Brookings: Topics - Public Health

Discuss Mental Health in the State of the Union

Kavita Patel — Fri, 08 Feb 2013 11:02:00 -0500

The State of the Union Address is often used to highlight the condition of our nation but also allows the president to outline legislative agendas for which he might need the cooperation of Congress. The Affordable Care Act deserves an acknowledgment in the speech namely because the nation is still in a state of frenetic planning and implementation for the addition of approximately 31 million new people who will have health insurance beginning this fall and building over the subsequent years.

Gun violence also should be mentioned in light of not just the tragedy in Newtown but also due to rising homicide rates in some major cities like Chicago and other gun-related fatalities that are too numerous to count. Let us hope these incidents compel both the president and Congress to action.

Mental health should be an important part of any national discussion. The State of the Union will likely address some of the president’s actions as well as recent efforts from a bipartisan group of legislators to expand access to mental health facilities and raise standards for mental health services. But such an approach should be applied with caution: laws which require mental health professionals to report names of patients who are likely to harm themselves or others to a state or local authority could unintentionally exacerbate stigma and the great chasm in seeking mental health treatment. Furthermore, expansion of the very same mental health care services will not be as effective as efforts to truly integrate behavioral and mental health services into other aspects of care delivery such as primary care, which is often an entry point for many patients. Such efforts are underway now. The president will have to balance the need for action with the need for credible and informed mental health models which can truly transform care. This does not meant that we should delay action—quite the opposite—patients and families have been waiting for too long. But we should apply a critical eye as well as offer perspectives from public health and other social determinants of health and primary care.

Authors

Kavita Patel

Image Source: © Shannon Stapleton / Reuters

Effects of an Individual Development Account Program on Retirement Saving: Follow-Up Evidence from a Randomized Experiment

Tue, 04 Dec 2012 16:06:00 -0500

ABSTRACT

Using data from a randomized experiment that ran from 1998 to 2003 in Tulsa, Oklahoma, we examine the 10- year follow-up effects on retirement saving of an Individual Development Account (IDA) program. The IDA program included financial education, encouragement to save, and matching funds for several qualified uses of the savings, including contributions to retirement accounts. The results indicate that, as of 2009, 6 years after the program ended, the IDA program had no impact on the propensity to hold a retirement account, the account balance, or the sufficiency of retirement balances to meet retirement expenses.

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Effects of an Individual Development Account Program on Retirement Saving: Follow-Up Evidence from a Randomized Experiment

Authors

Michal Grinstein-Weiss
Michael Sherraden
William G. Gale
William M. Rohe
Mark Schreiner
Clinton Key

Publication: Center for Social Development

Image Source: © Lucy Nicholson / Reuters

Public Health and Political Crises behind China’s Growing Tobacco Epidemic

Thu, 25 Oct 2012 14:00:00 -0400

Event Information

October 25, 2012
2:00 PM - 4:00 PM EDT

Saul Room/Zilkha Lounge
Brookings Institution
1775 Massachusetts Avenue NW
Washington, DC 20036

Register for the Event
While China’s remarkable economic growth over the past three decades has been one of the most impressive achievements of the last quarter century, the country has also gained a reputation as “the smoking dragon” due to its rapidly growing tobacco industry and ongoing smoking-related health crisis. Currently, the People’s Republic of China is the world’s biggest tobacco producer, largest cigarette consumer and gravest victim of the smoking-related health crisis with estimated one-million tobacco-related deaths a year. Growing public awareness of and interest in health issues, as well as ballooning medical costs, could trigger significant public resentment and social unrest. China’s anti-smoking campaign faces an uphill battle, though it has the potential – and an unprecedented opportunity – to change the course of the tobacco epidemic within China and across the world.

On October 25, the John L. Thornton China Center at Brookings will host a discussion of China’s tobacco epidemic health crisis and its political ramifications, featuring “The Political Mapping of China’s Tobacco Industry and Anti-Smoking Campaign,” a new monograph by Cheng Li, senior fellow and director of research at the John L. Thornton China Center. Brookings Senior Fellow Jonathan Pollack, acting director of the John L. Thornton China Center, will provide opening remarks. Former Deputy Director of China’s Center for Disease Control and Prevention Yang Gonghuan and Council on Foreign Relations’ Yanzhong Huang will provide commentaries. The discussion will be moderated by Sarah England of Bloomberg Philanthropies.

After the program, participants will take audience questions.

Event Materials

25 china tobacco li

Next Steps in Obesity Prevention: Altering Early Life Systems To Support Healthy Parents, Infants, and Toddlers

Fri, 01 Jun 2012 00:00:00 -0400

Summary

The widespread and increasing prevalence of childhood obesity in America presents a critical public health challenge, prompting the Institute of Medicine to call for new “systems approaches” to obesity treatment and prevention. This paper, published in the focal journal Childhood Obesity, describes the role that “obesogenic systems” play in early life and proposes specific strategies for combating their effects to prevent obesity. The authors support an approach that (a) targets the earliest stages of development and (b) takes a systems perspective, simultaneously implementing changes in multiple sectors and at multiple societal levels.

