Don Berwick, M.D., is concerned that federal health policy is "backpedaling."
Berwick, former Centers for Medicare & Medicaid Services administrator and co-founder of the Institute for Healthcare Improvement, sat down with FierceHealthcare at IHI's National Forum on Quality Improvement in Healthcare to discuss the current state of the health policy landscape, and he said federal-level actions, like steps to promote short-term and association health plans, are worrisome.
"I think at the federal level, unfortunately, the policy landscape is moving too much into what I call 'regressive policies,' instead of offering further guarantees in the safety net," Berwick said.
Berwick took over at CMS shortly after the Affordable Care Act was passed, and in his year at the agency oversaw the launch of initiatives like the Medicare Shared Savings Program and the Partnership for Patients. Though some of the actions taken by the Department of Health and Human Services and CMS of late raise red flags, Berwick said there are some bright spots, too.
Work at the Food and Drug Administration under Commissioner Scott Gottlieb, M.D., to boost the availability and affordability of generic drugs, for example, holds promise, he said. He also said that some states, such as California and Massachusetts, were getting creative and testing new models that could benefit people.
However, other states are testing work requirements in their Medicaid programs, which he warned could be harmful to vulnerable populations. In Arkansas, for example, thousands have already been purged from the Medicaid rolls.
"The Arkansas figure really worries me—12,000 people in a very short time losing Medicaid coverage," Berwick said. "We can’t do that as a nation—that's wrong."
Here's more from our conversation on the current state of health policy:
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FierceHealthcare: Do you think any of the policies aimed at addressing issues with the ACA or to offer flexibility are working?
Don Berwick: I think some of the movement toward Medicaid managed care—in some hands, in some insurers—is productive. Consolidating budgets, moving into social determinants of health, offering new kinds of supports to people, integrating services is promising, and that was already underway before this administration. But I think it is a useful direction to go with as long as the federal government is monitoring the effects on people and adjusting its regulatory environment, so that when things are going wrong for vulnerable people, it's corrective.
FH: What about the work requirements or the short-term plans and association health plans?
DB: The public has been sold a bill of goods on the belief that Medicaid is an area of widespread abuse by Medicaid beneficiaries. Most Medicaid beneficiaries—I believe it's 80%—are in working families. There is abuse, but it’s not the dominant thing. … It’s also putting up enormous barriers to re-enrollment and recertification. The way it’s being implemented, you have to show up with your evidence papers every month to stay on Medicaid. That’s ridiculous. These are people struggling already, why would we make it harder for them to access the support they want?
On the association health plans and the catastrophic coverage plans, this is just a deceptive market. The insurance companies want to sell insurance to people that don’t need it. That’s how the market is set up. And if you do have insurance, they want to limit your access to coverage as much as they possibly can through precertification and reviews and denials. So now permission has now been granted for insurance companies to offer products that actually will disappoint you when you need help. You will find out you don’t have the coverage you thought you had for mental healthcare, for cancer or for maternity services.
FH: Efforts in Congress to “fix” or stabilize the ACA’s exchanges have largely stalled. Do you think any of the reforms considered in those plans could be beneficial?
DB: If we we're committed as a nation to expanding health insurance to universality and if we want to use the private markets to do it, we have to have these forms of risk corridors and protections for the insurers. It sounds odd to some people. But they’re in business. If you create a certain circumstance that they can’t survive in, then they won’t be in business.
In a rational policy environment, we would have gone back to the drawing board and said, “OK, what have we learned in the first five years of Obamacare? And what does that mean about the next level of support for the exchanges and for the public markets?” Instead, we’re going backwards and we’re throwing away what we learned.
FH: The idea of a single-payer healthcare system, often dubbed Medicare-for-All, has begun gaining more attention but has drawn warnings from the administration that it would hurt Medicare overall. What do you think? Do you see this going anywhere?
DB: Politically it is very, very difficult in any administration, Republican or Democrat, because the status quo system—the insurers, the hospitals—they would be uncomfortable to know we’re moving toward a single, consolidated payment, especially one that the government administers.
No payment system would be perfect. Medicare functions very, very well. It’s highly popular with the public. It’s one of the best payers in reliability and timeliness that the hospital industry has. There are many hospitals that can make money at the current Medicare payment rates. Nobody I think could at the moment campaign on the idea that doing away with that would be a good thing for this country.
So if it works, why not expand it? Why not give more people a chance to participate in a system that is administratively simpler, that is understandable, that is publicly accountable, that has public oversight? Why not expand Medicare? If it works, let’s make it available.
FH: What about drug prices? Is anything going on there policy-wise promising?
DB: I think Civica’s a bright spot. That’s really, really good.
FH: If you put your CMS hat back on, how would you tackle the drug price issue?
DB: I actually wish that Congress would allow Medicare to negotiate for drug prices. It sort of does in Part D already because the Part D plans can negotiate. But in Part B, you can’t do anything, and I think it’s just common sense if we’re going to stand up for the interest of beneficiaries and we’re a big purchaser—let's negotiate prices. What is the problem here?
The big problem—and probably the biggest unsolved issue in some ways—is these new biologics and specialty drugs, and that’s only going to get more serious. Thank goodness we’re producing innovations for people with diseases that are relatively lower frequency. I don’t think we should be even thinking of denying access to those medications if they’re proven effective to beneficiaries. I think at our level of expenditure and wealth, if you need this drug you should be able to get it. But we need a different environment for regulation.
I think that if the drug companies can’t solve it, we’re going to need price controls. I know that’s a poisonous term, but I think if the industry is behaving irresponsibly in pricing and they can’t self-regulate, we have to regulate them. Drug reimportation intrigues me, and I would certainly be looking with FDA in partnership about how to make that possible.