Johnson, Jr. distorts Berwick's innocuous redistribution comments

In a 2008 speech at an event celebrating the 60th anniversary of the creation of the United Kingdom's National Health Service, Berwick stated:

Any health care funding plan that is just equitable, civilized and humane must -- must -- redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent health care is by definition redistributional.

Johnson, Jr.: Berwick's “comments about redistribution of wealth ... give a lot of pause for concern.” On the May 17 edition of Fox & Friends, Fox contributor Peter Johnson, Jr. stated about Donald Berwick:

He is a nominee that will run the entire $800 billion Medicare/Medicaid system in the United States. And, you know, this position has gone vacant for a long, long time, especially during the health care reform debate. Now we know why. He is a Harvard-trained pediatrician who runs a think tank up in Cambridge, Massachusetts now. And his comments about redistribution of wealth vis-a-vis the health care system, his comments about the romance of rationing, the British health care system, his comments really about end of life issues give a lot of pause for concern.

Health programs such as Medicare and Medicaid are inherently redistributive

Medicare and Medicaid are redistributive. Medicare and Medicaid -- which Berwick would oversee as Administer of CMS if confirmed -- are federal programs that provide health insurance to the elderly, disabled, and those with low incomes. Medicare is available to everyone over age 65, regardless of their ability to pay for private health insurance, and Medicaid is available to those who would not otherwise be able to afford insurance. The programs are financed out of federal tax revenues, including a 1.45 percent payroll tax on all earnings, and are thus paid for in large part by people who are too wealthy to qualify for Medicaid, as well as people who use Medicare or will in the future but could afford private insurance instead. Thus, Medicare and Medicaid redistribute wealth from those who can afford private insurance to those who cannot.

Medicare and Medicaid are extremely popular. According to a June 2005 Kaiser family Foundation poll, “Nearly three-quarters (74%) of adults say Medicaid is a 'very important' government program, ranking it close to Social Security (88%) and Medicare (83%) in the public's mind.” Similarly, an October 2005 Harris Interactive poll reportedly found that “an overwhelming majority (96%) of Americans 'strongly' or 'somewhat' favor Medicare, the medical assistance program for the elderly and disabled, while 91% say they support Medicaid, the program to assist people with very low incomes.”

Even Laura Ingraham acknowledged that Berwick's comments are “right.” Discussing Berwick's comments on the May 13 edition of Fox News' The O'Reilly Factor, right-wing radio host Laura Ingraham stated: "[O]f course, every safety net, Bill, and you and I are both in favor of there being a safety net where people don't go untreated, where people who need help get help. Obviously to pay for those people, it's obviously going to involve taxes and taxes come from people who make a living and make income. So that part is right."

Johnson, Jr. suggests Berwick blindly supports the NHS

Johnson, Jr. suggests Berwick's view of NHS is cause for concern. From the May 17 edition of Fox & Friends:

GRETCHEN CARLSON (HOST): Let's take a look at some of those. Here is exactly what he said: “I am a romantic about the NHS,” which is the National Health Service in Britain, “I love it. All I need to do to rediscover the romance is to look at health care in my own country.” He apparently said that back in July of 2008.

JOHNSON, JR.: Well my concern, which is the concern of a lot of Americans, is that health care in Great Britain, the statistics show that survival rates are lower in some categories of disease, cancer treatment is different and not as good at the United States, that the life span is lower in some categories, that people die more often as a result of heart attacks after admission in hospitals. So in my mind, and in the mind of a lot of Americans, there's nothing romantic about Great Britain's health care system. Great Britain's health care system, a single-payer universal health care system is a deeply flawed system.

In fact, Berwick both praised and criticized the NHS

Johnson, Jr. ignores that Berwick criticized NHS in his speech. Johnson, Jr. suggests that Berwick is blind to flaws in Britain's health care system, stating that “cancer treatment [in Britain] is different and not as good as the United States.” But in the same 2008 speech that Carlson cites, Berwick acknowledged that the NHS is “far from” perfect, and specifically cites “cancer outcomes” as an area in which the program has had “less progress”:

BERWICK: Is the NHS perfect? Far from it. Far from it. I know that as well as anyone in this room, from front line to Whitehall, I have had the privilege of observing performance and even to help to measure its performance.

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There is less progress in some areas, especially with comparison to other European systems, such as in specialty access, in cancer outcomes, in patient centeredness, in life expectancy and infant mortality for socially deprived populations. In other words, in improving its quality, two facts are true: The NHS in en route, and the NHS has a lot more work ahead.

Berwick then listed “ten suggestions” for how the NHS “can do even better.”

Johnson, Jr. says Berwick's “hopes” for “rationing” are “of some great concern”

Johnson, Jr.: Berwick's “record is a frightening one in a lot of ways.” From the May 17 edition of Fox & Friends:

JOHNSON, JR.: Dr. Berwick is a proponent of comparative effectiveness systems. He's a proponent of the government deciding which types of tests, procedures and surgeries are not only viable but economically viable. And so he has written hundreds of articles, he's written several books, he's been honored by Great Britain for his work with Tony Blair on the health care system in Great Britain but I think it needs to be understood through careful inspection what his record is, what his hopes are for rationing in the United States. It is -- and I'm not going to be overblown about it -- it is of some great concern if not fear for some Americans, and I intend to look at this record hard, because the record is a frightening one in a lot of ways.

As Berwick was arguing, rationing is already occurring

Berwick: “The decision is whether we will ration with our eyes open. And right now, we are doing it blindly.” From a 2009 interview Berwick gave to the journal Biotechnology Healthcare:

Q: Critics of CER have said that it will lead to the rationing of healthcare.

A: We can make a sensible social decision and say, “Well, at this point, to have access to a particular additional benefit [new drug or medical intervention] is so expensive that our taxpayers have better use for those funds.” We make those decisions all the time. The decision is not whether or not we will ration care -- the decision is whether we will ration with our eyes open. And right now, we are doing it blindly.

U.S. insurance companies already ration care. The insurance industry has readily admitted to using cost-benefit analyses in coverage decisions. For instance, during the July 15, 2009, edition of NPR's Morning Edition, WellPoint chief medical officer Dr. Sam Nussbaum told co-host Steve Inskeep that “where the private sector has been far more effective than government programs is in limiting clinical services to those that are best meeting the needs of patients.” Moreover, in Senate testimony, Wendell Potter, a former senior executive at CIGNA health insurance company, detailed ways in which the insurance industry makes cost-based coverage decisions, including how “insurers routinely dump policyholders who are less profitable or who get sick” and “also dump small businesses whose employees' medical claims exceed what insurance underwriters expected.”

U.S. health care also rationed by cost. As Peter Singer, professor of bioethics at Princeton University, noted in a July 15, 2009, New York Times Magazine article, “In the United States, most health care is privately financed, and so most rationing is by price.” He continued:

Health care is a scarce resource, and all scarce resources are rationed in one way or another. In the United States, most health care is privately financed, and so most rationing is by price: you get what you, or your employer, can afford to insure you for. But our current system of employer-financed health insurance exists only because the federal government encouraged it by making the premiums tax deductible. That is, in effect, a more than $200 billion government subsidy for health care. In the public sector, primarily Medicare, Medicaid and hospital emergency rooms, health care is rationed by long waits, high patient copayment requirements, low payments to doctors that discourage some from serving public patients and limits on payments to hospitals.

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Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse. If we ration we won't be writing blank checks to pharmaceutical companies for their patented drugs, nor paying for whatever procedures doctors choose to recommend. When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?