• 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?

    @afrakt

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    • quite honestly, atul gawande….
      great writer, addresses numerous issues of quality, a physician but doesn’t shy away from criticizing the medical establishment…
      he can (and I think will) be a powerful voice in the changing of medicine.

    • Making Paul Krugman the example is unnecessarily divisive since even Krugman admits that he shades the facts to support an advocacy agenda (see his response to Tyler Cowen with the phrase “this is not a game”).

      While health care researchers do need a higher profile, I would argue the Krugman approach is a very very bad one in terms of public policy and influence. Krugman is now fundamentally a journalistic figure. Someone like Larry Summers who kept more of his intellectual sheen would probably be a better model as he influences policy to a much greater extent…

      • The post: http://krugman.blogs.nytimes.com/2012/01/03/the-mendacity-of-dopes/

        “I will make the best honest case I can for moving in that direction.”

        Where does he admit he “shades the facts”? Making a sound (fact-based) argument that supports one position and not another is not shading the facts.

        UPDATE: See the 8th definition here http://www.merriam-webster.com/dictionary/shading

        • Austin–

          As you google searched Krugman’s response, I am sure you can google search Tyler’s responses.

          If you can’t see that Krugman openly implies that he believes pressing an agenda is more important than a nuanced, intellectually sound argument, then I think we need to work on your reading comprehension.

          • Oh dear! I thought we might have a nice discussion about this. Guess I was wrong.

            • Apologies if I misinterpreted the tone! That is the problem with purely written communication. Anyway, I do agree with your larger point about needing more high profile health econ public intellectuals so our differences are actually pretty small…

      • Krugman’s macro predictions have been spot on. And it is ability to predict correctly which makes an economic theory valuable.

          • Naturally one need not emulate every aspect of Krugman in being more assertive about the need for evidence-informed health policy change. I did not suggest that health services researchers use ad hominem attacks. I suggested the community might consider being ashamed of the degree to which it has penetrated the policy debate. Moreover, I couched all this in the form of questions. Should we be more like Krugman in this regard? Your answer could be, “No.”

            • “I did not suggest that health services researchers use ad hominem attacks”

              Using Krugman as your ideal example makes the case that you believe in his methods. After all, you could have used other powerful liberal economists with influence (e.g., Summers) or writers with a more reasoned tone (e.g., Yglesias). Denying it now to other commenters seems weak.

              “Should we be more like Krugman in this regard? Your answer could be, “No.””

              Is this really the best you can do when you start a discussion on it? There are numerous pro-Krugman arguments out there that you can use. Try Brad Delong’s site if inspiration fails you. The point is that your post seemed to advocate a model for the public intellectual and a very specific one at that (e.g., impressively pedigreed but shrill polemicist devoted to an agenda above all else). Obviously, you will get pushback on that…

            • No problem with pushback!

          • I actually followed some of the links provided (Barro, Powerline, Taylor). They were all hearsay. A more powerful argument would provide actual references that demonstrate his poor behavior.

          • It’s curious that Austin doesn’t seem to know about Krugman’s reputation amongst serious scholars (ie., someone who consciously chose to leave his intellectual roots behind and become a polemicist).

            Thanks for digging up the links! Austin does seem very impressed by googling (see his looking up Merriam Webster for the definition of “shading”–hahaha !)

            • V,
              Your attacks on Krugman are entirely ad hominem up to citing his “reputation” among “serious” scholars without saying whose those serious scholars are. As a columnist he is expected to take positions and defend them and to point out the problems he sees with the pronouncements of others. You do not say what problems you have with Krugman’s economic judgments or positions.
              For instance, do you think he has been wrong about our being in a liquidity trap where even large budget deficits will not drive interest rates up. That has been proved true by events.

              Do you think that, contrary to Krugman, austere federal budgets will restore “confidence” and lead to greater economic growth? Ask the Irish how that is working out for them.

              When Krugman criticizes other economists like Cochrane and Taylor for arguing that stimulus cannot work and basing that on the unspoken assumption that Say’s Law is correct, he points that out and they then deny that is their position or that they were claiming that stimulus would not work.

              Similarly, if he finds economists making arguments clean contrary to the one’s they were making during the Bush years, he points that out as well. None of this is ad hominem argument.

              And we must remember that it was the Chicago school which declared Keynesianism to be false without bothering to prove it.

              As to the question of whether health care economists should be more like Krugman I would say yes. If you see arguments which you know to be false, you should point out that they are false and explain why. You should also point out what, in the experience of the US and other countries, has proved to increase the coverage in health care and reduce the costs. Of course it would be easier to have a serious effect if you were invited to write a regular column for the New York Times, That is why Krugman has a greater effect than Dean Baker, Jared Bernstein, Brad deLong or Mike Konczal.

            • Stanley–

              See the links given above as well as google the discussion between Tyler Cowen and P. Krugman on real business cycle theory. P. Krugman could have engaged on the data and didn’t–calling your opponents mendacious idiots doesn’t exactly inspire confidence.

              As for your specific arguments, several points:

              1. These are all relatively recent (e.g., post-crisis) and don’t represent Krugman’s oeuvre of work over the last 11 years (e..g, think about his constant incorrect macro predictions during the Bush years)

              2. These points also presume that I actually disagree with Krugman’s economic philosophy. My objections to Krugman are primarily on the grounds of tactics (see my response to Mike earlier)…

              3. If you do want to have a discussion on Krugman’s theoretical basis, that would need to be much more extensive than cherrypicking 3 or 4 isolated talking points (e.g., liquidity trap arguments are much more subtle than you make them out to be and Krugman, despite his stances in the Times, is well aware of the literature surrounding this area).

