Dr. Donald Berwick on Leading CMS, Medicare Reform, and the Future of U.S. Healthcare
Why Medicare Reform Matters Now: A Conversation with Dr. Don Berwick
For our Fourth of July Special at The American Journal of Healthcare Strategy, we welcomed Dr. Don Berwick, Senior Fellow at the Institute for Healthcare Improvement (IHI), to cut through the noise. As a former administrator of the Centers for Medicare & Medicaid Services (CMS) and a globally recognized voice in healthcare quality, Dr. Berwick offers not only a front-row view of landmark reforms but a candid, soul-searching assessment of where we’ve advanced—and where we’re in danger of losing ground.
“Find your soulmates, find the people who want to do in the world what you want to do and join up…love and relationship have a role here, way beyond transactional stuff.” — Don Berwick
Below, we break down the major questions tackled in this illuminating conversation, offering actionable insights for today’s healthcare leaders and those shaping the sector’s future.
Who Is Don Berwick, and Why Was He Tapped to Lead CMS?
Dr. Don Berwick is a pediatrician by training, co-founder and Senior Fellow at IHI, and a longtime crusader for healthcare quality improvement. He led CMS during a historic window: the rollout of the Affordable Care Act (ACA).
Why did President @Barack Obama select Berwick? Dr. Berwick’s name surfaced thanks to his pioneering work on patient safety, quality of care, and a track record of building coalitions that deliver lasting change. He explained:
“Half that [Affordable Care Act] law had to do with the quality of care… creating circumstances in which we would focus much more strongly on patient needs, use money more wisely to meet needs for chronic illness… That was my main swim lane.”
Berwick didn’t see his work as heroic, but as the product of effective teamwork—a message echoed throughout his career.
What Did Berwick Actually Do at CMS? Three Jobs, One Vision
Dr. Berwick outlined his CMS tenure in three essential missions:
1. Running the Railroad CMS insures 110 million Americans. Just maintaining this behemoth, Berwick said, “is a full-time job”—from managing a staff of 5,500 to ensuring uninterrupted payment and access.
2. Implementing the Affordable Care Act (ACA) 70% of the ACA’s implementation fell to CMS under Berwick’s leadership. This meant:
- Regulation and Policy: Writing regulations to make the ACA real and actionable.
- Innovation: Establishing the Center for Medicare and Medicaid Innovation (CMMI), which Berwick called “an incredible gift to the American people—a place where we could really try things out to change our troubled healthcare system.”
3. Building a Quality-Focused Culture Berwick pushed for a culture shift at CMS:
“Any organization can be focused on need, can be quality-focused. I tried to change the culture there toward modern thinking about quality… I’m proudest that there still is a culture residual from that work at CMS.”
His time at CMS was about more than policy; it was about leading people to embrace innovation and quality as central values.
How Far Have We Come? ACA’s Wins and Losses
Has the ACA succeeded? In Berwick’s view, the answer is complex:
- Coverage: The ACA enabled 22 million Americans to gain insurance coverage who previously had none.
- Preventive Care: Medicare and Medicaid now offer broad coverage of preventive practices, often with first-dollar coverage.
- Payment Reform: CMMI has piloted alternative payment models focused on quality and outcomes, although, as Berwick candidly put it, “No home runs yet, but we’re learning a ton.”
- Social Determinants: CMS began covering services like housing security and food security under Medicare and Medicaid.
“On the coverage end, the Affordable Care Act was working… For the first time in its history, Medicare and Medicaid were covering a vast array of preventive practices.”
But there’s a shadow side:
- Millions remain uninsured.
- Gains are threatened by policy reversals and funding cuts.
- The privatization of Medicare (via Medicare Advantage) has introduced new inefficiencies and higher costs.
What’s Undermining Progress? Privatization and Political Headwinds
What’s the threat? Dr. Berwick didn’t mince words:
“The Trump administration has come in and done inestimable damage… The privatization of Medicare—taking public money and giving it to private insurance companies—has proved to be extremely expensive, maybe 80 to 100 billion dollars a year of excess payment.”
Key problems with privatization:
- Higher costs for the government and taxpayers.
