On Health Care, What Roles Do Evidence and Politics Play?

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June 15, 2012; Source: Health Affairs Blog

How much did evidence about how to incentivize Americans to buy health insurance factor into the Supreme Court’s decision on the Obama health care law yesterday? How much does evidence really factor into American decision-making about health care reform? The Health Affairs Blog addresses the composition of the Independent Payment Advisory Board (IPAB), a 15-member “expert” body charged with examining Medicare costs, “recommend(ing) changes in premiums, benefits, eligibility, or taxes, or other changes that would result in ‘rationing’ of care to Medicare beneficiaries” when spending is rising too fast. With the PPACA largely upheld by the Supreme Court, the IPAB represents a significant step for incorporating evidence-based policy making into the implementation of health care reform.

There is lots of evidence out there about the condition of the nation’s entitlement programs such as Medicare, but negligible action to this point because politics trumps the interpretation of the evidence, much less the possibility of taking steps to fix the programs. Will the American public and their representatives in Congress follow the recommendations of the evidence-focused experts who might call for “eliminating or reducing access to expensive new therapies, drugs, and devices?”

The Health Affairs Blog suggests that debates about the IPAB are “part of a larger philosophical debate about the appropriate role of science and evidence in government decision-making.” Will politicians pay attention to the recommendations of evidence-based recommenders? The blog points to some of the political forces in play. 

  1. It suggests that “a substantial proportion of Americans express little trust in expert panels in health care,” and less trust in an expert panel appointed by the federal government than one from an “independent scientific organization” (57 percent express little or no trust in the federal expert panel compared to 41 percent for the independent scientific organization). The distrust of expert panels on Medicare is higher on the Republican than the Democratic side (59 percent to 33 percent). 
  2. An expert panel’s recommendations on issues that are arcane and not particularly visible to the public are likely to get more support than those that are more visible: “As the visibility of an issue increases, so does the level of government responsiveness to the public’s view. When issue salience is taken into consideration, public opinion always has a substantial effect on policy.” If the IPAB topic is very salient to the public, Congress is less likely to give them an expert’s pass. If the topic is more nuanced, such as risk-adjusted payments to private health plans, the blog suggests that Congress and the public might be more likely to defer to the experts.
  3. The more polarizing the issue in front of the expert panel, the less likely that the public and Congress will defer to the experts. The Health Affairs Blog says that “introducing evidence in the context of highly polarized issues is likely to reinforce—as opposed to change—pre-existing opinions.”

“Issue salience, complexity, and polarization will also shape how the IPAB’s proposals are viewed in this environment,” according to Health Affairs. Doesn’t that observation also apply to expert panels making recommendations on policies and programs in many realms of society? Many advocates of social engineering harbor desires to excise politics from policies and programs. Aristotle said that human beings, by nature, are political animals. Few political animals are wont to hand the substance of their lives to the higher insights of Plato’s philosopher kings and queens—or, it appears, to expert panels.—Rick Cohen