The children of the Program Planning and Budgeting System

13The rise of these new experts was linked closely to the Program Planning and Budgeting System (PPBS), established by the Johnson administration in the 1960s, and the subsequent growth of the policy analysis sector. Beginning in this period, significant amounts of money were allocated for evaluation studies in areas where they previously did not exist. [6] The aim was to evaluate social impact relative to the costs and objectives of current and planned programs (ex-post and ex-ante evaluation), and therefore guarantee maximum efficiency in the allocation of resources. Health policy was targeted in particular because the two public insurance schemes, Medicare and Medicaid, were by far the most expensive programs.

14The great amount of importance that the federal state placed on evaluation studies gave rise to what some were already calling the policy analysis “industry.” [7] Because most of the studies were assigned to nominally independent bodies (Banfield 1980), numerous organizations were created specifically to respond to government tenders. [8] Universities began offering courses to train people for the new role of policy analyst. The New York Times was already claiming in 1970 that “policy science” was a “new field of study,” citing as evidence the number of new schools and courses with this phrase in their title (Dluhy et al. 1981).

15As a body of knowledge, policy analysis is dominated by microeconomics, from which it draws its main concepts and tools: efficiency, opportunity costs, incentives, and so on (Fourcade 2009; Rhoads 1985). [9] The rise of policy analysis encouraged the hiring of microeconomists, or at least those trained in microeconomics.

16The emergence of health policy analysts in Washington in the early 1970s—all of them microeconomists—was a direct result of this new situation. Most of those who had written dissertations on health insurance received funding from a program established under Johnson by the Department of Health to encourage microeconomic work in the area. [10] They were among the first in their universities to adopt this approach. Those who specialized immediately after their studies did so to meet demand by their employers, non-governmental centers of expertise that lacked staff trained in such topics.

Constraints and opportunities in the labor market in the early 1970s

17They may have had PhDs in economics, but young graduates who had specialized in health insurance had relatively little chance of finding university jobs at the start of the 1970s.

18

We—people like Stuart Altman, Joseph Newhouse, Paul Ginsburg, and Karen Davis—were basically the first cohort of health economists. And none of us thought we’d stay in academia, because we thought what we were doing wouldn’t be recognized there. In fact, many of us were sort of resigned to the fact we would probably never be professors. [11]

19In this generation, it was relatively common to have difficulty finding jobs as professors: mass enrollment in higher education had led to a sharp rise in the number of PhDs, and universities alone could not absorb this (Gaiger 1993). Furthermore, healthcare was still not recognized as a legitimate object of study in economics departments. Aside from an isolated article by the economist Kenneth J. Arrow (1963), research on the topic had not led to any theoretical advances—unlike education, for instance, which was at the center of the theory of human capital (Teixeira 2000). Microeconomic health research was still seen as applied work—valued little in academia—and was therefore marginal within university research and accorded only a small measure of academic respect. By contrast, the policy analysis industry that developed around the federal government offered young PhDs numerous job opportunities: their microeconomic training was heavily sought after by every organization wanting to position itself in the market for health policy evaluation and expertise. As well as being an open labor market where health policy analysts could easily find work, Washington provided a stimulating environment. As microeconomists interested in questions of allocating (necessarily scarce) resources, they were particularly appealing to American policymakers of the period. Politicians consulted them regularly, and they even received political appointments in the federal government (Lepont 2014). As the interview extracts below show, the feeling of being part of the development of public policy and government action was a motivating factor in these individuals’ decision to stay in Washington as health policy analysts.

20

Why did I stay there [at Brookings]? Because your research is used for something! It was a much more stimulating environment [than the university]. There were opportunities to testify before Congress, to take part in Congressional committees, and to work for influential organizations like the Institute of Medicine or the Research Review Committee. [12] I wanted to work for policymakers. Often, research is too separate from any public policy implications. I wanted to translate my research so that it was accessible to policymakers. [13]
You started your career as a university professor. Why did you choose to join the government? There was a lot of hope at the time in the possibility of reforming the national health insurance system. I was recruited by the cabinet secretary to work in his group. It was the atmosphere at the time and the fact that I was recruited by one of the cabinet that made me leave the university. Otherwise I would probably have stayed. [14]

21Different factors came together, forming a set of constraints and opportunities that explain why these young PhDs decided to remain in Washington and embrace careers as policy analysts—a role that at the time was still new.

