Wilensky G. The Agency Under Threat That We Need Now More than Ever. JAMA Forum Archive. Published online September 30, 2015. doi:10.1001/jamahealthforum.2015.0040
Two decades after a near-death experience, the Agency for Healthcare Research and Quality (AHRQ), the only federal agency devoted to health services research and improving the safety and quality of US health care, is at risk once again. Last June, the House Committee on Appropriations passed a bill that would terminate AHRQ’s funding. Two days later, the Senate Committee on Appropriations voted to cut AHRQ’s budget by 35%, decreasing the AHRQ FY 2015 budget by $128 million.
Gail Wilensky, PhD
In 1995, the agency, then known as the Agency for Health Care Policy and Research, was in danger being defunded for a variety of reasons, including having raised the ire of many back surgeons after developing clinical guidelines on the appropriate treatment of low back pain. Bill Frist, Sr, former senator and Senate majority leader from Tennessee, recently described his efforts to salvage the agency at that time, albeit ultimately with a 21% cut in its budget, and articulated his support for the current agency.
The rationale today for the proposed ARHQ budget cuts is different than it was in 1995, and the House and Senate differ in their reasons, as well. The position in the House is that a separate agency for health services research is unnecessary because AHRQ’s work duplicates work in the private sector or at other agencies, such as the National Institutes of Health (NIH). The House’s bill allows the transfer some of the AHRQ’s functions but without any funding. The Senate’s proposed reduction is driven by budgetary need, not policy. The Senate committee effectively made across-the-board cuts in the budgets of most health agencies so it could increase funding for the NIH and also respond to the need to keep spending below current levels because of sequestration, the automatic spending cuts that were enacted after the debt ceiling crisis of 2011.
With the fiscal year ending today, and expected that Congress to pass a short-term continuing resolution to keep government funding at its current level while a larger budget deal that determined the treatment of sequestration was worked out. At that point, the starting position for ARHQ funding was $0 for the House and a 35% reduction below current level for the Senate.
The Senate’s position is perhaps understandable, but it is short-sighted, given AHRQ’s function and purpose. The House’s position is just wrong.
People should care about how this portion of the budget debate is resolved because AHRQ is important for efforts to improve our health care system.
AHRQ focuses on health services research—research on improving safety, quality, and efficiency of delivering health care in different health care settings, as well as on the use of health information technology in achieving these goals. This focus is different from that of other health agencies, including the NIH, the Centers for Disease Control and Prevention (CDC), and even the Patient Centered Outcomes Research Institute (PCORI), a nongovernment institute created as part of the Affordable Care Act (ACA).
For example, NIH’s focus is on basic and applied clinical research—studying the causes of diseases and researching potential treatments—and on transferring new technologies and therapeutic interventions from the research bench into the clinic. The CDC’s focus has traditionally been on disease prevention and monitoring, as well as on collecting basic information and statistics on health status, insurance coverage, and health care use from surveys carried out by the National Center for Health Statistics. PCORI focuses on analyses of the comparative effectiveness of various ways to treat specific diseases—the “what to use when, for which patients, and under what circumstances.”
Certainly, the functions of these other agencies are important and need to continue. But they are not AHRQ’s functions, which are equally important and which also need to continue. US health care spending totals more than $3 trillion (almost 18% of the gross domestic product), yet as much as 30% of US health care may be of low value. Patient safety and medical errors also remain major problems.
Given the cost and the shortcomings of US health care, it shouldn’t be difficult to recognize the need for an agency that focuses on strategies designed to advance evidenced-based treatments, to improve patient safety, to foster the use of health information technology in facilitating these goals, and to aid the dissemination of improved clinical care strategies. But apparently it is, as I’ve observed during the 40 years I have been in the field.
Finding effective therapies for new and existing diseases, especially in an aging population, is obviously important, as is improving prevention and preventing public health disasters. Although ARHQ’s focus on improving our understanding of how to deliver these therapies and preventive interventions to the appropriate populations in the most efficient and effective ways may appear less compelling than developing new therapies, the agency’s efforts are providing essential information.
For example, AHRQ has been instrumental in developing and maintaining a series of surveys that are vital to improving patient experiences and quality of care, including surveys of patient safety related to care in hospitals, medical offices, and nursing homes. The agency has also fielded the Medical Expenditure Panel Survey (MEPS), an immense data set that began in 1996 and includes household data drawn from a sample of families and individuals that participated in another survey fielded by the CDC’s National Center for Health Statistics. MEPS provides a wealth of data on the specific health services US patients use and how frequently they use them, on the cost of these services and who pays for them, as well as data on the cost, scope, and breadth of health insurance held by the US public.
The ACA is helping to significantly reduce the number of uninsured individuals, but little is known about how the expansion of insurance is affecting the use or costs of health care or the health status of these individuals. The MEPS data will provide a unique opportunity to see how the changing pattern of public and private insurance coverage resulting from the ACA is playing out.
Eliminating or gutting the agency that focuses on these issues and on ways to reduce health care spending and improve quality could hardly come at a less opportune time. Everyone in Congress, including Republicans who want to improve or replace the ACA, should be interested in gaining a better understanding of the ACA’s effects and the likely effects of any proposed alternatives to the law.
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Gail Wilensky, PhD Gail Wilensky, PhD, is an economist and Senior Fellow at Project HOPE, an international health foundation. Dr Wilensky previously directed the Medicare and Medicaid programs and served in the White House as a senior adviser on health and welfare...