To read the article, visit the publisher's website »

Authors

Philip R. Nader
Terry T.-K. Huang
Sheila Gahagan
Shiriki Kumanyika
Ross A. Hammond
Katherine Kaufer Christoffel

Publication: Childhood Obesity

Image Source: Rick Wilking / Reuters

Obesity, Prevention, and Health Care Costs

Ross A. Hammond — Fri, 04 May 2012 00:00:00 -0400

Follow @BICampaign2012
Editor's Note: For Campaign 2012, Alice Rivlin wrote a policy brief proposing ideas for the next president on America’s health care system. The following paper is a response to Rivlin’s piece from Ross Hammond. Tom Mann also prepared a response arguing that Americans must accept the reality of today’s political polarization and challenge Washington to offer tangible solutions to the nation’s most urgent problems.

Alice Rivlin highlights the twin health care challenges facing America and the next president: covering the uninsured while curbing unsustainable increases in health care costs and their impact on the debt. She provides a compelling argument for how to address these challenges through health care legislation. I would like to focus here on the role that investment in public health and prevention can play as a complementary strategy for controlling health care spending.

Perhaps the most pressing public health challenge for the United States today is the epidemic of overweight and obesity, which is linked to an array of costly and debilitating health consequences. According to data from the National Center for Health Statistics, two in three American adults are now overweight, including one in three who are obese. A recent study also found that almost one-third of children and adolescents are overweight or obese. These rates are even higher among ethnic minorities, rural populations, and those with low income or education. The health risks associated with obesity reported by the Institute of Medicine include a much higher incidence of cardiovascular disease, diabetes, several cancers, hypertension, high cholesterol, asthma, osteoarthritis, and liver disease.

Not surprisingly, then, the obesity epidemic is a major driver of health care costs in the United States, and the costs may continue to increase significantly in the future if it is not controlled. The increased health risks for major disease that come with obesity carry not only a high social price tag but also a high economic one—relative medical costs for the obese are estimated to be 36 to 100 percent higher than for Americans of healthy weight. A 2009 study found that childhood obesity alone is responsible for $14.1 billion in direct medical costs annually. By some estimates, nearly 21 percent of all current medical spending in the United States is now obesity related. A significant proportion of these medical costs is paid by Medicaid and Medicare, and one recent analysis concluded that total Medicaid spending would be almost 12 percent lower in the absence of obesity. Beyond direct medical spending, additional costs from obesity are driven by increased rates of disability and by reduced productivity.

The impact of obesity on health care spending is likely to increase in the coming years unless further preventative steps are taken. Although recent data suggest that obesity rates may now be leveling off after a period of very rapid growth, the epidemic in children is especially worrisome because most obese children become obese adults. Childhood obesity means more chronic disease will begin earlier in life for more people—driving up lifetime costs considerably. For example, type 2 diabetes (for which obesity is a particularly strong risk factor) occurred primarily in adults until recently, but the Centers for Disease Control report that it is now beginning in childhood for more Americans. A recent report in the Journal of the American Medical Association estimates that one-third of all children born in the United States today (and one-half of all Latino and African American children) will develop type 2 diabetes in their lifetime. Even if the epidemic does not worsen, these costs are likely to prove an unsustainable burden on the health system given the long-term growth of the federal debt.

Keeping the costs of obesity from overwhelming the health care system will require a renewed focus by the next president on obesity prevention. This has the potential to contain costs much more effectively than the mere treatment of obesity-related chronic health conditions. Early childhood can be an especially important period—once obesity develops, a powerful set of physiological processes and behavior patterns make it challenging to reverse. From the perspective of health care costs, early prevention can produce substantial savings. According to an analysis in the American Journal of Public Health, as little as a 5 percent reduction in the prevalence of diabetes and hypertension would save almost $25 billion annually in medium-term health care costs.

Prevention is important, but designing effective prevention efforts remains challenging. The drivers of the obesity epidemic are complex and multifaceted, so there is likely no single solution. Continued investment in research on effective prevention strategies is needed, especially in support of what the Institute of Medicine and National Institutes of Health refer to as new “systems” approaches. Indeed, it may be critical to coordinate policy across many domains and levels of scale in order to see a rapid change in the obesity epidemic. To be most effective, prevention efforts must focus not just on educating individuals or on changing environments, but on doing both together.

The next president should take several steps to address the major public health challenge of obesity and help avoid the unsustainable health care costs it will generate:

Renew the emphasis on prevention efforts. Prevention is especially important, given the role of childhood influences in the development of overweight and the challenge of reversing obesity once entrenched.
Increase investment in public health research to develop an evidence base that supports the design and testing of powerful new prevention strategies for the future. As the scientific community emphasizes, innovative approaches are greatly needed to continue to improve how policy addresses the complex drivers of obesity.
Coordinate public policy across domains and agencies. Many policy areas “outside” of health—including education, housing, transportation, agriculture, and tax policy—have strong effects on public health and obesity. A more systemic approach that takes into account connections across these areas should be a central element in an effective obesity prevention strategy.

