Whitehouse: Recess Appointment of Dr. Berwick was Prudent and Necessary
Mr. President, I rise to express the appointment by President Obama of Dr. Berwick as the administrator of the Center for Medicare and Medicaid Services. I would disagree, respectfully, with my distinguished colleague from Arizona. I guess I would agree that it is regrettable that this was a recess appointment, but it is equally regrettable that - I believe on the part of the President that it was both prudent and necessary to make this a recess appointment, given a) the urgency of moving forward with healthcare reform and b) the relentless blockade that the Republicans have maintained.
In order to make these remarks, I would like to speak as if in morning business, until the conclusion of my remarks. If I may have unanimous consent for that? Thank you.
Dr. Berwick is perhaps the most qualified person in the country - to wheel the vast apparatus of the federal health care bureaucracy toward the comprehensive change we need to lower the cost of healthcare, while improving the quality of healthcare.
In evaluating the urgency in this, I would ask my colleagues to consider the situation that we are in, right now. [SEE CHART] We are in the midst of an accelerating and unsustainable rise in health care expenditures in America. In 1955, the year that I was born, we spent a little bit over $12 billion a year on heath care. That was the annual health care expenditure in the United States in 1955 - $12 billion. Last year, we spent $2.5 trillion. The increase over the previous year was $134 billion - 2008 to 2009, an increase of $134 billion; 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% of our national domestic product, our gross domestic product, spent just on healthcare every year. No other nation even comes close, to spending that much of its annual domestic product on healthcare.
In my home State of Rhode Island, had we done nothing on healthcare, a family of four would, by 2016, have faced more than $26,000 in premium for family health insurance. $26,000 per year in 2016, average cost. Last year, premiums for Medicare Advantage plans jumped an average of 14.2% nationally - just in one year, 14.2%. So, there's a clear and unmistakable case that our healthcare costs are out of control and we have to do something about it. The escalation, as I point out, is unsustainable, it is accelerating, but 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, by payors and providers of health care services. That status quo has to change.
Set aside for a moment, as you consider our healthcare system, the problem of duplicative tests, the problem of lost medical records, the problem of unnecessary treatments, 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%; overhead for private insurers is an astounding 20-27%.
A Commonwealth Fund report indicates that private insurer administrative costs more than doubled from just 2000 to 2006. In those six years, the overhead, the administrative costs of private insurance industry, more than doubled up 109%. The McKinsey Global Institute estimates that Americans spend roughly $128 billion annually just on what the report called "excess administrative overhead." There's $128 billion we pay for every year in excess administrative overhead, not healthcare, administrative overhead, in our healthcare system, in our private health insurance market.
And on top of that, of course, you have the duplicative tests, the lost medical records, the unnecessary treatments, and the uncoordinated care for patients with multiple and chronic conditions. I won't dwell on those particular topics because I have spoken so often about them on the Senate floor in the past.
My point is that because of all of this waste in the system, the President's Council of Economic Advisers concludes that "[i]t 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." 5% of GDP, Mr. President, is over $700 billion a year.
Other experts agree. The New England Healthcare Institute reports that 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 one trillion dollars a year in our healthcare system. And 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 a trillion dollars, 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. And this Congress rose to the challenge and in the healthcare reform bill passed what health economist David Cutler has called "the most significant action on medical spending ever proposed in the United States." And this isn't just a partisan view, analysts of all stripes agree that the reform law does more than any previous measure to begin to lift the dead weight of this wasteful cost off of our economy.
The Commonwealth Fund projected that the law will reduce the annual growth of national health expenditures - that's 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 ten 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 a trillion dollars over the next ten years. And that's what they can just prognosticate, what they can anticipate, what they can project.
But here's something that's interesting. Nobel laureate Paul Krugman writes "[t]here 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," he says, "health reform is likely to do much better at controlling costs than any of the official projections suggest."
He's 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, as a significant improvement on the status quo. 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 of 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 vigorously and wisely. Don Berwick is 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, just Past President of the American Medical Association, said that 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 that Berwick "has longstanding 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, "[y]ou're not going to do any better" than Don Berwick.
And Steven D. Findlay, the health policy analyst at Consumers Union, applauds 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 threatened 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, just to jam up the Administration's ability to administer the government. On our executive calendar, right here, we have the names of everybody whose 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 here on the Senate floor waiting for a vote. Some of them have been on for months. Some of them have cleared the committee unanimously, with full Republican support in the committee, and yet their jammed up here. That is the quagmire in which they were going to stick Dr. Berwick, not withstanding the urgency of the need. Since this nomination was first announced, the Republicans made clear they would subject Dr. Berwick to this treatment. There's no doubt about that. It was confirmed just now by the Senator from Arizona. A recess appointment was really 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 enumerable ways to reduce healthcare costs by improving quality. Hospital acquired infections, reducing and eliminating hospital-acquired infections is a perfect example. The North Carolina Medicaid effort to provide coordinated care, a medical home for people who were high users of the healthcare system is another example.
My Republican colleagues, who so loudly championed cost control, now claim this reducing cost by improving quality is "rationing." Well, here's my question: whose side are they on? A trillion dollars a year in waste, and they're 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's "rationing"? Organizing complex care of people who have multiple diagnosis and chronic conditions into coordinating medical homes, "rationing"? Whose side are they on, when they attack the reforms, the quality performing, cost reducing reforms that are Dr. Berwick's signature expertise?
One Senator even stood in this chamber and said that Dr. Berwick endorsed an "end-of-life pathway to death." Oh, boy: looks like the death panels are back.
Mr. President, 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 died 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. 38 countries, including most of Europe, do a better job of keeping moms alive through childbirth. We'd be willing to spend money to get better at that, I bet. But the strange thing is that the medical errors and the process failures that cause those deaths, 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.
And that's the area where Don Berwick specializes, and has specialized for years - improving care, eliminating process failures, and saving cost. But my Republican colleagues are against him, and want to talk about rationing.
I believe I am under a unanimous consent that I can speak until I conclude my remarks. That is what I asked for, and I believe I got an order to that affect. OK? Good.
So that's the area where Dr. Berwick specializes - the area of improving care, eliminating process failures, and saving costs. And our Republican colleagues are not standing up agains it. When it improves care, when it lowers maternal mortality, that's the kind of reform I think we could use. And if you're against that, and 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. And 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, as member of President Clinton's Advisory Commission on Consumer Protection and Quality.
It's that work that is probably why Tom Scully, CMS Administrator under President George W. Bush, said that "[y]ou're not going to do any better" than Don Berwick.
So I ask my colleagues, do you really need, 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 one trillion dollars 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'vefallen?
There is a huge window here, where we could work together on a win-win path, where we improve the quality of healthcare for Americans, while reducing its costs, by coordinating the care better, by coordinating in electronic health records better, by avoiding hospital acquired infections, by avoiding unnecessary care, by making sure that 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 bi-partisan, public, private, Republican, Democratic support and recognition, of his particular expertise in this area. I would urge my colleagues to treat Dr. Berwick as the highly qualified individual that 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 before us. At long last, my friends and colleagues, are we not better than that?
Thank you Mr. President. I yield the floor.
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