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Massachusetts Chooses a Governor: Implications for Us All

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DAVID BERWICK
ASSOCIATED PRESS

Fittingly, Beacon Hill is a neighborhood in Boston, and often used as a metonym for state government. Massachusetts has indeed served as a national beacon, most indelibly during the American Revolution -- but also of late, as the first state to implement a very close approximation to universal health coverage (notably, during the tenure of Republican Governor, Mitt Romney). All evidence to date suggests that the reform in question has saved both lives and dollars.

That capacity for Massachusetts to make innovative choices, and enhance the chances available to the rest of us looking on is very germane to the upcoming gubernatorial election. Governor Deval Patrick, a democrat, is not seeking re-election. Among the contenders in the Democratic Primary is Dr. Donald Berwick.

Dr. Berwick has himself been a beacon for those of us involved in efforts to reduce the toll of chronic disease. He is credited with developing models of chronic disease care that also save lives and dollars, blending the best of evidence, pragmatism, and humanism. Dr. Berwick's prominence took him to the helm of the Center for Medicare and Medicaid Services, where his efforts, short-lived though they proved to be, garnered widespread admiration among health care professionals.

As a long-time admirer of Dr. Berwick's work, I was delighted to discuss with him the implications of his run for governor -- in Massachusetts, and beyond.

Question 1: How do you think your training as a doctor helped prepare you to be governor?

A doctor's job, at the most basic level, is to listen. Patients come in with problems that are often nuanced and unexpected, and the doctor has to take the time to fully understand things from the patient's point of view before choosing a course of action.

Governing should be the same. Whether working to end child poverty or tackling climate change, our leaders have to listen to more than just the loudest or most well-financed voices. A good doctor has to think in systemic terms. As a pediatrician in some of Boston's lowest-income neighborhoods, I saw firsthand how a child's health is determined by far more than medicine -- it is the air they breathe, the streets they play in, the safety of their communities, their opportunities for a good education, the economic stability of their family. Simply put, doctors can't fulfill their mission in communities affected by inequality and unfairness. Health requires justice for all. That's what makes me want to run for governor.

Question 2: What are your priorities for Massachusetts?

With the gridlock in Washington and public trust at all-time lows, this nation needs a beacon to show that bold, progressive leadership can deliver for people. I think Massachusetts can be that beacon, and I want to help us become exactly that. Look at us: we were the first state to make health care a right, the first to say you can marry the person you love, and we have the best energy policy in the nation. When I ran Medicare and Medicaid, I saw leaders in Washington backing down from the values of social justice, equality, and compassion that I believe should be central to our public life. I'm running to bring those values back to the center of government's mission, and I think Massachusetts is the place to do it.

We've got big challenges -- our economy has come a long way, but too many people are left out. Our education system is good overall, but leaves too many behind. Our health care is world class, but skyrocketing costs harm families, businesses and governments, and prevent us from making the kind of investments in our future we need to create the society we want. We cram people into prisons when they really need mental health or substance abuse treatment. I want to bring my experience as an executive -- growing and leading large organizations and making complex systems work better -- to government to solve these and other problems.

Question 3: What do you see as the top health care priority for the next governor?

We should be proud of what we've done in health care. We were the first state to join the rest of the developed world by guaranteeing universal coverage. But our job is not done. Businesses and individuals across Massachusetts face unacceptably high health care costs. Health care is now 42 percent of our state budget, up 59 percent in the last decade alone. Every other major line item in our budget is down. So if we want to invest in teachers, bridges or the safety net, we need to bring health care costs under control.

I have spent a career working towards better care at lower cost all over the world. Here's what it looks like: it moves away from fragmented, fee-for-service payment that rewards hospitals for staying full and machines for staying on; and it moves towards coordinated, team-based, integrated care that focuses on care of populations, not just treatment of medical episodes. Chapter 224 was a good start, but it doesn't have the teeth it needs and progress has been too slow. That's why I favor a single payer system for our state -- like Medicare for all. This will give the payer the leverage it needs to help reform the delivery system. It also saves hundreds of millions -- if not billions -- by reducing administrative overhead and waste.

Question 4: What was the motivation behind your support for Medicare for All in Massachusetts?

Medicare is the most popular social program in the nation, and for good reason: recipients can benefit from a diverse array of health care providers while avoiding hassle and saving money. Anyone concerned about furthering a social justice agenda in this country has to address the sheer amount of wasteful health care spending eating away at our ability to allocate funds toward any other priorities. Affordable housing, for example, is a proven prerequisite for health and productivity.

In the early 1990s, Massachusetts offered over 20,000 affordable housing vouchers to low-income residents. Today, with a higher state budget, we can somehow only afford to offer 8,000. Where'd that money go? Health care. From consumer protection to aid for veterans to environmental conservation, almost every single budget line item has seen dramatic cuts to pay for health care expenditures.

This trend might be acceptable were it buying us better health outcomes, but we're wasting a large portion of this money, probably a third of it or even more. Medicare for all will open the door to a broader progressive agenda by freeing up resources to be allocated where they're needed most.

Question 5: What kind of impact will single-payer have on the economy?

In my travels across Massachusetts, business owners generally don't talk about taxes or regulations as barriers -- instead, they tell me how spiraling health care costs are ruining their competitive edge. Workers, likewise, have seen wages remain stagnant over the past decade as health care eats up larger and larger slices of paychecks. Medicare for all will save both employers and individuals money by replacing the rising and unpredictable costs of private health plans with a small payroll tax to finance health care. The savings come from decreasing the complexity of the payment system, and from a stronger voice for patients and families. Businesses will no longer have to manage the complexity of arranging for health care coverage for their employees; and employers and employees will no longer waste long hours and dollars navigating complex benefit structures to determine what a specific plan will cover and what it will not.

Lower costs will free up resources for businesses to innovate and pay their workers well. Firms will also benefit from the certainty of knowing what they will pay for health care in advance. The result in Massachusetts will be a more attractive climate for businesses to locate in and grow.

Question 6: How would you work to integrate mental health into the heart of our health care system?

Medical outcomes improve across the board when mental health treatment is fully integrated into the systems of care. But our current framework lacks the transparency or accountability necessary to ensure that behavioral health issues receive the attention they deserve.

A few weeks ago, I heard the story of a woman coping with severe mental illness. Following a long struggle, she finally found a therapist she worked well with. After almost a year of therapy, she felt capable of taking on a new job -- but upon signing on with her new employer, she found that her old therapist would no longer be covered. She faced an agonizing dilemma between quitting her new job to protect her mental health care, leaving the therapist who continued to make such a difference in her quality of life, or paying costly therapy bills out-of-pocket. Under a single payer, such arbitrary inconsistencies simply would not exist. We'd also have a system for determining coverage that is publicly accountable and transparent.

So if we want to, say, add more focus on mental health, or improve substance abuse treatment (as we desperately need to), we'll have the capacity to make that happen in a way that the current patchwork system of insurance on a fundamental level just can't.

I anticipate Dr. Berwick's comments will engender spirited discussion here, and I look forward to that. In the interim, my thanks to Dr. Berwick for indulging my questions. Those wanting to learn more about his campaign and candidacy can do so here.

-fin

David L. Katz, MD, MPH, FACPM, FACP

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