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Authors

Ross A. Hammond

Image Source: © Lucas Jackson / Reuters

The Quest to Balance Health Care Providers’ Consciences and Patients’ Needs

William A. Galston and Melissa Rogers — Thu, 23 Feb 2012 00:00:00 -0500

Recent controversies, such as the HHS rule on insurance coverage of contraceptive and sterilization services, raise fundamental and politically consequential questions. But they take place against a backdrop of longstanding tensions between claims of conscience and laws of broad scope and application—tensions well-known to experts but less so to public officials and most citizens.

In a new paper, William Galston and Melissa Rogers provide a broad overview of conscience from a religious, philosophical and legal perspective, and then home in on conscience in the context of health care. The paper surveys current federal and state law and regulation governing the right to conscientiously object in the provision of health care, and explores the ongoing tensions between claims of conscience and calls for access. The paper concludes with suggestions for policymakers when shaping laws and regulations in this arena.

Some of the questions explored in the paper include:

Who should be permitted to refuse to provide, pay for, or assist in the provision of certain heath care services?
Which institutions, if any, should be permitted to refuse to provide, pay for, or assist in the provision of certain heath care services?
What are appropriate grounds for conscientious refusals?
What should conscientious objectors be able refuse to do? Should providers be able to raise an objection regarding any health care service, or just some of them?
What conditions must be present for conscientious objections to be honored?
What sort of rules should govern disclosures of conscientious objections, notifications regarding alternative providers, and referrals to other providers?

Galston and Rogers offer a useful guide to the roots of this debate and highlight potential paths to common ground.

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Image Source: © Kevin Lamarque / Reuters

Honoring Religious Objections and Access to Contraceptive Coverage

Melissa Rogers — Fri, 17 Feb 2012 00:00:00 -0500

At the heart of President Obama’s announcement last week on the contraceptive coverage mandate are two goals: ensuring that religious organizations will not have to pay for or provide coverage for services that are objectionable to them and that employees of objecting religious organizations will have access to these benefits on the same basis as other employees.

These are the right goals. As the administration moves forward to implement them, it should carefully consider legitimate free exercise concerns and distinguish them from broader grievances about the contraceptive mandate and the Affordable Care Act as a whole.

In his February 10 remarks, President Obama offered a specific proposal about how to reach the goals of honoring religious objections and access to contraceptive coverage. Drawing on the provisions of certain state laws, the president proposed requiring insurers to provide these benefits to employees of objecting religious organizations via insurance contracts that are separate from the contracts between the insurers and objecting religious employers, with no referrals by these employers. The aim is to take objecting religious organizations out of the equation, while ensuring employee access to important health benefits. Many Catholics and other people of faith have said this proposal works well for them, and it makes good sense to me.

Since the announcement, however, some other Catholics and religious people have said even this accommodation would substantially burden the free exercise of their institutions. Some religious employers would like, for example, to be able to purchase insurance from insurers that do not offer contraceptive coverage so that none of their money supports such coverage in even the most remote way. Likewise, some nonprofit religious insurers have said they would object to a requirement that forced them to provide contraceptive coverage. The administration should address legitimate concerns like these in the upcoming rulemaking process. It has already pledged that religious employers with self-insured group health plans will not be required to pay for or provide coverage for services to which they object, while employees of those organizations will be guaranteed such coverage by other means. The solution the administration formulates for self-insured health plans may suggest fixes for these other cases as well.

Why should the administration address concerns like these? As UCLA Law Professor Eugene Volokh recently noted, free exercise burdens turn on the subjective understanding of the religious practitioner or body. One person’s or body’s understanding of their faith can differ from another’s. It is not the government’s job to try to determine what is the “right” understanding of a faith; instead, its job is to assess whether the faith practice is sincere and the burden on it is substantial. Having already demonstrated an interest in accommodating spiritual obligations, the administration can and should consider different understandings of those obligations.

Another key part of the administration’s proposed rule will be minimizing differences between what its current rule calls “non-exempted” religious employers (such as religious hospitals, universities, and social ministries) and “exempted” religious employers (basically, churches and other houses of worship). The ideal approach—rather than unnecessarily carving out distinct regulatory regimes for two different sorts of employers—is simply to include a single modified exemption, while still ensuring that employees of exempted organizations could access contraceptive coverage. The administration chose not to do this, but in his remarks last week President Obama treated these two sets of organizations the same way and announced a policy that has the practical effect of broadening the exemption. In other words, the current exemption is a faulty one that should not be extended to other areas of federal law; but, with care, the administration should be able to address the problem here in a workable way.

At the same time, the Obama administration should distinguish between legitimate religious liberty concerns about the exemption and broader grievances about the contraceptive mandate and the Affordable Care Act as a whole. For example, those who say the only way to remedy the free exercise problem is to scrap the contraceptive mandate—or the entire Affordable Care Act—are wrong. They are also badly mistaken when they suggest it somehow violates the free exercise rights of a religiously affiliated hospital, social service agency, or university for an insurer or the government to offer their employees contraceptive coverage. Further, there is certainly no free exercise obligation to exempt all employers from an obligation to provide contraceptive coverage due to their CEOs’ personal religious convictions.

