The Convergence of Science and Governance: Research, Health Policy, and American States (review)

In the aftermath of congressional passage of federal legislation that will shape American health care for decades to come, it is easy to forget that significant and monumental health reform has been shaped by state governments. Daniel Fox's Convergence of Science and Governance documents a gradual but substantial transformation in the way that states regulate and compensate health services. In Fox's lovely and concise volume, the states effect broad shifts in methods, rules, concepts, and resource allocation. These shifts portend and presage much of what can be expected to occupy the agendas and minds of policy makers in state capitols and Washington in the coming decades.

Fox conveys how state health policy makers have come to regulate therapeutics and health services by relying on systematic reviews of comparative treatment effectiveness. Some of the names and networks in this narrative are familiar—in particular Donald Berwick, who at this writing has been nominated by President Obama for head of the Centers for Medicare & Medicaid Services. Yet Fox introduces us to new personalities in this saga. They range from female effectiveness pioneer Mindel C. Sheps and University of Michigan scholar Avedis Donabedian to Oregon officials Mark Gibson and Mark Helfand to policy makers in Idaho, Washington, and Canadian provinces who became early and risk-taking champions of coverage policy based on systematic evidentiary reviews. There are also previously understudied networks and organizations that will now, thanks to Fox, populate the annals of health service reform: the Reforming States Group, the founders of the Drug Effectiveness Research Project (pp. 80-82) in the western states, the federal government's User Liaison Program.

In a volume that functions as an intersection of political and methodological history—I am reminded, in some ways, of Richard White's brief and boundary-spanning Organic Machine—Fox gives shrewd attention to the political economy of health research methods. He ably shows how randomized trials have transformed many debates but also how their prohibitive cost tends to confer advantages on the organizations that can afford to sponsor them (pp. 7, 22). The modern embrace of randomized controlled trial methods leads to a cat-and-mouse game about how to perform these studies and how to apply their lessons (see his concluding chap. 5). And Fox exhibits a sharp understanding of the role, limitations, and complicated politics of statistical inference. His musings about the tension between average effects and individual or subpopulation results and his cautionary notes about libertarian and industry-sponsored abuses of the distinction should be required reading in graduate seminars (pp. 92-93).

Fox devotes chapter 4 to an understanding of the Drug Effectiveness Review Project (DERP). It is, in my reading, the crowning effort of the book and represents simply the best encapsulation and narrative on the project that has been written. The fledgling effort received a political boost from its narrow passage in Oregon and the failure of a judicial challenge to Maine's law, and the role of DERP systems in sounding an early warning on Vioxx and its cardiovascular risks lent additional legitimacy to the effort. There is convergence is this narrative, but Fox avoids teleology.

There are limitations to an effort like this, not least a somewhat contrived distinction between "general government" and "specialist government." This binary both confuses the reader and results in what, for a gifted historical writer, are some rather anachronistic statements (the idea that state government specialists' "priority is to justify, and advocate for, more money and authority for their agencies"; p. 52). Yet the credits far outpace the debits here. The deep legacy of American health reform in the twenty-first century expresses and signifies, perhaps inescapably, a deeply federalist history. More than any scholar writing, Daniel Fox has set readers on that path of understanding.