Health Care Appointment
Mr. President, I rise to discuss the appointment by President Obama of Dr. Donald Berwick as Administrator of the Center for Medicare and Medicaid Services. I disagree, respectfully, with my distinguished colleague from Arizona. I guess I…
Mr. President, I rise to discuss the appointment by President Obama of Dr. Donald Berwick as Administrator of the Center for Medicare and Medicaid Services.
I disagree, respectfully, with my distinguished colleague from Arizona. I guess I agree that it is regrettable that this was a recess appointment, but I believe that on the part of the President it was both prudent and necessary to make this a recess appointment, given, A, the urgency of moving forward with health care reform and, B, the relentless blockade the Republicans have maintained.
Dr. Berwick is perhaps the most qualified person in the country to wield the vast apparatus of the Federal health care bureaucracy toward the comprehensive change we need, to lower the cost of health care, while improving the quality of health care.
In evaluating this urgency, I ask my colleague to consider the situation we are in right now. We are in the midst of an accelerating and unsustainable rise in health care expenditures in America. In 1955--the year I was born--we spent a little bit over $12 billion a year on health care. That was the annual health care expenditure in the United States in 1955--$12 billion. Last year, we spent more than $2.5 trillion. The increase over the previous year was $134 billion--from 2008 to 2009, an increase of $134 billion, which is the largest year- to-year increase in history, by the way, and 200 times what we spent in 1955--200 times. Anybody who is looking at this can see both the trend and the increasing acceleration of this curve. It is accelerating, it is unsustainable, and it adds up to, at this point, a stunning 17.3 percent of our national domestic product, our GDP, spent on health care every year. No other nation even comes close to spending that much of its annual domestic product on health care.
In my home State of Rhode Island, had we done nothing on health care, by 2016 a family of four would have faced more than $26,000 in premiums for family health insurance--$26,000 per year in 2016 average costs. Last year, premiums for Medicare Advantage plans jumped an average of 14.2 percent nationally--just in 1 year. So there is a clearly unmistakable case that our health care costs are out of control and we have to do something about it.
The escalation, as I pointed out, is unsustainable and accelerating, but it is not inevitable. Indeed, experts from across the ideological spectrum agree that a great deal of health care cost is simply waste-- waste resulting from an irrational, disorganized status quo that too often encourages the wrong choices by patients, payers, and by providers of health care services. That status quo has to change.
As you consider our health care system, set aside for a moment the problem of duplicative tests, the problem of lost medical records, the problem of unnecessary treatments, and the problem of uncoordinated care for patients working between multiple doctors. Set aside all those problems and look just at the administrative overhead of our private insurance market.
By way of reference, administrative costs for Medicare run about 3 to 5 percent. Overhead for private insurers is an astounding 20 to 27 percent. A Commonwealth Fund report indicates that the private insurer administrative costs more than doubled from just 2000 to 2006. In those 6 years, the overhead, the administrative costs of the private insurance industry, more than doubled, up 109 percent. The McKinsey Global Institute estimates that Americans spend roughly $128 billion annually just on what the report called ``excess administrative overhead.'' There is $128 billion that we pay for every year in excess administrative overhead--not health care but administrative overhead-- in our health care system in the private health insurance market.
On top of that, you have the duplicative tests, lost medical records, unnecessary treatment, and the uncoordinated care for patients with multiple and chronic conditions. I won't dwell on those particular topics because I have spoken about them so often on the Senate floor in the past. My point is that because of all this waste in the system, the President's Council of Economic Advisers concludes that it should be possible to cut total health expenditures about 30 percent. Let me repeat that quote.
It should be possible to cut total health expenditures
about 30 percent without worsening outcomes . . . which would
suggest that savings on the order of 5 percent of GDP could
be feasible.
Five percent of GDP is over $700 billion a year, and other experts agree. The New England Healthcare Institute reports as much as $850 billion a year in excess cost ``can be eliminated without reducing the quality of care.'' Former Bush administration Treasury Secretary O'Neill has written that the excess cost is $1 trillion a year in our health care system. The Lewin Group, which is often cited in this Chamber on both sides of the aisle as a respectable organization that does authoritative work in this area, finds that we burn over $1 trillion a year through excess cost and waste.
