Who is in charge of Medicare?

The wide-ranging debate over Medicare, a major factor in the presidential election next year, primarily focuses on whether future generations will benefit in the same way that the current 46 million recipients like me benefit. Politicians, critics and would-be-recipients express the illusion that the health care I receive from Medicare represents the ideal. I believe that the only way to save Medicare is to dramatically improve the way it is run today so that it remains a program worth saving.

The primary audience for this commentary is the men and women who provide DME other equipment necessary to sustain and maintain the quality of life. Recently, 87-year-old Lilian Hutchinson, who gets around on an unstable walker, fell and broke her elbow in an independent living facility for 90 elderly and disabled residents where I live in State College, Pa. I believe that if Lillian had access to a scooter or a power chair in her apartment, she would not have fallen. The tales of needless suffering you could tell resulting from a Medicare bureaucracy that increasingly limits access to mobility equipment and medical oxygen seem beside the point.

Durable medical equipment represents only a small fraction of the Medicare budget. The whole system for providing medical care for the elderly, disabled and poor is not working efficiently in large part because of the absence of leadership at CMS, an agency of the U.S. Department of Health and Human Services. My intention here is to answer the question: Who runs Medicare? In theory, Dr. Donald Berwick, a distinguished Harvard physician with an outstanding reputation as an advocate for efficient health care, runs CMS.

Last year, President Obama named Dr. Berwick to be administrator of CMS, a position one senator described as the nation's health czar since the job also includes putting in place much of the legislation passed last year, which, by one estimate, will extend health care to 32 million Americans who do not have coverage.

Sadly, the president had failed to appoint an administrator early on in his administration, when Senate confirmation would not have been a problem and when an adviser with the expertise and gravitas Dr. Berwick has in the medical community would have proven useful. The major flaw in the president's landmark legislation was how he intended to pay for it. He decided against raising taxes, which might have doomed passage.

Instead, half the estimated trillion dollars required to extend healthcare coverage was targeted to come from savings to the Medicare budget as a result of achieving cost savings, reducing fraud and abuse, and increasing efficiency. Anyone who has ever made a New Year's resolution to save money can tell you it is imprudent to spend it before the money is actually saved.

By the time Dr. Berwick arrived at Medicare, he was in the impossible situation of being required to save $500 billion, a requirement for which he had not been consulted and in a situation where the president had given him neither the time nor the authority to implement.

The political comedian Mark Russell observed, in a similar context, that exercising leadership without the necessary authority is equivalent to sending a eunuch to an orgy. Fearful of Republican reaction to Dr. Berwick's appointment and unsure of the allegiance of Democrats on the Senate Finance Committee, the president refused to fight for Berwick's confirmation or to find a replacement who would achieve bipartisan support.

Using the recess appointment mechanism, which allows a president to appoint an official on a temporary basis while Congress is not in session, Berwick currently serves as acting administrator and will be replaced next year by his deputy Marilyn Tavenner. Tavenner, while respected for her organizational skill, her background as a nurse and a hospital and state health care administer, does not have the stature required to lead what is in effect a cabinet level position.

Although CMS has a larger annual budget than the Pentagon, as I write this, there has not been a confirmed head of Medicare since 2006. For the purposes of comparison, if the Defense Department did not have a confirmed secretary for five years, there would be a national outcry.

Joel Solkoff was a political appointee in the Carter Administration, serving as special assistant to the Under Secretary of Labor. He believes a bipartisan solution to the problems of Medicare is achievable.