There’s a balance to be struck here because this debate involves more than simply the interests of religious objectors. In 2005 a unanimous U.S. Supreme Court said that when considering free exercise accommodations, “courts must take adequate account of the burdens a requested accommodation may impose on nonbeneficiaries." This constitutional principle deserves attention here, too. Also, some legal scholars have suggested employees of objecting religious employers may have Religious Freedom Restoration Act claims of their own if they are denied these federal benefits. In any case, a policy that would operate to allow employers’ religious convictions to deny hundreds of thousands of Americans federal benefits would be disturbing. It’s also worth noting that expanding contraceptive coverage will help greatly to reduce the number of abortions, a goal with strong support in both the pro-choice and pro-life ranks.

If all of this sounds complicated, that’s because it is. Indeed, my hope is this episode will prompt us to re-consider our employer-based health insurance system. It is right to honor the religious objections of faith-based employers, but it is also right to ask why we retain a system where the health coverage employees receive may be limited by those objections.

While the employer-based system endures, however, we must confront the dilemmas it presents. President Obama’s commitment to the twin goals of honoring objections and access and to opening a new rulemaking process provides the framework necessary to address these issues in constructive ways. The administration should continue to fast-track this policy-making process, even though obligations on religious institutions will not kick in until August 2013. It’s in everyone’s interest to try to find an agreeable solution to this problem. No one can be certain how lawsuits and legislation will fare, and no one can safely predict the outcome of the next election.

These matters are complex, but our debate over them need not be caustic. May cool heads and fair-mindedness prevail as we move forward.

This piece originally appeared in The Huffington Post.

Authors

Melissa Rogers

Publication: The Huffington Post

Image Source: © Jason Reed / Reuters

Why Obama Would Be Glad if the Culture War Is a Major Election Issue

William A. Galston — Tue, 14 Feb 2012 00:00:00 -0500

The furor over the Obama administration’s contraception coverage decision has generated a spate of articles proclaiming the return of the social issues in the 2012 campaign. But while they’re being discussed more, I doubt that they’ll prove decisive. Unless something drastic happens between now and November, trends in employment and real income will determine the result.

Now comes the traditional “to be sure” paragraph.

To be sure, it’s possible to sketch a scenario in which the social issues matter a lot. Imagine a very close election the outcome of which hangs on a handful of large states in the mid-Atlantic and Midwest. These states have high percentages of Catholics who favor government programs when they help the middle class, lean toward cultural traditionalism, and maintain a visceral loyalty to the Church even when they disagree with it on specific policies. It’s no accident that Pennsylvania’s Democratic senator is pro-life and served in the Jesuit Volunteer Corps after college.

Still, countless surveys have placed the social issues far down on the list of public concerns in an election cycle dominated by worries over growth, jobs, deficits, and debt. They are highly salient in the base of the Republican Party, but no one should confuse those voters with the national electorate. If the economy improves fast enough to allow abortion, gay marriage, and religious freedom to emerge from the shadows, Obama will win anyway.

That said, the contraception episode was what the tennis commentators call an unforced error. If recent reports are accurate, the president knew that his decision would create a firestorm. During the extensive deliberations that preceded it, Vice President Biden and many others counseled compromise. (Months ago, the White House was aware of the compromise the president eventually accepted.) Surely Obama knew that Catholics are a large and strategically located swing vote. And yet, despite well-received campaign speeches in favor of religious liberty (and against tone-deaf secularism), as president Obama chose to treat mandatory contraceptive coverage purely as a public health issue. That may indeed be his considered view.

It may also reflect election-year imperatives of base mobilization, especially women and pro-choice groups. And apparently it was bolstered by a political cost/benefit analysis. Politico reports that the president was encouraged by David Plouffe, who reviewed private polling data and concluded that “the vast majority of Catholic voters, who don’t adhere to the church’s dictates on birth control anyway, wouldn’t punish Obama for his decision.”

But when the backlash from supporters as well as adversaries escalated (even loyalist Tim Kaine, now running for Virginia’s open Senate seat, pleaded for a shift), Obama unceremoniously abandoned the position he had staked out just days earlier. I can imagine the advice he got before this reversal: “Mr. President, we have to get this behind us so we can get back to the issues that are working for us. It’s better to take the hit now than to let this controversy linger.” Whatever the motivation for the initial decision, the latest shift can only be interpreted as a response to intense political pressure.

I’m sure Obama meant what he was saying about religion’s role in public life during the years preceding his presidency. But when the crunch came, it took a back seat to other considerations. We reveal ourselves most clearly, not when we declare the things we deem worthy, but when we are compelled to choose among them. All things considered, this has been an instructive episode.

