• Should health services researchers be more like Paul Krugman?

    From time to time I ponder the extent to which the work in health services research and related domains (health economics, public health, and the like) influences policy. Though there are examples of health research influencing policy, on the whole I think most of my colleagues feel they have little voice and make no impact.

    I don’t think they’re wrong, and maybe it’s the natural state. Maybe most of us can’t penetrate because we and our work don’t rate. We’re not the “chosen ones,” with the right pedigree. Or our work is just not that spectacularly important or compelling. This is not Lake Woebegon. We cannot all be above average.

    But should we be satisfied with what our community has done collectively. Are we happy with the degree to which research informs and shapes health policy? Or do we despair? Should we?

    Were it not for the ACA, I would answer with an unequivocal, “Yes.” Despair would be clearly warranted. However, aspects of that law are shaped by research. Maybe we should be satisfied.

    Then again, the same could be said of economic policy too. Aspects of it are shaped by advice of academics. But, in that domain, Paul Krugman, for one, is not satisfied, and justifiably so.

    The inadequacy of policy is something that should bother economists greatly – indeed, it should make them ashamed of their profession, which is certainly how I feel. For times of crisis are when economists are most needed. If they cannot get their advice accepted in the clinch – or, worse yet, if they have no useful advice to offer – the whole enterprise of economic scholarship has failed in its most essential duty.

    Krugman is holding his discipline to a very high standard. He expects macroeconomists to step up in a time of need, to speak with near unanimity about what they all fundamentally know is the right thing to do. He thinks they should be ashamed in their collective failure to do so. Ashamed, even though academic economists have, perhaps, penetrated the policy sphere to a far greater extent than those of any other field of study, except, maybe, law.

    If this is not enough, what do we say about health services researchers and their colleagues in related fields? What about me? Should we, should I, feel ashamed that we have not done more? Are we ashamed about the decades of uninsurance higher than any other industrialized country? Are we ashamed about the high level of spending? The mediocre population measures of quality? The medical errors? The insufficient hand washing among surgeons? The lack of adherence by providers to evidence-based guidelines? The rampant under-use of high-value care? The over-use of low-value care? I could go on.

    Do you, do I, have such a high expectation for our fields? Should we be speaking in a more unified, firm voice? Should we expect to shape policy to a greater extent? Are we doing enough? Is the ACA  — the implementation of which is threatened judicially, legislatively, across several levels of government (state and federal at least) — enough? Can we do better? Could we if we tried?

    At least macroeconomics has Paul Krugman, someone secure in his job, having received the highest award in his field, and with a large megaphone. At least macro has someone like him to tell members of his profession they’re not stepping up.

    Where is the Paul Krugman of health care? Doesn’t something that consumes nearly one-fifth of our economy deserve one? Who will tell us, loud and clear, that we can do better? Who will hand that individual the megaphone he or she deserves?


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