I’ve long been concerned about implementing public health policy without really studying it. Sometimes, it’s because I worry the policy won’t work. Sometimes, it’s because I think the policy will cost a lot of money, and it won’t be worth the results. And – sometimes – it’s because I worry that the policy might backfire. A good example of this last concern was illustrated in a recent study in the American Journal of Public Health. “The Unintended Consequences of Changes in Beverage Options and the Removal of Bottled Water on a University Campus“:

Objectives. We investigated how the removal of bottled water along with a minimum healthy beverage requirement affected the purchasing behavior, healthiness of beverage choices, and consumption of calories and added sugars of university campus consumers.

Methods. With shipment data as a proxy, we estimated bottled beverage consumption over 3 consecutive semesters: baseline (spring 2012), when a 30% healthy beverage ratio was enacted (fall 2012), and when bottled water was removed (spring 2013) at the University of Vermont. We assessed changes in number and type of beverages and per capita calories, total sugars, and added sugars shipped.

As the article states, American use about 50 billion plastic bottles each year, almost 80% of which end up in landfills. There are environmental consequences to this fact. Plastic bottles, especially those intended for single-use, don’t degrade easily, consume a lot of resources, and take up a lot of waste disposal resources.

In response to this, many colleges and universities have banned the sale of bottled water. On its face value, this seems like a reasonable response if your goal is to reduce the amount of plastic waste your campus is producing. But there’s a catch. One of the reasons that bottled water was becoming more popular was because people were turning to water as a beverage choice instead of drinks with calories, like soda, juice, or milk. That was also a good thing, as beverages with sugar are thought to be one of the causes of the obesity epidemic.

This study was an attempt to see how a ban on bottled water might affect people’s choice of beverages in general. Researchers looked at shipments of beverages to the University of Vermont before, during, and after the ban went into effect. The outcomes of interest were number and types of beverages consumed, the number of calories per person consumed, and total and added sugars shipped.

After the ban, the number of bottled beverages shopped overall went up. Concerningly, though, so did the number of calories (3249 to 3958 kcal), total sugars (714 to 864 g), and added sugars (528 to 638 g). The overall nutritional value of beverages shipped went down significantly. Here’s the chart you need to see:


Yes, the percent of sugar-free beverages increased. But so did the percent of sugar-sweetened beverages. It appears that people want portable beverages that they can drink. If they can get bottled water, they will drink that. But if they can’t, they will choose other beverages rather than start to bring their own water. That may be good for the environment, but it’s not clear that’s good for health.

So was this policy bad? I don’t know the answer. It’s possible that the environmental gains of banning bottled water outweigh the harms of drinking more sugar-sweetened beverages. But I’m not sure. What I do know is that many, if not most of the discussions I see about colleges taking action like this focus only on the potential harms of plastic, though. I see too few thinking about the unintended consequences for health. A balanced discussion would consider both. Without research, that discussion can’t take place. We need both when we consider and implement policy.



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A recent study by Amelia Haviland and colleagues found that consumer-directed health plans (CDHPs) offered by employers are associated with reductions in health care spending over three years. CDHPs are high deductible plans coupled with tax-advantaged personal medical spending accounts.

The study, published as an NBER working paper, examined changes in health spending for individuals at firms that began offering CDHPs, compared to those at firms that didn’t offer CDHPs. It’s an intent-to-treat design, as it considers individuals in the “treatment” group if they worked at a CDHP-offering firm, whether they enrolled in one or not. (The study also employed a second analysis using an instrumental variables design that I’m not covering in this post.)

The design eliminates selection bias at the individual level that could arise, for example, from healthier individuals opting into CDHPs. The authors also argue that it reduces firm-level selection bias because “offering a CDHP alongside other plans is a moderate step relative to full replacement with a CDHP.” That is, perhaps firms that institute a full switch to a CDHP are systematically different from firms that do not. Arguably, firms that offer CDHPs alongside other plans are more similar to firms that do not offer one at all.