The sense of belonging to a distinctive professional community

22By opting for careers as policy analysts or policy experts, these individuals took up a distinctive sort of professional activity. They emphasize how different this was from academia. Prima facie, there were ways in which their work differed little from academic work: they had to stay up-to-date and broaden their knowledge by reading books and articles, and they had to produce (or supervise the production of) new knowledge about their field of specialization, health insurance, addressing questions about care access, costs, hospital operations, the behavior of patients toward physicians, and so on. This knowledge activity was distinguished from academic work by its exclusive orientation toward producing solutions to the problems identified, and formulating recommendations for political decision-makers. These experts therefore published memos, policy briefs, and articles in expert journals. They also published books in the 1970s, but with non-academic presses. Much of their time was given to events (meetings, conferences, and lunches) with health sector actors and/or political decision-makers. One of the main expectations of the expert organizations that employed them was that they communicate with the media—something universities also valued, but did not require to the same extent. Similarly, there was far more active demand for providing advice to decision-makers nominated to official positions or, less formally, when they were running for election. [18]

23The actors I interviewed emphasized the gap between the logics of these two directions: a career as an academic or as a policy analyst. They generally defended the value of the one they had chosen. As one said, “Most academics write for other academics, they’re talking to the academic world. Their life consists of writing papers for other academics.” [19] Another remarked: “If you only write on the academic model, you might get a Nobel Prize, but you won’t have much influence. And then what? Have you changed anything?” [20] Using the traditional opposition between expertise and academic knowledge, they defended policy analysis as a body of knowledge directly useful for decision-makers—unlike academic knowledge, which is grand but practically ineffective. Much as Medvetz (2010) observed in his study of think tank policy analysts, the actors themselves experienced the decision to pursue this career as one that contrasted with academia. This choice provided the basis for a feeling of being part of a separate group, made up specifically of individuals invested in the domain of expertise, with a shared vision of their work.

24

If you’ve worked for a government, you’ve necessarily been interested in the question of making research more useful for decision-making. First of all, experiences like that make you understand who’s got power and who doesn’t. Other questions are important: the way evidence is presented in government is very different from the way it’s presented at a university. I’ve briefed the vice-president, but I’ve never seen anyone present a model. I’ve never met a president or a cabinet secretary who calculates! To understand how politicians make decisions, elected or not, you have to work very close to government.
So the people you meet and who make up your network are academics who are really interested in understanding how politicians take decisions and who want to take part in that battle. They know what’s important or not for the president, for Congress, or for a cabinet secretary. You meet all these people. They haven’t spent their whole career in government. But what connects you, it’s that you’ve been through there and understood the reality of the decision-making process. Anyone who saw Nixon’s office remembers it their whole life! You’re part of a group that knows their experience is different.
So there was this little group I met because I was interested in the impact of policy science on the government, and that’s not something academics typically spend much time on. [21]

25The feeling of belonging to a specific group is based on the conviction that they shared a distinctive personal interest in public action that set them apart from academia, as well as an unusual grasp of the political world’s rules and standards. This knowledge was based on a shared experience of the political world, which had come from jobs in which they frequently encountered decision-makers. This was accompanied by a shared approach that viewed adaptation to the political world’s particular constraints as imperative—and entirely legitimate if one wanted to be effective at all. They were “professional” experts in the sense that they had no job beyond that of being experts. They absolutely had to occupy situations of expertise regularly if they were to maintain their positions in the organizations that employed them. But health policy analysts did not make up a profession (Freidson 1970) or even a professional group (Demazière and Gadéa 2010) in the late 1970s. There was no professional association or certificate defining its boundaries (Abbott 1988). Instead, as emphasized in the interview quoted above, they made up an informal network of individuals who knew each other and recognized themselves as forming part of a small group of people who did the same work. This informal network was based on links of sociability, constructed by frequenting the same places and institutions (Lepont 2016a). The political events of the early 1980s pushed them to put more structure in place.