So is it $700 billion a year in excess cost and waste, is it $850 billion a year, is it $1 trillion or over a year in excess cost and waste? Whatever it is, it is a big number, and we needed to do something about it. This Congress rose to the challenge in the health care reform
bill and passed what health economist David Cutler has called ``the most significant action on medical spending ever proposed in the United States.''
This isn't just a partisan view. Analysts of all stripes agree the reform law does more than any previous measure to begin to lift the dead weight of all this wasteful health care cost off our economy. The Commonwealth Fund has projected that the law will reduce the annual growth of national health expenditures--that is the amount that private and public sectors would otherwise spend on health care every year--by 0.6 percentage points annually and nearly $600 billion over the next 10 years. The Council of Economic Advisers writes that ``total slowing of private-sector cost growth'' will be approximately 1 percentage point per year--more than $1 trillion over the next 10 years. That is just what they can prognosticate, what they can anticipate, what they can project.
Here is something that is interesting. Nobel laureate Paul Krugman writes:
There are many cost-saving efforts in the proposed reform,
but nobody knows how well any one of these efforts will work.
And as a result, official estimates don't give the plan much
credit for any of them. Realistically, health reform is
likely to do much better at controlling costs than any of the
official projections suggest.
Health reform is likely to do much better at controlling costs than any of the official projections suggest.
He is not alone. Other respected health economists--Len Nichols of George Mason, Ken Thorpe of Emory, and Alan Garber of Stanford, described the bill's cost controls as vital, a significant improvement on the status quo. And MIT Professor Jonathan Gruber, one of our leading health economists, said of the bill's cost control measures:
I can't think of a thing to try that they didn't try. They
really make the best effort anyone has ever made. Everything
is in here. You couldn't have done better than they are
doing.
So that frames the picture for the appointment of Dr. Berwick because the President's signature of our health care law was just the beginning of the reform project that lies ahead. This law gives those unprecedented tools to fight health care waste and inefficiency, but those tools are meaningless, they are useless unless they are applied both vigorously and wisely. Don Berwick is simply, hands down, the best person to do that. He has vast experience, proven expertise, and he has earned the respect of colleagues in the public and private sectors and on all sides of the ideological spectrum.
For instance, Dr. Nancy Nielsen, immediate past president of the American Medical Association, said Dr. Berwick is ``widely known and well-respected for his visionary leadership efforts that focus on optimizing the quality and safety of patient care in hospitals and across health care settings.''
Gail Wilensky, the Administrator of CMS under President George H.W. Bush, said Dr. Berwick ``has long-standing recognition for expertise and for not being a partisan individual, so I think that will assist him in his dealings with Congress, both with the majority and hopefully the minority, as well.''
Tom Scully, George W. Bush's CMS chief said:
You're not going to do any better than Don Berwick.
And Steven D. Findlay, health policy analyst at Consumers Union, has applauded what he calls ``a spectacular appointment.''
Don has been an intellectual force in health care for
decades. He helped forge many ideas incorporated in the new
health care law.
So given this chorus of praise from across the ideological spectrum and the urgency of the task at hand to control those costs, one might think that bipartisan support for Dr. Berwick's nomination would be strong and swift.
Well, you heard the Senator from Arizona. Unfortunately, my Republican colleagues, regrettably, threaten the familiar old Washington playbook of delay and obstruction.
I have spoken many times about how the Republican minority has delayed without substantive justification far too many of the President's executive branch nominees, jamming up the administration's ability to administer the government; usually not because they have any objection to the nominee but just to jam up the administration's ability to administer the government.
On our Executive Calendar right here we have the names of everybody who is waiting on the Senate floor languishing, waiting for a vote. That doesn't even count all the names that are stuck in committees. These are the people on the Senate floor waiting for a vote. Some have been on for months. Some of them have cleared committee unanimously with full Republican support in the committee. Yet they are jammed up here. That is the quagmire into which they were going to stick Dr. Berwick, notwithstanding the urgency of the need.
Since his nomination was first announced, the Republicans made clear they would subject Dr. Berwick to this treatment. There is no doubt about that. It was confirmed just now by the Senator from Arizona. A recess appointment was the only way for the President to ensure that CMS is fully equipped to handle the vital and voluminous and immediate tasks that we have asked CMS to perform.