The data are from 54 large U.S. employers, span 2003-2007, and include about five million and eight million person-years of data from CDHP-offering and non-offering firms, respectively.

The investigators found that firms that offered CDHPs experienced 6.6%, 4.3%, and 3.4% lower annual spending in the first three years after offer, respectively, and relative to non-offering firms.* The spending reductions were concentrated in outpatient care and prescription drugs, not inpatient care or the ED.

Relative to non-offering firms, annualized spending growth on pharmaceuticals is 5 to 9.5 percentage points lower in the three years after firms offer CDHPs (p < 0.01) and spending growth on outpatient care is 3.0 to 6.8 percentage points lower in the first three years though the estimate loses statistical significance in the third year (p < 0.05 in first two years). In contrast, for inpatient cost growth, we have only marginally statistically significant evidence of lower spending relative to non-offering firms in the first two years of CDHP offer (p < 0.10) while the third year estimate is non-significant and very close to zero. Finally, we do not detect any differences in cost growth for emergency department (ED) care in any of the first three years of CDHP offer although, due to high variance in ED spending, estimates are imprecise.

The findings are consistent with some prior work, including that of Paul Fronstin, Christopher Roebuck, and Martín Sepúlveda. They examined one, large, midwestern manufacturer that fully replaced its PPO with a CDHP. Like the Haviland study, this one also found sustained reductions in health care spending concentrated in outpatient care and prescription drugs. Also like the Haviland et al. study, Fronstin and Roebuck found lower savings over time.

One can speculate why CDHP savings might erode over time. My own hypothesis is that perhaps early on, CDHP enrollees try relatively hard to forgo care, saving their money under the deductible for only things that seem urgent. This may also have the effect of putting off some care they needed, to the extent that people can’t easily distinguish between necessary and unnecessary care. In turn, perhaps in subsequent years there was a relief of this self-imposed, if accidental, pent-up demand.

Because the study focused on workers for large employers, findings may not generalize to other insurance markets (like individual market exchange plans) or other populations (like non-working, Medicaid enrollees).

* When restricting to firms in the sample for all three years, savings also decrease over time, but the differences are not statistically significant. Thus, we can’t completely rule out the possibility that compositional changes explain reduced savings over time.

Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs and an associate professor at Boston University’s School of Medicine and School of Public Health. He blogs about health economics and policy at The Incidental Economist and tweets at @afrakt. The views expressed in this post are that of the author and do not necessarily reflect the position of the Department of Veterans Affairs or Boston University.



I have written many times, here and elsewhere, about malpractice in the United States. Recently, I wrote over at The Upshot about how a significant body of evidence points to the fact that if doctors were likely better at communication, their risk of being sued would go down.

A recent study published at JAMA Internal Medicine makes the case that we aren’t headed in that direction soon, though. It looks at nondisclosure agreements, specifically in a large academic health care system, something I hadn’t considered before:

Importance  Honesty and transparency are essential aspects of health care, including in physicians’ and hospitals’ responses to medical error. Biases and habits associated with medical malpractice litigation, however, may work at cross-purposes with compassion in clinical care and with efforts to improve patient safety.

Objective  To determine the frequency of nondisclosure agreements in medical malpractice settlements and the extent to which the restrictions in these agreements seem incompatible with good patient care.

Design, Setting, and Participants  We performed a retrospective review of medical malpractice claim files, including settlement agreements, for claims closed before (fiscal year 2001-2002), during (fiscal year 2006-2007), and after (fiscal years 2009-2012) the implementation of tort reform in Texas. We studied The University of Texas System, which self-insures malpractice claims that involve 6000 physicians at 6 medical campuses in 5 cities.

Main Outcomes and Measures  Nondisclosure provisions in medical malpractice settlements.

