The Hardest Job To Fill (And Keep) In Washington: CMS Chief

President Obama is fighting to save his signature health law on two fronts: in the Supreme Court and on the campaign trail, where Republican candidates are promising to kill the Affordable Care Act.

Yet even if the president prevails, he faces another daunting challenge: implementing the law in a seamless, timely manner. The Centers for Medicare & Medicaid Services is charged with making the health law work, drafting regulations, setting up new programs and providing oversight. But for years Congress has undermined the agency’s leadership and potential effectiveness, raising questions about its capabilities and resources even as the health law ramps up its responsibilities.

For starters: consider the revolving door leadership at CMS.

Since its creation in 1977 as the Health Care Financing Administration, the agency has had 29 administrators in 35 years – an average tenure of just 14 months. The longest-serving administrator held the job for four years and five months. The shortest: two months.

The most recent CMS administrator, Dr. Donald Berwick, resigned in December after 16 months. His replacement, Marilyn Tavenner, currently holds the title of acting administrator. That’s hardly uncommon.

Acting administrators have run the agency 20 percent of the time. And the trend appears to be increasing: the Senate hasn’t confirmed a full-time CMS administrator since 2006, when Mark McClellan resigned midway through the second Bush administration.

“Imagine if somebody went two years without a Secretary of Defense,” Thomas A. Scully, who was CMS administrator under President George W. Bush, told the journal Health Affairs in April 2010.

For decades, government and private researchers have pointed to a widening gap between the agency’s responsibilities and resources. As the largest purchaser of health care in the world, with a budget of $820 billion, CMS pays for the care of one in three Americans, and interacts daily with thousands of hospitals, doctors and other providers.

4,900 vs. 62,000 Employees

The number of Medicare and Medicaid beneficiaries has soared since the programs started in 1966, with tens of millions of Baby Boomers and uninsured expected to swell the rolls even more in coming years. Yet today the agency has the same number of employees it had during the during the Carter administration – about 4,900.

By comparison, the Social Security Administration, with a smaller budget, has 62,000 employees. Even including work that CMS outsources to private contractors – bill-paying, coverage decisions and quality oversight – the agency operates with about half as many employees as Social Security.

The shortages have hurt the agency’s ability to implement crucial reforms, ensure adequate oversight of hospitals and other providers and find ways to stem spiraling medical costs, researchers say. For years, CMS executives weren’t even sure if they could consider cost as part of their coverage decisions, paying high-quality and low-quality providers the same amount.

In 1999, a bipartisan group of former administrators and health policy experts wrote an open letter to Congress decrying “the mismatch” between the agency’s resources and its “mammoth assignment.”

Three years later, the nonprofit National Academy of Social Insurance wrote, “This mismatch has grown worse in recent years as CMS’ responsibilities have increased dramatically.”

“Really, when you consider what they have to work with, they do a fairly remarkable job,” adds Robert A. Berenson, a former CMS administrator, and now a health researcher at the Urban Institute. “Assuring adequate staff at CMS has not been a priority for Congress even though it might more than pay for itself in more efficient programs.”

‘What’s Missing Is … A Consolidated Strategic Vision’

Berwick, a physician and national expert on health quality, said he was “impressed and gratified” by the way senior staff rallied around his calls to implement the sprawling health law. But much of staff time is taken up writing rules and regulations.

Career executives “perform these core components well,” said Berwick. “What’s missing is a kind of coherence and consolidated strategic vision of where to head next.”

In recent years, Congress has added more programs and complex legislation to the agency’s plate, including overseeing a 2003 prescription drug benefit for seniors, ensuring patient privacy, helping to weed out waste and fraud and developing a system for grading hospitals and nursing homes.

The Obama administration’s nearly two-year-old health law adds yet more duties: helping to oversee insurance exchanges in 50 states, operating a program to spur ways of delivering care more efficiently, and guiding big expansions of Medicare and Medicaid, the agency’s core programs.

CMS will be expected to do so even as “frequent changes” at the top “have inhibited the implementation of long-term Medicare initiatives or the pursuit of a consistent management strategy,” according to a 2000 study by the U.S. General Accounting Office.

