FACULTY Q&A: Heidi Allen

Associate Professor Heidi Allen joined the School of Social Work faculty in 2012, after working as a research scientist on the landmark Oregon Health Insurance Experiment. In this interview we talked with her about how the life of a health policy researcher compares to that of a clinical researcher, some of her top achievements of late, and her blue-sky vision for healthcare in the United States.

Your interest in researching Medicaid and the American health care system goes back to when you were a clinical social worker. How did you get started in this area?
I was an emergency department social worker in Portland, Oregon, and EDs are very sensitive to changes in health care policy. Some call the ED the canary in the coal mine of health care. Our state legislature made significant cuts to the state’s Medicaid program, causing thousands of people to lose coverage. In the ED, I saw a patient who had received an organ transplant who couldn’t afford her anti-rejection medications. I saw a man who jumped off a bridge because he was shut out of a methadone clinic that had kept him sober for years; he said he would rather die than relapse. The health care safety-net basically imploded, and I had no idea where to send people to get their health care needs met. I remember thinking, surely this is not what policy-makers wanted—they must not have known what the impact of these decisions would be. So I went into research with the pretty naïve idea that I would “speak truth to power.” I would try to amplify the voices and experiences of people who suffer the health consequences of poverty. I’m not as naïve as I once was, but this is still what motivates me.

What is unique about policy research compared to clinical research?
In policy research we are usually studying someone else’s idea of how to solve a problem, rather than our own. We examine policies to see if they are meeting their stated objectives and if they are unintentionally helping or harming people in ways policy-makers might not have expected. For example, in the last couple of years I have published papers that demonstrated that Medicaid expansion reduces the use of payday loans and lowers the probability of experiencing a housing eviction. Both of these study findings could be considered positive spill-over effects of a health policy. I have also studied how health insurance expansions and retractions impact low-income adults’ access to care and their health. In clinical research, by contrast, the trajectory of the body of work is generally in the researcher’s hands. I think this is one primary difference.

Additionally, in policy research we don’t know if policy-makers are going to take our study results into consideration in policy-making or not. We might care about and study an issue for years, waiting for a policy window to open up where our evidence might be useful. So we are measuring our impact in fits and starts, rather than a smooth line.

Speaking of impact, how would you say your research has been received by policy-makers thus far? Can you point to any policies that have actually changed due to your input?
I find that policy-makers, like many of us, take what they like from study results and largely ignore what doesn’t align with their own thinking. That said, as a body of evidence builds, it does change the conversation. Over time, I think my research on Medicaid has contributed to a broad acknowledgment that Medicaid does increase access to health care, improve overall health and mental health, and improve the financial stability of low-income families. I think some policy-makers still think that private insurance would have done better, but I hope to contribute more to that particular line of conversation in the future.

As you mentioned, health care policy in the United States is a complex, politically charged issue that doesn’t proceed in a straight line. What keeps you motivated when progress seems to be stalled?
I have worked in policy long enough to know that something is only stalled until it is moving lightning fast. When I was writing my dissertation on Medicaid and even in the early days of collecting data for the Oregon Health Insurance Experiment, there had not been any significant federal movement on Medicaid for decades. Then, in 2010, the Affordable Care Act passed and suddenly Medicaid was on every state agenda. I know that low-income uninsured Americans are suffering. I know we can do better by them. I keep doing the research because I’m waiting for that moment our evidence can contribute to a tipping point. I want the evidence to be there to guide a path forward.

You’ve had a string of successes of late: academic articles in major journals, awards, an NIH appointment. Which of these are you most proud of?
I would say that the Society for Social Work and Research (SSWR) 2019 Social Policy Researcher Award was definitely a highlight of the year. Even though social workers are boots on the ground in every institution where people have needs, we are not as visible in the places where policies are made. I’m quite proud to be #macrosocialwork. It was also a highlight to have my abstract selected for Best of ARM (Annual Research Meeting) at AcademyHealth. There are very few social workers in health services research. A win for one of us is a win for all.