Transparency and good communication aren’t just good for avoiding malpractice suits; they’re also good for patient care. However, when settling a malpractice case, an institution might seek a nondisclosure agreement from a patient. This would prevent anyone from discussing the details of the case. For the purposes of this study, researchers looked at malpractice cases, including settlement agreements, that took in the University of Texas health system in three time periods: 2001-2, 2006-7, and 2009-12. These three periods are important, because they occurred before, during, and after Texas implemented pretty comprehensive tort reform.

What they found is interesting. Over the study period, there were a total of 715 closed malpractice claims and 150 settlement payments. Some of those 150 were excluded because they involved only defendants not from The University of Texas making payments, and some because they involved only minor dental injuries.

Of the 124 analyzed, the median payment was $100,000, with a range of $500 to $1.25 million. The average payment was just over $185,000.

The vast majority of these (89%) involved nondisclosure provisions. All of them prevented anyone from disclosing the settlement terms or the amount of any payments. More than half (56%) prohibited disclosing a settlement had been reached at all, 46% prevented discussion of the facts of the claim. More than a quarter prevented involved parties from reporting anything to regulatory agencies, and 9% not only prevented any disclosures from the claimants, they also prevented disclosures from physicians or hospitals.

The disclosure agreements that were signed in the last period, after tort reform, had stricter provisions than those signed before. They were more likely to prevent disclosure of the settlement event, the facts of the case, or the reporting to regulatory bodies.

There are legitimate reasons that the system might want to keep claimants from discussing the terms of cases. Settling is sometimes a financial decision (ie when it’s cheaper to settle than to fight a claim in court). When that is the case, discussing settling could look like an admission of guilt when it’s really not. Some people also worry that if the terms (and sometimes large dollar values) of settlements got out, it could spur others to take a chance and see if they could get some money out of the malpractice system.

But part of the reason malpractice cases are important is to identify areas where errors occurred, and then to make sure that they don’t occur again. Nondisclosure agreements run against that purpose by preventing open dialogue about what happened, and how we can prevent it from happening again. It’s also telling that after tort reform, when there would have been less of an incentive to sue, restrictions became stricter.

It’s especially concerning that some of the settlements prevented any disclosures to regulatory bodies. It’s unclear if this is even legal in many states, and to the system’s credit, the paper reports that the health system stopped doing this when the findings of this analysis were brought to light. It makes you wonder how many other systems might still be doing this, though.

Our health care system will become better and safer through honesty, transparency, and a commitment to improvement. It’s unclear how nondisclosure agreements help that at all.



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AcademyHealth prides itself on being a non-partisan resource for congressional staff, members of Congress, and other federal, state, and local policymakers who wish to connect with some of the best and brightest health policy researchers when implementing evidence-based policy. Thanks to our members’ deep and broad expertise, we are able to serve as a one-stop-shop and trusted knowledge broker for those working across all areas of health policy and research.

On June 17, the U.S. House of Representatives passed the bipartisan “Strengthening Medicare Advantage through Innovation and Transparency for Seniors Act of 2015” (H.R. 2570), and AcademyHealth had a role in linking some of our member experts to the policymakers behind the initial legislation.

The legislation, originally introduced as the VBID for Better Care Act by Reps. Diane Black (R-TN) and Earl Blumenauer (D-OR), establishes a demonstration project in which eligible Medicare Advantage plans would implement value-based insurance design (VBID). As described by the University of Michigan, VBID “aligns patients’ out-of-pocket costs, such as copayments, with the value–not the cost–of health care services” by reducing cost-sharing for high-value health care. Over the years, VBID has gained increasing attention from employers, insurers, and policy experts as a tool to improve health care quality while lowering financial barriers to essential medications and care.

