Besides short-term budgetary or political advantage, what considerations enter into policy pronouncements made by health care decisionmakers? Does history enter into it? And do they really ask themselves if what they know to be true actually has a factual basis?
A recent paper posted on the British History & Policy web site considers this question in the context of the policies of the British National Health Service. Author Virginia Berridge, of the Center for History in Public Health at the London School of Hygiene and Tropical Medicine and a cofounder of History & Policy, interviewed 15 “key informants”–advisers on health policy–to explore the issue. Her findings: The history of health policy was used in an ad hoc way in policy formulation, without input from historians.
“Historians are mostly seen as the providers of the raw materials for analysis. Policymakers like to use history but they do not usually see historians or historical interpretation as a necessary part of the frame. There is little knowledge of the interpretative role of history and views of history are dominated, in the view of historians, by out of date perceptions or by mistaken views of personalities and ‘great men’. Invoking (NHS founder) Nye Bevan is a cottage industry among health ministers.”
She adds that historians are at a disadvantage when compared to political and social scientists:
“It is difficult for historians to be aware of the direction of the current narrative within government. Historians mostly lack those networks and entrée. Journalist-historians and social scientists with policy networks were clearly at an advantage, with more policy antennae. Social scientists in advisory positions are key users and promoters of history for policy advice. However, the history they are using is not always in accord with what historians are saying and this is a general problem in the health advisory field.”
The complaint is similar to that of Morris Barer and colleagues in paper written nearly 10 years ago Barer and colleagues cite five health policy “zombies” or, as they call them, “discredited ideas that will not die.” The five “zombies” they cite are that the aging population drives spending growth; that user fees can help control spending by reducing frivolous services; that covering the uninsured would drive health care spending higher; that high U.S. health care spending produces the best care in the world; and that more care equals better health. “What makes these ideas ‘zombies’ is their remarkable persistence in the face of apparently decisive refutation,” they write. “Like the bunny in the battery commercial, they go on and on and on.”
Barer concludes by putting the persistence of those zombie narratives into a construct first proposed by Francis Bacon: that human beings would continue to believe stories that are false because human nature seeks a simple answer, based on direct experiences, filtered by the marketplace of human communication, and affected by personal dogmas.
Does history matter? In commemoration of Health Affairs’ 25th anniversary, we’ll be publishing a book that contains the best policy commentary from the last quarter-century, with its historical context. Look for excerpts from the “Classic Health Affairs” book here on the Health Affairs blog.