Earlier this summer, when the House Subcommittee on Appropriations Bill for Fiscal Year 2013 was considered, Republicans included a provision (section 227) to get rid of the federal Agency for Healthcare Research and Quality (AHRQ).
The AHRQ conducts systematic reviews of medical evidence to better inform providers and patients about which treatments seem to work. It does so by evaluating how new treatments stack up to other existing therapies, and by evaluating whether there is good supporting evidence to recommend them. This research, then, helps people make smarter decisions about medical care by analyzing what is known and by making available information about the comparative effectiveness of different treatments.
Sounds like a useful thing, right? So why might Republican lawmakers want to defund an agency that helps us understand more about which medical care is most effective? I have a couple of ideas.
First, it allows Republicans to recycle anti-Obama talking points about both the stimulus bill and the Affordable Care Act. The provision in health care reform that makes preventive services available to insured patients with no copay — such as the many preventive services for women that are now covered — requires that that list of services be based on the U.S. Preventive Services Task Force’s evidence-based recommendations. Although AHRQ and USPSTF aren’t exactly the same thing, it gives opponents a chance to confuse voters by conflating evidence-based reviews to inform care with rationing to limit care.
Likewise, when funding for comparative effectiveness research — primarily conducted through AHRQ — was included in the 2009 stimulus bill, it kicked off conservative outcry about “rationing” of care. A political analyst for Consumers Union called that outcry “a very clever effort by a bunch of well-paid lobbyists funded by people who don’t want the American people to know some pills work better than others.”
And that brings us to a second reason. Comparative effectiveness research can identify where highly advertised expensive new drugs or treatments aren’t any more effective than less expensive therapies or placebo. For example, a recent AHRQ review concluded that the heavily advertised drugs for urinary incontinence may help less than basic lifestyle changes and may not provide enough benefit compared to placebo to offset the cost and side effects for many patients.
For another example of hostility toward evidence-based reviews, it was a similar process that resulted in the recommendation that women in their 40s who are not at high risk for breast cancer don’t necessarily need regular mammograms — a finding that makes a lot of sense based on the medical evidence, but was controversial both among health care institutions getting paid for doing mammograms and the giant, screening-focused Komen organization.
So the pharmaceutical industry, health care lobbyists, and other associations with vested interests might have a pretty strong interest in minimizing research that could negatively affect industry bottom lines. Both major political parties take a lot of money from pharmaceutical companies, which might be why we haven’t heard as much political opposition to this move as you might expect.
Some expert health professionals, though, have not been so quiet on the proposed elimination. The American Academy of Family Physicians wrote a letter urging Congress not to defund the agency, calling the move, “pennywise and pound foolish,” and pointing out that “this research helps Americans get their money’s worth when it comes health care. We need more of it, not less.” The president of the Association of American Medical Colleges has also spoken out against the provision.
In a recent op-ed in the Philadelphia Inquirer, Jeffrey C. Lerner, president of the ECRI Institute (a center that does evidence-based medicine research for AHRQ), explains the value of AHRQ’s work for patient safety and effective health care and notes that this isn’t the first political attempt to kill the agency. He asks an essential question — “Why is objective information so threatening?” — and goes on to write:
The answer is that objective information shakes up the status quo. Many constituencies think objective information is information that supports their perspective, and are resistant to change, no matter what the evidence shows. So, truly objective information is a very dangerous weapon.
But it is tough to argue publicly that objectivity is bad, so a time bomb is buried in this House bill in an attempt to avoid having to first openly engage the public in a national debate on the best ways to improve quality and reduce unnecessary expenditures.
How will we find out what quality is and how will we find out what unnecessary expenditures are? Without AHRQ, we won’t.
It’s not completely clear what will happen next in the effort to defund AHRQ, as the 2013 spending decisions will be delayed until after the presidential election. It’s worth keeping an eye on, though, and we’ll update as this moves forward.
[Disclosure: some of my work involves systematic reviews/comparative effectiveness research funded by AHRQ.]