The Legislative Battle Over Health Services Research

Prologue: The large geographic variations that characterize medical practice trouble health policymakers because of implications that a rational basis is lacking for much medical care and that money is being wasted. In 1989 these concerns took legislative form in the law that created the Agency for Health Care Policy and Research (AHCPR) and gave it a mandate that focused heavily on research on the outcomes and effectiveness of medical care and on the development and dissemination of practice guidelines. As Brad Gray notes in this paper, this legislation almost did not pass, not because of its controversial nature but because of political complexities like those that face any legislative proposal. Both the improbability of this legislation and its implications regarding accountability in health care led Gray to seek to understand how it came into being. The results of his inquiry should interest both health services researchers and students of the policy process. Gray's history is followed by the brief comments of John Wennberg, whose ideas and research on practice variations are central in Gray's account. Gray, a respected researcher and scholar of ethical and policy issues in health care, is a professor in the Department of Epidemiology and Public Health at the Yale School of Medicine and director of Yale's Program on Non-Profit Organizations. He received his doctorate in sociology/medical sociology from Yale. For ten years he was a senior staff officer and study director at the National Academy of Sciences' Institute of Medicine. His book, The Profit Motive and Patient Care: The Changing Accountability of Doctors and Hospitals, was published by Harvard University Press in 1991. Abstract: Budget reconciliation legislation in 1989 created the new Agency for Health Care Policy and Research (AHCPR), which folded in the National Center for Health Services Research and Health Care Technology Assessment, among the law's other provisions. The creation of the new agency represented a shift in priorities toward outcomes and effectiveness research in medical practice and made explicit the federal government's role in developing practice guidelines. The new agency was born in the midst of an extraordinary bipartisan budget negotiation process in late 1989; its becoming linked to the contentious issue of physician payment reform nearly killed the new agency before it appeared. The narrative of political wrangling that resulted in the creation of AHCPR spans Capitol Hill, the White House, the agencies of the Department of Health and Human Services, and renowned health services researchers on either coast and in Washington, D.C.