Facing What May Be the Affordable Care Act’s Ultimate Challenge: The Gap Separating Evidence from the Policy-Makers Who Need It

Mar 29, 2013, 9:00 AM, Posted by

David Grande, MD, MPA, is an assistant professor of medicine at the University of Pennsylvania's Perelman School of Medicine, a senior fellow at the Leonard Davis Institute of Health Economics, associate director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program and an alumnus of the RWJF Health & Society Scholars program. This is part of a series of essays, reprinted from the Leonard Davis Institute of Health Economics’ eMagazine, in which scholars who attended the recent AcademyHealth National Health Policy Conference reflect on the experience.


It’s a time of unprecedented upheaval in U.S. health care. Big changes are bursting through on virtually every front. Legislators and administrators in Washington and 50 state capitals struggle daily to reinvent their health care systems even as they lack an exact blueprint for the new things they’re supposed to be building.

This was nowhere more evident than at the recent AcademyHealth National Health Policy Conference, where state and federal officials and interest groups lined up to present long lists of policy questions that confront them as they grapple with implementation of the Affordable Care Act and mounting public budgetary pressures.

Managing 'Churn'

For instance, in the “Opportunities & Challenges for State Officials” session, New Mexico’s Medicaid Director Julie Weinberg described the unknowns surrounding how “churn” between private and public coverage will change and how new Medicaid eligibility standards will impact enrollment processes.

Patty Fontneau, the executive director of the Colorado Health Benefit Exchange (Colorado’s health insurance exchange), outlined the challenges involved in providing decision support to consumers to assist in the selection of a plan from many often-confusing choices. Staff members from key congressional offices described additional major policy challenges on the horizon such as how to replace the sustainable growth-rate formula and fee-for-service payment with a new physician payment system focused on producing value.

All Require Good Evidence

Something these many challenges have in common is that they are difficult to solve and all require good evidence to shape rational, effective policy.

Yet, throughout the conference venue, policy leaders seemed to lack the detailed evidence as well as a systematic way of locating and acquiring that relevant evidence from across a national research community.

When Lisa Simpson, president and CEO of AcademyHealth, asked top congressional staffers in the Congressional Plenary how researchers could better feed evidence into the Washington policy process, there were few specific or concrete answers.

I wasn’t surprised. In the past, when I’ve asked other elected officials or legislative staff how they get information, they say it usually comes down to a small network of personal relationships. The process of outreach is more often focused around building political consensus through stakeholder engagement than gathering scientific evidence. This strikes me as a very incomplete and imperfect way to shape policy, particularly considering our public investment in research.

Connecting Evidence and Policy

A central challenge to the research and health policy communities is how these worlds of evidence generation and policy formulation can become more interconnected. At a time when there is a push to invest further in health policy and health services research (see the National Institutes of Health, the Agency for Healthcare Research & Quality, the Patient-Centered Outcomes Research Institute), it is even more important to find ways to more closely link knowledge generation to policy decisions. The public investment in research will be a failure if we don’t figure out how to translate it.

In a recent review in Implementation Science, the authors found little published evidence to inform how to improve knowledge transfer to policy. The limited evidence that exists supports the anecdotal observation that informal relationships play a key role. Thus, getting evidence into the right hands might require a better understanding of the networks of influence that exist around legislative staff and building bridges with those networks. This is a profound challenge for researchers because academic culture does not embrace or reward the type of investment needed to build policy relationships.

A Poor Communications Method

Another major challenge for researchers is that the typical research product, a journal article, has become a poor method of communication. Finding new forms to communicate primary evidence should be a priority for academic institutions.

Researchers can’t do it alone. They need support with communication infrastructure and further professional development to be more effective communicators of their own work. Academic institutions might also play a role in providing professional education to legislators and staff. This would be consistent with the educational mission of academic institutions.

Politics gets in the way of the development of evidence-based health policy. But evidence-based health policy can’t be developed without evidence being brought to the table in the first place.

In an ideal world, the demand for evidence would be so high that investigators’ phones would always be ringing. But that is not reality. It is the academic institutions and individual researchers that will have to adapt to make knowledge transfer more effective.

Perhaps in many ways, academia is as much in need of reinvention as the national health care system itself.

Learn more about the RWJF Clinical Scholars program.
Learn more about the RWJF Health & Society Scholars program.

Reprinted from the Leonard Davis Institute of Health Economics' eMagazine.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.