Prior to the bill’s release among congressional offices, AcademyHealth was contacted by a staffer in Rep. Black’s office, who in consultation with Rep. Blumenauer and his staff, was drafting the legislation. Dr. Lisa Simpson, president and CEO of AcademyHealth, acted as a convener [click to continue…]


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As the House and Senate Appropriations Committees’ fiscal year 2016 spending bills have shown us over the past few weeks, now more than ever before, our field must unite and convey to policymakers that it is stronger than ever. For this reason, it is imperative that passionate, compelling leaders representing the many critical perspectives encompassed within health services research stand at the forefront in this time of uncertainty for federal funding for health services research.

Over the next few months, AcademyHealth members will have an opportunity to elect three new members to its Board of Directors through an online election. The Board of Directors plays in important role in helping AcademyHealth meet the needs of its members and keeping the community informed of the latest trends and opportunities. Its designated responsibilities include helping to set the organization’s direction, overseeing its activities, and ensuring the necessary resources for the organization’s success as well as other fiduciary responsibilities.

However, being a member of the AcademyHealth Board of Directors provides value far beyond shaping AcademyHealth; the Board of Directors promotes the advancement of health services research and the students and professionals who produce and use this important work. But don’t take our word for it. As current board member Don Goldman, Ph.D., describes, the AcademyHealth Board’s work revolves—and does its best work—around AcademyHealth’s membership:

“You may be thinking that boards are boring. Perhaps you think that the AcademyHealth Board is just another administrative body that oversees the work of the organization, guides its strategy, and insures its financial viability. Boring. In reality, the AcademyHealth Board is a vibrant, collegial, diverse community of individuals who are dedicated to growing the field of health services research. Most importantly, we all work hard to understand the needs and careers of our members and advocate on their behalf. Our richest conversations occur when we examine health services research–current and future–through your eyes.”

Building on Dr. Goldman’s points, Robin Newhouse, Ph.D., R.N., underscores the Board’s important role in supporting the field health services research, thus enhancing the performance of the health care system:

“Improving health and the performance of health systems has never been more important- which is why health services research is so critical. As a Board member, my role is to focus on the strategic direction of AcademyHealth to foster science that informs policy, resources that support members’ professional development and networking, and advocacy for the field. Take a few minutes today to vote for your selected candidates for the AcademyHealth Board.”

AcademyHealth’s Board members are critical to the organization’s success, and as with any election, they should be representative of you, our members. We encourage you to take Dr. Newhouse’s advice and vote.

This year’s online-only election runs thru September 30, 2015. AcademyHealth individual members, active as of June 1, 2015, are eligible to vote and all votes are confidential. All AcademyHealth members who vote in the Board election will be entered into a drawing to win a complimentary registration to the National Health Policy Conference (February 2016) or Annual Research Meeting (June 2016), winner’s choice. For more information about candidates, current Board members, and voting instructions please visit the AcademyHealth website.


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You get hit with a major health condition and your health care needs and spending spikes. A lot. Welcome to the 10% club, whose members spend at least $30,000 on health care in a year. Yeah, most of it is covered by insurance, but selecting the plan with the $2,500 deductible you blew through (not to mention the thousands more in copayments) looks like a bad idea in hindsight.

It could be worse. It could happen to you next year, and the year after, and the year after that, and so on. Will it?

This is a question of health spending persistence. And, as surprising as it may sound, we don’t know a lot about it, at least for the working age population. The basic problem is that researchers rarely have access to many years of health care spending data for the same set of individuals. Those data are proprietary. Some are available, but expensive to purchase.

So, most of what we know about health care spending persistence is from Medicare—clearly not representative of the working age population.

A study by Alan Garber and colleagues examined Medicare beneficiaries in the top 5% of the spending distribution in a single year. They found that 15% remained in this high cost group one year later, and 9% did so two years later. Their analysis is now quite dated, extending only through 1995. A somewhat more recent analysis by Gerald Riley found greater persistence; among top 5% spending Medicare beneficiaries in 2001, 24% were in that group one year later, 16% two years later, and 12% three years later.