The contradictory position of health policy analysts in the early 1980s

26In the early 1980s, health policy analysts who had acquired strategic positions in the space of expertise during the 1970s found themselves in a contradictory position. On the one hand, their central role was confirmed, particularly by the adoption of major reforms based on the body of knowledge they had promoted. [22] On the other, their institutional “rear bases”—non-governmental expert organizations—were threatened by a decline in funding. In 1981, the newly elected President Reagan announced he had little interest in the agencies funding health insurance experts, which he felt were mostly wasting federal money.

27This new political context reveals the fragility of the new leading experts’ professional status. They were connected to non-governmental expert organizations that depended on public funding for their survival, and this put them in a distinctively vulnerable position compared to the experts who had preceded them—physicians and Social Security Administration officials—who had professional jobs to fall back on and a salary independent of their expert work with decision-makers.

28The fragility of their professional position was increased by the weakness of their collective structures. Individually, the economists consulted were recognized as experts. And, as we have seen, they had the sense of belonging to a distinct group of health policy experts. But they did not form a coherent group that could easily be identified from outside. Their knowledge was recognized—it had been the basis for major reforms—but it was not enough to grant them existence as a professional group with a particular, immediately recognizable field of intervention. They decided to use the adoption of these reforms as an opportunity to gain such recognition, but this project went nowhere: “We had a hard time, a very hard time, at the beginning pointing to evidence that we had actually made a difference. The first thing that anybody could point to for at least six years was DRGs.” [23]

29Once again, recognition of a particular body of knowledge was much less of an issue for Social Security Administration officials and physicians, who enjoyed a legitimacy that was attached directly to their professional activity. Physicians were recognized as possessing this because of their medical practice, and officials were recognized as possessing it because of their knowledge of the workings of bureaucracy and the conditions in which programs were put into operation, acquired in the time they had spent in government. By contrast, health policy experts had neither medical nor bureaucratic legitimacy. To secure their current jobs in the long term, they needed recognition for a particular body of knowledge that identified them as a professional group associated with a particular body of knowledge. They consequently needed to rely more heavily on legitimacy of the academic type, based on “scholarly” knowledge associated with a particular discipline. This is shown by their heavy emphasis on publishing, something physicians and Social Security Administration officials did not require of themselves. The resume of a heavily consulted expert might include several books and more than a hundred articles and book chapters. As Medvetz notes, this was the only way for them to distinguish themselves from lobbyists, activists, staffers, and other political aides (2010, 560-1). As we have seen, they did not have the university support: the discipline they had immediately attached themselves to, health economics, was not sufficiently recognized or established in economics departments. Their position in the early 1980s was enviable from the point of view of access to expert strategic roles, but raised concerns about the long-term viability of their jobs.

30In my view, this contradictory situation explains these actors’ desire to join an identifiable professional group, one that had more institutional resources and support from academia and an association with a particular body of knowledge. Two such projects emerged at the same time. The first involved reforming health economics to turn it into a respected sub-discipline of economics by establishing the conditions for its scientific autonomy. This relied on the traditional path to academic professionalization—the one taken by health economists in France, who had also initially been dependent on political and administrative demand. In the United States, the first to move in this direction was Joseph Newhouse, a well-known health economist at the RAND Corporation (see Box 2), who in 1981 founded the first economics journal specialized in the field, the Journal of Health Economics.

31The second project took a very different approach. It was the work of another health economist, Stuart Altman, also an important figure among health policy analysts: under Nixon, he led the first team of health economists who worked directly with the department to develop reforms. His project was to build links with another group of researchers who produced expertise on questions related to health insurance, and who were broadly labelled “health services researchers.” In 1981, Altman founded a professional association, the Association for Health Services Research (AHSR). The aim was to give health services research the status as a discipline that it had lacked up to that point. But, unlike the path taken by health economics, there was no claim to scientific autonomy. Rather, it was a matter of creating a discipline adapted to the demands of expertise.

32The second of these two options proved decisive for health policy analysts in constructing a space of scientific expertise on health insurance and making their positions sustainable in the long term. I will therefore focus on this aspect of the conditions for its emergence. Still, the failure of the first option seems to me particularly interesting for understanding the specific advantages of health services research and its success with health policy analysts, which I will return to below.