Authors

William A. Galston

Publication: The New Republic

Image Source: © Jim Young / Reuters

President Obama's Birth Control Solution Balances Religious Freedom and Women’s Health

Melissa Rogers — Fri, 10 Feb 2012 00:00:00 -0500

Today the White House announced a revised rule regarding the contraceptive mandate addressed by Department of Health and Human Services Secretary Kathleen Sebelius on January 20, 2012.

Given the White House description of the revised rule, it both resolves the religious liberty concerns and respects the interests of Americans who would like to have these important health benefits. President Obama and his administration deserve great credit for implementing a solution that honors free exercise rights and fairness. I deeply appreciate the fact that the White House has taken the religious community’s concerns so seriously.

Under the revised rule, no religious employer that objects to providing contraceptives and sterilization services will have to pay for or provide coverage for it. The plan rightly recognizes that the government should not force religious communities to pay for or provide services forbidden by their faith. Also, no objecting religious employer will be required to make referrals for services to which they object. This will remove any burden on the free exercise rights of religious employers. At the same time, employees of objecting religious hospitals, universities, and social service agencies will have access to these important benefits directly from insurers. These benefits strengthen health and families and help to reduce the number of abortions.

My faith tradition and conscience support the use of contraceptives, so for me this was never about whether the use of birth control is theologically sound. It was about the freedom of religious bodies to practice their faith as they see fit, not as government sees fit. The latitude of religious communities to define and practice their faiths is a precious liberty, one cherished by people of all theological and political stripes. Just as we would not want the government to force pacifist religious organizations to have to pay for and provide military training for their employees, we do not want to force Catholic and other religious organizations to pay for and provide services that are objectionable to them.

With this solution in place, I hope we can move beyond this acrimonious debate and work together on the serious challenges facing our great nation.

Authors

Melissa Rogers

Image Source: ï¿½ Joshua Roberts / Reuters

@ Brookings Podcast: Can the World Sustain Seven Billion People?

Homi Kharas — Fri, 06 Jan 2012 16:20:00 -0500

With better health care and nutrition, people around the world are living longer and having more children, pushing the population of planet Earth above the seven billion mark. Expert Homi Kharas says while the reasons for growth are positive, the population explosion means world governments must develop more sustainable policies to provide goods and services.

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@ Brookings Podcast: The Policy Implications of Happiness

Carol Graham — Fri, 09 Dec 2011 12:34:00 -0500

Along with such classic economic indicators as wages and consumption rates, economists are starting to look at measures of well-being and how they can subtly improve public policy and the general happiness of a nation’s population. Expert Carol Graham says this field of study, still in its infancy, exposes otherwise hidden aspects of public policy that can increase its efficiency and effectiveness.

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Brookings Roundtable on Active Medical Product Surveillance: Overview of the Mini-Sentinel Pilot

Thu, 15 Sep 2011 16:00:00 -0400

Event Information

September 15, 2011
4:00 PM - 5:00 PM EDT

Live Webinar
The Brookings Institution
1775 Massachusetts Ave., NW
Washington, DC

On September 15, the Engelberg Center hosted the second webinar in the Sentinel Initiative 101 Webinar Series, “Overview of FDA’s Mini-Sentinel Pilot.” This webinar featured a presentation from the Mini-Sentinel principal investigator, Dr. Richard Platt, Professor and Chair of the Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care.

Dr. Platt’s presentation described Mini-Sentinel’s capabilities and lessons learned since the contract was awarded in October, 2009. Specific topics included:

Governance principles and policies,
Key achievements from the Mini-Sentinel Data Core, Methods Core, and Protocol Core, and
An example of a recent rapid query assessment conducted by Mini-Sentinel.

The third and final webinar will cover other Sentinel Initiative activities: Federal Partners Collaboration, the Observational Medical Outcomes Partnership (OMOP), and the Brookings Institution’s broader convening activities.

Participants

Panelists

Rich Platt

Harvard Pilgrim Health Care and Harvard Medical School

Building the Connection between Policy and Evidence: The Obama Evidence-based Initiatives

Jon Baron and Ron Haskins — Wed, 07 Sep 2011 17:09:00 -0400

Introduction

There is a growing belief in both the US and the UK that intervention programs addressed to domestic social problems can be greatly improved if policymakers and managers will support programs shown by scientific evidence to produce impacts. Since his inauguration in 2009, President Barack Obama and his administration have developed and are now implementing the most extensive evidence-based initiatives in US history. The purpose of this paper is to trace the evolution of these initiatives and to examine both their promise and problems.

Muddling through vs. rational policymaking
In 1971, Alice Rivlin published a seminal book on decision making entitled Systematic Thinking for Social Action.¹ She identified four ‘propositions’ that can be taken as a reasonable summary of the basic elements of what is often referred to as rational decision making. They are:

Define the problem.
Figure out who would be helped by a specific program attacking the problem and by how much.
Systematically compare the benefits and costs of different possible programs.
Figure out how to produce more effective social programs.²

Rivlin believed that at the time she was writing, economists, statisticians, and other analysts had made good progress on most of the steps in this approach to rational decision making, but that little progress had been made in determining the benefits of particular programs.