Most work focused on the working age population is only able to track people for two years. For example, an analysis using the Medical Expenditure Panel Survey by Steven Cohen found that 34% of high-cost individuals in 2009 were so in 2010. But another study, by Pauly and Zeng, examined a longer time period. From a sample of insured workers and adult dependents, it found that almost half of those in the top quintile of health care spending in 1994 were in the top quintile four years later. Again, these findings are now quite dated.

Richard Hirth and colleagues recently were able to take an analysis of persistence for workers and their dependents a lot further, and using recent data. They looked at six years of health spending data (2003-2008) for a sample of millions of individuals with coverage from over 100 medium and large employers. One of their findings is that at least one in every three high spenders in a given year will be a high spender in any of the next five years. (Here, high spender is defined as in the top 10% of the annual spending distribution.) I don’t know what your prior is, but this is a much higher level of persistence than I expected. Their chart below has the details.


What does this mean in dollar terms? The following chart from the paper gives you a sense. In it “high” spending is that in the top 10% and “low” spending is that in the bottom 70% of per-person annual expenditures. With that, “usually low” means low spending in at least four of six years and no years with high spending; “low/moderate” means low spending in three or fewer years out of six and no years with high spending; “sometimes high” means one or two years out of six with high spending; “often high” means three or four years out of six of high spending; and “usually high” means five or six years of high spending.

persist amount

Eyeballing the chart, those in the “usually high” group had average annual expenses around $30,000. That’s well above typical deductible levels for employer-sponsored plans (usually below $2,000) or Affordable Care Act plans (whose silver rated plans usually have deductibles in the $1500-$4000 range, for example). Even people in the “often high” and the “sometimes high” and probably many of those in the “low/moderate” groups would max out their deductibles too.

So, if you’re unlucky enough to get hit with a very costly health condition, consider yourself relatively lucky if it’s not highly persistent. The new work by Hirth and colleagues shows that such persistence is surprisingly common and remarkably long. This is how sickness saps savings, for those with coverage that comes with high enough deductibles and copayments. Today, we call that “insurance.” Is it?

Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs and an associate professor at Boston University’s School of Medicine and School of Public Health. He blogs about health economics and policy at The Incidental Economist and tweets at @afrakt. The views expressed in this post are that of the author and do not necessarily reflect the position of the Department of Veterans Affairs or Boston University.


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For those of us that live and breathe health services research, the past two weeks of House and Senate appropriations committee markups give us a sense of déjà vu, frustration, and cause for reflection. The Agency for Healthcare Research and Quality (AHRQ) was once again placed on the chopping block in the fiscal year (FY) 2016 spending bill for the House of Representatives Labor, Health and Human Services, Education and Related Agencies Subcommittee, and the agency’s budget was slashed by 35 percent in the Senate Subcommittee’s bill.

We’ve heard this song before. In 1994, AHRQ (then the Agency for Health Care Policy and Research) suffered a near-death experience in retaliation to unpopular evidence. More recently, the agency was also proposed for ‘termination’ in the House’s FY 2013 spending bill that, though released, was never considered by the subcommittee. We understand that subsequent House spending bills that weren’t made public in FY 2014 and 2015 also included the same language we see today.

We know AHRQ’s work is important–critical, in fact, when we consider the challenges facing health care. We witness preventable medical errors and unnecessary care that waste valuable resources (dollars and labor); observe the sciences being pitted against other sciences; see medical discoveries and effective advances that languish on paper or in laboratories never to reach patients or improve their health, withering away while others rediscover their findings; and continue to debate the best way to pay for care so that quality and value are enhanced.

The challenges are infinite. So why, at a time when we need to understand our health system most, is Congress proposing the abolishment of an agency that, at its core, is tasked with helping us address many of these challenges? Challenges that by policymakers’ own admission, are top of mind?

