Obamacare Q&A: ‘I Don’t Really Think You Could Stop This Law’ 

An interview with the man originally charged with the implementation of the Affordable Care Act

Less than a month after President Obama signed the Affordable Care Act into law, he nominated Dr. Donald Berwick to lead its implementation as administrator of the Centers for Medicare and Medicaid Services. Months later, when Congress failed to act on the nomination, the president used a recess appointment to install Berwick in the post. Berwick resigned in late 2011 and is now running for governor of Massachusetts.

Berwick has positioned himself as a leader in the health reform effort, but he has tried to distance himself from the problem-plagued rollout of Healthcare.gov, the federal health insurance exchange. "Those were staff level functions," he said in an interview last month with the Boston Globe. "My leadership investment was in the vision of CMS as a major force of improvement of care for the nation."

I caught up with Berwick Friday as he was heading to the airport.

For many in the public, the disastrous rollout of Healthcare.gov has come to define the law itself. But Berwick emphasized — as other defenders of the law have — that its features extend well beyond the health insurance marketplaces.

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Among other things, he said, the law provides free preventive care benefits to millions of Americans, allows young adults up to age 26 to remain on their parents' health insurance policies, gives additional assistance to seniors with high medication bills, and improves oversight of insurance companies. He said the law also has many provisions to improve the quality of patient care and cited a recent drop in hospital readmissions.

Berwick said he hasn't had much interaction with those responsible for the rollout because presidential appointees are barred from having substantive interactions with their former agencies for two years after they leave office.

The interview has been edited for clarity and length.

Q. How do you think things are going with the rollout?

A. I guess I answer in two tiers. I think for the law as a whole, things are going well. This implementation has after all been going on really since the law was passed. And there are many, many benefits that are in place — things that are much better for millions of people. The discussion of the exchange rollout tends to dominate the visual field when there's so much else that's going on under the law that I'm very familiar with, because that happened when I was there — much of it.

In terms of the rollout [of Healthcare.gov], it's unfortunate for sure. Nobody's happy with this. I don't have much more information than an average newspaper reader has. But my general view is that this is a significant technical problem. It's reminiscent of some of the Part D [prescription drug program] implementation problems, but it's big and it's unfortunate. I think it's technical and therefore can be solved technically, and I assume will be. I can only guess the amount of resources that are now being put into an understanding of what's wrong and fixing it. I'm confident that this is going to be behind us, but like everyone in the country, I'm sorry that it hasn't gone well so far.

If we weren't so polarized, if there weren't people trying to shoot down the Affordable Care Act going way back to 2010, I think we'd have a different kind of national attitude, which would be, "Oh my goodness, that's a problem. Let's fix it." Instead of "Oh this is proof this law doesn't work and the government can't do anything." I mean that comes out of the political rhetoric, not out of the facts.

Q. How long do you think the administration has to fix the problems before it actually begins undercutting the law?

A. I don't know. I think that the facts on the ground should favor the administration in some important ways because the benefit structure of the law as a whole is so widespread. Actually I don't really think you could stop this law because the minute you tried to take it down, millions and millions of people would realize that they're losing something right now, let alone in the future. Preexisting conditions applying to kids again, prevention benefits lost, drug access down. That should help. I'm not an actuary, and I don't know how to calculate the actuarial consequences of the delay. I can make arguments on either side of the case. I will say that given the intensity of the commitment that I'm sure exists in the administration and the enormous technical competence of the nation, I think it will be fixed. I think it will be fixed in good enough time.

Q. As far as the whole issue of canceled plans, one of the things that's bothered me in this discussion is that there has not been as much of a willingness to acknowledge that indeed there are people who had good plans and who will pay more. How many people like that do you think there are and is that a problem?

A. I don't know how many people there are. Remember you're talking to a newspaper reader and not an insider right now. A large portion of the change in plans does apply to people who have very, very substandard coverage, and most of them are going to turn out to get what they need. I take it from you and from what I read that there are some people who will lose plans that they would, fully informed, still have chosen. I don't know the numbers there. I have no idea what the proportion is. I assume and believe that the president made his earlier presentations in good faith. He thought and hoped that the implementation process would allow people to keep all the coverage they wanted. That apparently is not the case now for some. I believe he apologized for it. Although I feel sympathetic to people who have coverage that they wish they could keep but cannot now, at the national level, the overall profile in the country will be far better coverage for so many people. This is an unfortunate thing for some but for the vast majority this will be an improvement in coverage.

Q. Do you think that the level of opposition has increased since the time that you were here?

A. Increased? I think there's been a consistent, really perpetual series of assaults on the law with different rhetoric. There is a long-term plan here being carried out by the opponents of this law to try to make a law of the land that was upheld by the Supreme Court not the law of the land. That's bad, but I think it's consistent behavior. I wish they would settle down and try to make health care a human right in the country and get into the job of health-care reform, which is what this law can let us do.

Q. Is there anything that keeps you up at night now that you're not there with respect to this law?

A. My hope and dream is that America can become a nation where health care is a human right for all and where the health-care system is evolving into the [system] of care that people really need — care of chronic illness, continuity of care, prevention-oriented, different from the care system we have. Much lower cost and much better at the same time. And the sooner we get there, the better. I just only lose sleep over tempo because people are still left out now.

In the Medicaid states that are not expanding [coverage under the Affordable Care Act], it's really terrible. People reeling and very much in poverty are going to be denied access to coverage, and I just think that's bad news. Can't we please get about the job of making health care a right and organizing around the proper, just, compassionate and excellent care that this law intends? It's just loss of time. I'm sorry about it.

Q. Some have said that the big problem here if you take a look at it from a policy perspective, the health-care system in this country is so disjointed that you really can't right it with a law short of going toward single payer. Do you agree?

A. It's not a binary thing. This is about progress. There's no question in my mind that the policy environment in the Affordable Care Act was a better environment. It's more sensible payment, more accountability and transparency, more orientation toward continuity of care, more investment in prevention, more investment in innovation. All of that is progress. I don't see it the same way as the people who say it's all or none. We did choose as a nation a pluralistic payment system under this law. That does add complexity. It adds political and administrative complexity. This law does permit states to try a simpler payment system, including single payer. It looks like Vermont may go that way and I think we might learn a ton from states that choose that pathway about whether that is indeed as much simpler and better and easier to manage as some believe it is.

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