The Political Challenges in American Health Reform: Former CMS Administrator Don Berwick on the Need for Clinician Activism

Dr. Donald Berwick

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Margaret Flinter: Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter , a show where we speak to the top thought leaders
in health innovation, health policy, care delivery , and the great minds
who are shaping the health c are of the future. This week , Mark and
Margaret speak with the f ormer CMS administrator , Don Berwick ,
who's also founder of the Institute for Healthcare Improvement , a
global organization dedicated to improving health care and health
systems around the wor ld. He'll talk about decades of work towards
reform of the health care system and how to make it more accessible ,
higher quality , and less costly.

Lori Robertson also checks in , the managing editor of FactCheck.org ,
looks at misstatements spoken about heal th policy in the public
domain , separating the fake from the facts . We end with a bright idea
that’s improving health an d well - being in everyday lives.

If you have comments , please email us at [email protected] or find
us on Facebook, or Twitter , iTunes , or wh erever you listen to
podcasts . You can also hear us by asking Alexa to play the program ,
Conversations on Health Care. Now , stay tuned for our interview with
Don Berwick on Conversations on Health Care .

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Mark Masselli: We're speaking today with Dr. Don Berwick , President Emeritus and
senior fellow at the Institute for Healthcare Improvement , and former
administrator of the Cent er s for Medicare and Medicaid Services . A
pediatrician by training , Dr. Berwick has served on the faculty of
Harvard Medical School and Harvard School of Public Health. He was
vice chair of the U.S. Preventive Services Task Force and served on the
Institute of Medicine's governing board. He earned his MD cum laude
from Harvard Medica l School.

Dr. Berwick , welcome back to Conversations on Health Care .

Dr. Don Berwick: It's a real plea sure to be with you. Thank you.

Mark Masselli: Yeah . We had you back in early 2012 . Affordable Care Act had been
passed in the spring of 2010 . You were on that ground floor of the
policy development . You've recently published a powerful article in
The Journal of American Medical Association , in which you lay out
some of the political challenges that have long been embedded in the
American health policy. I'm wondering if you can just give our
listeners an update on the ACA and really sort of where it stands. I'm
thinking about the two lenses that you've used to describe the
Affordable Care Act . One that it was to give people more insurance ,
and two is to make the health care system better. What's currently
going on there , if you could just give us a lay of the land ?

Dr. Donald Berwick

Dr. Don Berwick: Yes . I have , as you said , conceded the Affordable Care Act as actually
kind of two laws in one . One to get more people covered wi th better
coverage , and the second to help health care change and improve , so
it does a better job. On the first grounds, the Affordable Care Act ’s
potential was to cover about 32 million people , 16 million by
expanding Medicaid coverage and 16 million by setting up these
affordable exchanges with subsidies to people , so they can afford
insurance , if they're not eligible for Medicaid, but are lower income.

Unfortunately , we're back - paddling on both. The Trump
Administration is doing everything it can to slo w progress in coverage.
They want to dial back the Medicaid expansion. They have made it
possible for Medicaid benefits to now be much less valuable to
discourage states from expanding and to eventually end up with what
it called block grants , that is inst ead of the federal government being
the coinsurer in Medicaid , they just give money to states and states to
do whatever they want with that money. As a result , Medicaid
expansion has slowed . There are people now , especially under the
new work requirements , who have had Medicaid who are going to
lose it.

This is hurting people badly at the lower end of the economic
spectrum . On the expansion of exchanges , in order for the exchanges
to be vibrant , the federal government has to step up and make sure
that the e xchanges are offering insurance policies that cover what
they should , so that people aren’t going to be surprised to find
themselves not covered and the subsidies have to stay in place. There
are a number of maneuvers the government is now made to cut back
on the subsidies to make it possible for insurance companies to offer
a far less valuable insurance coverage . You're going to buy insurance
and discover it doesn't cover something you really need . Effective
coverage is going backward. It's a toxic trend . I think we're backing
away.

By the end of the Obama Administration , we had about 20 million
people coverage of the 32 million that could have been . That 's
decreasing now , unfortunately. On the make health care better front ,
there's also some dialing back. There's been some wonderful
experiments done with new forms of payment that help health care
providers offer far more continuity . Those experiments could have
been cut back on . I think we're seeing less progress than otherwise
would. We lack the kind of fe deral leadership we need to have
universal coverage in health care reform . It concerns me.

