Slashing and Dissolving
As reported by the Kaiser Family Foundation’s Health News site blog, last week the Trump administration “dissolved” the Agency for Healthcare Research and Quality (AHRQ), the agency that has for decades been at the center of the US Federal Government’s support for health services research in the service of improvement of our healthcare system. The agency had about 300 employees and a budget of $369M (less than 0.04% of HHS spending), allocated mostly to grants to university-based health services researchers. This month, the administration slashed more than half of the employees, draining essential PhD-level expertise. They proposed to dump the remainder into the NIH for now, where it is unlikely that the prior focus will persist. KFF reported that when members of Elon Musk’s “DOGE” team first met with AHRQ leaders last month, they said they planned to cut the staff by 80-90% even though they acknowledged they did not know what the agency did. In the US House of Representatives, the Republican 2025 budget proposal for AHRQ is zero.
It felt like home
Since my career started in 1990, I’ve been involved in various interrelated fields, with the field of health services research near the center, with nearby adjacent fields being quality and outcomes measurement, clinical effectiveness, practice guidelines, quality improvement, and population health management. The U.S. federal government’s involvement in health services research touches a number of different agencies, including NIH, FDA, CDC, CMS, CMMI, and ASPE. But the part of the federal government that was most focused on supporting the health services research community was the Agency for Healthcare Policy and Research (AHCPR), which was renamed the Agency for Healthcare Research and Quality (AHRQ) in 1999. Among all the government agencies, that felt most like home.
1990s: Guidelines and Cost-Effectiveness Era
When I first got to know AHCPR in the early 1990s, it still had “policy” in its name. Policy included broad ideas about how healthcare should be organized and financed. But, in that era, the policy emphasis was on the type of policies that applied to the actual decision-making of clinicians at the point of care: clinical practice guidelines (and their cousins: protocols, algorithms, care maps, appropriateness criteria and quality metrics). This was the era when science was revered. Among physicians, particularly in specialties such as cardiology and oncology, clinical trials were worshiped. The term “evidence-based medicine” was on everyone’s lips. But the reverence for science was not limited to biomedical science. The fields of epidemiology and economics were also respected, along with other social science disciplines. This co-existing respect for biomedical science and economics led to intellectual integration. We understood that healthcare resources were not unlimited, and that we could use rational thought, logic and data to inform and optimize the allocation of resources. We understood that we had to focus not only on efficacy (the outcomes achieved in rigorously controlled clinical trials), but also on effectiveness (the outcomes achieved in real-world conditions). We understood the need to avoid waste and improve efficiency. And we understood that we needed to consider not only the “hard” outcomes such as deaths, but also more subjectively measured patient experience, including pain and physical function. To enable the simultaneous consideration of multiple health outcomes, we understood the need for summary measures — most notably the concept of the “quality-adjusted life year” (QALY). To simultaneously consider both health and economic outcomes, we understood that we needed to create summary measures that combined both — most notably the concept of the cost-effectiveness ratio. I consider this era to be the golden era, when things fit together into a coherent, internally consistent whole and there was a sense of optimism that our thinking and methods were only going to improve, for the benefit of the whole population.
2000s: Safety and Quality Era
But then, toward the end of the 1990s, there was a backlash. While the idealistic health services research community was flourishing, the HMOs were being taken over by more opportunistic people who realized that clinical process improvement was tedious and that there was money to be made by focusing instead on two main alternative strategies: (1) avoid sick people, and (2) deny payments. These strategies harmed the HMO members, and they also were particularly harmful to specialist physicians for whom denials were pay cuts. So, the specialists got their patients riled up, and “managed care” was transformed from an idealistic euphemism to a nasty insult, as I described in a blog post in 2011. During that era, the AHCPR was busy developing guidelines, openly and innocently considering cost-effectiveness based on cost per QALY metrics, declaring certain procedures to be cost-ineffective, even if they were profitable to the specialists. The mustache-twisting HMO administrators were happy to apply those guidelines to justify their denials, and the specialists (starting with the urologists) were incensed that the government (AHCPR) was complicit in the evil called “managed care.” A political furor erupted, leading to regulations prohibiting the US government from uttering the word QALY. AHCPR needed to be cleansed, which was accomplished by removing the word “policy” from the sign outside their headquarters and renaming it the Agency for Healthcare Quality and Research (AHRQ). No more government meddling in “guidelines.” Avoid controversy. Stick to the boring topics like safety and quality. I was disappointed in the defanging of the agency, and more broadly in the fact that our noble field had been discredited by HMO CFOs and that we were banished from real influence for what I call the lost decade. Nevertheless, quality and safety are actually important. We were able to remember to order needed mammograms, pap smears and immunizations more often. We were able to reduce hospital-acquired infections. We developed lots of HEDIS metrics and produced a lot of “report cards.” It kept us busy and occupied and not talking about QALYs or cost-effectiveness.