          • With the case of those who object to PK’s writings, I think it’s more of the truth hurts phenomenon.

            Right Wing & Laissez Faire types have been arrogant and rude for decades and now are surprised when their love of Newtonian Mechanics for an Economy is upset by real data and logical challenges.

            I don’t agree with him on all issues but he has a great influence and is widely read. That is somewhat like the problem Economists had with Galbraith that he had the sin of being popular and well written. The larger difference is that PK is of greater stature with his professional work in International Trade and other areas.

      • Dear V,
        I believe you are shading the facts as regards Paul Krugman; your politics are showing.

        • Mike,

          I will admit that I am biased towards Krugman’s rivals like Summers or even Romer (though she is much closer to PK than Summers). I am not sure that counts as politics given they are all part of the same party technically.

          Anyway, not sure that really argues against the consensus on Krugman’s tactics. There are plenty of people who would otherwise be allies of the policies he promotes (i.e., Tyler Cowen) but are embarassed by the methods he uses. Its not like there is a shortage of eminent economists who make similar arguments to him without the divisiveness…

    • Don Berwick comes to mind, though hopefully the political kerfuffle surrounding his appointment to CMS won’t hurt his credibility.

    • I think Gruber, Cutler and Rheinhart have clearly had a bunch of influence. Goodman has had a lot of influence. I think politicians are influenced by the work that comes out, but on health policy, they have everything interpreted by their aides. We meet with our Congressman yearly now. He seldom addresses anything directly on health care w/o having first discussed it with an aide. That means they are usually unaware of where or from whom that advice is derived.

      Steve

    • There is a slight problem with this argument. Paul Krugman has done well, speaking out strongly about policy. But how much influence does he actually have? Macroeconomists are far from unanimous about policy prescriptions — they disagree in the fundamentals. Some sacrifice their integrity to promote their party’s position. Some are just completely ignorant of certain aspects of macroeconomics. (Paul Krugman has complained precisely this about the education of “Freshwater” economists.)

    • Yes.

      Desperately

    • One area I think Health Care Economists could stand up more strongly is to weigh in with the Fact Check sites about proposals and rhetoric.

      My own view is that they have badly damaged health care debates by attempting to characterize the vouchers/premium support plans by the House GOP members as not ending medicare. How is converting a single payer system to a voucher not ending Medicare. You have to be a logical contortionist to change those meanings. If they were merely to say that the guarantees are eliminated but not the role of the Government is providing a level of funding but that it wasn’t for them to judge whether that was ending Medicare then it would be at least informative.

      What they have done is to distort the debate not improve on it.

      I would hope that Health Care Economists would weigh in as the public really could use some help and the ivory tower stuff doesn’t help reach the average guy near so much as these type sites/columns.

      And yes– that’s something PK and a few others in the general Econ blogging field will do, but don’t see near so much of it from the specific experts.

    • As I read through this long thread and Austin’s post, images of folks both in and out of the (health care) policy world kept popping into my head–but only those who have had an impact. Not conventionally trained individuals mind you, but people who have had the greatest impact on policy.

      Kristoff, Cousteau, Goodall, etc.

      Austin’s question should not be whether health service researchers should be more like Krugman. The question should be should a health services researcher touch, talk, and feel with patients on occasion. People who impact the greatest change have appeal. To my knowledge, Krugman–outside of writing about a second hand patient anecdote or a story from a friend on occasion, has made little emotional connection in his columns. That will never capture the imagination or generate a ripple amongst the populous. Accolades within the glitterati set yes, but not with the majority of folks.

      I am not saying PK warrants secondhand status. No. The question is how should a HSR’r generate change.

      Try this: make a connection like Art Buchwald or Jimmy Breslin, and a little less like Krugman, and maybe evolution could happen.

      Unless a health services researcher watches someone pass away, struggle with a terminal diagnosis, or see what stressed providers undergo, they only will have half the story, I mean data.

      Krugman will never have that,

      Brad

    • Despite the quote and mention of Krugman in the title, the post is really about whether practitioners in the field of health services research (and related disciplines) should be satisfied with their degree of influence on policy.

      I used Krugman because I was impressed with his strong conviction that his profession has failed and should be ashamed. This, despite a much greater influence on policy by economists than health services researchers.

      If Krugman is justified in asserting his colleagues should be, collectively, ashamed, then what about me and my colleagues. Should we be ashamed too?

      That was my main question. I failed to make that clear, I guess. However, having just reread it, it is hard for me to see how I did. My hypothesis: even just mentioning Krugman, no matter what the context and point, is enough to distract from one’s point. Fine. But it was his words that moved me to post. I was inspired. Yes, by Krugman. Not that there’s anything wrong with that!

    • I *really* don’t intend this statement to be insulting, but what specific benefit would the public derive from granting academic health policy specialists more influence over legislation (e.g. how medicine is practiced and paid for)?

      It seems like the first task for anyone who claims that granting them more authority over a specific process would have tangible benefits in the future would be empirical evidence that they had delivered tangible benefits in the past.

      The public benefits derived from contributions made by basic scientists, clinical researchers, and practitioners are massive and the benefits that investing their conclusions with a particular authority over how medicine is practiced and delivered is clear. The empirical case that there are tangible benefits to be derived from granting academic policy specialists more authority over how medicine is practiced and paid for seems far less clear.

      How would you answer this question in empirical terms? Or is there another basis upon which you think this question could or should be settled?