Barack Obama's healthcare reform has already progressed so far in most parts of the United States that it will not be possible to unpick it even if the supreme court rules the law unconstitutional, according to the former head of Medicare and Medicaid.
Dr Don Berwick, who resigned the job in December when it became clear Congress would not confirm his recess appointment made by President Obama, said a great deal of change was under way. "There is so much tectonic motion now – the plates are shifting – and I don't think they can go back. I'm speaking now to a lot of communities all over the country and I've not seen one where there isn't major change in motion," he told the Guardian in Boston.
Berwick, who has now joined the think tank Center for American Progress, said he thought the supreme court might allow the law to stand. "Maybe they'll choose to say this is something that should be hashed out in Congress but not brought to the courts to decide," he said.
"I suspect that if they do act they may well just take the individual mandate only – take the narrowest possible decision. But I don't know what they'll do. I'm concerned if they tamper with the law they will produce a cascade of effects that will be bad for people. Fewer people will have insurance and a lot of the productive logic that is starting to enter healthcare about let's focus on patients, let's co-ordinate, let's work on quality – a lot of that would be eroded."
The justices in Washington are expected to deliver their ruling in the next 10 days, a decision that could have a serious impact on Obama's re-election hopes as well as the healthcare of the millions of Americans who currently have inadequate coverage or none at all.
But Berwick says the clock cannot be turned back on moves that are under way everywhere to improve the co-ordination and quality of care as the Act requires, he says. Doctors and hospitals are exploring different relationships. Accountable care organisations (ACOs) are springing up to provide the entire network of care many people need – specialist, primary care doctor and home health care as well, instead of just the separate parts – and these are being offered not just to Medicare patients but to the privately insured as well.
"So I don't think we will ever go back," said Berwick. "And if the court strikes the law, you may well see the private sector momentum continue and overtake the public sector momentum for a while. Medicare is so big and so important that you really can't get the whole system to move without Medicare's involvement, but Medicare can lead or it can follow. If either the court or the Congress choose to back down from this progress then I think Medicare will find itself following in the long run."
He admits it is an optimistic view. "I guess we can't go on as we are. What I'm not optimistic about is that if we enter a phase now of chaos and recision, I think the most vulnerable part of our population will be the poor, the disadvantaged," he says.
"Medicaid is more vulnerable than Medicare because it serves a less vocal population and it's a state/federal partnership, so the politics are more difficult. You can see damage to Medicaid occurring. If I were a governor, I'd face a terrible problem right now with state budget deficits and Medicaid is an obvious target. But it worries me a lot. If you don't get the kind of reforms in healthcare on quality and continuity and patient centred-ness that the ACA progresses in Medicare and Medicaid, then the poor will get hurt, and we're really on a knife edge on that one."
He rejects suspicions of Medicaid recipients. "It's naïve. You go into communities, and people say I met this Medicaid beneficiary who is driving a Cadillac. I say: well I've met bad examples wherever I've looked but that is not the mean case. When I was in practice in paediatrics the majority of my patients were people who were disadvantaged, and they weren't there by choice. They were there by circumstance and a compassionate country would reach out a hand and that's what Medicaid does."
'England … makes healthcare a human right'
Berwick's downfall was considered to be his praise for Britain's universal national health service at a rally in London's Wembley stadium to celebrate the NHS's 60th anniversary. "I was congratulating England, as I still feel as a country that makes healthcare a human right. In that same speech I was talking about the problems. There are many things that need to be fixed in British healthcare," said Berwick, who was knighted by the Queen for his work on improving the quality of healthcare in the UK under the Blair government.
But it gave his Republican opponents in Congress the reasons they were looking for to reject his appointment. "I would say I was a kind of symbolic target. If I hadn't said nice things abut the NHS, something else would have been picked up on. I think there was no way they would have confirmed me.
"I went to a number of the senators who opposed me and talked with them and explained my real beliefs which did not coincide with the rhetoric they were using. But they would go ahead and ignore me, and the truth was not in their interests. The minute that law passed things became polarised and the old hands in Washington said it was polarised to a degree they have never seen before. I would say polarised to an irresponsible degree. The public should expect more of their public servants." He points out that a mere 9% of the population now approves of the way Congress is doing its work.
The act is set to improve and give access to healthcare for millions of people, but the Republicans "grabbed the high ground of communication", he says. "They had concerns about rationing, about government takeover of medicine, about death panels, about the socialisation of medicine, none of which were accurate and many of which were completely deceptive, whether consciously or unconsciously so."
The story did not get well told, but in the last six months, as provisions such as rebates on prescription drugs and children no longer being excluded from insurance for pre-existing conditions kick in, that has begun to change, he believes.
He warns that increasing the role of the private sector in the NHS, as the British government is now doing, is risky. "I would be cautious – very cautious," he said. "When you invite entrepreneurial private sector investors into the delivery of care, under most payment systems, they will be very interested in volume. They will be very interested in doing more things to people and you may find that you lose control of that level of discipline to the disadvantage of patients. When more things are done, more unnecessary things get done and more hazard enters the system – not just cost.
"You want hospitals that seek to be empty, doctors that seek to be idle, machines that are few. In healthcare you want to find the way to help that is the least invasive of the person's life and body. A volume-based system does not have that incentive structure."
Berwick wishes he was still running Medicare and Medicaid. "I loved the job. It was an amazing opportunity, and I loved my staff . It was a great chance to try to help and very interesting – I learned a lot. I feel that my background in quality and systems was relevant. [He previously founded and ran the Boston-based Institute for Health Improvement]. I regret that I was unable to stay."
