JAMA Forum: The Politics of AHRQ

After a hiatus of a little more than a year, I’m pleased to be invited back as a contributor to the JAMA Forum. I took a leave to serve as Director of the Agency for Healthcare Research and Quality (AHRQ) from May 2, 2016, until the end of the Obama administration. AHRQ is a unique agency with an inspired, highly dedicated, and effective staff. On a budget that is about one-hundredth of 1% of all US health care spending, the agency plays a central role in translating evidence into practice to improve quality and safety.

AHRQ is the champion for efforts that have resulted in significant reductions in medical errors, one of the leading causes of US deaths.  The agency also oversees the US Preventive Services Task Force and maintains data sources, such as the Medical Expenditure Panel Survey, which provide the basis for monitoring the performance of the US health care system and the costs within it.

Given a choice, I would have remained in the position after a change in the administration of the federal government, but like most political appointees, I was told to resign, or I would be fired.

The AHRQ director does serve at the pleasure of the President. However, for longtime observers of AHRQ, my situation did seem to be a departure from what had occurred in the past. None of the 5 previous agency directors had been dismissed because of a change in administration. This highlights the political vulnerability of the AHRQ director, which is widely considered a scientific role. My replacement, Gopal Khanna, MBA, appointed by Tom Price, MD, secretary of the Department of Health and Human Services (HHS), on May 9, 2017, is the first nonscientist to lead the research agency.

Reorganization Ahead?

The Trump administration reduced AHRQ’s 2017 budget by $10 million below the agency’s 2016 appropriation of $324 million. It has also recommended as a part of its fiscal-year 2018 budget to dissolve the agency and reformulate its functions as an institute within the National Institutes of Health (NIH), with an additional 16% budget cut. Secretary Price testified before Congress that the administration perceives AHRQ’s work as somewhat redundant with that performed at the NIH and that he expects that relocating it within the NIH can help to rectify this situation.

Although there are reasons to be skeptical about the motivation for the proposed change in AHRQ’s governance, there are some potential benefits as well. The NIH enjoys broad bipartisan support and were it to be a part of the NIH it might not only benefit from that support but also anticipate that the steady historical growth in the overall NIH budget over time (notwithstanding the president’s current proposal to cut the NIH’s 2018 budget by 18%) would apply to AHRQ as well.

On June 22, 2017, NIH Director Francis Collins, MD, PhD, testified before Congress that the NIH could either absorb AHRQ as a new institute or distribute its functions within the current structure of the NIH. Although Dr Collins expressed indifference regarding these 2 options, the distinction could have major implications for investigators who rely on it for support.

The NIH is a federation of research entities—institutes, centers, and offices. Institutes are the most powerful, reflecting what Congress perceives to be the highest priority areas of research, and they receive line item appropriations from Congress. Institute directors enjoy a degree of autonomy in leading the effort to organize research in their field. Center directors lead other efforts within the NIH but they are less prominent and are more reliant than institutes on the cooperation of the NIH director to formulate their research agendas. Programmatic office directors are housed in the office of the director and typically control very small budgets. They require cooperation from institute and center directors to support and administer the research studies. At the NIH directors meetings, they literally do not have a seat at the table.

Consequences of Change

Were AHRQ to be moved to the NIH as an institute, its director could expect a specified budget and opportunities to have regular interaction with the other NIH institute directors as an equal. This could enhance the potential for AHRQ to collaborate and develop cofunding opportunities with other institutes. AHRQ’s traditional focus on translating evidence into practice would be a natural extension of the work the NIH does to discover new treatments.

AHRQ could also play a leadership role in helping other institutes connect their narrowly defined disease-based efforts to a larger whole-person agenda needed to support patient-centered care. However, downgrading AHRQ to an office or center within the NIH could undermine its capacity to be an effective partner and threaten the viability of current AHRQ functions, such as primary care research, which are poorly understood or undervalued within the existing NIH institutes.

There would be other important consequences of AHRQ becoming part of the NIH. The AHRQ director would be challenged to convince other research leaders about the value of investigation beyond the perceived boundaries of a biomedical model. The AHRQ director would also lose direct access to the secretary of the HHS, who has often served as an ally in connecting AHRQ’s work more broadly within the HHS. However, as an institute director within the NIH, the AHRQ director would not be subject to replacement tied to political elections. With the exception of the National Cancer Institute director, which is a presidential appointee, the other institute directors are chosen using a vetting process akin to an academic search for a medical school’s department chair. Although institute directors are accountable to the NIH director, a scientist who is also a political appointee, historically, they have been insulated from the political process so that they can provide stable leadership that spans across administrations.

Stakeholders with an interest in AHRQ face a difficult decision about how to advocate for the agency’s future. Is it best to hunker down and try to defend AHRQ as an independent agency or embrace a change in its organizational governance, which involves some risks but perhaps greater financial security?

The House Appropriations Committee has passed a fiscal-year 2018 budget that would reduce AHRQ’s appropriation by $24 million while increasing the NIH’s overall budget by $1.1 billion. If passed by Congress, this would amount to a $64 million cut to AHRQ’s annual budget over the past 3 years (18% of its $364 million appropriation in fiscal-year 2015).

The House appropriators did not make a recommendation to change AHRQ’s organizational governance, but they did direct AHRQ to conduct a study to formulate recommendations regarding its future organizational location. In the current political climate, it is reasonable to wonder how long AHRQ can survive as an independent agency and whether, paradoxically, it might enjoy greater freedom and be more effective in sustaining its work as an institute within the NIH.

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About the author: Andrew Bindman, MD, is professor of medicine and epidemiology & biostatistics based within the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco (UCSF). He is a former Director of the Agency for Healthcare Research and Quality and a member of the National Academy of Medicine. (Image: Ted Grudzinski/AMA)

 

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