Why, 20 years later, are we still struggling to defend the flagship agency for the field of health services research–the research that tells us what works, for whom, under what circumstances, and at what cost? [click to continue…]


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I have to begin any discussion about how much doctors make with a full disclosure – I’m a physician. I, like all of you, enjoy making more money than less money, so take all of what I say in that context. However, it is possible to have data-driven conversations about how much people who work in health make versus other sectors, and what that might mean for health care spending.

In a recent piece in Health Affairs, Sherry Glied, Stephanie Ma, and Ivanna Pearlstein did just that. In “Understanding Pay Differentials Among Health Professionals, Nonprofessionals, And Their Counterparts In Other Sectors” the authors state:

About half of the $2.1 trillion of US health services spending constitutes compensation to employees. We examined how the wages paid to health-sector employees compared to those paid to workers with similar qualifications in other sectors.

Every time I write about health care spending, I like to remind people that one person’s waste is another person’s income. Money that isn’t spent on health care isn’t put into a big pile and burned. It’s put into other people’s pocket. Even the first line of the abstract here is instructive. More than one trillion dollars a year is spent on employee compensation for health care. That’s more an 8% of GDP alone. We spend a lot of money employing people in the health care sector.

The researchers used data from the March Current Population Surveys from 1979 through 2013, and controlled for many other factors that could be associated with income. If you’re interested in the full methods, I encourage you to go read the paper, as it’s well written. I want to focus on the results here.

Workers in health care are more educated in general than those in other sectors. Non-professional health care workers average between 0.3 and 0.6 years more in schooling that non-health-sector employees. Professional health care employees, like nurses and physicians average from more than 1 to almost 6 more years of schooling.

After controlling for other factors, workers in health care make about 3% more than those of comparable workers in non-health care sectors. That’s more, but not as much as many might think. The spread is not even though. Those in the bottom quartile of health care employees make about the same as non-health care employees, while those in the top quartile make about 4.7% more than their non-health care counterparts.

Health care professionals, on the other hand, make quite a bit more. Nurses make about 40% more than would be predicted by education, experience, and demographics. Physicians earn almost 50% more than would be predicted. The spreads are different, though. Nurses at the lower end of the pay spectrum earn more than their counterparts in the non-health care world, compared to those at the higher end of  the pay scale. For doctors, the opposite it true; there’s more of a difference at the higher end of the spectrum.

Contrary to what many might think, having a job in the health care sector does not lead to larger salaries, on average, compared to working in other areas. Nonprofessionals in health care earn very similar amounts to those outside of health care. Those employed in nursing homes earn less than you would expect, even. The exception is professionals, including nurses and physicians. But such professionals comprise a minority of the health care workforce, making it unlikely that high salaries, in general, can be blamed for outsized health care spending. Physicians compensation is less than 10% of all health care spending, and nurses account for less than 7%. As this paper reports, if tomorrow somehow policy makers were able to strip all extra pay for health care professionals above what you’d expect they’d make in other sectors, overall health care spending would be reduced by only 6%. Further, given that the pay differentials haven’t been increasing over recent time, doing so would do nothing to bend the curve in the future.

The conclusion of the paper is as follows:

These results suggest that efforts to reduce the rate of growth in prices paid for health care services cannot be accommodated primarily through reductions in the pay of health-sector employees. Instead, such efforts will likely require providers to improve their productivity, producing the same services with fewer, or less costly, labor inputs.

I think that makes a lot of sense. I look forward to hearing what you think, in comments or on Twitter.



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The following is a statement from Dr. Lisa Simpson, president and CEO of AcademyHealth: 

Yesterday, the Senate Appropriations Committee passed its Labor, Health and Human Services, Education, and Related Agencies appropriations legislation. Starting with a spending level of $3.6 billion below current levels, there were bound to be painful cuts. Indeed, the Agency for Healthcare Research and Quality (AHRQ) is cut by 35 percent–a deep cut as the result of the woefully inadequate levels of available discretionary spending.

