The work by Marsha Gold on identifying the pathways that influence policy makers' use of health services research is a very important report for this field (Gold 2009). Using an in-depth analysis of the social science literature in this area, as well as sage insights from her own experience as an interlocutor between researchers and policy makers, Gold's article develops a framework for improving the presentation of research findings to policy makers. This will undoubtedly be useful for many researchers.
The pathways in Gold's article are premised on the fact that health care policy maker decisions are influenced by “underlying politics.” We suggest that it is also important to understand these underlying politics. For individual research results to have a more significant impact on policy decisions, they must reflect a deeper understanding of the context in which these decisions are made. Researchers must identify specific topics for study that have policy leverage and present them in a manner that corresponds to the way that policy makers think about these issues. We want to emphasize that understanding the politics of health policy is not an invitation to alter research results so that they align with political interests, but rather an opportunity to better match unbiased, scientific research to policy makers' priorities in order to help ensure that health services research findings are more relevant and meaningful to the decision making audience.
We believe that to do this requires researchers to understand more broadly the history and politics of health care issues and how these factors, on one hand, narrow the usefulness of particular research results and, on the other hand, make certain research results critically important to a policy debate. In order to provide researchers with this understanding, the field of health services research will have to make a greater commitment to the study of the politics of health care policy decision making itself.
What is too often missing from the field of health services research—and thus from the tool kit of individual researchers—is an awareness of how explicitly political factors such as partisanship, voters' views, the beliefs of key interest groups, the nature of media coverage, and the jurisdictional responsibilities of Congressional committees shape the receptivity to or lack of interest in particular research results.
Surprising as it may seem, we also lack independent knowledge of the factors influencing policy positions of health care–specific professional groups and institutions, such as those serving physicians, nurses, hospitals, and medical scientists. Health services research results may get less attention from these professional groups not because of the substance of their findings, but rather due to the fact that the issues addressed in specific studies are seen as less salient than the ones that group leaders are pursuing. Research with a political lens might therefore explain, for example, why a national study of practicing physicians' views of the top problems facing medicine found malpractice costs to be a much more salient concern than the need to improve the quality of care more broadly—an issue of high priority to health services researchers (Blendon, DesRoches, and Brodie 2002; Commonwealth Fund 2004;).
We suggest that this relative void in research-based knowledge of political factors in health services research is not accidental, but rather may be a consequence of the historical evolution of the field over the last 40 years. In the 1960s, many universities decided to launch a new series of interdisciplinary academic teaching and research programs. These included programs focused on environmental policy, poverty/welfare studies, educational policy, and—what emerged as one of the largest areas of focus—health policy/health services research. The health services research field diverged substantially from these other policy fields in the lack of emphasis placed on research about the political factors that affected decision makers' views.
In the years since the field's founding, there have been relatively few studies of the politics of health care issues, as compared with educational, poverty/welfare, or environmental policy studies. As a very rough comparison, for example, we did a quick search of the word “politics” in relevant sections of three databases where health policy and educational research is published:
- the Government Printing Office online database, which is “the Federal Government's primary centralized resource for gathering, cataloging, producing, providing, and preserving published information in all its forms” (Government Printing Office 2008);
- Harvard University's online catalogue (HOLLIS), which represents an extremely large academic library (Harvard University 2007), and
- JSTOR, which is a large database of scientific, social science, and other academic journals (JSTOR 2009).
We were able to retrieve only 4 documents related to politics and health care from the GPO database as compared with 99 related to education and politics. Hollis showed us only about 200 titles related to politics and health care, but nearly 1,700 related to education and politics. And JSTOR revealed only 61 articles in health care and politics as compared with more than 200 related to education and politics.
One could certainly take issue with concluding too much from this rather crude approach to classifying the relative quantity of politically relevant studies in these fields. Nonetheless, we suggest that the results provide evidence of the larger point—there is a dearth of independent research about the politics of health care decision making.
There are some important exceptions. In particular, while much policy debate in the health care field has been about incremental changes, the debates over national health insurance and the enactment of Medicare have been on a larger scale. These issues have received considerable independent study and analysis from a political/historic perspective. However, even in this realm, few studies focus on the political lessons and implications for future health care policy decision making.
Our working thesis is that this absence exists because the founders of the field conceptualized health services research as an analog to the extraordinarily successful field of biomedical research. As an example, the 1972 report of the Panel on Health Services Research and Development of the President's Scientific Advisory Committee defines the field as follows: “Health services research seeks to improve the network for providing health care so that the fruits of biomedical research are readily available to all citizens” (Lohr and Steinwachs 2002). In the area of biomedical research during the period after World War II, there had been a pattern established where the results of vigorously designed clinical research led to major changes in professional practice. Innovations such as penicillin, the sulfanomides, and vaccines became standard care, without any necessary changes in the process of care structurally or any explicitly political controversy (Starr 1982). This experience appears to have shaped the perspectives of the founders of health services research and their evaluations of what types of research are important. It was envisioned that health services research would be a continuation of this tradition—just changing the focus of research from understanding and improving care for categories of ill patients to understanding issues of access, quality, and effectively of the health system as a whole. And thus, in early texts that describe the “state of the field” of health services research, we see vastly more attention paid to major, controlled, epidemiologically styled studies in health policy than to the politics of health care (Flook and Sanazaro 1973).