For years, the agency was criticized for focusing more on getting checks out to hospitals and doctors than ensuring quality or finding ways to trim health spending. Part of that had to do with Medicare’s unique history. For the first 11 years of its existence, the program was housed in the Social Security Administration, which issues monthly income support checks to retired Americans.

But even after the Medicare and Medicaid programs were put under one roof in 1977, the agency continued to struggle, facing criticism from Congress and medical providers. “It’’s almost paradoxical the extent to which Medicare is so important and valued in the lives of so many families and communities, and the overwhelming communication the people running the program get is hostility,” said Bruce Vladeck, an administrator in the Clinton administration.

Not Just A Check-Writing Agency

Gail Wilensky, who ran the agency for two years under President George H.W. Bush, said CMS has evolved into a much more sophisticated operation. “It’s not just a check-writing agency anymore,” she said. But the turnover at the top sends the wrong message to employees, who respond by being “more inward and protective.”

The CMS administrator’s position is a political appointment requiring Senate confirmation. Berwick’s name surfaced as a potential CMS leader shortly after Obama’s election. A pediatrician by training, Berwick gradually shifted his focus to quality improvement, steering the nationally recognized Institute for Healthcare Improvement, a nonprofit based near Boston.

The Obama administration waited to submit his name for the CMS position until April 2010, one month after it won passage of the Affordable Care Act. By then, Republicans were openly attacking the legislation as unduly burdensome and costly. Berwick never did get a Senate hearing and was appointed by the president during the congressional recess that July.

The recess appointment avoided what many predicted would be a losing battle with Senate Republicans. Some of them accused Berwick of promoting rationing, based on favorable comments he had made in the past about the British National Health System. Sen. Pat Roberts, R-Kan., said Berwick’s focus on cutting costs would lead to a rural health system consisting “of a Band-Aid and a bed pan.”

In an interview, Berwick said Republicans “twisted and distorted” his words and used the agency as “a political football. It’s a game to them,” he said. Berwick added that the churn in administrators “demoralizes and confuses” senior staff and hurts the agency’s ability to develop a consistent long-term vision. “What happens, I think, when you have a lot of turnover is senior staff loses its confidence and is less willing to take risks.”

Wilensky said she was “especially frustrated” with what happened to Berwick. “I like Don Berwick. I don’t always agree with him but I have a lot of respect for what he has done and for his passion for the great issues he takes on.”

Berwick had little choice except to resign. His acting term was set to expire at the end of 2011 and 42 Republican senators had already announced their intentions to block his confirmation as a full-time administrator. The administration nominated Tavenner, a former Virginia health official and executive with the for-profit Hospital Corporation of America, just days later.

Several prominent Republicans, including Republican House Majority leader, Eric Cantor, said Tavenner was “eminently qualified” to run the agency. But months later Tavenner still hasn’t gotten a hearing and, with the heated politics of an election year, some wonder if she will.

This story was produced in collaboration with The Washington Post.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

18 replies »

  1. I would tend to agree with the sentiment, “that it is unclear whether or not CMS needs more employees than it has now.” I would also ask for clarification around what the author specifically has used as the basis for this statement,”the agency operates with about half as many employees as Social Security.”

    For example, a large share of CMS dollars are floated to State Medicaid Agencies to administer title 19 and 21 programs etc. and by proxy each state programs effectively push portions of these funds to other contractors. This typically includes portions to the private sector and other state agencies beyond the traditional “Medicaid Agency” including perhaps portions of Attorney General’s offices (ie. fraud), a states financial eligibility agency, and numerous other players.

    If for no more than my own selfish edification can you please clarify the detail related to this. Thank you so much.

  2. Wonder why they didn’t want to talk details?

    “President Obama’s national health care law will cost $1.76 trillion over a decade, according to a new projection released today by the Congressional Budget Office, rather than the $940 billion forecast when it was signed into law.

