“State Health Policy: Does Evidence Really Make a Difference” was the title of the spring Research into Policy and Practice Lecture, April 11 in Light Hall. The semi-annual lecture is sponsored by the Department of Health Policy.
Speakers included Christopher Koller, president of the Millbank Memorial Fund and former health insurance commissioner for the state of Rhode Island, and Victor Yung-Tao Wu, MD, PhD, chief medical officer, Bureau of TennCare. The moderator was Blake Farmer, senior healthcare reporter with Nashville Public Radio.
The speakers left the audience with the impression that in health policymaking at the state level, appeals to evidence can be drowned out at times by inordinate reliance on personal experience on the part of lawmakers, undue influence from special interest groups and political partisanship.
Koller graded state lawmakers across the nation on their use of established evidence in four policy areas: work requirements for public assistance, opioids, provider consolidation and the role of primary care.
Work requirements for public assistance have not been shown effective in increasing employment, he said, and where discussion of work requirements for Medicaid recipients is concerned, “I would give grades from A to D, based on the state conversation.”
Regarding the opioid crisis, he said the strongest evidence at play supports a significant role for medication-assisted therapy for treatment of substance abuse.
Noting that discussions are currently raging about how to address the crisis, he gave lawmakers a grade of incomplete, adding, “I give states credit for really trying to marshal their forces.”
Regarding regional consolidation among providers, “There is every bit of evidence that provider consolidation increases costs and has no effect on the quality of care,” he said, adding, “it has nothing to do with improving population health.” He gives lawmakers a D for their uptake of this evidence.
Regarding primary care, “The evidence is pretty clear that when you have a more primary care-oriented delivery system you have better population health and lower population costs,” he said, adding that salary differentials between primary care and specialty care are a crucial issue. Here he gave lawmakers another D.
Lessons to be drawn from these examples, according to Koller, include the importance of persistence for those who would use evidence to forge policy, and attention to the role of special interests and communication, as well as attention to how the opposing values that animate our major political parties enter into conversations around evidence. He briefly advised students and faculty on the best way to assist policymakers.
Wu responded to Koller’s talk with comments on how best to engage people in evidence-based policymaking discussions.
He said that while he happens to relish the nuances of research methodology, “that’s not what makes you the life of the party. I learned that very quickly — that is not really what gets people’s attention.”
More vital to policy discussions, he said, is often “what feels right, what feels true to you.” He summarized this attitude as, “If it feels true, I don’t care about the evidence; if I trust you as a person and that’s the way I like to make my decisions, then whatever you say is evidence.
“I think that’s actually a real issue. Partly academics are here to combat that ‘truthiness’ feel, but it’s also the reality of where we’re at.”
He outlined areas where such gut feelings play into policymaking: partisanship can blind lawmakers to evidence; the readiness with which some states copy solutions put forward by other states can be counterproductive if states fail to review evidence and put their own stamp on policies; the personal experience of lawmakers can derail policy discussions; ignoring details of policy implementation in favor of policy bullet points can be perilous for policymakers and their constituents.
According to Wu, the remedies include more attention to basic skills of political conversation on the part of policymakers, including readiness to use personal anecdotes to illustrate evidence, willingness to engage with policymaking details, and less reliance on trendy jargon.
The event concluded with wide-ranging questions posed to the speakers by Farmer and members of the audience.