Margaret Flinter: Well , Dr. Berwick , for all of us who were deeply engaged in health
care before the ACA , there are certainly so many things which we
thought clearly in a very tardy way addressed some of the persistent
problems that people in this country faced in getting the coverage

Dr. Donald Berwick

and the care they needed. You laid out in your article , Politics and
Health Care , some of the political challenges that we've grappled
with . You chart the rise of these new potential threats to health
reform , some of which you've referenced and in the context in the
environment of changes in the makeup of the Supreme Court.

I wonder if you could just help our listeners understand how the
makeup of the High Court really has the ability to significantly affect
the health reform progress that's been made , and also how state
government could play a strong role in determining health policy as
we go forward.

Dr. Don Berwick: Yes, that editorial in The Journal of American Medical Association , it
was actually an editorial about two articles that were in that issue.
One was an analysis of the probable effects of a shift in center of
gravity in the Supreme Court and the nomination , and confirmation o f
Brett Kavanaugh we have on health care. First of all , the Affordable
Care Act itself requires support from the Supreme Court. There are
interpretations that matter that say that it's okay for Congress to set
up a system , which expands Medicaid , and which provides more
coverage to people. I think there's a threat now that the ability of the
agencies in HHS , CMS , and others to actually protect beneficiaries will
be decreased under a Supreme Court that where the center of gravity
has shifted.

The basic funda mental idea here is health care human right. The
question is do we have a court that actually wants to make sure that
people have access to care as a matter of justice. I'm worried about
that. Obviously , the well - being of women is at stake here . Certainly
should Roe v. Wade be overturned , w e're going to see a wave of
serious harm to women of childbearing age . I think we could see
contraceptive coverage decrease as well . I think there's enormous
harm possible with a court with a shift in the center of gravit y.

The bigger picture in my editorial was kind of speaking to doctors and
nurses . If you're a doctor , you want to see patients . You really would
prefer not to have to deal with politics. Let me see my patients . This
political circus go on. What I' m saying is that's not possible. Politics is
in health care in America as well as other countries , but in America
especially because with $3 trillion of the economy at stake , vast forces
enter the picture . I'm really urging clinicians to step up and protect
patient s , and become politically activated. I think we'v e got to do it
rather than being naïve .

Mark Masselli: Your article really is a clarion call. In particular to the young
practitioner who's starting off their career , you know that physicians
ignore politics at their own [inaudible 00:07:29] , and those of their
patients as well . I'm wondering what your advice is. What do you
think a meaningful engagement will be for someone who's also got a

Dr. Donald Berwick

full - time clinical practice? What's the practical advice that you hav e?

Dr. Don Berwick: I don't want to be glib about it. There are tiers of engagement where
people have their lives to lead . First , vote . The turnout in American
politics , the voting turnout is dreadful . The very people that are being
hurt the most aren't th e ones that are voting . I'd say physician , nurse ,
you vote and get people to vote , and be part of that call. Doctors are
respected . Nurses are respected . When they take positions , patients
listen . They're trusted . I think that it's your judgment call as to
whether you want to bring that in the consulting room. I think
speaking out now about the idea that if we don't protect health care
as a human right , we're all going to get hurt.

I believe physicians should run for office and nurses too on the left .
We ha ve a number of memb ers of Congress who are doctors . They
are almost all on the right wing side that I disagree with . I think we
need activation . I'm seeing that there are more and more clinicians
running for office , especially women . I celebrate that . I re ally
encourage people to consider doing that.

States stepping up is key. The biggest difference in this realm between
the state and the federal government is the federal government can
print money . It can borrow money . It can have a deficit budget . States
cannot . That's a big inhibitor . That doesn't mean states can't take
highly protective acts toward protecting access. I'm seeing attorneys
general around the country step up and say that they're bringing a
suit against the adminis tration to protect human ri ghts.

On benefit structures , there are some more subtle things to do. A very
important one is that as any doctor or nurse knows , health is not
really determined by health care . It’s determined by social factors ,
education , transportation , housing , income i nequality . When state
legislatures and state leaders act on issues like that , they actually are
working on health and they need to . Housing and transport , and
education are very important contributors to health and well - being .
Doctors ne ed to speak about t hat as well.

Margaret Flinter: When we first came to know you , it was really through your work on
patient safety . You've taken that work all over the world. I know you
were called upon by the National Health Service in the United
Kingdom. I think Queen Eli zabeth knighted you for the contributions
that you've made . Love for you to comment on the big advances
we've made in patient safety in health care.