University Professor Nabila El-Bassel is now doing a study of the opioid crisis across New York State. You’ve often worked at the state level for your research. What observations can you share?
I think Nabila is a master collaborator, as demonstrated by her success in bringing so many stakeholders together to solve the opioid crisis in New York. In my experience, state partnerships are incredibly rewarding and state partners are more than a means to obtaining data and research permissions— they are experts in the programs and populations they offer. These experienced public servants can improve the quality and rigor of a study if we treat them as valued partners in the work. I also find it helpful to pay for their time. State agencies are lean, and when we ask them to do things without adding to their capacity, the research can get put on the back burner.

You did a TEDMED talk about the cost of being uninsured in America. What was the most challenging/best thing about doing that, and what feedback have you gotten?
The best thing about doing a TEDMED talk was having an opportunity to interpret findings from the Oregon Health Insurance Experiment to a broad audience. Over the years, I have watched our study findings used in the policy debate for and against Medicaid expansion. I would like to see us as a country have a more nuanced discussion about the Medicaid program, which is what I tried to do. So much is at stake for the uninsured and low-income Medicaid enrollees. We need to elevate this conversation. The most challenging thing about giving a TEDMED talk was memorizing fifteen minutes of speech and then trying to recite it in front of 500 people, while standing in a bright circle on a big empty stage. I have the memory of a goldfish and I am terribly dependent on PowerPoints to remember who I am and what I’m talking about. I still have nightmares about that part!

You are now involved in a Medicaid research hub based at the Harvard T. H. Chan School of Public Health. What is a research “hub” and how will its work differ from some of the other projects you’re involved in?
Our Medicaid Hub is part of the Robert Wood Johnson Foundation Policies for Action portfolio. The Hub brings together researchers with complementary expertise to produce actionable policy evidence. This funding mechanism encompasses traditional research projects but also includes support for more rapid-fire policy analyses. For example, through the Hub we are working on a very rigorous examination of the tradeoffs between Medicaid and private Marketplace in health care access, quality, and costs for low-income enrollees. We are also brainstorming how to capture potential impacts of a new federal rule, called Public Charge, that may penalize immigrants for using programs like Medicaid by making it more difficult for them to become citizens.

And now for a “blue sky” supposition. Right now you are in the middle of your career as a health care policy researcher and advocate for the uninsured in this country. By the time you are ready to retire from academe, what kinds of developments do you hope to see in this area? Please be as specific as possible.
Health care is always going to be in competition with other societal priorities, such as good wages, education, transportation, and recreation. In a world with finite resources, I hope we will move from implicit rationing in health care to explicit rationing. Implicit rationing ignores the fact that as costs of care go up, whole groups of people lose access. Explicit rationing asks us to consider what is worth paying for, with the assumption that when resources are tight, we will make hard choices about services, not people. In a world of explicit rationing, we look carefully at every new drug and technology and ask, Is this markedly better than what we currently have? And if it isn’t, we won’t pay more for it. In a world of implicit rationing, we pay hundreds of thousands of dollars to extend one person’s life for two months, while letting fifty people die decades early because they had no access to effective low-cost care.

I anticipate the next thirty years will bring revolutionary advances in medical capacity. We will be able to do things that are unimaginable now. But who will pay for it? Will we sacrifice everything else we care about to chase longevity? Will we let our neighbors die early because they are poor? I very much hope we have established health care as a basic human right by then.

Thank you very much, Professor Allen, for your thoughtful answers and for painting that blue sky for us! Readers, you can follow Professor Allen on Twitter @Prof_HeidiAllen.

Related Links:

• Heidi Allen’s faculty page
• Medicaid Expansion and Health: Assessing the Evidence After 5 Years (9.9.19 news article)
• Heidi Allen on American Healthcare and the People Left Behind (6.3.19 news article)
• Heidi Allen Named to NIH Health Disparities Committee (10.11.18 news article)