Ungoverning and the Future of Health Services Research

The first months of the second Trump administration have, as predicted, been a matter of ungoverning. In the name of efficiency and budget reduction, but with other more vindictive motives scarcely hidden, the administration is intentionally degrading the historical functions of government, laying off federal workers, defunding programs, and undermining support for long-time, bipartisan national priorities. One such federal investment priority that has produced consistently positive economic and social returns over the past decades has been the work of biomedical science.

There has been an irregular removal of topics that scientists interested in health have historically taken up (e.g., vaccines, discrimination), and also assaults on scientific review processes, the organization and governance of institutions, and the calculations related to the costs of doing research (facilities and administrative cost rates) at the thousands of colleges and universities that receive federal funding. Any biomedical scientist who is writing an editorial in March 2025 is of two minds: is this a moment that calls for an earnest re‐examination of what we do in science and how it gets done, or is it rather the very moment for a full-throated defense of the workings of an incredibly successful biomedical ecosystem that the government is perversely sabotaging?

The National Institutes of Health (NIH) generates $2.46 of economic activity for every $1 of research funding. Indiscriminate cuts to health-related research through NIH will have broad societal implications for scientific progress, and community and individual well-being. The case for federal funding of certain kinds of biomedical research—basic science, and clinical trials addressing important patient decisions related to cardiovascular disease and cancer—has been emphasized by others. Less attention has been directed at funding research aimed at the broader health of the American population and the health systems that serve it.

Health services research—investigations into the quality, delivery, organization, financing, structure, and processes of health systems—is funded through multiple federal sources, the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC), as well as NIH. As has been amply documented, the United States continues to spend more on health care per capita than any other country, yet its life expectancy falls below those of its peers. It always comes as a surprise, then, that federal funders have historically underinvested in studies on how to reduce health care costs and improve efficiency, devoting only a small slice of their budgets to these trillion-dollar issues. It is clear that scientific discovery contributes to health only when it is successfully applied to policy relevant questions, so implementation of findings remains critical.¹

The potential damage from reducing support for health services research is high at this moment when the current administration in on the verge of making deep cuts to Medicaid, which pays for health care for 72 million Americans. Yet one could imagine this administration arguing: why would we need to continue to study the effects of Medicaid, its adaptations and effectiveness, given its downgrading in our list of national interests? We can foresee that this administration’s reconfiguration of Medicaid will limit eligibility and lead to significant reductions in benefits and access to care. The impact on hospitals and health systems will be significant, particularly for safety-net and rural hospitals, which already are on the brink of closure. Patient revenues will fall, uncompensated care will rise; there will be staff layoffs and site closures; there will be damage to the nursing home infrastructure in the country.

Medicaid has been a central focus of health services research over the past decade, with investigations picking up speed following passage of the Affordable Care Act. Along with Medicare—another focus for health services researchers—these two federally-funded programs represent major streams of taxpayer spending and are certainly worthy of intense study. Given how much we spend on health care as a nation, health services research has shown that markets do not function well in this part of the economy because consumers are not able to judge the value of expensive drugs, tests, and procedures.² Therefore, we need rigorous evidence on effectiveness and value to allocate our limited public resources to the most beneficial investments in our health. Generating such evidence is what health services and policy researchers do. Without it, drug companies, device manufacturers, and service vendors of all kinds will engage in competitive marketing to sell their products and services without hard evidence of benefits and risks. The most aggressive and deep-pocketed marketers usually will be the most successful, and that’s not a recipe for our financial well-being.

Or for our health. The popular understanding of health has often remained limited to descriptions of health care, with an overwhelming focus on clinical practice and curative approaches.  Health is, of course, shaped by the world around us—where we live, work, and play. Medical interventions constitute only 10-20% of modifiable factors affecting health.³ There has been a longstanding underappreciation of the foundational role that social structures and policies play in shaping the conditions for health and preventing ill health. Prevention is central to health maintenance (the avoidance of health care use) but remains underfunded in our disease-focused biomedical paradigm.

The months and years ahead will be rough for all biomedical research, including health services research. Reducing funding levels for science is an existential threat to our society’s chances to improve health, lengthen life expectancy, and reduce illness and disability.  Let me offer ten areas (threats) that health services researchers will need to watch out for over the next few years.

