US Health Policy Expertise: In Keeping with the Pluralistic Democratic Model?

• In Event: Health Policy Elites in a Populist Age: Comparative Perspectives

Abstract

This proposal focuses on the experts who have been most consulted by US decision makers since the 1970s on questions of healthcare policy, i.e. the actors to whom US decision makers turn for their expertise to advise them on healthcare policy issues, develop programs and instruments of reform, and to hold executive positions within the administration (cf. box outlining methodology). When, from the late 1930s to the 1960s, this type of role was primarily carried out by doctors (among the Republicans) and by senior civil servants from the Social Security Administration (among the Democrats), this situation began to change in the 1970s. From then on, the vast majority of such individuals have belonged to the category of “policy specialists” described by Hugh Heclo and John Kingdon: individuals who dedicate their career to a particular area of public policy, and are affiliated to non-governmental expert organizations. The emergence of these actors, who describe themselves as “health policy analysts”, is thus closely linked to the development of policy analysis as an established form of expert knowledge that claims autonomy from academic knowledge and that has given rise to the particular professional status of “policy analyst”.
This paper analyses the emergence and conditions of institutionalization in the United States of theses health policy analysts in a space of professionalized health policy expertise outside the state, especially around think tanks, foundations, and applied research centers.
By posing the question of the construction of their legitimacy, the paper shows how, contrary to the literature on expert opinion which generally postulates the importance for the experts to relate to a recognized and autonomous area of scientific knowledge, health policy analysts have taken over an operational discipline – health services research - that has no claim to autonomy but which, while assuring them a certain scientific credence, remains adapted to the requirements of their profession of expert . The hypothesis is that this limited claim to autonomy, far from being an obstacle to their institutionalization, was instead an asset. This research then raises more generally the question of the form of knowledge that the development of these areas of professionalised expertise based on applied disciplines tends to produce in the public space. The priority given in particular to “feasibility” limits the critical dimension of the knowledge produced, as well as risk-taking in the hypotheses and predictions being formulated, which must remain in conformity with what is perceived as being within the universe of possibilities.
Relating to the annual theme of the conference, the paper will show that contrary to what is sometimes claimed, the externalization and dispersion of the production of expertise across multiple non-governmental institutions does not necessarily render American health policy expertise more conform to the pluralistic democratic model, in both terms of sociological profiles and content of knowledge and recommendations.
Most consulted health policy experts during the period were identified thanks to the building of an original database (15 000 individuals), which served as a basis for the qualitative study. This one combined extensive reading of written sources (CVs of health policy experts, publications by experts, professional archives of the Association for Health Services Research, partisan documents, official reports, etc) with evidence from 78 interviews (1,5 hours long on average). Half of these interviews were with experts identified (thanks to an original database built by Ulrike Lepont and including 15 000 individuals) as being, or as having been, regularly consulted by policy makers from 1970 to 2010. The other half was with marginalized or less consulted experts, as well as with actors working in contact with health policy experts (officials from the federal government, Congress staffers, employees of AcademyHealth [previously the Association of Health Services Research]).

Author

• Ulrike Lepont, Université Versailles Saint-Quentin