    Democrats employed many accounting tricks when they were pushing through the national health care legislation, the most egregious of which was to delay full implementation of the law until 2014, so it would appear cheaper under the CBO’s standard ten-year budget window and, at least on paper, meet Obama’s pledge that the legislation would cost “around $900 billion over 10 years.” When the final CBO score came out before passage, critics noted that the true 10 year cost would be far higher than advertised once projections accounted for full implementation.

    Today, the CBO released new projections from 2013 extending through 2022, and the results are as critics expected: the ten-year cost of the law’s core provisions to expand health insurance coverage has now ballooned to $1.76 trillion.”

    The public satisfaction of this bill tracks the discussion of it, the more the public learns the more they don’t like it. The only way it was ever going to pass was on meaningless sound bites and the media covering for it. Once people started discussing it the public became aware just how bad of a bill it was.

    Besides the two RINOs in Maine there was a half dozen other Republicans that liked Berwick. He would have easily been confirmed but ObamaCare would have been slaughtered. The Obama Administration chose the bill over Don

  3. The Dems had 59 votes when Berwick was nominated, and they only needed one RINO (Collins, Snowe?) to break a deadlock. They wanted to NOT talk about health reform, and the Republicans were surely going to use the hearings to stir up the considerable public opposition to the law. This was about PR, not about votes. They hung Don out to dry.

  4. rubbish. there was no threat to filibuster Berwick. Baucus wouldn’t even schedule a hearing, and White House didn’t want to tear the band aid off the health reform debate by forcing him to. They abandoned regular confirmation track less than ninety days after proposing him and made him a burnt offering (by using a recess appointment). This was an unforced error on the Dem’s part.

  5. Priorities. Never seen a Republican filibuster blocking defense (war) spending.

    “Our Global Infrastructure

    The national security depends on our defense installations and facilities being in the right place, at the right time, with the right qualities and capacities to protect our national resources. Those resources have never been more important as America fights terrorists who plan and carry out attacks on our facilities and our people.

    Our military servicemembers and civilians operate in every time zone and in every climate. More than 450,000 employees are overseas, both afloat and ashore.

    The Defense Department manages an inventory of installations and facilities to keep Americans safe. The Department’s physical plant is huge by any standard, consisting of more than several hundred thousand individual buildings and structures located at more than 5,000 different locations or sites. When all sites are added together, the Department of Defense utilizes over 30 million acres of land.

    These sites range from the very small in size such as unoccupied sites supporting a single navigational aid that sit on less than one-half acre, to the Army’s vast White Sands Missile Range in New Mexico with over 3.6 million acres, or the Navy’s large complex of installations at Norfolk, Virginia with more than 78,000 employees.

    In Comparison …

    In terms of people and operations, we’re busier than just about all of the nation’s largest private sector companies.

    The Department of Defense has a budget of four hundred nineteen point three billion dollars and more than three million employees; Wal-Mart has a budget of about two hundred twenty-seven billion dollars and employs about one-point-three million people; Exxon-Mobil has a budget of two hundred billion dollars and employs almost ninety-eight thousand; the GM company budget equals one hundred eighty-one billion dollars, it has a workforce of three-hundred sixty-five thousand people; and Ford has a budget of one-hundred sixty billion dollars, and employs three-hundred fifty-four thousand, four hundred people.”


  6. Let me flesh it out for you Nate.


    Baucus opposed it on principle, not because it was a way of avoiding questions. Also, most filibusters are just a threat. That is all that is needed.

    Grassley? Gang of Six? Master of delay? Have a fake hearing that goes past the recess so the appointment does not take place? Absolutely! The newer, naive Obama fell fro that once.


  7. The memo also said Grassley did not intend to delay Berwick’s confirmation hearing, and had wanted the hearing to take place before a similar hearing for Supreme Court nominee Elena Kagan.

    “I want to make sure it is absolutely clear up front that we were prepared for a nomination hearing to occur,” the staffer writes in the memo. “Furthermore, Senator Grassley had in fact requested that the hearing take place the week of June 21 (before the hearing on the Kagan nomination in Judiciary). So these items were not a precondition for holding the nomination hearing. Republicans were in no way holding up this process. We wanted the hearing.”

