We spoke yesterday afternoon about how the Affordable Care Act has changed our health-care system, what challenges it faces in coming years and why Berwick’s time as Medicare administrator may be his only stint in government service. What follows is a transcript of our conversation, lightly edited for grammar and clarity:
Sarah Kliff: The Affordable Care Act is hitting its two-year anniversary. Tell me a bit about how you think it’s changed the health-care system over the past two years.
Don Berwick: It’s profoundly changed the conversation for the good. The momentum in the country towards an expansion of coverage is underway. I think people have an understanding of how important that is, to have insurance be accessible. The second part of that, the improvement of our health-care delivery system, is going to be slower for people to notice. It will take time to build and have people understand how it’s changing.
It’s also not only the programs contemplated within the law that are changing and gaining momentum. I definitely see reflections of what we want to see in health care. There’s faster progress in the private sector. I think the Affordable Care Act has changed the mentality of the nation, towards one where we realize we can provide better care.
SK: You spent 18 months at Medicare, and did a lot of trips across the country to visit health-care providers. What’s one that had a big impact on you, and gave you a sense of where our health-care system is headed?
DB: One of the most impressive visits was a rural road trip I did with the regional Medicare staff in Seattle. It was a bunch of us in a van, playing U2, and it really was quite fun. I visited western Oregon, and was traveling down the coastline visiting these tiny hamlets that have critical access hospitals that were having a really tough time in this economy. You had primary care doctors there who impressed the heck out of me. You had a hospital that was recruiting retired dentists from the area, putting them in a van, and setting up a mobile clinic. I think that’s really related to the goal of health reform: Figuring out a better way to deliver health care.
SK: I’m curious if you could reflect a bit on your experience in Washington, working for the Obama administration. Republicans opposed your confirmation as Medicare head, and there were a lot of accusations about you wanting to “ration” health care. What’s the climate feel like for discussions about health policy here?
DB: The old-timers in Washington said to me they had never seen the degree of polarization and sometimes even rancor that seemed to exist among the stakeholders in Washington. I found it sad and unfortunate that the debate had deteriorated into hurling sound bytes and three-word phrases, death panels and rationing and that kind of stuff.
I made myself as available as I could. I never turned anyone down to my knowledge. But I often had a feeling that it was prelude to theater. In some cases I would meet with a senator or a House member who would talk to me quite cordially and then go out and angrily criticize me in public.
That being said, congressional staff worked incredibly hard and I have a deep respect for everything they did. The discourse didn’t stop progress, but I do hope a time comes when Washington is a place where people can disagree with more civility. That’s what we ask of a civilized community, and what we should ask of ourselves.
SK: Do you think you would return to Washington and serve in government again?
DB: That was the highlight and privilege of my career. This was one of the most inspiring and satisfying parts of my whole career. To help the people in the agency work more effectively and engage in tough questions, I absolutely loved it. And I’m very sorry that I had to leave.
SK: What will you be watching on the health reform law in the next year? What looks to be the biggest challenges to its success?
DB: Pivotal to the next phase of implementation is the establishment of the exchanges. A lot of the act lies in the structure of the exchanges. That discussion has become quite politicized and, technically speaking, it’s a difficult task. These exchanges require information and you can’t decide, the day before they launch, you want to do one. It’s a bit of a horse race to see whether it will go well enough, and whether the federal and state exchanges will be ready on time.
I firmly believe that the best way to make care affordable is improve it. The Affordable Care Act is a foundation, and there’s a lot of stuff going on around it. It’s game time now. In the next couple of years we’re going to need to see health-care costs coming under firm control. If that happens, I’ll be optimistic.