- Delays, denials, and administrative hurdles for beneficiaries.
- A focus on profit over patient outcomes.
Worse yet, Berwick warns that a rollback of ACA subsidies could strip coverage from 7-10 million people and undermine preventive health investments. He calls out the “attack on science,” noting that cuts to agencies and research will have long-tail effects on population health and innovation.
Why Can’t the U.S. Fix Healthcare? The Social Contract and the Power of Money
Why is U.S. healthcare so chaotic compared to Europe? Berwick points to two core issues:
1. A Frail Social Contract Most wealthy countries treat healthcare as a human right. In the U.S., that’s still a point of contention.
“There’s a fundamental values issue here… unless you can rely on that value system, it’s hard to recruit the investments that you’re seeing actually as the norm in every other Western democracy.”
2. The Influence of Moneyed Interests Healthcare in the U.S. is a $4 trillion industry—nearly 20% of GDP. Corporate interests in insurance, pharma, and hospital sectors exert enormous lobbying power to maintain the status quo.
“Sector by sector, it’s all about the money. And until we change that, we’re not going to have the resources to invest where they can make us healthy.”
Why don’t Americans support more public insurance? Berwick separates two concepts:
- Public insurance (e.g., Medicare) is very popular.
- Government-run care (hospitals and clinics) is less so.
He asserts: “There’s never been in American history a more popular government program than Medicare. Try to take it away.” But, he cautions, the public doesn’t realize how privatization is slowly eroding this bedrock.
Is Payment Model Reform the Answer? And Can We Reverse the Damage?
Is value-based care still the future? Berwick is uncertain. He’s optimistic about experimentation but warns of lasting harm from current policy directions:
- Permanent workforce losses from layoffs and “brain drain.”
- Erosion of scientific infrastructure as clinical trials and research face funding cuts.
- A “long tail of illness” as millions lose coverage and care access.
“I fear we may be naive to think, oh, we’ll just flip a switch and it’ll be rebuilt… I just don’t know.”
He also noted that success will require a return to truth-telling, public investment, and an honest reckoning with the role of money in policy.
Can Government Lead Innovation? Lessons from CMS, NASA, and Beyond
Dr. Berwick rejects the notion that government can’t innovate. He cites CMMI, the NIH, the CDC, ARPA/DARPA, and NASA as proof that with the right leadership, government can be an engine for groundbreaking change.
“Government’s a superb innovator. It’s a place where we can concentrate resources and, with proper leadership, change the world.”
But innovation depends on leadership. Bureaucracy isn’t the problem—the absence of bold, visionary leadership is.
What’s Next? The Call for New Leadership and a Values-Driven Future
Is there hope? Berwick’s answer is that the next generation—equipped with new technologies and a renewed sense of values—holds the key.
“It’s the only place for hope right now… It’s values plus innovation, values plus invention that lead to progress. If not, we’re cooked.”
Advice for future healthcare leaders:
- Never Go It Alone: “It’s not a game for heroes. It’s a game for teams…We say in IHI, never worry alone.”
- Seek Intersections: Learn from other fields and disciplines. Berwick’s most creative breakthroughs came from reaching outside healthcare—to NASA, Bell Labs, economists, and engineers.
- Embrace Discomfort: “I am happiest when I’m outside the familiar… constant joy in crossing boundaries and finding people who could teach me stuff.”
- Fight for Truth and Public Good: Recognize and resist the seductive power of moneyed interests. Tell the truth about what works—and what doesn’t.
Takeaway: Reclaiming Leadership, Values, and the Power of Teams
Medicare reform is more than a policy lever; it’s a mirror reflecting America’s values, leadership, and commitment to public good. As Dr. Don Berwick argues, real progress demands that we:
- Reaffirm healthcare as a human right.
- Push for quality-driven, innovative public programs.
- Tell the truth, even when it’s inconvenient.
- Build coalitions—because systemic change is never a solo act.
For healthcare executives, policy leaders, and students alike, the call is clear: Don’t sit on the sidelines. Find your allies, cross boundaries, and lead with values. The future of U.S. healthcare depends on it.
