Donald Berwick joined Jim Braude and Margery Eagan for another Boston Public Radio interview. Berwick is the former head of the Centers for Medicare and Medicaid Services. He was also CEO of Institute for Healthcare Improvement. Berwick talked about the imprisonment of former Mass. House Speaker Sal DiMasi, the Massachusetts Department of Children and Family Services, and the fun of running in the Mass. governor's race.
The following interview was lightly edited and condensed.
If Donald Berwick were governor, would you move Sal DiMasi back to Devens prison?
Yes, I would. Compassion is part of my view of how public policy has to run.
Would you let him out of jail?
I wouldn't let him out of jail.
If you were governor, what would you do to fix the Department of Children and Families?
My heart goes out to [the family of Jeremiah Oliver]. Can you imagine being in that situation? I have four children. (...) My whole career, 30 years, has been focused on management and executive leadership for excellence — how you get real reliability into a system. Now, I don't have access to the details of what's going on inside that agency, but there's a management failure here.
The way I lead is to organize around absolute excellence, getting it right every single time. You have to work with a work force, make sure they understand the mission, are connected to it. As a leader tune in to some of the problems the work force is facing here, and I think there are serious resource issues here in this agency.
You must've seen some troubled kids in your practice as a doctor.
I saw a lot of it. Probably half of my population were kids on Medicaid. Very stressed families. I dealt with this for 19 or 20 years as a practicing doctor — fighting every day to get them the resources they need. It was a real problem.
The problems I saw were largely issues of fragmentation. So, you had a kid who needed services. Often they were mental health services — the under-investment in mental health, substance abuse, behavioral services is very severe — and I would have to fight every day to get services to an adolescent or a young person who was really in emotional difficulty.
The other problem was fragmentation. You would have different agencies — social services, mental health, corrections, schools — in which there weren't the habits or support systems to have them surround the kid and really create a unified, coherent plan to help the child and the family back into the mainstream.
Many times the kid wouldn't get the help?
A lot of people tried but the fragmentation was a big problem. And yes, they didn't get the help they needed. I have tragic stories (...) of patients I fought for and fought for. And when they finally got to an age where they left the young child support system, they got lost.
There's not a huge constituency for poor people. What do you do to convert the public mind to be more sympathetic to the poor?
I do agree. It's a national, not just a local issue. But we're in a country of increasing income disparity. People at the low end [are] really losing out, and there are many people there than there are at the upper end of the income ladder. It's become conventional to talk about the 'well-being of the mainstream' without being able to speak absolutely clearly about poverty, and poverty alleviation, and the need to be a society that is compassionate, organized around social justice, and equality as a mainstream issue. I think we need leaders who will talk about that. (...)
When you walked in here, Margery asked if you were having fun running for governor. You said yes!
Remember, I worked in Washington for a year-and-a-half. Big, deep sigh of a relief to be back here. This is a Commonwealth interested in the issues I'm interested in. You can talk about social justice, you can talk about equality, you can talk about opportunity in this place, and it's a big relief.
I think the most fun for me has been going around the state in living rooms, and libraries, and homes and town committee meetings, and speaking a progressive language about, 'Aren't we a Commonwealth that has a vision about helping each other and being centered on issues of justice?' And the heads nod. (...)
You released an education plan where one of the centerpieces is early education. We want to talk about later education — like college. What's your plan for higher ed?
You have to view it as an investment, not just a cost. There are a lot of people looking for jobs that can't find them, but there are a lot of jobs looking for people, and can't find them [either]. That's because the education system isn't lined up — that happens in higher education system, especially the community colleges and the state-supported higher education, which are gems in the state. If we really invested in these places, in preparing people for the workforce of the twenty-first century, we have a solution on our hands.
As for people who can't access that education, we need to help them access it. Part of my education platform is to make sure that if a young adult in Massachusetts wants to go public-supported higher education and cannot find other sources of support, we should provide the last-dollar coverage to get them into higher education. That should just be part of our social policy.
So is this free community college?
Yes. My view is that people who can pay for it should do so. (...) We want to make people enter the economy. We want to create jobs. (...) Let's invest in people, that's the best investment you could make. So yeah, I want it to be a guarantee.
How do you feel about merit pay for teachers, or charter schools?