A much more skeptical view of the potential for rational, evidence-based policymaking can be seen in the classic 1959 article by Charles Lindblom on making decisions by “muddling through.”³ Lindblom argued that no program administrator could actually follow the rational decision making model because the demands on knowledge required to compare all alternative programs are too large, the effects of most programs are not known with any confidence, and not enough time is usually available to perform elaborate analyses before a decision must be made. Thus the choice set faced by managers is limited to incremental adjustments in current policy and practice, and the most important factor in policy choice is usually reaching consensus on a particular alternative. Lindblom argued that this process of what he called “successive limited comparisons” among alternatives not radically different from the status quo – or more famously, “muddling through” – was both a better description of how policy actually is made and a more practical guide to action than the rational approach.

Our view is that the dichotomy between the rational decision making approach and the muddling through approach is a false one. Policymaking inevitably involves political constraints on choices as well as limitations on evidence and time. But that does not mean there is no evidence available, or that policymakers should ignore the evidence that does exist or fail to devote resources to obtain better evidence. Indeed, Rivlin argued that the case for “systematic analysis” was strong and had been well made, even by 1971, and that “hardly anyone explicitly favors a return to muddling through.”⁴ Rivlin also held that the key challenge is to recognize the limitations of analysis but to nonetheless employ a systematic approach whenever and wherever possible. Rivlin was especially forceful in calling for better evidence of program effects, perhaps the central feature of any systematic approach. Few would disagree that everyone from program managers to senior level policymakers could improve their decisions if they had reliable information about program impacts, or that developing programs with strong positive effects that can be widely replicated should be a fundamental objective in both policymaking and program evaluation.

Rivlin’s propositions today
Updated to 2011, the Rivlin view of rational policymaking is still central to improving policy decisions. Ironically, the Rivlin proposition that now provides the strongest basis for expanding evidence-based policies is the dramatic expansion of high-quality evidence on programs that work (or not), the proposition that Rivlin thought the weakest in 1971. The most important contribution of social science to the public good is the use of scientific designs that allow definitive answers about whether specific intervention programs produce their intended impacts. Given this powerful tool, in a perfect world policymakers could follow a simple decision rule on program funding: if the program works, continue or even expand its funding; if it doesn’t work, reduce or end its funding or find ways to improve it.

Evidence from scientific designs is now available for a large and growing set of interventions in early childhood education, K-12 reading and math, treatment of families that abuse or neglect their children, preparation of high school students to enter the world of work, community-based programs for juvenile delinquents and their families, several program models that reduce teen pregnancy, ‘second chance’ programs for children who have dropped out of school, prison release programs, and many others.

Broadening the evidence-based approach to achieve greater impacts in attacking society’s social problems, government (and the private sector, especially foundations) can employ two approaches. First, as government provides money to establish new social programs, the money should be accompanied by a requirement that the specific programs implemented at the local level be supported by strong evidence from scientific evaluations. Indeed, government might even specify a set of evidence-based programs that can be funded in order to avoid conflicts over what constitutes strong evidence. As we will see, the Obama administration has pioneered methods of identifying evidence-based programs and of ensuring that only evidence-based programs are implemented with government dollars.

Of course, anyone who has watched policymakers in action knows that they will rarely allow evidence on program effectiveness to be the sole or even major factor driving the policy process. Politicians focus on costs, the needs and desires of their constituents, the position of their party leaders, public opinion, their own political philosophy, pressure from lobbyists, the position favored by people and groups that finance their campaigns, and a host of other factors in making decisions about how to vote on program proposals. Allowing an adequate range for all these factors however, does not gainsay the possibility that in some circumstances evidence can have (and has had) a major impact on political decisions.

The second approach to employing evidence to improve social programs is to ensure that programs are implemented in a way that reliable information about program impacts is continuously generated. One of the Achilles heels of social programs is diminishing effectiveness as program models are implemented in more locations. A leading example of this problem is Head Start in the US. Over the past four decades, numerous preschool programs have shown that they can have both immediate and lasting impacts on children learning and other behaviors.⁵ Yet a recent high-quality evaluation of Head Start, a program specifically designed to spread the benefits of preschool to a very large (enrollment in 2010: 900,000 children) group of disadvantaged children, produced only modest impacts that were barely detectable at the end of the first grade.⁶ To combat the problem of diminishing impacts as programs are expanded to new sites, program operators must be vigilant in following the program model, perhaps adapted in some ways to local conditions. The key to replication of effective program models is continuous generation of evidence on program effects on participants and adjustments in implementation if the program is not achieving its expected effects. For this reason, enabling legislation should provide a mandate for continuous evaluation and the funding to make it possible.