The foundation of the Association for Health Services Research

33The term “health services research” was coined in the 1960s by a group of epidemiologists who represented a new approach: clinical epidemiology (Berkowitz 1998). They aimed to increase the level of health in the population not by improving medical science, but by “rationalizing” the care system. [24] The idea was promoted intensely in Washington as a necessary accompaniment to investment in medical research, and in 1968 these researchers secured the creation of the National Center for Health Services Research (NCHSR) to fund research in pursuit of these goals (Berkowitz 1998). As with many “sciences of government” (Desrosières [1993] 2002; Ihl et al. 2003; Rueschemeyer and Skocpol 1996), it was this institutional resource that laid the foundations for the recognition of a specific body of knowledge by providing funding for a journal, Health Services Research, and for the first specialized research institutes, all hosted by departments of medicine. [25]

34But health services research was not a well-established discipline in the early 1980s. It had emerged in a “context of application,” and was mostly restricted to the administrative sphere and a few isolated centers in medical schools. Like many applied disciplines in their early days (Benamouzig 2005; Pavis 2008), it enjoyed no real academic recognition. [26] Even within the government, its position was fragile. The NCHSR was effectively marginalized within the Department of Health; it had difficulty justifying the studies it financed to the political world, and faced severe institutional crises on a regular basis (Fox 1976).

35Up until the 1970s, health economists who had leading expert positions in Washington were only very marginally associated with health services research. The two groups claimed to work on different subjects: the health insurance system and economic analyses of physician-patient-insurance relationships (the “health care system”) for the former, and the care system and the organization of medical practices (the “delivery system”) for the latter. It appears that the closer links resulting from Altman’s project were based on a mutual exchange of resources. Clinical epidemiologists could offer economists institutional resources that, even if not yet very stable, were substantial. While health services research had not been widely accepted within academia, it was more firmly established in departments of medicine than health economics was in economics departments. And there existed a dedicated federal agency that, while fragile, nonetheless offered a crucial institutional base. Conversely, economists could offer clinical epidemiologists the political resources they had yet to obtain. In the words of the first president of the AHSR, a clinical epidemiologist, the main goal was “to connect the research community with the policy people who were making decisions.” [27] Health economists were “indispensable” for this, and this is why they were made spokespeople for the association and were the keynote speakers at the first meetings. [28]

36But strategic interests alone cannot explain the alliance between economists and clinical epidemiologists, which was also made possible by their relatively close epistemological positions and the fundamental assumptions the two groups shared. The aim of health services research as conceived in the 1960s and 1970s was to improve the “efficiency” of the medical system and to “rationalize” it. It belonged squarely to a context in which the evaluation of public policy was being encouraged. The National Center for Health Services Research (NCHSR) was created in 1968 as a direct result of this context. Economic incentives were supposed to be the primary means for such rationalization. A sort of “analytic compatibility” existed between the two groups of researchers that, as Christopher M. Weible (2008) has argued, encourages such alliances.

37The result was an expansion of the definition of health services research, whose field of investigation was extended from the care system to include the entire healthcare and health insurance system. [29] But health services research was still presented as an applied, interdisciplinary field, unallied to any specific methodological or theoretical approach and defined instead by its practical goal: to improve the efficiency of the healthcare system (Institute of Medicine 1995).

The work of the Association for Health Services Research: Lobbying and the formation of an operational discipline

38Like Altman, many of the founders of the AHSR led institutions that were threatened by the reduction in public funding. The new association’s main goal was therefore to defend the interests of those who made a living from healthcare expertise by guaranteeing funding in the area would be maintained. The association began lobbying, devoting much of its resources to building links with representatives of Congress. Its aim in the 1980s was to reinforce the NCHSR, which was felt to be on its last legs. As one of the founding members explained, however, the primary difficulty the association faced was health services research’s lack of recognition as a discipline.

