“Evidence based”has become a prominent goal in recent years in many aspects of health care, such as clinical decision making, health care management, health benefit design, and in both health policy and population health, the Quarterly's central concerns. (A Google search for “evidence based” and “health” yields more than nine million hits!) Many aspects of the challenge of incorporating scientific evidence into the policymaking process have been explored in these pages in recent years (see Jacobson, Butterill, and Goering 2005; Lavis et al. 2002, 2003; Lomas et al. 2003; Mitton et al. 2007; Tetroe et al. 2008). But only limited attention has been given to the perspective of policymakers themselves. That is the topic of the first article in this issue of The Milbank Quarterly.
In “‘Developing Good Taste in Evidence’: Facilitators of and Hindrances to Evidence-Informed Health Policymaking in State Government,” Christopher Jewell and Lisa Bero share lessons learned from interviews with twenty-eight state-level policymakers who were sufficiently interested in the use of research-based evidence to attend the five-day Rocky Mountain Evidence-Based Workshop between 2000 and 2005. Considering several types of policy decisions faced by state legislators or bureaucrats, Jewell and Bero identify factors that hinder the use of research evidence in policymaking. These include common institutional arrangements and competing sources of information, as well as the quantity, quality, accessibility, and usability of research evidence. Jewell and Bero also identify several facilitators of evidence-informed health policymaking, including linking results to costs and benefits, reframing policy issues to resonate with research evidence, educating policymakers about the nature of evidence, creating “research-focused venues” connected with policymaking, and developing collaborations involving researchers and policymakers.
The next article in this issue, “State Responses to New Flexibility in Medicaid” by Teresa Coughlin and Stephen Zuckerman, focuses on a largely overlooked form of policymaking: the Medicaid waiver. The Medicaid program is administered and partially funded at the state level, but many requirements regarding who and what services must be covered are attached to the federal government's significant share of the program's costs. The federal government also must bear the same share of the costs of certain optional services and beneficiary categories that the states can choose to cover. This structure has provided enough flexibility to turn Medicaid into fifty-six different programs (not only all states but also the District of Columbia and several territories). Even so, states have found that federal requirements limit their ability to make certain desired changes in order to expand programs or contain costs. Waivers of federal Medicaid requirements have become an instrument by which the federal government gives states additional flexibility to modify their Medicaid programs.
Coughlin and Zuckerman describe the ways that Medicaid waivers have been used in recent years: to provide more benefit flexibility, to allow the imposition of more cost sharing by beneficiaries, to expand coverage, to put caps on enrollment, to incorporate more market principles into Medicaid, and to promote public-private partnerships. The idea of states as laboratories of reform (or laboratories of democracy, as Justice Louis Brandeis famously put it) is commonly invoked in policy discussions about the United States' federal structure. The number of current policy experiments in the Medicaid program presents both an opportunity and a challenge for the policy research community.
Racial/ethnic disparities in health status and differences in services received have been well documented in the United States and elsewhere (Exworthy et al. 2006; Institute of Medicine 2002). But what can providers of health care do to reduce patterns of disparities in care? That is the topic of the next article in this issue, “A Plan for Action: Key Perspectives from the Racial/Ethnic Disparities Strategy Forum,” by Roderick King, Alexander Green, Aswita Tan-McGrory, Elizabeth Donahue, Jessie Kimbrough-Sugick, and Joseph Betancourt.
King and his colleagues report on the efforts of a working group assembled to bring several streams of research to bear on the problem of reducing disparities in care. Their effort to map out a plan of action to reduce disparities quickly confronted limitations in our knowledge. Although many kinds of disparities in care have been documented by researchers, the causes are not well understood. One of the reasons for this is that few health care organizations develop the information needed to show whether there are racial/ethnic differences in the services received by their patients. Many do not routinely collect information about patients' race and ethnicity, and even fewer analyze utilization data to locate differences in treatment that could be subject to a further search for root causes. King and associates urge the routine collection and analysis of such data by health care organizations, and they suggest that established quality improvement techniques be applied when disparities in care are identified.
The next article in this issue is also concerned with disparities, but at a global level. In “Population Causes and Consequences of Leading Chronic Diseases: A Comparative Analysis of Prevailing Explanations,” David Stuckler analyzes trends in patterns of mortality in poor and rich countries. His specific concern is the rapid growth in poor countries of chronic conditions such as cardiovascular disease, cancers, respiratory disease, and diabetes.
Stuckler presents evidence that factors associated with globalization—direct foreign investment, urbanization, market integration, and improving economic status—are more important than the aging of populations as determinants of the rising mortality rate of chronic disease in poor countries. The more proximate causes are familiar ones: tobacco use, alcohol consumption, unhealthy diets, and lack of physical activity. His findings regarding disease trends add to a growing body of knowledge suggesting that chronic disease deserves much greater attention than it has received to date from the agencies and organizations concerned with population health in poor countries.
The final article in this issue analyzes a problem that has been addressed many times in these pages over the past twenty years: the state of professionalism in medicine (Light and Levine 1988; Mechanic 1996; Stevens 2001; Wolinsky 1988). In “Rethinking Medical Professionalism: The Role of Information Technology and Practice Innovations,” David Mechanic lays out what he sees as the essential elements of medical professionalism, including competence, respect for patients, and not allowing self-interest to influence treatment decisions. After touching on the now-familiar threats to the traditional expectations of physicians as professionals, he argues that three elements can lend new strength and plausibility to claims of following professional ideals.
Mechanic suggests that the rise of the information technologies associated with evidence-based medicine can address certain challenges to professionalism, including the proliferation of evidence and competing demands on physicians' time. Changes in payment methods could alter incentives that push in directions inconsistent with professional ideals. Developments in disease management also hold promise of improving the situation. Mechanic does not claim that the developments on which he focuses are the entire solution (problems resulting from physicians' involving themselves in unnecessary economic conflicts of interest remain), but he does believe that the situation regarding medical professionalism is more hopeful than is sometimes depicted.