What’s the best way to treat prostate cancer? What are the benefits and risks of different rehabilitation options for survivors of stroke? Unfortunately, the answer to these and similar questions often is: Nobody knows. The United States spends $3 trillion annually on health care — much of it funded by taxpayers through programs such as Medicare — yet only a limited amount of information exists about what treatments work best for which patients. Although estimates vary, some experts think that less than half of all medical care is based on clear scientific evidence.
The good news is that the federal government is now making a significant investment in health services and patient-centered outcomes research to identify waste and improve the safety, effectiveness and quality of care. The bad news is that House Republicans are trying to abolish one of the main agencies carrying out this research, the Agency for Healthcare Research and Quality (AHRQ), and cut the funding of another, the Patient-Centered Outcomes Research Institute (PCORI). The puzzle is why.
One possible reason is that Republicans oppose taxpayer funding of all scientific research as a matter of principle. Yet the same House Appropriations Committee draft bill that targets health services research also provides a $1.1 billion increase in the budget of the National Institutes of Health.
A second possible reason is that Republicans are uninterested in evidence-based policymaking. But both Democrats and Republicans argue that better information is needed to make government more effective. For example, Rep. Paul Ryan (R-Wis.) and Sen. Patty Murray (D-Wash.) recently introduced the Evidence-Based Policymaking Commission Act of 2015 to evaluate the effectiveness of federal programs.
What makes the situation even more perplexing is that evidence-based medicine has a solid Republican pedigree. Perhaps the most important advocate of an increased federal role in paying for research on the clinical effectiveness of treatments has been Gail R. Wilensky, a Republican economist who served as George H.W. Bush’s Medicare director.
In 2008, former House speaker Newt Gingrich (R-Ga.) published an op-ed with Billy Beane, the “Moneyball“ general manager of the Oakland A’s, and Sen. John F. Kerry (D-Mass.) in which they lamented that “a doctor today can get more data on the starting third baseman on his fantasy baseball team than on the effectiveness of life-and-death medical procedures. Studies have shown that most health care is not based on clinical studies of what works best and what does not — be it a test, treatment, drug or technology.”
Republicans have turned against government funding of evidence-based medicine research for five reasons.
- Federal investment in this research (although it predated the 2008 election) became closely tied to the Obama administration’s health-care reform agenda, because big funding increases were tucked into the 2009 stimulus legislation and the Affordable Care Act — two measures the GOP strongly opposed. An increased federal role in comparative effectiveness research, together with payments to physicians for voluntary counseling to Medicare patients about end-of-life options and the creation of the Independent Payment Advisory Board (another agency the GOP wishes to kill) contributed to the “death panels” myth, which Republicans have used to frame health-care reform as “rationing.” As University of Maryland political scientist Frances E. Lee argues, partisan conflict over technocratic issues such as medical research is often “opportunistic and focused on electoral advantage.” As she writes, “The politics of good government, ironically, is hardball.”
- Although evidence-based medicine might seem likely to have bipartisan support, it has become a partisan issue among voters. In 2010, Alan Gerber, David Doherty, Conor Dowling and I conducted a national survey to gauge public support for government funding of research on the effectiveness of treatments. Among those who reported not voting in 2008, there was not a large difference in support across Democrats and Republicans, but there were significant partisan differences among voters. Republican voters were much less supportive than Democrats. During the debates over the stimulus bill and health-care reform, the two parties took opposing stands on the federal government’s role in this effort, which led to the significant partisan split among politically engaged citizens.
- Research on the effectiveness of different treatments is a threat to the incomes of some health industry stakeholders. In 1994, the Agency for Health Care Policy and Research (the precursor to AHRQ) issued a report concluding that there was little evidence to support back surgery over nonsurgical alternatives for many cases of lower-back pain. Back surgeons went ballistic, and successfully lobbied Republicans in Congress (who associated the agency with the Clinton health-care reform plan) to slash the agency’s budget and curb its authority. Although some health IT companies see the value of AHRQ and PCORI, there are powerful interest groups that wouldn’t mind if the agencies were weakened.
- The public is not engaged. Although patients, caregivers, and family members would benefit from better information about the effectiveness of treatments, the benefits of a stronger base of medical evidence are too diffuse to mobilize ordinary citizens. AHRQ and PCORI are public-interest agencies that lack a natural constituency.
- Republicans have attacked government funding of evidence-based medicine research because there is little political penalty to doing so. The penalty would be higher if Republicans feared getting on the wrong side of doctors. In our survey research, we found that when it comes to the role of evidence in patient decisions as well as in the allocation of health-care money, the public believes that “doctors know best.” The public views doctors as trusted agents of their interests; when respondents are told that doctors support government funding of evidence-based medicine research, the argument of opponents that study findings will be used as a pretext for rationing loses its sting.
Clearly most doctors do believe in the need for research on evidence-based medicine (although medical societies frequently protest when studies question the efficacy of treatments used by their members). “Cutting funding to AHRQ would be a huge mistake in our mission to improve the quality & efficiency of healthcare,” tweeted one surgeon. But the physician community has not organized around the issue.
There is a good chance the proposed cuts to evidence-based medicine research won’t be enacted in this appropriations cycle. Nonetheless, the episode is a reminder that information is a powerful resource in government — one that can be destroyed when people aren’t looking.
Eric M. Patashnik is professor of public policy and politics and director of the Center for Health Policy at the University of Virginia. He is also nonresident senior fellow at the Brookings Institution and a fellow of the National Academy of Public Administration.