39

And we had trouble defining the field at that point. When you would go to a social gathering of any kind and someone would say, well, what do you do? And you’d say, well, I do health services research. People would look at you for a second and then they’d walk away. They didn’t have any idea what that was—or care. And I think we had a long time there where we had to convince not only other academics, but policymakers that this was, in fact, a field. [30]

40This problem of recognition also affected many of the individuals whom the association counted as health services researchers but may not have immediately identified themselves as such. There were only a few dozen members of the association when it was created. Its task was to construct a professional community that mostly did not yet exist. [31] To consolidate health services research, the association’s founders tried to provide it with some of the characteristics of an academic discipline. AHSR took over publication of the existing journal Health Services Research, aiming to increase its circulation. It also created a number of prizes and grants to encourage and reward researchers working on health services research, like the Distinguished Investigator Award (1985), the Alice S. Hersh New Investigator Award (1986), and Article of the Year (1988). It established an annual meeting in 1983 that was meant to announce the discipline’s existence to the outside world. Finally, the same year, the association began to publish a quarterly bulletin for its members, the HSR Report, containing job announcements, information on research grants, and news about the association and its institutional partners, such as the NCHSR and a number of foundations (particularly the Robert Wood Johnson Foundation), who provided funding for the sort of work the association supported.

41In this sense, the association’s founders took a traditional path to constructing a new discipline, one that is encountered in work on both applied and so-called fundamental disciplines (Benamouzig 2005; Grossetti 2000; Pavis 2008). It was a matter of circumscribing the limits of authorized and legitimate knowledge in the field (Abbott 1988), and thereby organizing the closure of access to scholarly positions in the intellectual sphere, and to expert positions advising governing elites (Gouldner 1979). But while the project was a traditional one, it was distinguished from what has typically been observed even for applied disciplines by the lack of any desire to establish distance from other social spheres. In the case of health management and health economics, it was a matter of weakening and, to some extent, obscuring the discipline’s applied dimension. The project of constructing health services research did not require health policy analysts to establish the conditions for autonomizing their discipline. Instead, from the moment they laid its foundations, they affirmed that the discipline’s goal was to assist and advise the government. During the AHSR’s first annual meeting, the association’s president declared that the group’s aim was to encourage cooperation between researchers and decision-makers in the public and private sectors. Other founding members made similar remarks.

42

We wanted to develop credible policy research that would have more direct influence on political decisions. Just because you publish in journals, it doesn’t mean that the president’s going to behave differently. The association’s main goal was to develop an interface for connecting those who came from policy research and those who came from the government. [32]

43The association’s founders had a strong desire to keep health services research in a position very close to what Robert and Vauchez (2008), writing about European studies, called a “hybrid space.” Three characteristics of such spaces can be identified: the substantial importance given to practitioners in driving the discipline and producing knowledge; the claim of going beyond disciplinary boundaries; and, for those who founded and are most invested in the discipline, careers marked by professional experience in the very institutions they study. The subject of the same interview pointed out that the distinctive feature shared by all the association’s founding members was their previous work in government, which very clearly set the association apart from any other academic professional group.

44

When the association was founded, and I was part of that, the policy researchers who had served in government dominated the group… All of us, and especially the director, had worked in Washington for a very long time. It wasn’t the normal group of sociologists or others who had built themselves big reputations in the academic world and were at the top of their disciplines. Instead, the association was rather unusual, and that continued afterwards; the board of directors always included people who had worked for an administration or for the federal government. [33]

45Furthermore, politicians and leaders in the medical sector were systematically invited to take part in and contribute to the organization’s events, whether it be the annual meeting or other seminars and conferences. They also authored papers for the discipline’s journals, particularly Health Affairs, which was also established in the early 1980s and which is particularly representative of this hybrid space.

