Studying Health Programs to Close the Gaps

    • May 2, 2013

Sometimes it takes a personal tragedy to drive an important policy point home—as political scientist Andrea Campbell, PhD, knows all too well. In June 2012, when the U.S. Supreme Court issued its decision upholding the Affordable Care Act, Justice Ruth Bader Ginsberg cited a New York Times op-ed that Campbell wrote about the plight of her brother and his wife. A car accident earlier that year had left Campbell's sister-in-law, who was seven months pregnant, paralyzed from the chest down. Thankfully, the baby survived. Two months later, however, the mother's state-funded temporary health insurance ran out.

At that point, Campbell wrote, the family fell "through the welfare medicine rabbit hole." The small business that employed Campbell's brother didn't offer health insurance. The baby got coverage through California's version of the State Children's Health Insurance Program, and the mother's new disability qualified her for the state's version of Medicaid. But cost-sharing requirements will keep the family at an income level close to the federal poverty line, and asset limitations prevent them from owning a second car, saving for retirement or college, establishing an emergency fund, receiving or bestowing an inheritance, and accepting financial help from relatives.

"These are the limitations under which 7.5 million Medicaid recipients in California... and more than 50 million people nationally" live, Campbell explains in the article. To obtain coverage through these programs, "you not only have to be poor but stay poor."

Today, Campbell is writing a book about her relatives' predicament to illustrate how difficult it is to negotiate the insurance and health care systems and how means-tested programs can affect participants' lives well beyond the delivery of health services. But Campbell, who teaches political science at Massachusetts Institute of Technology, was an expert on these matters long before her sister-in-law's accident.

Launching a career. Campbell grew up in northern California with thoughts of becoming a research scientist, "maybe a microbiologist." As an undergraduate at Harvard, however, she found she enjoyed social science classes more than her science classes. "I've always been a data/factoid/statistics junkie, and social science allows you to find out the reasons behind the facts and figures you see in the media or government reports," she observes.

After graduating from Harvard, Campbell worked in management consulting and then in college admissions. While doing demographic research for the admissions office, she says, "I realized I had political questions about demographic changes in the United States. My application to grad school was about the political implications of three demographic shifts: increasing racial/ethnic heterogeneity, increasing suburbanization, and the aging of the population."

Campbell went back for a PhD in political science at the University of California at Berkeley, where she wrote her doctoral dissertation (and, later, her first book) on the role of Social Security and Medicare in creating a constituency of politically active senior citizens. After getting her doctorate in 2000, Campbell received a fellowship from the Robert Wood Johnson Foundation Scholars in Health Policy Research program, spending from 2001 to 2003 as a Scholar at Yale University. The program provides newly minted PhDs in economics, political science, and sociology with two-year fellowships to bring their disciplines into the field of health policy research. The program is based on the belief that engaging talented young people from these disciplines in debate about health policy will result in better health policy, and ultimately in better health. See Program Results Report for more information about Scholars in Health Policy Research.

Campbell's work in the program. Campbell, the daughter of a registered nurse who worked in gerontology, has been interested in health policy for senior citizens for most of her career. While at Yale, Campbell and fellow Scholar Kimberly Morgan, PhD, compared long-term care reform in the United States and Germany. In the United States, Medicaid requires older disabled individuals to pay out of pocket for nursing home stays or home health care until they exhaust their own resources. Meanwhile, Germany switched from a state-run, means-tested program to a national program in which all workers pay a payroll tax and those who become disabled receive an insurance benefit they can use for long-term care in whatever setting makes the most sense for them.

The U.S. approach "tends to shunt people into nursing homes rather than allowing them to stay at home," Campbell notes. It also is "a budget buster for states," which must pay for part of Medicaid.

Continuing her work with RWJF support. After their fellowships ended, Campbell and Morgan won a thee-year award from the Robert Wood Johnson Foundation Investigator Awards in Health Policy Research program to study the effects of the Medicare Modernization Act of 2003, which established a prescription drug program, on more than 1,000 senior citizens. That research led Campbell and Morgan in 2011 to publish their book, The Delegated Welfare State: Medicare, Markets, and the Governance of Social Policy, which explores how this country provides social programs mainly through private entities and tax breaks rather than through direct-spending programs. For instance, rather than adding prescription drug benefits to Medicare, the federal government delegated the responsibility to private insurers, who developed plans that senior citizens purchase independently—yet the federal government still subsidizes much of the cost of the drugs.

In 2012–13, Campbell received another fellowship, this time with the Radcliffe Institute for Advanced Study, where she is looking at variations in how states moved to close their budget gaps during and after the Great Recession. Since Medicaid is one of the largest line items and drivers of structural deficits in most states' budgets, Campbell notes, it is a major focus of her budget analysis. Although it is too early to report specific findings, her research indicates that Democrat-led state governments and Republican-led ones appear to make different health policy choices to address budget deficits.

Campbell has written extensively about her work, for both political science and health journals. Her article for Foreign Affairs entitled "America the Undertaxed" was the most viewed piece in the issue. Her articles have appeared in other journals including the Annual Review of Political Science, and the Journal of Health Politics, Policy and Law. She has also written two books and 12 book chapters.

What happens next? Campbell credits the broad training that she received in RWJF's Scholars program with helping her understand how the complex web of government and private efforts add up to a system of care and how many different aspects of health policy intersect. Looking forward, she sees the need to find a politically feasible solution to skyrocketing health care costs, especially one that ensures sufficient access, choice, and quality of care.

"The long-term challenge for the United States is whether this system is sustainable," Campbell says. "There has to be a tipping point, and we need to find the trigger for it, because we can't afford the status quo indefinitely."

RWJF perspective. The Robert Wood Johnson Foundation Scholars in Health Policy Research program is designed to foster a new generation of creative thinkers in health policy research within the disciplines of economics, political science, and sociology. The fellowship program, established in 1991, annually selects a total of nine recent PhD graduates from among those three disciplines to spend two years studying at one of three participating sites (currently Harvard University, University of California, Berkeley/San Francisco, and University of Michigan).

Participants learn about health and health policy, gain exposure to the perspectives of the other two disciplines through seminars with peers, receive mentoring from prominent scholars, develop research ideas, and conduct research while receiving a stipend and benefits that free them from other professional obligations. "We're looking for people who aren't too far along in pursuing a specific research agenda. Our goal is to catch people early and tempt them into the field of health policy," says Lori Melichar, PhD, RWJF director for the program.

While in the Scholars program, participants have conducted research on issues and policies related to individual health, public health, social and economic determinants of health and health care, health care financing, and health care systems and institutions. After completing the program, alumni stay connected to their peers through a network facilitated by the Boston University Health Policy Institute, which serves as the national program office.

Scholars from the Health Policy Research Program have made significant contributions to their disciplines and to the field of health policy research. The program's 200-plus alumni, many of whom hold faculty appointments at universities and colleges, have authored hundreds of widely cited books and articles; held editorial posts at top scholarly journals; sat on scientific advisory panels; served as senior advisers to presidential, Congressional, federal agency, and national scientific councils; and received numerous professional awards for their research.

Although the original purpose of the program—to increase the number of economists, sociologists, and political scientists conducting health policy research—remains important, RWJF's focus has expanded to include "building the community" of health policy researchers and supporting them at institutions nationwide. "Now it's more about creating a critical mass so that we have a self-sustaining community [of researchers]," Melichar says.