We do need to understand the peculiarities of the U.S. health and public health systems in order to fix them. There are already two agencies in the federal government that sponsor research on public health and on health services: the Centers for Disease Control and Prevention (CDC) and AHRQ, respectively. CDC is the nation’s foremost “public health” agency, with a critical research mission. For issues that involve risk communication, interfacing with state health departments, or studying contagion and public health interventions, CDC is the “go-to” agency rather than NIH.
Expertise in organization, financing, and delivery of health care is shared among the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare and Medicaid Services (CMS), and other agencies. CMS programs alone spent $887 billion in 2009 (7
). The Veterans Health Administration (VA), military health system, and Indian Health Service all operate entire health care systems for defined populations. The federal government also pays for health care of military families and federal employees, and funds health services through the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration. The federal government thus spends over a trillion dollars a year on health services and is the biggest payer and purveyor of health care in the world. If the goal is to change health outcomes, then doing research that enables federal health agencies to make better decisions is a great place to start. Among them, AHRQ alone has health services research as its core.
AHRQ conducts and supports health services research and patient-oriented research for the U.S. Department of Health and Human Services. Its mission is “to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.” AHRQ originated in 1989 as the Agency for Health Care Policy and Research (AHCPR). AHCPR nearly died 6 years later. The House and Senate Budget Committees zeroed out its allocation, and Rep. Sam Johnson of Texas introduced a floor amendment to kill its appropriation. AHCPR politics were already complex (8
), but its troubles were fomented by an angry constituency: displeased back surgeons objecting to an AHCPR clinical practice guideline (9
Federal funding for health services research was rescued by a shift of mission, a change of name that removed “policy,” and a systematic effort to rebuild a bipartisan coalition to support it (8
). AHRQ stepped back from developing clinical practice guidelines, instead gathering the evidence that others organizations could use to develop guidelines. AHCPR morphed into AHRQ (see the figure), which emerged from the fray with a 21% budget cut.
AHCPR’s brush with oblivion makes plain the dangers confronting an agency whose research is relevant to health care policy. The experience led to a consensus on “production and synthesis of evidence as well as strategies to assure its use” (11
) while avoiding recommendations for practice or policy. It also led health services researcher Jack Wennberg to argue that health services research should be based at NIH, because it had “the stature required to protect science against rogue critics” (12
In 2008, AHRQ spent roughly $335 million for health services research, compared with $523 million from the private Robert Wood Johnson Foundation and NIH’s $1 billion (13
). The Coalition for Health Services Research estimated federal expenditures for health services research at $1.9 billion in 2011, corresponding to 4% of the overall health research budget, 0.19% of what the federal government spends on health services, and just 0.07% of national health expenditures (7
A bipartisan committee assembled by AcademyHealth in 2005 explicitly rejected the option that NIH take charge of research on the health-care system (16
). It noted that only AHRQ had health services research as its central mission. Moving health services research into an NIH institute would lead to budget battles within NIH in which health services research would be the weak sibling.
Federal health services agencies need to be major users of such research. Coordination will be a huge task, but it pales in comparison with reaching the other users in the highly decentralized U.S. health system: private payers, state Medicaid programs, hospitals, clinics, and a myriad of city and county health and public health programs.