Donald Berwick: Good appointment, good strike against a terrible nomination process

The Berwick recess appointment will be evaluated through a partisan lens. It’s deeper than that. Too many obviously qualified people are caught in the confirmation process. I hope Democratic and Republican presidents do recess appointments more often.

President Obama gave Dr. Donald Berwick a recess appointment to head the Center for Medicare and Medicaid Services (CMS). I’m sure this story will be reported as an expected dose of presidential resolve in the partisan health policy trench wars. I suppose it is. President Obama surely benefits politically by having Berwick in place rather than begging some moderate Republican to grant the good doctor a confirmation hearing. This means more than that, too.

Berwick is arguably the nation’s leading expert on medical care quality. He has played a huge role in reducing medical errors, saving thousands of lives through his work at the Institute for Healthcare Improvement, which he founded. (If you’re unfamiliar with Berwick’s perspective, listen to this NPR segment.)

His nomination is supported or praised by experts across the political spectrum, including Mark McClellan and Gail Wilensky, the two most prominent Republicans to hold this job in recent years. Here’s what McClellan says:

What happens at CMS in the next few years will determine whether the new legislation actually improves quality and lowers costs… Don has a unique background in both improving care on the ground and thinking about how our nation’s health care policies need to be reformed to help make that happen.

Berwick is a pediatrician, and he’s not an economist. Both aspects of the resume are valuable now. He must implement health care delivery reforms to emphasize primary care, improve quality and cost-effectiveness—all without scaring the daylights of the American public or damaging much that is precious and fragile in our health care delivery system. He must manage the difficult transition from today until 2014 when the main pillars of health reform become operative.

Enacting health reform was, unavoidably, a partisan fight. Too much was at stake for the future of the Obama presidency, for the size and scope of American government for the fight to have gone all that differently. Now the Affordable Care Act has become law. We are thus handing a huge task to bureaucrats, senior civil servants, and expert political appointees who provide the backbone of American government.

Berwick is a key member of this group. Republicans might dig up some embarrassing complements he paid to the British National Health Service. Berwick is not a partisan at all. He’s spent the last quarter-century as a health services researcher with relatively little connection to partisan politics at all. There is no particular reason for his nomination to attract controversy. There is certainly no reason to hold it up with threats of filibusters and delaying tactics. Berwick might well have served in Republican administrations.

Berwick’s looming confirmation fight exemplifies ways that Senators abuse the confirmation process to damage American government and, incidentally, to make life hell for hundreds of highly qualified men and women who take huge pay cuts, put up with an intrusive and difficult vetting process, and are then put in limbo for months over issues that have nothing to do with them. In many cases, the real issue is some Senator’s desire to have the Secretary of whatnot kiss his ring.

This goes beyond health reform, beyond the usual partisan or ideological fights. For a long time now, the executive branch has been filled with too many unconfirmed people, outside consultants, way too many “acting” officials of all types. Too many officials are subjected to the confirmation process. Too many qualified people refuse to run this gauntlet at all. CMS has not had a confirmed director since 2006.

This goes to the basic capacity of American government to function well, our ability to find good people, efficiently scrutinize their qualifications and goals, and to put them to work addressing the nation’s serious problems. Other industrial democracies have far fewer political appointees. They do not decapitate their governments at major elections and then expect landmark legislation to emerge 100 days later. They do not erode the quality and the professionalism of their government and then denigrate public officials for their poor performance.

I’m gratified President Obama used this recess appointment. To tell you the truth, I hope the next Republican president uses recess appointments if Democratic Senators employ the same delaying tactics Republicans are now using to stall confirmation of obviously qualified nominees. It’s time to put Dr. Berwick to work, and to free him from a broken confirmation process that does not serve the nation well.

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect,, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

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