Footnotes
1. Rivlin, A. (1971) ‘Systematic Thinking for Social Action.’ Washington, DC: Brookings.
2. Rivlin, pp. 6-8.
3. Lindblom, C.E. (1959) The Science of ‘Muddling Through’. ‘Public Administration Review.’ 19, (2): 79-88.
4. Rivlin, p. 3.
5. Ramey, C., Campbell, F., and Blair, C. (1998) Enhancing the Life Course for High-Risk Children: Results from the Abecedarian Project. In ‘Social Programs that Work.’ Ed., Jonathan Crane. New York: Russell Sage Foundation; Schweinhart, L.J. and others (2005) ‘Lifetime Effects: The High/Scope Perry Preschool Study through Age 40.’ Ypsilanti, MI: High/Scope Press; Reynolds, A.J. (2000) ‘Success in Early Intervention: The Chicago Child-Parent Centers.’ Lincoln, NE: University of Nebraska Press; Barnett, W.S. and others (2007) ‘Effects of Five State Pre-Kindergarten Programs on Early Learning.’ Rutgers University: National Institute for Early Education Research; Gormley, W.T. Jr., Phillips, D., and Gayer, T. (2008) Preschool Programs Can Boost School Readiness. ‘Science’ 320: 1723-1724.
6. Puma, M. and others (2010) ‘Head Start Impact Study: Final Report.’ Report prepared for the Office of Planning, Research and Evaluation Administration for Children and Families, US Department of Health and Human Services. Rockville, MD: Westat.

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Authors

Jon Baron
Ron Haskins

Publication: National Endowment for Science, Technology and the Arts (UK)

Brookings Roundtable on Active Medical Product Surveillance: Overview of FDA’s Sentinel Initiative

Wed, 07 Sep 2011 10:00:00 -0400

Event Information

September 7, 2011
10:00 AM - 11:00 AM EDT

Live Webinar
The Brookings Institution
1775 Massachusetts Ave., NW
Washington, DC

It has been three years since FDA launched the Sentinel Initiative and, since then, FDA has made significant progress. On September 7, the Engelberg Center hosted the first of the three-part Sentinel Initiative 101 Webinar Series, “Overview of FDA’s Sentinel Initiative” to review ongoing activities and accomplishments. The roundtable featured a presentation from Dr. Judy Racoosin, Sentinel Initiative Scientific Lead, Office of Medical Policy, Center for Drug Evaluation and Research, U.S. Food and Drug Administration.

Dr. Racoosin’s presentation provided a high-level review of the Sentinel Initiative’s scope and achievements including:

FDA’s 3-year vision for the Sentinel Initiative
A brief overview of the role of the Mini-Sentinel pilot, the Observational Medical Outcomes Partnership, the Federal Partners Collaboration, and the Brookings Institution cooperative agreement
Next steps for the Sentinel Initiative

Subsequent webinars in this series will provide a more in-depth overview of these pilot activities.

Audio

Brookings Roundtable on Active Medical Product Surveillance: Overview of FDA’s Sentinel Initiative

Transcript

Presentation Slides (.pdf)

Event Materials

Sentinel Update_Brookings 20110907

Participants

Panelists

Judy Racoosin

U.S. Food and Drug Administration

Brookings Roundtable on Active Medical Product Surveillance: Learnings from the Department of Veterans Affairs Active Surveillance Activities

Mon, 20 Jun 2011 13:30:00 -0400

Event Information

June 20, 2011
1:30 PM - 2:30 PM EDT

Live Webinar
The Brookings Institution
1775 Massachusetts Ave., NW
Washington, DC

On June 20, the Engelberg Center hosted a roundtable webinar, "Learnings from the Department of Veterans Affairs Active Surveillance Activities." The roundtable featured presentations from Dr. Fran Cunningham, associate chief consultant, Center for Medication Safety program manager, Outcomes Research, Department of Veterans Affairs (VA) and Dr. Chester B. (Bernie) Good, associate professor of Medicine and Pharmacy, staff physician, VA Pittsburgh Healthcare System, co-director, Center for Medication Safety.

The VA has been conducting a number of activities related to active surveillance within their own databases, which contain clinically enriched data for war veterans, a population that may differ in important ways from the general population. Dr. Cunningham and Dr. Good discussed methods used and lessons learned from three of the VA’s active surveillance activities:

Signal refinement studies conducted to evaluate safety concerns arising within the VA population.
Conducting risk reduction and intervention assessments to enhance patient safety, prevent untoward outcomes, and assess outcomes of specific VA interventions (e.g., formulary decisions).
Assessing and operationalizing the common data model used by the Observational Medical Outcomes Partnership (OMOP).

Audio

Brookings Roundtable on Active Medical Product Surveillance: Learnings from the Department of Veterans Affairs Active Surveillance Activities

Transcript

Presentation Slides (.pdf)

Event Materials

VAMedSAFE ActiveSurveillanceLessonsBrookingsSeminiarJune20_FINAL_for distribution

Participants

Panelists

Fran Cunningham

Department of Veterans Affairs

Chester B. Good

VA Pittsburgh Healthcare System and Center for Medication Safety

Health IT in an Era of Accountable Care: Update from the Beacon Communities

Tue, 17 May 2011 08:30:00 -0400

Event Information

May 17, 2011
8:30 AM - 12:00 PM EDT

Falk Auditorium
The Brookings Institution
1775 Massachusetts Ave., NW
Washington, DC

The Beacon Community Program – a major project of the U.S. Department of Health and Human Services' Office of the National Coordinator for Health Information Technology (ONC) – provides funding to 17 selected communities throughout the United States that have made inroads in developing secure, private, and accurate systems of electronic health record adoption and health information exchange. The Beacon Program supports these communities to improve care coordination, increase quality of care, and slow health care spending growth.