My daughter is a teacher, she's in her second year of teaching middle school, absolutely loves it. My brother was a 40-year teacher, retired now, he lives in South Hadley. I guess I'm a teacher! My background is partly as a teacher. Teachers are not the problem. They're the solution.
Of course there are some bad teachers and we have to get them out of the system. That's true of any workforce, but it's one in 100, one in 200. We need to reinvest in the pride and joy of the teacher workforce. That means giving them the supports they need. The unions will argue for that. They're not always right. They're sometimes wrong. But I think they're on the side of success. They know that a successful school will be a good place to work. (...)
I've been tracking this really interesting story in Lowell where the head of the teacher's union (...) worked out a good understanding with the then-superintendent. (...) They agreed to work together: not teaching to the test, not ticking the box, not 'MCAS, MCAS, MCAS.' But, Let's get teachers to really grow in their skills and their ability to get advanced degrees. I think it was Fitchburg State that helped them. They've turned around schools there. The Murkland School was a failing school. In 18 months it was a level-one school. (...)
Why not pay extraordinary teachers $150,000 or $200,000?
I so admire people that are dedicating their lives to helping young people become the citizens they should be. And yes, I would argue for giving them more support. This is part of a larger picture of economic inequality in the nation and the state, where there's so little relationship between these soaring amounts that the wealthy are making — and I don't begrudge that to them — at the expense of investment in other things that our communities need. Like schools. Working (...) on income equality is going to be the flagship issue of our next decade.
But great teachers shouldn't make more?
[You have to be] very, very careful with incentive pay. People come to work to be proud at what they do. Whenever you have that 'reward the great, hurt the not-so-good,' you create many more losers than winners. I'd like to encourage teachers to do well and have everyone grow no matter where they're starting. (...)
I ran an organization for 19 years as a CEO. We never had merit pay in that organization. We always used team-based compensation, and [worked] with the workforce to get better at what they did. We invested in them instead of creating struggles and win-and-lose situations.
You ran the Centers for Medicare and Medicaid for a year-and-a-half. You were there when the Affordable Care Act was being implemented. Why are you not responsible for some of the problems we're seeing with Obamacare now?
I'm proud of what I did there. We made a lot of wonderful steps forward with the early stages of the Affordable Care Act — covering kids under their parents' policies up to age 26 (...), putting in prevention benefits, we began to close the donut hole of drug coverage for elders, we put insurance companies under new restrictions — we had a lot of really good work to do.
The contractor that was hired apparently really screwed up.
But they were hired when you were there, weren't they?
Yeah, but the rules of leadership forbid the administrator from dealing in the contract process — as you'd want. You wouldn't want a political appointee to come in and manipulate contracts. I was kept at quite a distance from that. Since then, the day I left, in December of 2011 (...), I came under a prohibition of any contact at all that was substantive with the Health and Human Services department. So all I could do is read the papers like you for two full years. (...) I wish I was there, I wish I knew what was going on, but I just don't.
What was your relationship to Pres. Obama prior to your recess appointment?
I only met him after I was nominated in office. My contact at that time was Sen. Daschle. Sen. Daschle was going to be the Health and Human Services secretary for a while, and he was taking some of the lead in healthcare reform design. I had met with him a couple times, giving the new President advice on the direction to go. I guess they thought the advice was worthy, and it was he who invited me.
Do you feel in Massachusetts your association with the Affordable Care Act will hurt you?
I'm proud to be associated with a law that's trying to make healthcare a human right in this nation. This is a majestic step. It is very troubled in implementation. There are serious management flaws here, and I can see them at a distance. But look at the big picture here — we are the only Western democracy that has not yet made healthcare a human right, now we're going to if we stick with it. If these enemies that are trying to take this law down are shut down, it's a big step.
Will it last after Pres. Obama is gone?
Yeah, I would bet a lot that it's going to prevail. The reason is, if you ever tried to take it away now there'd be public outrage because people would realize what they're losing. They'd be losing their right to health insurance if they have preexisting conditions. Their kids would not have coverage. There is so much already good happening with this law. This attack (...) is obscuring the real facts, which [are], this is a step forward for our nation.
Charlie Baker thinks we should get a waiver from Obamacare here in Massachusetts.
