acute needs of individual patients. ... An integrator would act differently. ... An integrator would approach new technologies and capital investments with skepticism and require that a strong burden of proof of value lie with the proponent.”

What health care would Berwick act to limit? In a 1994 article in the Journal of the American Medical Association, he wrote, “Most metropolitan areas in the United States should reduce the number of centers engaging in cardiac surgery, high-risk obstetrics, neonatal intensive care, organ transplantation, tertiary cancer care, high-level trauma care, and high-technology imaging.”

In order to “reduce the use of inappropriate surgery, hospital admissions, and diagnostic tests,” Berwick wrote, “Important initial targets include management of stage I and stage II breast cancer, prostatectomy, carotid endarterectomy, coronary artery bypass surgery, treatment of low-back pain, hysterectomy, endoscopy, blood transfusion, chest roentgenograms [x-rays], and prenatal ultrasound.”

Berwick is quite a fan of government-imposed rationing abroad. In his 2009 Biotechnology Healthcare interview, he said, “The United States is not the only country struggling with healthcare costs. The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom and [its French counterpart] have developed very good and very disciplined ... models for the evaluation of medical treatment from which we ought to learn.”

Reminded by the interviewer that “NICE is a bogeyman here in the United States,” [editor’s note: To see why, visit] Berwick responded, “I know that, and it’s a misunderstanding of the deepest sort. NICE is extremely effective ... . The fact that it’s a bogeyman in this country is a political fact, not a technical one. ... The social budget is limited—we have a limited resource pool. It makes terribly good sense to at least know the price of an added benefit, and at some point we might want to say nationally, regionally, or locally that we wish we could afford it, but we can’t.”

In a 1998 paean to the British National Health Service (NHS) on its 50th anniversary, Berwick, adopting the literary device of pretending to give a “looking back” speech on its 75th anniversary in 2023, said—optimistically from his perspective—“A lot has changed since 1998. ... In the United States ... real reform finally took hold. ... Today American health care is administered under a single, government sponsored insurance scheme, with public accountability not at all dissimilar to the NHS. For the first time in nearly a century, American healthcare costs are falling ... .”

Unless his confirmation is rejected by the U.S. Senate, Donald Berwick will soon get not only to see the fulfillment of his dream, but also to preside over it—the dream of being able to use government power to force limitations on Americans’ health care and on the resources they are allowed to devote to it.

Senate Finance Committee Chairman Max Baucus (D-Mont.) has announced that he hopes to schedule a confirmation hearing for Berwick before the congressional July 4th recess.

For rebuttal of the claim that Americans cannot afford to keep spending more to save their lives and protect their health, which is central to the argument that rationing is necessary, see

This article is based on research by Roger Stenson.