• 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.


    • A sobering thought as well: as quickly as media opens the door, it shuts it.

      Recall the momentum for change in end of life care and the application of palliative medicine. It was real and entailed hard work over years. The time was ripe, and “the door was open.” Then poof. Set back years thanks to many who shall go nameless.

      The very force we wish to empower, social media, is the same force that can destroy.

      • A cautionary tale. Who has the best take on how it might have been handled?

        • Good question. I have never seen anyone suggest a successful response to those attacks. I think that the media could have published more details, and done a better job explaining how the issue was being demagogued. However, it would have required accusing prominent figures of lying and looking like they were taking sides. Our media does not work like that. It presents “both sides” of an issue, even when one side is fallacious, when an issue begins. Only later do the deeper analysis pieces begin to appear, but by then it is usually too late. We have national ADD.

          I think you are correct about the timing issue, but I also think we need a steady stream of information going out so that people can be generally informed. I think that information also needs to be concentrated into easily accessible, well known sites so that those who want to know can find out what the research really says. Since the literature is too large for anyone to know and remember it all, journalists and academics need to help us with that.


          • I tried to think of the right venues Steve. The News Hour or ProPublica come to mind. However, any attempts at using the best we have will go down in flames. “Dont like what they say,” well it must be the liberal or conservative blowhards underlying that message. Inferred justification and motivated reasoning win the day.

            The ones who listen with an open mind were never the impressionable folks on the fence to begin with.