I'm for the laboratories of democracy, and the states trying new things. As you know, I'm supporting a single-payer direction for this state. I don't think that's the whole secret. We have really do healthcare reform. It's delivery reform that's the real key, so care is more organized around your needs. But part of the reform could be a much simpler payment system. And that's what intrigues me about single-payer. And we would need some federal waivers in order to get that. Luckily, in the Affordable Care Act, there are provisions in that act that allow states to take some states forward.
Massachusetts has always been a pioneer. We are the template for the Affordable Care Act. I think we can be a template for a much simpler and more user-friendly insurance system.
You're the only one of the candidates for governor to embrace single-payer. It doesn't seem like there's any appetite for change in the legislature, though.
My intention as a candidate is to say what I think. (...) I didn't know how it would play. I didn't make that decision as a political move. When I go out — I'm in these living rooms and libraries, and I'll tell you, the heads are nodding. I think people are fed up with the complexity and the opacity. (...)
Let's talk about ballot questions. You'd vote for the repeal of casinos, correct?
I'm against the casinos, and for a repeal. Casinos are a bad deal for the state. There's evidence (...) they hurt small businesses and their communities, DUIs go up, minor infractions go up, the communities become less safe. They're bringing a new mental health burden into the state, absolutely. Here we are, struggling with healthcare costs with an under-supported mental health system, and here we're going to add gambling addiction to our needs.
The revenue estimates (...) are inflated. We know there's cannibalization, so some of the casino revenue will come out of the lottery, that's going to offset at least a third, maybe more. I just think the costs so far outweigh the benefits here. We've heard the Governor and the Speaker say they wouldn't want it in their town, well, let's not have it in our state.
How do you feel about marijuana, as a physician?
The medical use of medical marijuana is absolutely right. I've had patients whose nausea or pain just can't be controlled any other way. I would not deny them the relief they can get from this. I think decriminalization is a very important move, in fact, we need to think further about that. Our prisons are full of people who have minor infractions or mental health problems, and they're not getting the right kind of care.
Full legalization — I'm actually a little more cautious about this. I don't know what the total effect would be. I am a physician, I'm worried about the public health implications. Now we have experiments going on — Colorado's going to experiment for us. Why don't we wait? Give me 24 months. Let's let it play out, see what begins to happen, and then, sure, I'd be happy to consider it at that point.
What do you think about the federal government seeking the death penalty against Dzhokhar Tsarnaev?
Look, I have no sympathy for the crime, let's get that straight. The Boston Bar Association said the death penalty has no place in American jurisprudence. It just doesn't. It is a form of punishment that is often unfairly distributed according to ethnic and wealth levels. It's not an effective deterrent — we know that empirically. And you know what? We're flawed, it's sometimes wrong, and it's irreversible. So, I don't think it's the right way to be dealing with a corrections system.
Aren't you a supporter of a graduated income tax?
It's a tough fight. We need revenue to work within the state. There are other sources: healthcare reform, if we do that properly will bring back dollars that we can reinvest. We need to get rid of the loopholes and tax exemptions, there are so many of them. I'll keep the ones that add jobs, and the ones that support the safety net, but not others. We need to hit the reset button on that.
We'll come down to the point where we're going to need some revenues, and I'm for fair taxation. Fair taxation to me means, people at the lower end of the spectrum pay lower rates, and people at the higher end pay higher rates. That is a fight I'm willing to engage. I think it's just, I think it's right, and it's the kind of Commonwealth we want to have, and I'll take that on.
What's the likelihood of it happening?
I'm a believer that change is always possible. We're an evolving society, we learn as we go. The levels of income inequality we're now living with in this country have grown and grown. There's an extraordinary level of aggravation with this. People in the top one percent of income in this country have had almost a 300 percent raise in their income since the 1970s. The bottom 20 percent is an 18 percent increase, and at the bottom-bottom it's a decrease. Enough. It's time to engage in public policies that allow us to be a more equitable society. To me, it's right. Those with great wealth I don't begrudge them that, but let them contribute because they can.
Are you realistically going to be on the ballot?
I think we'll be there.
Because we're running a campaign right. I'm using everything I know about management and executive leadership in the campaign the way I would as governor. I want to lead for excellence and lead for delivery, lead for results. It's hard because you have to organize field staff, you have to be all over the state, but we have a very well-organized field operation because we care about it. The response has been there.
As I articulate my agenda — single-payer, casino, the poverty alleviation, and the concept of a just and equitable society as fundamental — I think that message holds, and I expect to be on that ballot.