Since President Clinton made healthcare reform the cornerstone of his administration, the thunder of special interest groups and policymakers stampeding for studies to shore up their political views on the issue has been deafening.
The federal government, think tanks and consulting groups have met the relentless demand by producing a mountain of healthcare reform-related reports. Many of the studies made headlines by becoming the subjects of an endless stream of press conferences by lobbying groups, or the focus of an equally endless march of healthcare reform hearings on Capitol Hill.
Researchers and economists agree that the quality of these reports has varied immensely, and they worry that little or no differentiation has been made between good research and bad.
"In the course of the healthcare reform debate, there's been a process of study disinformation, in which proposals, notably the president's, have been grossly distorted," said Henry Aaron, director of economic studies at the Brookings Institution.
According to Ted Marmor, a professor of politics at the Yale School of Management, Washington's definition of research is "anything with a coherent sentence or number.
"The paradox is the enormous gap between the ample supply of first-rate research and the dwarfed receptivity to actually using it," he said.
A menu of findings.The volume and variety of healthcare research have made it possible for anyone with a political or financial stake in the outcome of the debate to pick and choose among the reports to find one that satisfies their need, experts said.
"Given the fact that healthcare is so complicated, and there are so many winners or losers, research can easily be used-even if it's not done intentionally-to justify so many different positions, because there's so much ambiguity in the outcomes," said Stuart Altman, an economist at Brandeis University and chairman of the Prospective Payment Assessment Commission.
This is especially true of such politically charged reform options as the employer mandate. Small-business groups have commissioned studies showing that job losses could number in the millions if employers are required to finance healthcare for their workers. The Clinton administration, which along with Democratic leaders in Congress supports a mandate, maintains that job losses would be negligible and concentrated among those at the bottom of the pay scale.
Such vast differentials are possible because predictions "depend on how steep the supply-of-labor curve" is, said Uwe Reinhardt, an economist at Princeton University. Using a steep curve, projections of the effect of an employer mandate would show a less-dramatic job loss, but a greater loss in wages, as employers shift the cost of financing healthcare to workers. A flatter labor supply curve, on the other hand, yields a greater job loss estimate with less impact on wages, Mr. Reinhardt said.
"There probably exist in the literature 30 estimates of the shape of this supply curve," he added. "If I'm a Republican and want to show a big job loss (from the mandate), I might want to draw from simulations that show a high sensitivity to that. If I'm a Democrat, I might cite reputable studies which show wage sensitivity."
While the research is objective, it "gets used in an adversarial fashion," Mr. Reinhardt said.
Obfuscating the debate.The abundance of reform studies has done little to clarify the healthcare debate for the public, according to many experts. Nor has it stemmed the flow of unfounded assertions designed to frighten and confuse people.
"The most dramatic example is confusion over choice in the healthcare debate, which is now at the level of the 3rd grade," said Mr. Marmor. President Clinton correctly claimed that his healthcare plan would expand employees' choice of health plans and providers, he added. Yet, a year of negative publicity by the health insurance industry and small-business community-both of which have worked to beat back elements of the Clinton plan they oppose-has succeeded in creating the belief that "universal health insurance is the enemy of choice.
"It's another illustration of the way in which the debate has been completely undisciplined," Mr. Marmor said.
ProPAC's Mr. Altman compared the public's dilemma to that of patients trying to treat themselves by reading medical literature without a guide. The public is "being deluged by information overload," he said. "You reach a point where you say, this information, rather than educating us, actually confuses the situation, unless you have a guide to take you through the information forest."
Little impact.Furthermore, given the highly politicized climate in which the issue is being debated, researchers wonder whether their work will make any difference.
"If you want to have an impact, I'd advise you to become a lobbyist," said John Holahan, director of the health policy center at the Urban Institute, which has done extensive research for the federal government but doesn't accept private commissions. The impact of high-quality health policy research is "pitifully limited," he said. Insurance companies and small businesses "have won this (debate) so far," he added.
It hasn't always been possible for politicians and lobbyists to arm themselves with volumes of data.
"In the good old days, when we passed Medicare, no one was doing health research," Mr. Altman said. "A few people had a few numbers."
