Dr. Donald Berwick is an outstanding and superb appointee to be Administrator of the Centers for Medicare and Medicaid Services (CMS). He is a leading expert on health care quality, health delivery systems, health systems transformation, and an accomplished pediatrician. The appointment fills a critically important post of overseeing Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) and is long overdue, as CMS has been without leadership for over three years.

Although people can complain about the recess appointment, what is more disturbing is how the Senate confirmation process has become so convuluted and destructive that is amazing that anybody these days would actually want to go through the process. I have immense respect for people like Gail Wilensky, Tom Scully, and Mark McClellan for having put themselves through the process in the past and for having performed well as public servants. However, the fact is that no senator ever proposed holding up their nominations in the way that people were talking about with respect to Dr. Berwick's nomination.

As Tom Scully said about Berwick, “He’s universally regarded and a thoughtful guy who is not partisan. I think it’s more about … the health care bill. You could nominate Gandhi to be head of CMS and that would be controversial right now.”

Mark McClellan added, “What happens at CMS in the next few years will determine whether the new legislation actually improves quality and lowers costs. Don [Berwick] has a unique background in both improving care on the ground and thinking about how our nation’s health care policies need to be reformed to help make that happen.”

Dr. Berwick, in fact, is highlighted in a new book entitled Switch: How To Change Things When Change Is Hard for having led the effort to reduce medical errors and deaths in hospitals through the "100,000 Lives Campaign." Hospitals took his challenge and instituted a series of reforms that significantly reduced medical errors and achieved the 100,000 lives saved goal. As Dr. Berwick said, "And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended that, without our work, would have been only beds of weeds." These are real people, real lives, and real health reform.

Unfortunately, we have an appointments and confirmation process that is terribly broken, but it truly begins with the confirmation process. Just a few months ago, over 70 nominations were put on hold by a senator in order to demand that unrelated pork projects be finalized to the senator's state. Moreover, in testimony before the U.S. Senate, Senator Charles Schumer reported, "As of June 17, President Obama had 137 nominations pending on the [Senate] executive calendar. At the same point in his first term, President Bush had only 45." In other words, there are over 300% more pending nominations compared to the same point eight years ago.

Presidents have one weapon at their disposal to counter extensive and excessive delays in appointments and that is to make recess appointments. As a congressional staffer for 12 years, I have extreme disdain for executive branch excess, but the confirmation process has become such that I understand and support President Obama's decision to make Dr. Berwick one of his 18 recess appointments thus far. In fact, according to the Christian Science Monitor, this is mild in comparison to President George W. Bush, who made 171 recess appointments, and President Bill Clinton, who made 139.

Therefore, although Dr. Berwick had the support of a clear majority of the U.S. Senate, a pending filibuster threatened to hold up his nomination indefinitely. Certainly, those are within the rules of the Senate.

In response, the President decided to make the appointment without congressional approval during a recess. Those are also well within the rules created by the Appointments Clause in the Constitution.

Interestingly, James Gelfand described the latter manuever as "a partisan, backroom trick," but how is it any more partisan or outside the bounds of fairness? It simply isn't.

In fact, as Jonathan Chait has said about the process, "If you're going to push the rules as far as they can go, you can hardly complain when the other party does the same thing."

For those criticizing the recess appointment of a well-qualified and superior person in Dr. Berwick, I hope they are also critical of a process in the Senate that has led to the filibustering of a multitude of well-qualified people. Without a change, it is a miracle that anybody would ever agree to go through the current process to be a public servant...even somebody like Gandhi.

If America's health care system is to seriously address its cost and quality challenges, the Administrator of the Center for Medicare and Medicaid Services (CMS), charged with guiding new payment and delivery reforms, will play a vital role.

By choosing Dr. Donald Berwick, the Obama administration has chosen a real leader who has built his career doing exactly what CMS must now accomplish: helping health care institutions cut costs while improving quality of care. It’s a goal that a wide range of constituencies and the American public support. It should have the support of political leaders of all stripes.

This task and this appointment should not have been so controversial. That it has become one is seriously disappointing for anyone, liberal or conservative, who cares about the cost and quality of our health care.

We had no position on whether or not Berwick should head CMS. His writings and sayings in the past did present some cause for concern (in 1995 he wrote criticizing ERISA preemption, and statements glorifying NICE etc.), but we figured he deserved a fair chance in the hearing process. Maybe he had a good explanation.

And then he was just appointed, with no hearings. That was bad. But not as bad as lying, saying someone was "delaying critical nominations." How was anyone delaying it, when there was never a hearing or a vote? Chairman Baucus can call hearings of the Senate Finance Committee whenever he wants, and Majority Leader Reid can force a confirmation vote whenever he wants.

Everyone inside the beltway realizes, this was a partisan, backroom trick trying to avoid having any more negative news cycles about health reform. I wish Dr. Berwick the best and I hope he does a good job at CMS, but this whole process is just another example of why people in flyover country, including (and especially) small business owners, are disgusted with what they see in Washington, DC.

I think that President Obama’s decision to appoint Don Berwick to head the Center for Medicare and Medicaid Services (CMS) without going through any Senate confirmation process, without having any hearings to find out what his views are, without taking the time to allow the American people to understand will turn out to be a sad mistake.

Don Berwick is a smart man. He deserved better than this. There are many, many questions about the person who is going to head up implementation of the largest, most expensive and most intrusive reform in American history. For this new health reform to be implemented by somebody who hasn’t had a single day of hearings, who has had no public explanation of his views, who has had no chance to explain some of his more radical statements, is a serious mistake on the President’s part and one more example of the way in which the Obama Administration simply runs over the American people and runs over their concerns.

This is a bipartisan concern. As Senate Finance Chairman Max Baucus, a Democrat from Montana said, "[I] was troubled by the Senate confirmation of Presidential appointees as an essential process prescribed by the Constitution that serves as a check on Executive power."

The fact is that this is an example in the most important single reform involving the largest amount of money with the greatest impact on the average American, and the President has taken the decision to simply bypass the Constitutional process, impose his person, in a way which I think will increase public distrust and increase public concern.

I agree with Gail Wilensky. There is an enormous amount of confusion around the country about the new health reform act. Adding to that confusion is Don Berwick’s praise of the British National Health Service – a system that not only rations care, but systematically denies medical services to people who lack political connections or the ability to pay out of pocket.

I can’t think of an occasion in which there was a greater need for a confirmation hearing than this one.

It has been incredulous to me that the Obama Administration waited until April of 2010 to announce a CMS candidate, as opposed to making a selection around March/April of 2009 when they announced the FDA commissioner and deputy commissioner. Those have traditionally been the controversial positions in HHS.

Having waited so very long, to my mind they have now compromised Don Berwick’s effectiveness and for sure, limited his tenure to 17 months. Maybe it would have been necessary to make a recess appointment if there had been no movement in his hearing process by the time of the election, or if a Senator had put an indefinite hold on his name, but to have done this two months into the process before his hearing had even been scheduled is inexcusable (and truly inexplicable).

Do Berwick, the administration, and the agency did not need this. It will complicate life for everybody. I normally don’t feel quite so strongly. but I am very frustrated and saddened for Don and the extra burden he will carry. It will be interesting to observe his first Congressional hearing to see how that plays out.