Don Berwick, M.D., was installed as Centers for Medicare & Medicaid Services (CMS) administrator in July 2010, just a few months after the Affordable Care Act (ACA) was signed into law.
That put him on the front lines of the rollout of the law’s early initiatives, including much of the early work to improve the quality of coverage and care.
“I was thrilled to be able to become administrator, but nothing thrilled me more than the idea of participating in the implementation of the ACA,” Berwick told FierceHealthcare in an interview. “I think it was a transformative opportunity for the country—I still do. It was very exciting.”
Berwick resigned from his post at CMS in December 2011 and now serves as president emeritus and senior fellow at the Institute for Healthcare Improvement. He’s also a leading national voice on health policy and care quality.
We caught up with him to look back on 10 years of the ACA and weigh in on what's next.
FierceHealthcare: What was it like at CMS directly after the passage of the ACA?
Don Berwick: I think the number of pathways of regulation and change that the ACA had in it was daunting. I knew right from the start we needed a pretty methodical way to keep on track. The staff there were marvelous, as was the White House Office of Health Reform, because, pretty quickly, there was a Gantt Chart that laid out what had to happen by when.
FH: What were the biggest challenges?
DB: We had 5,500 employees and 10,000 contractors, so this was an enormous community which we had to pull together. My approach was to be quite personal about it and try to give everybody a sense of the meaning and the mission in their work. On the third day of my tenure there I had an all-staff meeting and I presented my family—I showed them a picture of my wife and kids and grandkids—and talked a bit about the mission.
I created a vision statement, which was that we would be a major force and a trustworthy partner for the continual improvement of health and healthcare for all Americans. That was the catchphrase; I repeated that over and over and over again for all the time I was there. I found the response electrifyingly positive. It was amazing. People were so grateful to be asked to come together for a common mission. I said there were five values to our work: boundaryless-ness, speed and agility, unconditional teamwork, constant innovation and consumer focus.
My work was to try and organize around that set of values that I thought would be essential to proper implementation of the ACA, not just running our usual business.
FH: Where do you even start with that?
DB: They only had acting administrators up to this point for six years, so I was the first fully empowered administrator. I set up an email box in which anybody in the organization could read the draft strategy and come back to us with ideas. I think we had 260 or 270 responses. I tried to respond to as many as I could, just trying to build a sense of collective endeavor, which I thought was essential to getting that place back together. It had become somewhat fragmented and siloed.
So that was hard work. It was really reorienting the agency around being one organization.
I wanted to increase the clinical skill of the organization. I tried very hard to consolidate clinical knowledge and expertise. I really had this idea that there ought to be a centralized, consolidated system of work on improvement of care.
I did a lot of training. I taught 90-minute classes for everyone, all 5,000 people. One was on patient safety, one was on process quality, one was on customer focus. We had guests come in—I had a panel of doctors and hospital leaders to tell us how we were doing. I had the session on safety, was co-taught by Sorrel King, whose child was killed by an error at Johns Hopkins. I was trying to get personalization around the training processes, which I felt would bring people together.
FH: Where do you see that there has been success under the ACA?
DB: It did cover more. By the time I left, we had 22 or 23 million more people covered. And that would be regarded as big deal. The Trump administration has done everything it could to weaken that, but we made progress on coverage.
I think Medicaid, thanks largely to Cindy Mann’s brilliant leadership, made some important strides. Under Cindy’s leadership, the enrollment processes improved all over the country; there was very, very diligent work on the quality of Medicaid coverage. [Updating] the prevention benefits, that went really well. We had really good statutory support and an excellent staff. We were able to introduce the prevention benefit structures on time and in a way that was really picked up by both the private insurers and of course the Medicare system.
FH: Where do you think there’s still room to improve?
DB: In retrospect, there was more that I could have done with [the Center for Medicare & Medicaid Innovation]. But it was a plus for the country, I think. I was sorry I never convinced the White House to focus on quality as a major issue; I think that was a missed beat that probably could have won more public support.
And we didn’t press on cost containment at the level we should have. There were certain elements implemented around pricing structures and hospital payments, but there was a lot more we could have done on cost reduction if we had a strong partnership about that with the White House and other government agencies. I think what was happening was getting the ACA passed involved so much negotiation and compromise that they were not up for a fight.
FH: What do you think should happen next with healthcare now that we’re 10 years out?
DB: On coverage, I did support single-payer. That’s not going to happen now, but we have lots of things that we can do to extend coverage, through wooing more states into Medicaid expansion. I wish we could increase the generosity of the subsidies on the exchange. I think 400% of poverty is still a pretty low limit. And I think if we can get Trump out of office, we have to get to back to the essential health benefits and the quality of the coverage and get the garbage plans out of the scene. They’re not helpful.
I think there’s the statutory authority to do a lot of what I said, and some creative stuff can be done with the exchanges around extending the supports. We have to be diligent about Medicaid coverage, I think the threat of block grants and the cutbacks to enrollment—that's all damage done.
On quality of care, there’s a ton that we could do. We need a national center, and I think it could be located at CMS or in [the Department of Health and Human Services], that focuses on healthcare quality and that deals with ongoing dramatic problems with patient safety.
I further believe that we need to move much faster than we’re doing toward global budgets and population-based payment. We keep talking the language of getting away from fee for service, but until we do, it’s really hard to get anything together to work on quality of care … I think there needs to be stronger cooperation with [Department of Justice] and the [Federal Trade Commission]. We know now the side effects of market consolidation; that’s gone too far and we need to do something about that. That’s just gone ahead without any breaks at all. A lot of it would be assisted by global budgets. Although I think the ACO move was a good one, it’s very incomplete. It’s sort of a small step toward what we really need.
FH: What do you think the next 10 years of health reform look like?
DB: It completely depends on the presidential election and the complexion of Congress.
I’ll tell you what it should be is progress in this country toward universal coverage as a mainstay to guide public policy. And like I said, investment in the improvement of care, through a lot of the mechanisms that we’ve talked about, switching resources toward social determinants and cost reduction.
I think that if we get a Democratic administration in place, I think it will be viewed as improving the ACA. That’s where Biden seems to be. And I think there’s a number of things that we can do on that front because the original intent of the ACA was great.
The one worry I have is that the current version of moving toward a public option has gotten a little bit captivated by Medicare Advantage for all, an option that basically is an increase in Medicare Advantage. I do not think that’s a good move. I think the behavior of the Medicare Advantage world has not been as responsible as it needs to be.