The bill isn’t without its winners, at least some of which come at AHRQ’s expense. The National Institutes of Health (NIH), for example, receives a much needed $2 billion increase. As the Subcommittee Chairman Roy Blunt highlighted in a recent op-ed in The Hill, “Now is the time to prioritize biomedical research to increase critical life-saving medical treatments and high-quality cures available to all Americans.”

Like health services research, biomedical research is a critical function of the federal government. There’s no denying that investments in NIH help discover cures for patients and strengthen the economy. The Chairman notes, “NIH-funded biomedical research is the catalyst behind many of the advances that are now helping Americans live longer and healthier lives.” But, if biomedical research is the “catalyst,” AHRQ’s health services research is the fuel to keep the fire burning. Without evidence about how to optimally deliver cures to patients, or how to make the best use of the cures already available on the market, NIH’s medical discoveries will fall short of their promise to patients. These two agencies have important, complementary, and mutually beneficial functions.

AHRQ’s unique role in collecting data and funding health services research on the performance of the health care system helps doctors and health systems develop and test innovations on how to deliver high quality care in less costly and more effective ways. Our nation spends $3 trillion annually on health care–the largest share of which are federal purchases through Medicare, Medicaid, the Federal Employees Health Benefits Plan, insurance exchanges, TRICARE, and veterans’ health care. Health services research tells us as much as 30 percent of this spending is wasted on inappropriate, unnecessary, and sometimes even harmful care. Already, our nation spends less than one-tenth of one cent on health services research to determine how to do better: to deliver the best possible care, at the greatest value, with the best outcomes. Under the Senate’s spending bill, we’d spend even less. With health care spending continuing to rise, can our nation really afford the short-term gains as a result of AHRQ cuts?

Chairman Blunt asserts, “This is a time of promise in medical research and the United States should be at the forefront of this era. To do so, we must commit to paying for the research to do it.” AcademyHealth and the community we represent couldn’t agree more. But our nation needs to invest in the full continuum of health research–basic, clinical, prevention, health services, and translational research–to get the best return on NIH investments. AHRQ is a critical pillar of America’s health research enterprise, and worthy of fully restored funding in fiscal year 2016.


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In its landmark 50th anniversary, the Social Security Act legislation that contains Medicare and Medicaid has undoubtedly been a force to be reckoned with throughout the course of health care’s history. This legislation–the 97th bill introduced in Congress that year, passed in six months, and signed by President Johnson–has been an issue of debate and a source of much contention over its fifty years, but panelists sitting on both the Medicare and Medicaid 50th Anniversary special sessions noted how the programs’ longevity is astounding.

50th Anniversary of Medicaid

During this panel, some of Medicaid’s leading policy thinkers and researchers discussed the program’s evolution since the law’s passage in 1965: its history, what we know from research, where there are opportunities and challenges moving forward, and the political dynamics involved. Sara Rosenbaum kicked off the session with a reminder:

“While Medicaid has been a vital source of health insurance, growing more so every year, and has been the basis of tremendous health services research into the health care needs of poor and disadvantaged populations and how well financing meets those needs, Medicaid is also a law. And Medicaid as a law has had a remarkable life in the law, which is something that is overlooked in the program’s history.”

Much of the story of Medicaid policy over the past half century is the story of the courts—an aspect “absolutely central to understanding it.” Through the courts and congressional action, Medicaid has experienced many evolutions, and yet, despite those changes, its basic structure and foundation remains intact; it’s a partnership between the federal government and the states that has endured for 50 years and is a fascinating case study for those interested in health policy history.

Reaching an apex in NFIB v. Sebelius, Medicaid has been the battleground on which the fraught question of federalism has played itself out. Over time, the program has evolved to meet changing population needs. Among its adaptations have been meeting children’s needs beyond health insurance through the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program; adding the disabled, elderly, and blind populations to the program; and severing ties between it and welfare.

