The health policy impact of research

Tomorrow I’ll be on a panel with Ezra Klein and Merrill Goozner and moderated by Trudy Lieberman at AcademyHealth’s National Health Policy Conference. We’ll be talking about the role of the media in health policy. I hope to infuse the conversation with my views on how the media translate research to policymakers and how the research community can help facilitate that role.

An editorial by Carolyn Clancy, Sherry Glied, and Nicole Lurie in the latest issue of Health Services Research provide some excellent examples of how research has influenced health policy. Is there any doubt that the media helped facilitate? Not in my mind.

Almost all recent developments in health policy—from the conceptualization of accountable care organizations to the structure of health insurance expansions—are rooted in policy informed research, because researchers increasingly recognize the importance of applying their energies to policy-relevant questions.

Some examples from the editorial:

  • “Iatrogenic injury has been recognized since the time of Hippocrates. Highly publicized incidents, media attention, and public advocacy drew attention to these mistakes. But research, such as the analyses of hospital records in New York, Colorado, and Utah, which has illuminated how frequently errors occur, persuaded policy makers that the problem deserved more than sympathy and hand-wringing.”
  • “Careful studies of insurance plans that implemented value-based insurance design persuaded policy makers to incorporate these designs into the Affordable Care Act.”
  • “The budget estimators [CBO, OMB] ground their estimates in the published literature, often directly citing publications in their documentation. […] For example, the Congressional Budget Office’s estimates of the costs of mental health parity in 2007, which were instrumental in passage of the Mental Health Parity and Addiction Equity Act of 2008 (PL110-343), relied heavily on a study of parity in the Federal Employee Health Benefits plan, published just a year before the budget estimate.”

It would not be hard to come up with other examples. Yet, when asked to provide explicit evidence of the policy-relevance of research, it often seems difficult. Why? The answer, I think and as the editorial authors point out, is that often a significant amount of time — a decade or more is not atypical — elapses between research that identifies a problem or even potential solutions and the legislation or regulation that addresses it. During that time an enormous amount of constituency building and political maneuvering take place. Ultimately it seems like something happens because of a political opportunity, not because of research. Of course that’s true. Without political opportunity, nothing happens. But the research plays a crucial role of ignition, framing the technical issue, infusing the issue space with evidence, and pointing toward potential solutions.

The last point, also articulated by the authors, is that though the gestation period is long, the opportunities for delivery are brief. Within the long arc from initial research to policy implementation, the moments when the world (or part of it) is receptive to the relevant research evidence may be short due to shifting political alignments and the ever-changing focus of policymakers. Think days, weeks, or months, not years. These are not long enough to conduct research, but plenty long to inform the debate with the body of existing work. If research is to be relevant to policy, the “work on the shelf”  must be translated and disseminated not just once to raise awareness or initiate interest, but multiple times to sustain it. The time of journal publication is not necessarily the right or only time to conduct this translational work; it must be done time and again during the brief periods when it can make an impact. (The story of value-based insurance design as told by Frendrick, Martin, and Weiss also in the latest issue of Health Services Research is an informative case study illustrating these points.)

Sensing the proper timing is not something researchers are particularly good at. It’s not their job in that they are rarely rewarded for it. However, journalists are good at timing. They are rewarded for their awareness of the hot policy and political issues of the moment. That is their job. Consequently, relationships between researchers and journalists are important for evidence-based policy. Evidence is only relevant to the extent it is communicated at the right time and in the right way.

AF

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