Understanding Inequities in Health Care and Policies

    • May 2, 2013

A volunteer experience shapes a career. Like many young people interested in health care, Helen Levy, PhD, considered becoming a doctor. That inclination changed during Levy's college years, however, when she volunteered at a health clinic for low-income families. The stark contrast between the high-tech hospital that operated the clinic and the high-poverty neighborhood in which it was located touched her deeply.

"That juxtaposition triggered the thought that the problems I was interested in were not going to be solved by me being a doctor," Levy recalls. "I got interested in the allocation of resources in health care: Who gets what? How do we, as a society, make decisions about who gets access to resources? What system produces this inequality? And can policy do anything about it?"

Those fundamental questions continued to drive Levy over the ensuing decade. In 1993, two years after obtaining a BA in mathematics and history from Yale University, she worked as policy assistant to President Clinton's White House Task Force on Health Care Reform. Helping task force members estimate the cost of reforms reinforced Levy's interest in the economic side of health care policy, and soon she was pursuing her own PhD in economics at Princeton University.

From Scholar to academic. Levy received a fellowship from the Robert Wood Johnson Foundation Scholars in Health Policy Research program immediately after completing her economics PhD, spending two years as a Scholar at the University of California's campuses in Berkeley and San Francisco. The Scholars 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.

It wasn't Levy's first exposure to the Foundation; during graduate school at Princeton, she had worked as a research intern at RWJF, analyzing survey data to determine how employers set health care insurance policies for employees. But the Scholars program especially enhanced Levy's exposure to perspectives beyond the focus on labor economics she had found at Princeton.

The Scholars program "was the first place where I had to think a lot about other people's approaches to these questions," Levy says. "I have spent the rest of my career in interdisciplinary environments."

That career path took Levy first to a faculty position at the University of Chicago's Harris Graduate School of Public Policy Studies. Surrounded by colleagues who focused on poverty, she began to think about access to health insurance as a consequence and cause of poverty and the role that insurance can play in mitigating people's exposure to financial risk.

Levy moved from Chicago to the University of Michigan in 2004, first as a visiting scholar at the National Poverty Center and then as a faculty member of both the Institute for Social Research and the School of Public Health. A popular debate at the time was whether expanding low-income individuals' access to publicly subsidized health insurance increased health coverage or simply replaced the coverage previously provided by private insurers. With a grant from RWJF in 2008–09 (ID# 65093, under the Changes in Health Care Financing and Organization program), Levy and two colleagues studied the State Children's Health Insurance Program (CHIP) and found that, while the program did produce more switches from private to public insurance than instances of first-time coverage, it had beneficial results for parents who no longer had to pay for health insurance for their children.

"The resources people had available to them [because of CHIP] led to an increase in savings and ... consumption," Levy notes. "The policy implication was that just because [the program] gives public insurance to people who already had private insurance, it doesn't mean that it doesn't leave them better off. It wasn't wasted money. That [finding] restored some balance to the discussion."

Broad context and specific details. In 2010–2011, Levy served as a senior economist on President Barack Obama's Council of Economic Advisers. Congress had just passed the Affordable Care Act (ACA), and Levy's job was to review the regulations being put forward for eligibility rules, program design, and other implementation issues.

Poring over the ACA's "picky details" satisfied the self-described policy wonk. "I think of myself as an economist who likes to know a lot about the institutions and policies of whatever I'm studying," Levy explains. "I like the rigid theoretical framework of economics that helps me think about very complex things, but I also like to know a lot of the institutional and policy context."

Levy's 2013 research continues the same dual attention to broad context and specific detail. She is studying the fiscal impact on states of expanding the Medicaid program, one of the ACA's key provisions, as part of a larger goal of understanding the impact on health care coverage that Medicaid expansion will have.

In another study, Levy is using the University of Michigan's Health and Retirement Study, a longitudinal study of older Americans, to examine how older people make decisions about insurance. For example, what kinds of people sign up for Medicare Part D, which provides coverage for prescription drugs? What racial disparities exist in prescription drug coverage among older Americans, and how are they affected by Medicare Part D? And Levy is studying how health literacy affects older people's ability to make decisions about health care and insurance.

The same concern about health care disparities that struck Levy as a young clinic volunteer continues to shape her research agenda. Observing that poor elderly Americans often choose between cutting back on medication or food, Levy says the issue is related not only to financial resources but to the patient's cognitive resources and social support. "I'm interested in why one person with the same level of resources will be able to make ends meet and another won't," she says.

With the Affordable Care Act poised to extend health insurance coverage to millions more Americans, potentially affecting many health outcomes, this is an exciting time to pursue such health policy questions. As someone who has studied health care coverage and its effects from so many angles, Levy says, "it's fascinating to see the obstacles knocked out of the way, one by one."

Continued involvement with RWJF. Levy continues her relationship with RWJF. "The Scholars program was tremendously useful in giving me exposure to people. At Chicago, I was on the faculty of the Clinical Scholars program, and several papers came out of collaborations there. Here at Michigan, I'm on the faculty of the Scholars in Health Policy Research program. So, RWJF, from grad school to now, has been an incredible source of putting in place communities of people where a lot of interesting collaborations occur."

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.