The dearth of information had advantages and disadvantages. On the downside, it made it impossible to predict the program's cost explosion, Mr. Altman said. On the plus side, the research vacuum made it easier for lawmakers to enact significant legislation, since they didn't have to contend with ominous cost predictions. Had lawmakers known then what they know now, Medicare might never have passed, which would have been a "serious mistake," he added.
Information overload.In today's information-soaked environment, some experts fear the overload could paralyze the public policy process.
"We are now much more conscious of the implications of what we do," Mr. Altman said. As a result, the current healthcare reform debate could end in a "non-decision" because the research leads to a "standstill."
Lawmakers have become obsessed with quantifying the cost impact of healthcare reform proposals for two reasons. One is their experience with Medicare and the daunting challenge to continually rein in the program's costs; the other is the focus within the legislative process these days on assuring accurate cost assumptions. The Congressional Budget Office is the final arbiter of cost and savings calculations for all legislation. Before lawmakers can be sure spending programs are fully funded, therefore, they must get an assessment from the CBO.
Lawmakers' fixation with cost appraisals isn't always possible to satisfy because proposals change faster than most researchers can work. The CBO, for example, is so far behind in its score keeping that some congressional committees have voted on healthcare reform proposals without the benefit of CBO estimates.
For quick results, lawmakers and private interest groups have turned to Lewin-VHI, where political interests and the insatiable thirst for quantifiable projections of healthcare reform options frequently intersect. The respected, but heretofore behind-the-scenes, research and consulting firm in Fairfax, Va., has, over the past two years, become the 800-pound gorilla of healthcare studies. Unlike the Urban Institute and many other not-for-profit organizations with sophisticated research tools, which primarily work on government contracts, Lewin-VHI works for private interest groups as well.
Results to order?The organization has produced estimates for a numbing array of healthcare-related interest groups, liberal and conservative. Lewin-VHI has been tapped to quantify the cost impact of everything from moderate daily doses of wine to the pressure President Clinton's reform plan would put on hospital margins (See chart, p. 29).
The ability of the number-crunching firm to produce results favorable to such a vast number of groups, all with a political ax to grind, has raised eyebrows in the research community.
"This is not research," said Yale's Mr. Marmor. "These are forecasts, whose validity rests on the plausibility of assumptions that go into them. This is thinking by computer, and a perfect example of how not to think about public policy."
Lawrence Lewin, founder and chairman of Lewin-VHI, dismissed concerns about the firm's overexposure as "a fig leaf for envy." Mr. Lewin, who described himself as a "moderate Democrat," said the organization sought "on all issues to be politically objective and nonpartisan."
Lewin-VHI's work is generated from a computer model containing hundreds of assumptions capable of producing estimates of the impact of reform on employers, healthcare providers' revenues, household spending, wage and job loss, and state and local governments.
The firm's 184 employees work in a sprawling complex that belongs to the research company ICF. Avon, Conn.-based Value Health, a healthcare information company, acquired Lewin from ICF in 1992.
The Lewin-VHI model has made it possible for the firm to turn healthcare reform predictions around on a dime, relative to the speed with which government number-crunchers are able to work. But while few question the integrity of Lewin-VHI's estimates, many believe they are too sensitive to even minor changes in the assumptions used and to the ability of special interest groups that commission studies to manipulate findings.
Lewin-VHI's work is "high quality, but very narrowly framed," said Mr. Reinhardt.
"If you have a private group commission a piece of work, you usually get low-quality work, because you're not really into the truth, but into making a point," he added. "Even more sophisticated research can be framed to have assumptions drive conclusions."
A secondary concern among researchers is what many consider an unhealthy and simplistic preoccupation with numbers in the healthcare reform debate.
"There is this fallacy of misplaced specificity," said the Brookings Institution's Mr. Aaron. "If you've got a number, you've got something tangible and real to point to." But, he warned, "it's easy to attach too much significance to numbers."
In the context of healthcare reform, numbers have become "politically potent symbols in the absence of potent thought about their meaning," Mr. Marmor said. "It's easier to remember a statistic than an argument."