Dr. Don Berwick: Well , the progress has been tremendous. We now know the problem .
You can't work on a probl em you can't see . The evidence base is now
showing how much error there is in medicine , how many people are
harmed by care . That's in a way , good news. Now that we know about
it , we can pour point attention to it . That's happening. Just this

Dr. Donald Berwick

month , three r eports appeared on the global health scene , one from
the Lancet Commission , one from the WHO, one from our own
National Academy of Sciences , which I report that I co - chaired , called
Crossing the Global Quality Chasm . The y are three important reports
laying out the dimensions of the problem.

We also have examples of success. I ’ll take for example the Country of
Scotland. Amazing what's going on there . The entire country has been
mobilized to make patient care safer . The results are stunning.
They've got well over a 20 % decline in surgical mortality. They've got a
major decline in errors in care that they can document. When yo u get
mobilized , we can do stuff. The science is advancing really fast. We've
woken up . We understand the science i s a safety . Now we ne ed
leadership. The big deal here is with boards of trustees , CEOs of
hospitals , chief medical officers , chief nursing officers , please
understand that making patient safe is job one.

Mark Masselli: We're speaking today with Dr. Don Berwick , President Emeri tus and
senior fellow at the Institute for Healthcare Improvement , and former
administrator of the Center s for Medicare and Medicaid Services.

Dr. Berwick , you've talked about these inherent challenges in the
American health care system . We're seeing big p layers coming in.
You've got Amazon partnership with Berkshire Hathaway , JP Morgan,
Chase coming in , you've got Apple , and other technology giants
entering into the personal health technology space , but also looking
at how do you control cost here. I'm wond ering what you think about
these disruptive innovations and business models that are entering
the health care space ? What's good about it and what keeps you up at
night?

Dr. Don Berwick: Health care is - - it's really , I gu ess , broken is the way to say it. The way
we book the health care system in our country is far too expensive . It
way under serves populations for all sorts of reasons. It's like asking a
tank to fly . You need airplanes . Some basic restructuring is going to be
needed. We need to work much ha rder on continuity of care , on
reliability , on safety . The health care system has had trouble doing
that . It’s had trouble changing . There are too many changes in store.

With these new entrants , like the Amazon , Berkshire Hathaway ,
JP Morgan entry , the comb ination of C V S and Ensure [ PH 00:12:18] ,
the work I think developing in Google and IBM , and others , I think
we're going to be seeing some really wonderful innovations , basically
new ways for people to find help , to get care , more immediate , lower
cost , mor e responsive , customized to them as individuals , more
adaptable , more portable . There is really good news here.

Of course , the downside risk is we better do it with discipline. Some of
these innovations are not going to work . We need to make sure they

Dr. Donald Berwick

are subject to proper scrutiny and evaluation , and regulation when
needed . Back to the mainstream , we ’re still going to have hospitals .
We're still going to have doctors ’ offices. They're not going to go
away . We have to work on quality within the mainstream s ystem as
well. I'm pretty excited about what's happening. My recent
encounters with telemedicine and telehealth for example , where you
can take consultations and project them virtually , it's amazing . The
miles between has dissolved . Suddenly we can help ea ch other in
ways w e didn't think possible before.

Margaret Flinter: Well , Dr. Berwick, we are also very excited about all those things and
the possibility of relationships between patients and their care
providers being enhanced and augmented , not replaced necessarily
by virtual care. A lot of very interesting work going on . A really big
issue of concern and we're reading more and more about it in the
literature is the epidemic of clinician burnout. We're hearing that
people are kind of at the end of their wits, the people who are
providing care , that they're exhausted , that the work demands
outpace what they can do , that they're challenged by everything from
some of the additional responsibilities that have come with electronic
health records , which we embr ace on the one hand , that have made
things difficult somewhat on the other han d.

What are your thoughts on this ? We see this as a patient safety issue
obviously . You want your clinician to be satisfied and filled with joy
and practice , not feeling burned o ut . What are your thoughts about
what we should be doing in that are na?