2010s: Health Disparities Era
Even back in the 1990s, it was a common subject of health services research to measure and comment on the lower utilization of healthcare services and worse health outcomes among “disadvantaged” groups, defined by race, ethnicity and soci0economic status. In the 90s, I was a coinvestigator in an AHCPR-funded “Medical Treatment Effectiveness Program” (MEDTEP) center at Henry Ford Health System in Detroit, addressing such disparities among the African American population through efforts to improve the “cultural sensitivity” of our care processes and by engaging with churches and other community organizations. So, we’ve been on the case for a long time. But, during the 2010s and particularly in the the first half of the 2020s, the emphasis on health disparities by AHRQ and other government agencies continually increased, and the goals of health disparities efforts changed from the types of things we were doing in the MEDTEP center to a more “affirmative” and “reparative” approach. I can fully understand why people that have been subject to injustices and who have long been frustrated with slow and seemingly insincere efforts to resolve those injustices to demand stronger and more exclusive focus. They are rightfully angry and they want the problem solved yesterday. However, it is also true that the health disparities focus of the AHRQ and other agencies increased to the point of crowding out efforts to make fundamental improvements in healthcare structures and processes intended to help everyone. It has sometimes seemed as if the AHRQ team (and cousins at CMS CMMI and in other agencies) were saying “first things first, we reallocate resources to the disadvantaged and underprivileged, and then maybe later we can talk about improving the overall healthcare system.”
During this era, the federal government continued efforts to push further into the background the 1990s interest in cost-effectiveness. When leaders of the private healthcare and health insurance industries talked about health care “value” and advocated for “value-based contracts” — the federal government agencies continued to treat the topic as an untouchable third rail. As I’ve noted in a blog post in 2024, the CMS CMMI played Animal Farm-style linguistic games to define “value-based care” so that it had nothing to do with cost, efficiency, waste, economics, population or finances — it is just about quality of care, provider performance, and whatever experience individual patients value. The’ve been continuing the health economics denialism of the late 1990s.
2025 to ?: Anti-Science Era
Now, we have entered a new era. In the current era, the federal government prioritizes loyalty over evidence. The federal government is no longer just focused on directing the priorities of health services research. From the perspective of the current administration, scientists, and particularly social scientists, cannot be trusted because the scientists say their loyalty lies with the evidence, and to the degree they have shown bias, it has been in favor of fighting injustice or saving the environment. In the specific context of health services research, the administration sees the track record during the health disparities era, and concludes that the agencies and the community of health services researchers they fund are unlikely to become loyal to the administration’s commitment to end “woke” and “DEI.” Therefore, burning down the agencies and starving the researchers is the best option. Unfortunately, there is an asymmetry between the tediousness of building up a scientific community and the expediency of destroying such a community. The brain drain can occur quickly. Health services researchers will reluctantly but certainly move on to other domains of research, or perhaps take up gardening.
Rebirth Era
Although I am not feeling optimistic, I’d rather not end with gloom. At some point, in four months, or four years, or forty years, the anti-science era will wane. At some point there will be an opportunity to start again, to reestablish the scientific and philosophical foundations of the field of health services research, and of the healthcare field itself. My hope and expectation is that a fresh start will look more like the 1990s, before health economics denialism set in, before the field was co-opted to any particular narrow focus, and before loyalty was prioritized over evidence. I hope to live to see the day when health services researchers operate again at the intersection of biological sciences and health economics, willing to bravely:
- Acknowledge limited resources and make trade-offs even when others prefer to blame the messenger,
- Get into details and take on complexity even when the audience demands simplicity,
- Stay on mission even when others focus on serving narrower interests and signalling their own virtue, and
- Follow facts and logic to conclusions even if they are opposed by those profiting from the status quo.