Some academics voiced concern, even early on, that the politics of health policy would be neglected. For example, Herbert Kaufman wrote a piece entitled, “The Political Ingredient of Public Health Services: A Neglected Area of Research,” (Kaufman 1966) in the 1966 Milbank Quarterly series titled “Health Services Research I and II,” which were two issues dedicated to publishing papers commissioned by the newly formed Health Services Research Study Section of the U.S. Public Health Service in 1966 (1966a; 1966b; Andersen et al. 2005). But this concern has not translated into a substantial body of research both because of the biomedical paradigm and, by extension, because of the funding streams that supported it.
Over time, this analogy to biomedical research has proven itself to be inappropriate. The experience of health policy research has been much more similar to its sister area studies—environmental, poverty/welfare, and educational studies. The political context in which research results are received in these fields has very much shaped the responsiveness of decision makers to the outcomes of these studies. But in these other fields, national leaders and funders placed a greater priority on the independent study of factors affecting decision makers' judgments, particularly the political factors. Studies in these other fields not only examined the impact of governmental decision making (Martin 2008; DeBray-Pelot and McGuinn 2009; Scott, Lubienksi, and DeBray-Pelot 2009;) but also the major professions and other stakeholders such as teachers, business organizations, as well as grassroots organizations and public voting (Bali 2008; Cibulka and Myers 2008; Cooper and Randall 2008;).1
We believe that as a result, the research community in these other fields has a more grounded view of what types of research and what channels of presentation might more effectively influence policy makers' decisions. Also, these fields have a somewhat greater awareness of why policy innovations are so hard to move into practice and where/when additional research might be helpful.
Growing from a biomedical research vision, the field of health services research tends to overlook a series of policy/political questions that are likely to arise and affect the use of future research for policy. For example, current discussions of research on payment reforms suggest there would be an advantage to “bundling” various financial payments to physicians and health systems for a range of care situations (Hackbarth, Reischauer, and Mutti 2008; RAND Corporation 2009;). Few are asking the question of what we learned from the politics of prior financial capitation reforms.
A notable example that would provide valuable lessons is the careful study of the politics that first spurred the growth of HMOs and other forms of prepaid managed care organizations in the 1980s and helped usher in their decline. About 5 years after these innovations were widely implemented, politics contributed to nearly every state passing antimanaged care legislation and to the fact that federal legislation designed to curb managed care organizations failed by only a close vote after debates about such legislation became a major issue in the 1998 election. What did we learn politically from this experience that would lead this round of payment reform to end differently (Toner 2001; Gray, Lowery, and Godwin 2007;)?
And what have we learned about the politics of past efforts to introduce cost-effectiveness principles in health policy that would help us think about the current Presidential initiative around cost-effectiveness research (Pear 2009)? The case study of Oregon's efforts in the late 1980s to use cost-effectiveness research in its priority decision making might provide important leanings. In particular, the Oregon Health Plan involved the creation of a list of services “deemed ineffective” by experts using a cost–benefit perspective. Two years later, commentators on the failure of that plan have concluded that this list became a “political albatross” and a major contributor to the Plan's ultimate failure (Fox and Leichter 1993).
Studying health policy decision making from a political perspective would also encourage researchers to consider the political lessons of related fields. For example, the field of public education has more than two decades of experience with pay for performance. After all these years, it turns out most school districts have not chosen to adopt this reform on a widespread basis. Why? Are teachers less malleable than practicing physicians? Are there lessons to be learned from the public schools' experiences that might guide health policy researchers in their own “pay for performance” studies (Johnston 2000; Olson 2007;)?
In summary, in order to impact health care policy more effectively, researchers need to better understand the politics of health policy decision making. Knowledge of political forces, including voters, interest groups, Congressional committees, and the media, can help researchers select topics with the potential for policy leverage and present scientifically valid findings that are also relevant to key decision makers. The field of health services research can facilitate such understanding if it moves away from the idea that research results translate directly to policy without political considerations—a legacy of the field's early focus on biomedical research models. Instead, health services research may benefit from looking to its sister field in educational policy and making the same commitment to research about the politics of decision making. In order to do this, critical institutions in the field of health services research will need to prioritize this area of study, and researchers themselves will need to recognize more consistently that the study of the politics of decision making is a useful area of inquiry with the potential to improve the effectiveness of health care policy research. In such an environment, health services researchers could better take advantage of lessons like those described in Gold's piece and more likely influence health policy decisions to improve health care.