Obama’s Next CMS Administrator?
Press reports over the past several months have indicated that Senate Democrats are unlikely to act on the controversial nomination of Dr. Donald Berwick for a full-time appointment as CMS Administrator – in which case Dr. Berwick’s term in office would end with the expiration of his recess appointment next year. However, the Administration may have found one possible replacement in an unlikely source late last week, when Paul Krugman wrote a column on health care, patients as consumers, and the inevitability of government rationing. This column should be a must-read for critics of the House Republican budget, as it sets out the only alternative vision developed by Democrats to date – one built around arbitrary rationing by government bureaucrats. As the below spreadsheet shows, Dr. Krugman’s vision for health care as an outside observer closely aligns with the views of Dr. Berwick, the chief implementer of Democrats’ health care law:
| Paul Krugman | Donald Berwick | |
| Patients as Feeble-Minded Consumers | “There’s something terribly wrong with the whole notion of patients as ‘consumers’ and health care as simply a financial transaction….Making [health care] decisions intelligently requires a vast amount of specialized knowledge.” | “I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.” |
| Need to Enact Caps on Government Health Spending | “The point is that choices must be made; one way or another, government spending on health care must be limited.” | “The social budget is limited—we have a limited resource pool.” |
| Bureaucrats Rationing Care | “We have to do something about health care costs, which means that we have to find a way to start saying no.” | “The decision is not whether or not we will ration care—the decision is whether we will ration with our eyes open.” |
Krugman’s broader point is that bureaucrats will have to ration care because patients are incapable of functioning as health care consumers due to the technical nature of health care decisions, many of which are made in emergencies. A response would go something like this: Of course patients will not function as pure consumers in all circumstances – the heart attack patient will obviously go to whichever emergency room an ambulance takes him. But as Regina Herzlinger and others have pointed out, a small vanguard of the population functioning as educated consumers can drive important changes within the entire health care system – just as early adopters help spread technological innovations. Put another way: You may not know the details of how a car works – I sure don’t – but a small percentage of educated consumers, and a ruthlessly competitive marketplace, can easily drive innovation while penalizing firms with lax attention to quality control. (If Dr. Krugman cares to take issue with that comparison, I would be happy to provide him a copy of the latest innovation in government-run automobile manufacturing, to provide an illustration of what happens when bureaucrats micro-manage car companies, just as he would have bureaucrats micro-manage Medicare.)
The central debate around entitlement reform is whether patients or government bureaucrats will make the critical decisions in health care. By setting out a vision closely mirroring the Administration’s, in language starker than the President himself has dared to use, Dr. Krugman has helpfully clarified the stakes for patients – and illustrated the fact that the Administration’s version of health “reform” will be far more costly to patients than the President would have most Americans believe.