  8. Reid has brought other bills to the floor that did not have 60 votes and did not pass. It was an outright lie to say Republicans filibustered Berwick. Its also a lie to claim Reid didn’t want to waste time, he has wasted the past 4 years.

    For an honest account of what really happened, the truth the left doesn’t want to discuss;

    “The Berwick nomination caused such an uproar that the Obama administration began to fear how bad his confirmation hearing would be from a public-relations standpoint. An odd situation developed: Senate Republicans began pressing for a nomination hearing for a controversial Democratic nominee instead of dragging their feet, which is the ordinary custom. It was Democrats who wanted to avoid one.

    In order to avoid having Berwick answer uncomfortable questions about his views and the new law, the Obama administration waited until Congress adjourned for its summer break to install Berwick to the office on July 7 as a “recess appointee.” This was an unusual maneuver, so questionable in its mockery of conventional process that even Democrats like Finance Committee chairman Max Baucus criticized it. The unwillingness to allow Berwick to air his views in public indicated the degree to which Democrats had become the party on the defensive in the health-care debate.”

    Or is Baucus a Faux News watching Tea bagger to?

  9. You remember wrong. There were 58 confirmed Dems, plus Saunders and Lieberman. There was horse trading at the end to get the last couple of votes.

    The filibuster has been constantly used in the last few years. To pass anything in the Senate you have to be sure of 60 votes. That is a fact of life in the Senate.

    “If he could force on a vote on the judges why not Berwick?”

    There was no forcing. There are a number of Senators who on principle believe that it is wrong to use a filibuster on a SCOTUS nominee. Note that they continue to block many, many other nominees. They also do not want to see their nominees filibustered since they assume they will win in 2016. If you are unaware that the filibuster has been used a lot recently, I would recommend you start reading more. The WSJ, the NYT or any major newspaper will have covered this.


  10. I seem to remember 48 that opposed PPACA yet he brought that to the floor and passed it.

    Further that filibuster threat was after he was installed with the recess appointment and was payback for doing that.

    Further still Reid has brought countless bills to the floor he knew the Republicans would filibuster to get them on record of filibustering. Why was this different? Why not get them on record then blame them?

    Because you Steve, and Bobby are lying your asses off. Berwick never got to the floor because Obama was scared to death of someone in his admin being questioned by anyone but the weak media and their softball questions.

    The pathological levels you on the left will go to never ceases to amaze.

    If he could force on a vote on the judges why not Berwick?

    Want to try making up another story, hopefully a little bit more believable next time.

  11. When people first become eligible for Medicare after turning 65 or two years after qualifying for disability benefits or starting on kidney dialysis, it’s the Social Security Administration (SSA) that handles the paperwork, issues Medicare cards, etc. and not CMS. For the 2% of beneficiaries that must pay a high income surcharge for Part B and Part D benefits, it’s the SSA in conjunction with the IRS that determines how much they owe, not CMS. The Internet and automated telephone systems made vast improvements in the services both Social Security and Medicare beneficiaries can access from downloading forms to getting answers to frequently asked questions. As noted, claims processing is outsourced to insurance companies. Private Recovery Audit Contractors help to determine whether payments are appropriate and recover inappropriate payments. In short, it’s far from clear whether or not CMS needs any more employees than it has now.

  12. 42 Republicans had announced their intention to block his confirmation.

    Reid didn’t see any point in wasting time on something that would go down to defeat.

  13. please enlighten is Steve and Bobby how you filibuster a vote that wasn’t scheduled?

    You can’t filibuster hearings or the senate schedule.

    Your argument is BS, Ried never even put them on the calendar so there was nothing to filibusrter, Spin some more.

  14. “. The ONLY reason he did not get a vote and her a hearing is Democrats and Ried.”



  15. lots of republican bashng but not one mention that democrats did and still do hold a majority in the senate. The ONLY reason he did not get a vote and her a hearing is Democrats and Ried.

    This post wasn’t about telling the truth though was it, just pushing more of the same tired propoganda