1. Biomedical budget-cutting aimed at health services research areas deemed too “politicized,” such as Medicaid.
2. Medicaid and Medicare data, already difficult and expensive to access, could be made off limits to academic researchers. Coverage and cost figures thereby could be more easily manipulated in public announcements to hide policy truths.
3. Longstanding national population-based surveys, such as the Pregnancy Risk Assessment Monitoring System (PRAMS), have been cancelled, and others may impose new limits on the measurement (e.g., poverty indices) of certain research domains.
4. Data sets have already been removed from certain federal agency websites, limiting longitudinal studies. Efforts to coordinate and align ongoing state-level efforts to develop all-payer claims databases to inform policymaking in the public and private sectors may be at risk. 
5. Altering or blocking guidance documents and recommendations from US Department of Health and Human Services agencies, such as the CDC and the Food and Drug Administration (FDA), would change the way the population thinks and learns about health.
6. Reversing the Foundations for Evidence-based Policymaking Act of 2018 (signed into law by Trump), which requires all cabinet-level agencies to support their policy and budget decisions with evidence, could put an end to policy research and economic analysis that builds evidence for developing and coordinating policy, crafting legislation, and establishing budgets.
7. Modifying the rubric used to assess grant applications to consider the cultural values of the parent academic institution, rather than limiting review to the methodologic rigor and significance of the research proposed, could upend the grant review process. This strategy could become part of an effort to control universities through biomedical grants.
8. Advancing health equity in a health care delivery system that too often fails minority, rural, and other underserved communities, could be at risk if “equity” work becomes what the administration considers unacceptably “controversial, high profile, or sensitive.” 
9. Interruption of graduate student training would deplete the next generation of health services researchers. Congress specified in 1989 that one-half of 1% of the National Research Service award budget for training be allocated for training health services researchers, increasing that outlay to 1% twenty-five years ago; this investment could be revoked.
10. Attacks (grant audits, refusal to fund) could target individual researchers for political views expressed in original research papers, editorials, or social media posts that offend the government.

The administration’s direction in these ten areas will be a product of financial and philosophical considerations; there is unlikely to be a theory of science involved, just a world view. As we have seen outside the biomedical health domain, a climate of fear may be more useful to the state than any sort of logic if repression is the goal. Even if imposed randomly, institutional instability will lead to self-censoring by researchers.

This administration, which purports to be interested in reducing inefficiency, may need reminding that the only way to pinpoint wasteful spending—that is, payments for activities that do not improve health or improve it enough to warrant the amount spent—is through detailed study. At whatever level of funding decided upon, what should we want government funding of health services research to support? Work on unprofitable problems like the opioid epidemic (partly policing rogue pharmaceutical companies), veterans’ suicide, and the health care system’s ability to mitigate the effects of climate change and be more resilient during natural disasters. Investigations stemming from interesting natural experiments that produce causal inference studies of comparative effectiveness, both for treatments and for programs. Continuing work on patient safety, particularly in much-needed diagnostic safety research to prevent errors and delays in diagnosis.

As cuts occur, one bit of good news for health services research is that it has become increasingly decentralized. The broad relevance of health services research has contributed to federal funding through multiple agencies, unlike the funding of most other areas of health research. Even if AHRQ, the lead agency for health services research, were defunded, NIH funding has been directed at services research focused on questions related to the delivery of health care for specific diseases and disorders. The Department of Veterans Affairs (VA) and the Department of Defense (DoD) support research focused on their delivery systems as well.

If public funding declines, will the private sector step up? Private foundations played a critical role in sustaining the health services research field in the first twenty years following its emergence. Will major foundations and private corporations once again fill the gap?

Health services research highlights issues or populations that warrant intervention, can help to scale a delivery model that’s proven effective, and can reform or discontinue a program that’s been ineffective. However, changes in health and health care require not only robust research but also policy development and execution. Health services research is an applied field. But implementation always occurs in a context and landscape, one shaped by Americans’ beliefs, concerns, and ultimately, votes.⁴ We can only hope that today’s anti-scientific atmosphere does not blind policymakers to the fact that greater generation of evidence enables tax dollars to stretch further in the improvement of health.

Health is always a central concern for governments. Health has also become a source of contention during politically divided times. Still, even in the ungoverning of 2025 there is little that matters more to citizens than their health.

References

1. Clancy CM, Glied SA, Lurie. From research to health policy impact. Health Serv Res 2012; 47: 337-343.
2. Reed M, Fung V, Price M, Brand R, Benedetti N, Derose SF, Newhouse JP, Hsu J. High-deductible health insurance plans: efforts to sharpen a blunt instrument. Health Affairs 2009; 28(4): 1145-1154.
3. Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the cause. Pub Health Rep 2014; 129: 19-31.
4. Blendon RJ, Benson JM. American’s Views on Health Policy: A Fifty-Year Historical Perspective. Health Affairs. 2001; 20(2):33–46.

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