Dr. Don Berwick: Well , the problem s of clinician burnout are serious and dangerous ,
and pervasive. Half the doctors in the United States now say on a
survey that they would not advi s e a young person to become a
doctor. That’s terribly sad , if you consider how wonderful this
profession has been and can be. We're asking people to do impossible
jobs now. We've taken health care and we've layered in
administrative burdens , reporting burdens , measurement burdens ,
payment systems , productivity targets that make no sense . We will
never ever get excellence by trying to drive doctors and nurses , and
other workers in health care harder and harder. They will burnout . Of
course they will.

What we ne ed is different care , care that supports them , and doesn't
stand in their way. Part of this is getting out of this current wave of
way excessive metrics . Everybody ’s spending all their time reporting
measures . Yeah , we want transparency , but w e need doctor s to spend
their time talking to and being with patients. The electronic health
record , which has tremendous promise , it's now pervasive . Almost all
hospitals have it . More and more doctors do . It isn't working right.
The way we built the electronic health record is actually adding work .

Dr. Donald Berwick

It's adding nonsense to care . Doctors and nurses know it . We need a
whole round of revision of the way we're looking at electronic
records , so they actually support the care instead of standing in the
way of it. There were actually more bills often as the billing systems
than these care systems .

We need a change of attitude. We're not going to fix this by yelling at
doctors and nurses . It's not going to happen . They're doing their best.
We're going to fix it by creating syst ems in which people really can
focus back on the needs of individual patients. P art of it is changing
financing. I am publicly in favor of Medicare for All global payment , in
which we finally give health care organizations budgets to he alth care
for popula tions , so they don't have to keep running on a durable cage
and doing more and more in order to survive financially. We need
them to focus on what matters to patients . That's going to require a
different financing.

Mark Masselli: I was thinking about your comment about Scotland and the work
that's going on there , and talking about Medicare for All . We see a lot
of these European systems where their government is financing them.
What are we seeing around the globe that you think can cross walk
over to the Sta tes ? Or I think we had David Gergen on th e show . He
really talked about we need an American solution. I'm not sure that's
always the case . Are there best practices that can be integrated into
our system that could flourish here ? What are you seein g as you look
around the globe?

Dr. Don Berwick: Your question is right on target . When you say best practices , we --
like for almost any question , we do have an answer . The problem is
the answer is not everywhere. Even if we just look within the United
States , I'l l take for example Kaiser Permanente ’s focus now on well -
being and upstream work on housing and transportation , and risks in
their population . It's quite thrilling to watch. On the environmental
responsibility , health care has a big role to play in stoppin g global
warming . We see examples like the Gundersen Luthe ran System in
Wisconsin , which has -- it's become not just carbon neutral , it's
actually -- it's a carbon reducing part of the health system . That's
exciting.

With respect to patient - centered care , we have plenty of examples
where patients are getting tower in health systems and changing the
systems like Cincinnati Children's Hospital in Cincinnati , Ohio. Patient
safety breakthroughs , we've seen zero . We've seen actually reaching
zero in infection ra tes and complication rates in places that are
dedicat ed to it. Outside the United States , I'd say even more
innovation in delivery because of a different financing system. Not all
are single payer s . Some are multi - payer systems . They have
government as an insurer of last resort , so everyone is covered . In

Dr. Donald Berwick

places like Scotland and Sweden , and Singapore , and even Malaysia
now , you're seeing innovations toward moving to much more health
and well - being in care systems . We can certainly learn from those.

Margare t Flinter: We've been speaking today with Dr. Don Berwick , the President
Emeritus and senior fellow at the Institute for Healthcare
Improvement , an i ndependent , not - for - profit organization , seeking to
improve health and health care worldwide. You can learn more about
their work by going to ihi.org or follow Dr. Berwick on Twitter
@donberwick .

Dr. Berwick , thank you so much for your dedication to improving the
health care system here around the world , for all you've contri buted
to our advances of recent years , and for joining us on Conversations
on Health Care today.

Dr. Don Berwick: You're v ery kind. Thanks for having me.

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Mark Masselli: At Conversations on Health Care , we want our audience to be truly in
the know w hen it comes to the facts about health care reform and
policy . Lori Robertson is an award - winning journalist and managing
editor of FactCheck.org, a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in U.S. polit ics.

Lori, what have you got for us this week?