On May 17, the Engelberg Center hosted a forum highlighting various Beacon Community accomplishments and plans for upcoming years. Discussion focused on health IT implementation strategies to accelerate clinical transformation, and how various Beacon communities are advancing broader health care reform efforts. Presenters focused on how health IT and related delivery system improvements are being utilized to increase care coordination and accountability in order to demonstrate feasible paths to higher-quality and lower-cost health care.

Learn more about the Beacon Community Program »

Video

Transcript

Walker presentation (.pdf)

Event Materials

AccountableCareNeedsJimWalker

Participants

Panelists

Aneesh Chopra

White House Office of Science and Technology Policy

Joe McCannon

Centers for Medicare & Medicaid Services

Farzad Mostashari

U.S. Department of Health and Human Services

Marc H. Bennett

HealthInsight, Inc.

Ted Chan

University of California, San Diego Medical Center

Sherry Reynolds

Beacon Community of the Inland Northwest

Julie Schilz

Colorado Beacon Consortium

Herbert C. Smitherman, Jr.

Wayne State University

Catherine Bruno

Eastern Maine Healthcare Systems

Christopher G. Chute

Mayo Clinic College of Medicine

Sabrina Heltz

Blue Cross and Blue Shield of Louisiana

Robert Steffel

HealthBridge

James M. Walker

Geisinger Health System

Family Planning Subsidies: Much Ado about Something

Isabel V. Sawhill and Adam Thomas — Tue, 12 Apr 2011 12:11:00 -0400

Last week’s inter-party feud over publicly funded family planning was pure political showmanship and had nothing to do with curbing abortions, cutting spending, or helping women and children. Here’s why.

First, family planning subsidies reduce the incidence of abortion. The Republican rider that became a bone of contention last week (and was stripped from the final budget agreement) would have ended federal support for Planned Parenthood, which provides women with contraception, pregnancy tests, screenings for cancer and sexually transmitted infections, and—yes—abortion services. However, the so-called Hyde Amendment prohibits federal funding for abortion under nearly all circumstances, and the approximately $320 million in federal support that Planned Parenthood receives each year pays for its other activities—most importantly, its contraceptive services.

Detractors argue that, as a result of the federal funding that the organization receives for those other activities, it is able to reallocate some of its resources to the provision of abortions. While some reallocation undoubtedly occurs, it is almost certainly overwhelmed by the reduction in abortions brought about by federal financing for the contraceptive services that Planned Parenthood provides. Subsidizing contraception is an effective way of reducing unintended pregnancies, which are responsible for virtually all abortions (40% of unintended pregnancies are terminated, whereas the same is true of only 3% of intended pregnancies). In several recent studies, we estimated that a $235 million expansion in publicly subsidized family-planning services would reduce the number of abortions each year by more than 40,000. In short, family-planning subsidies are an important tool for policymakers who are genuinely committed to reducing the number of abortions.

Second, subsidies for family planning more than pay for themselves. The pregnancies that are prevented by publicly financed contraception tend to involve low-income women who, if they were to become pregnant, would be disproportionately likely to claim government benefits (Medicaid, welfare cash assistance, food stamps, and so forth) for themselves and their families. Preventing these pregnancies—even if they are simply delayed until the women in question have improved their financial situations—saves taxpayers money. In the studies described above, we found that an expansion in subsidies for family planning services would likely save taxpayers more than five dollars for every one dollar that the government spends. Given the strong cost-saving properties of these subsidies, they ought to be particularly appealing to fiscal conservatives who are concerned about our yawning national debt and the burden that it will place on current and future generations of taxpayers.

Third, subsidized family planning is good for children and their families. Women who experience unintended pregnancies are less likely to graduate from college, have lower levels of labor-force participation, and are more likely to be unmarried than women who experience intended pregnancies. Similarly, children who were conceived unintentionally have lower levels of educational attainment and higher rates of infant mortality, and they are more likely to engage in criminal and delinquent behavior as they get older. By reducing the prevalence of unintended pregnancy, family-planning subsidies help to ensure that a larger share of children are raised in stable and healthy household environments by mothers and fathers who are ready to assume the responsibilities of parenthood.

In sum, subsidized family planning is a public-policy trifecta: it reduces the prevalence of abortion, it saves tax dollars, and it improves the lives of children and families. If this policy comes under fire once again, we hope that cool heads will continue to prevail. It would be a disservice to children, their families, and American taxpayers if family planning subsidies were relegated to the status of a political football that is one day kicked to the curb.