From a state lens, Medicaid’s history and its opportunities and concerns have transcended politics. As Trish Riley, National Academy for State Health Policy, said, “It would be a mistake to base too many conclusions based on the party in control” because the cost and growth of the program is a concern for all, and that concern increases all the time. Interestingly, she noted, while states are concerned about cost, 60 percent of those incurred costs have been optional; states chose it.

Yet, as all panelists noted in some capacity, Medicaid is wrought with difficulties. With the growth in the program and the variation in populations served, there is enormous complexity. Furthermore, as Benjamin Sommers, Harvard School of Public Health, described, managing and improving upon Medicaid becomes increasingly challenging. Some people don’t realize they have Medicaid, what it entails, or when their coverage has lapsed–factors that will only become more complicated under the Affordable Care Act. There is also the added complexity of multiple types of care delivery, in other words, ’50 states, 50 Medicaid programs.’ As a result, Medicaid is difficult for researchers to study.

The areas where researchers have studied, Genevieve Kennedy said, reveal that no matter where Medicaid is expanded, no matter the implementing state and its enthusiasm or lack thereof, public health insurance responded and there was lower uninsurance among the target population. Beyond coverage, researchers are consistently finding an increased likelihood of having a usual source of care and receiving a broad range of preventive and other health services. There is also evidence that Medicaid improves self-reported mental and physical health and depression screening.

Moving forward, there is much space for health services researchers, who can help answer questions about things such as program trade-off, i.e., “Medicaid compared to what?” In a world contemplating different ways to provide coverage, it is difficult to know what to make of the literature on quality and the other alternatives available. Medicaid continues to grow despite being under attack, and those accounting for the difference between rhetoric and reality, are health services researchers.

50th Anniversary of Medicare

“The objective of this session is not to celebrate the triumphs of the past,” said Robert Reischauer setting the stage for the panel, “…but rather the purpose of this session is to reflect on and discuss the roles that HSR has had on the evolution of Medicare.”

Don Berwick did this by citing evidence on variation in practice as the most important aspect of health services research to inform Medicare policy. Using data from geographic variations to craft legislation that works for diverse states continues to be vitally important. He also outlined a “wish list” of topics for health services researchers to focus on over the next three decades:

  • Research on how to train physicians to change the delivery system;
  • Transition models and financial plans;
  • Data on scale and change in delivery systems;
  • How to change the demand of consumers;
  • The study of waste and its forms;
  • New roles, workforce distribution; and
  • Telemedicine and telehealth.

Karen Davis spoke to the history of the program: how health services research shaped Medicare and how Medicare has impacted health services research. “Medicare has shaped the health services research community by developing the databases for claims data…it provided a wealth of information that let us understand what was going on with the health system as a whole,” she said. She also cited the desegregation of hospitals as a way in which Medicare impacted health services research. Due to Medicare’s provision to receive hospital funding, hospitals had to be in compliance with the Civil Rights Act. Health services research documented the increased use of hospital services of elderly African Americans. She concluded that research has helped shape and make Medicare an innovator in coverage design and payment/delivery system.

Jon Christianson discussed the impact of health services research on private markets and competition on Medicare and focused on managed care programs. The opportunity for future research in these sectors, he outlined, include payment options and how risk is handled and noted the importance of private sector research on influencing Medicare. He ended by speaking to the current challenge of consolidation on the provider side and called for health services researchers to help address it.

David Durenberger concluded by addressing the ongoing need for health services research to inform policy and help lawmakers make decisions on health care reform legislation. Highlighting Medicare’s impact on HSR, he cited Medicare as a rich source of comparative data for health services researchers. He stressed the importance for health services researchers to stay the course and continue to keep lawmakers focused on the goal of health care reform by using evidence and data.

Each of these panels at the 2015 Annual Research Meeting succeeded in providing a panoramic view of the two programs, considering the past and future of Medicaid and Medicare and thinking long-term about their futures in an era of health reform.


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