Lori Robertson: The Department of Justice is siding with plaintiffs in a lawsuit that it
said , if successful , would end Affordable Care Act protections for
those with preexisting conditions. Yet President Dona ld Trump
claimed that “ preexisting conditions are safe. ” He said that he “ will
always fight for patients with preexisting conditions. ” The lawsuit in
question was filed in district court in Texas in February by 20 states. It
argues that because Congress el iminated the tax penalty associated
with the ACA ’s individual mandate , that the mandate itself is now
unconstitutional . Without the mandate , the entire health care law
must go. The suit bases this argument on the Supreme Court's 2012
decision that Trump’s mandate was lawful under Cong ress' power to
tax.

In June, the Department of Justice said this was a rare case , where it
would not defend the federal government in the lawsuit . Instead the
DOJ lar gely agreed with the plaintiffs. Attorney General , Jeff Sessi ons ,
wrote in a June letter to Congress that he had made this decision
“ after careful consideration and with the approval of the President of
the United States. ” Sessions explained that the administration didn't
agree that the entire ACA would have to go . Two provisions would
need to be eliminated. Those guarantee ing that people can't be
denied coverage by insurers or charge d more based on certain

Dr. Donald Berwick

factors. Those provisions protect those with preexisting conditions
from being denied a policy or charge d highe r premiums . Before the
ACA instituted these protections , insurers could deny coverage or
charge more based on health s tatus on the individual market.

In early September , the district court judge in the case heard oral
arguments on a preliminary injunction against the ACA , requested by
the plaintiffs. It's misleading for the president to say he “ will always
fight for and always protect patients with preexisting conditions ”
when his Justice Department with his approval has decided not to
fight .

That's my fact check for this week. I'm Lori Robertson , managing
editor of FactCheck.org .

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country’s
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you ’d
would checked, email us at chcradio.com . We ’ll have FactCheck.org’s
Lori Robertson check it out for you here on Conversations on Health
Care .

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Mark Masselli: Ea ch week , Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Over the past
few decades , kids have been getting less and less physical activity
throughout the school day . As budgets have been tight ened and
achievement requirements have increased , Phys Ed. has become less
prevalent in many schools. University of Michigan researchers wanted
to find a creative and effective solution that would increase kids ’
movement wit hout disrupting the school day.

Dr. Rebecca Has sa n : We looked at the scientific literature in terms of prolonged sitting .
They have demonstrated that if you just two minutes of activity , get
up , do some movements , sit back down , activity in that small of a
doze can have dramatic improvem ents on health , on cognition , on
learning. We decided to develop an intervention , a program , that
would allow children to get these small bursts of activity throughout
the day.

Mark Masselli: Dr. Rebecca Hassan [ PH 00:22:31] wanted to find out just two to
three - minute short bursts of physical activity five times a day done
right at the student ’ s desk would impact the kid's cumulative
movement.

Dr. Rebecca Hassan: We typically see in PE or recess lower participation in girls compared
to boys . In classroom ac tivity breaks , you actually see similar rates of
participation , if not higher rates of participation , in girls compared to
boys. We also saw that for children who are carrying few extra

Dr. Donald Berwick

pounds that those children also were exercising at a high intensity .
W e did not see any differences by weight status. Even children with
asthma , they were even able to do the activity breaks.

Mark Masselli: Dr. Ha ssan said they wanted to design the intervention that would be
easy fo r teachers to adopt and manage.

Dr. Rebecca Hassan: Our lab , we created a compendium of 200 activity breaks that are just
three minutes long. We got a lot of positive responses , particularly for
the videos from the teachers because it was really easy to implement.
There's no rules that you have to explain . It's quickly , get the children
up , press the button , move , get the kids back d own , and then we're
back on task.

Mark Masselli: Dr. Hass a n said that the most promising results were in the
cumulative effects of the multiple burst of activity through out the
day. Kids burned on average about 150 more calories per day and at
the end of the week had accrued a significa nt amount of physical
activity.

Dr. Rebecca Hassan: The kids , when they went home , they still continue d to be physically
active. We had th ese little accelerometers . It tells us how much
physical activity were they getting.

Mark Masselli: A low cost , easily adoptable fitness intervention for kids , allowing
short bursts of physical act ivity throughout the school day, enhancing
fitness , empower ing kids to move more , n ow that's a bright idea.

[Music]

Mark Masselli: You've been listening to Conversations on Health Care. I'm Mark
Masselli .

Margaret Flinter: I’m Margaret Flinter.

Mark Masselli: Peace and h ealth.

Margaret Flinter: Conversations on He alth Care is recorded at WESU at Wesleyan
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listen to podcasts. If you have comments, please email us at
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