Don Berwick and the Railroading of America’s Social Sciences

Part of the past glory, and superiority, of the United States lay in the vigor and rigor with which the country’s social scientists pursued new ideas and developed models ready for policy implementation. Beginning in the 1960s, an appointment of such individuals to senior government jobs provided an avenue not just for the implementation, but also the subsequent real-life testing of their new concepts.

Back then, similarly inspired appointments were completely unthinkable in Europe, with its much more staid government bureaucracies. To an extent, this is still the case, giving the U.S. government an inherent advantage.

If the practice worked as intended, the United States as a country, and Americans as a people, would benefit from this short-circuiting of an otherwise laborious and usually very lengthy process of seeing policy ideas move from the academic community and think-tank world into government.

To be sure, many government policies that are contemplated are inherently complex and difficult to gauge ex ante. It is never easy to “predict” what will happen in a “live” social system. However, experts whose predictions of the effects of certain measures were proven correct ex post facto had an almost hallowed status when it came to discussing, and possibly deciding, future public policy issues.

Simply put, he or she who had gotten it right before, and preferably on quite a regular basis, had a strong claim to be considered an expert who should be accorded due deference.

This brings us to the fate of Harvard Medical School professor Don Berwick. Here is a man who has devoted his entire career to the matter of achieving improvements in the quality of health care, while keeping a close eye on the related costs.

Lucky for the United States that it has long had great flexibility to recruit people without a civil service background to senior positions in government. And that’s how Barack Obama selected this man to serve as Administrator of the Centers for Medicare & Medicaid Services (CMS).

While the title is a true mouthful, Mr. Berwick’s primary assignment was to bring reason, economic rationale and optimization to what easily accounts for one of the largest economic entities in the United States. At a combined volume of roughly $750 billion, federal spending on Medicare and Medicaid presently accounts for over one-fifth of all federal government spending and about 5% of U.S. GDP – and, even at present, is in very close range to the amount the United States spends on defense (including war costs).

Alas, the United States is not so lucky. Circumventing the Senate, President Obama used a recess appointment to put Mr. Berwick in his current position. In the face of opposition by Republican Senators who vowed to block his confirmation, Mr. Berwick has chosen to resign. He will step on December 2, after just a year and a half on the job and a month before his recess appointment was set to expire.

So why were conservatives so dead-set against this man, who is both highly experienced and dedicated to his work? Because he was bound to rock the boat of all-too-comfortable industry interests, which have so effectively, but disastrously conspired to drive up healthcare costs in the United States.

In his effort to pursue both cost effectiveness and quality of care – in fact, by linking the two – Mr. Berwick was doing exactly the right thing for a country that is otherwise facing an unabated explosion of healthcare costs.

But, wait a minute, you might say – aren’t Republicans banging the drums every day about how the United States is going to go bankrupt over the Medicare/Medicaid issue? You bet they are. So was Mr. Berwick being driven out of town for failing to try to rein in those costs? Is he perhaps a closet socialist, a man who talks tough, but then, secretly, lets costs explode?

Far from it. Mr. Berwick actually meant what he said – and, better yet, did what Republicans demand government do: bring those exploding healthcare costs under control.

Why, then, was he so castigated? Evidently, because the Republicans are, there is no other logical way to put it, quite schizophrenic in the pursuit of their stated mission of cutting Medicare and Medicaid costs. In their ill-directed zeal, they label Berwick, the very man who is trying to accomplish their mission, as somebody who is out to “ration” health care. That word is made out to be a big no-no in the U.S. political debate.

Trouble is, as that great American folk wisdom goes, one cannot have one’s cake and eat it too. That, however, is precisely the effort the Republicans are engaged in. They want severe cost cuts, but no “rationing.” Call the latter anything else, say, “cost cuts,” or “ensuring much higher accountability of providers for costs they create,” and you are essentially describing the same thing. Anybody who thought, and continues to think, that this undertaking is the essence of what Republicans stand for against all those supposedly pinko, government-expanding Democrats, can only be thoroughly confused.

The Don Berwick saga contains some further lessons that seem to run entirely against Republican core beliefs. First, it just doesn’t appear wise to continue relying on that great old American tradition of picking people from outside government for top-level posts.

Given the current atmosphere in Washington, there is only one possible solution. Just let all the civil servants rise to the top through an orderly process of selection over the course of their careers inside each government department. Forget about all other “political” appointments (other than the cabinet secretaries themselves). In other words, become like the Europeans and the Japanese. That certainly is the very direction in which the Republicans, consciously or not, are driving the American body politic.

Second, to all those currently outside the government and contemplating public service at a senior level, beware: Never write something thoughtful (and therefore likely controversial). Rest assured it will be used against you later in your confirmation hearing, even if it is decades away.

It’s not just the way databases are set up that makes all your utterings easily findable. No, the truth squads that make up the U.S. Senate committees, empowered to provide their “advice and consent” on any and all presidential appointments, require that you submit such a list yourself. And if you have been a prolific writer, beware the grave sin of omission.

If you accidentally don’t include any and all of your written record in the files accompanying your nomination to Congress, then all bets are off. You will be called out for seeking to hide something. Next step: You are labeled as deceitful or, somewhat milder, careless. In either case, you are not deemed worthy of being granted an appointment to the public service.

In case you wonder what Mr. Berwick’s recorded offense was, it is this: In some of his past academic writings, he had looked favorably on certain parts of Britain’s National Health Service. Apparently, he did not realize at the time that this is considered tantamount to saying he loved the Soviet Union. So much for the “special relationship” with Britain – and for academic freedom.