So why do my colleagues on the other side of the aisle clamor in opposition to Dr. Berwick, the foremost expert in the field of reducing cost by improving quality of care? There are innumerable ways to reduce health care costs by improving quality. Reducing and eliminating hospital-acquired infections is a perfect example. The North Carolina Medicaid effort to provide coordinated care of a medical home for people who are high users of the health care system is another example.
My Republican colleagues, who so loudly championed cost control, now claim this reducing cost by improving quality is rationing--rationing. Well, here is my question: Whose side are they on? One trillion dollars a year in waste, and they are lining up to defend the waste and call efforts to restrain it rationing? Protecting you and your family from expensive and dangerous hospital-acquired infections, that is rationing? Organizing complex care of people who have multiple diagnoses and chronic conditions into coordinated medical homes, rationing? Whose side are they on when they attack the reforms, the quality improvement, cost-reducing reforms that are Dr. Berwick's signature expertise?
One Senator even stood in this Chamber and said Dr. Berwick endorsed an end-of-life pathway to death. Oh boy, looks like the death panels are back. Dr. Berwick is not just a pioneer in health care quality improvement, he is the pioneer. He was a lead author of the Institute of Medicine's watershed report, ``To Err Is Human,'' and the follow-on report, ``Crossing the Quality Chasm.'' ``To Err Is Human'' launched the quality movement in this country. That report exposed the breathtaking fact that 100,000 Americans die needlessly in this country every year from medical errors--100,000 Americans dead every year in this country because of needless medical errors. Is getting rid of the errors that killed those 100,000 Americans rationing? Don Berwick has devoted his life to saving those lives. Whose side are my colleagues on when they oppose Dr. Berwick?
The connection between quality improvement and cost savings which Don Berwick has spent his career exploring is demonstrated by global maternal mortality figures. Maternal mortality is a cold and statistical way of saying moms who die in childbirth. We in the United States are 39th in the world. Thirty-eight countries, including most of Europe, do a better job of keeping moms alive through childbirth. We would be willing to spend money to get better at that, I would bet. But the strange thing is the many medical errors and the process failures that cause those deaths--and that cause us to be 39th in the world at maternal mortality--also cause a lot of other complications which cost lots of money to treat and recover from. So if you make those quality improvements, you save money. That is the win-win connection between cost saving and quality reform.
That is the area where Don Berwick specializes and has specialized for years--improving care, eliminating process failures, and saving cost. But my Republican colleagues are standing against him and want to talk about rationing. When it improves care, when it lowers maternal mortality, that is the kind of reform I think we could use. If
you are against that, and if you are against Dr. Berwick, whose side are you on?
Dr. Berwick founded the Institute for Healthcare Improvement, one of the first organizations to promote systematic and sustainable health care quality improvement. He has worked on quality initiatives as a board member of the American Hospital Association, as chair of the Advisory Council for the Agency for Healthcare Research and Quality, and as a member of President Clinton's Advisory Commission on Consumer Protection and Quality. That is his work.
That is probably why Tom Scully, CMS Administrator under President George W. Bush, said:
You are not going to do any better than Don Berwick.
So I ask my colleagues: Do we really need to raise the phony scarecrows of rationing, of death panels, of socialized medicine?
Do we really need to go there against $1 trillion in waste and inefficiency every year? Do you really want reform efforts to fail against 100,000 American lives lost every year due to avoidable medical errors?
Do you really want reform efforts to fail against eliminating hospital-acquired infections and providing better coordinated care for patients who have multiple doctors and multiple conditions? Do you really want the reform effort to fail? Is this how far we have fallen?
There is a huge window where we could work together on a win-win path, where we could improve the quality of health care for Americans while reducing its cost by coordinating the care better, by coordinating electronic health records better, by avoiding hospital- acquired infections, by avoiding unnecessary care, by making sure doctors know what the best evidence is for treatment as they have to take on patients with multiple difficulties and symptoms. We could do this together. This is a win-win, and Dr. Berwick is an expert with bipartisan public/private--or Republican and Democratic support and recognition of his particular expertise in this area. I urge my colleagues to treat Dr. Berwick as the highly qualified individual he is, not as an opportunity for political grandstanding--we do enough of that around here--not as a way to wish failure on America in this vital task that lies before us. At long last, my friends and colleagues, are we not better than that?
Mr. President, I yield the floor.