46This commitment to health services research matched that of the organizations that employed most health services researchers: expert organizations like think tanks, foundations, consulting firms, and specialized university centers attached to “schools”—medical, public health, business, law, and public policy schools—rather than departments. These centers were part of the university system, but their management primarily demanded knowledge that was directly “useful” and “relevant” for public policy (Fox 1990, 485-6). The practical consequence of this was that the demands and criteria for evaluating the careers of their researchers were often closer to those used in think tanks than traditional academic departments. As shown in the following remarks by a health economist, this was particularly visible in terms of publication expectations:

47

There are still only a few health economists in academia. Most of them are in public policy schools, public health schools, business schools, or other schools like that.
What is the difference for a health economist between working in academia and working in one of these schools?
Expectations in terms of publications aren’t the same. In academia, if you want to become a well-known professor, you have to publish in journals like the American Economic Review, journals like that. In the other schools, you can do the same thing, but that’s not what’s expected. What is expected, instead, is that you publish in Health Affairs, The New England Journal of Medicine, journals like that. [34]

48The last two journals cited are expert publications whose explicit mission is to reach an audience of decision-makers. [35] In the case of European studies, discussed by Robert and Vauchez (2010), their construction as a “hybrid space” seems to be the result of scattered, diluted efforts over the long term. What is striking in the case of health services research is that their position was the result of a conscious and deliberate desire, or strategy, which can be situated at a precise moment in time. This position was successfully maintained in the future.

A discipline providing material and financial resources

52The success of HSR with health policy analysts was due first of all to the discipline’s growth, which led to an enormous rise in the number of courses offered in public health and medical schools during the 1980s, 1990s, and 2000s. The number of specialist courses in HSR (which generally began at masters level) went from fewer than a dozen in the 1970s to several hundred in the 2000s. [38] HSR offered relatively stable university employment opportunities to experts for whom access to university economics departments continues to be very difficult, as shown by the extract above from an interview with the health economist Thomas Rice. [39]

53The spectacular growth of HSR courses is due primarily to their applied dimension, which became a source of attraction for students beginning in the 1980s, as observed for other disciplines like management (Pavis 2008). One of my AHSR interviewees explained that most new members were students. [40] HSR courses offer direct training in organization and management roles in the medical sector (in hospitals and insurance). This resonates with developments in the American medical sector since the 1980s. The rise of for-profit insurance and hospitals, mergers and consolidation in the medical industry, and the growth of “managed care” have led to increased demand for new management positions in hospitals, insurance firms, and even public agencies (Starr 1982; Pierru 2007). Health services research had an advantage when it came to these jobs that it exploited very successfully. These jobs are all the more attractive because healthcare is one of the most dynamic sectors of the American economy. [41] HSR’s highly applied nature resonates with a trend characteristic of academia since the 1980s, which Gibbons et al. (1994) have described—probably wrongly (Pestre 1997)—as the advent of a second mode of scientific production in which practical effectiveness is the key concern.

54Another reason HSR has grown since the 1980s is increasing financial support from foundations and government agencies. This has been obtained mainly through the strategy of the AHSR which, beginning in the late 1980s, reoriented its political lobbying to concentrate on cost-effectiveness research (cost-benefit studies to identify the most effective medical protocols) and variation research (reducing cost variations between institutions by rationalizing how medical facilities are organized). The association proposed a solution to the problem of rising healthcare costs that did not adversely affect either the structure of the insurance system or the incomes of healthcare professionals. Thanks to this argument, which was particularly attractive to political decision-makers wary of the reaction from interest groups in the sector, the association successfully doubled the funding of the NCHSR, which had been renamed the Agency for Health Care Policy and Research (AHCPR) (Gray et al. 2003). In 2009, the association used the same argument to secure $1.1 billion in the American Recovery and Reinvestment Act for “comparative effectiveness research” (another name for cost-effectiveness research). These reforms were accompanied by new institutional and political resources. The AHCPR had been part of the Department of Health, but was moved closer to the cabinet, playing a far more substantial role in the Clinton and Obama reforms than the NCHSR ever had. The final version of the Affordable Care Act of 2010 created three new government centers of expertise, headed by representatives of health services research. [42]

55Private foundations have also been very receptive to HSR’s position on solving cost problems and, after several decades of withdrawal from health insurance issues, have returned to the subject by lending strong support to HSR (Fox 2010). Once again, health services research provides a good match for the “mode 2” of knowledge production described by Gibbons et al. (1994), which values sciences that can “sell themselves” and attract funding from outside the university. [43]

56Health services research has grown remarkably as a discipline since the association was created in 1981. The annual meeting had three-hundred participants in 1983, 2,400 in 2005, and more than 4,000 in 2012. This dynamism has been accompanied by growth on the part of the journals in which health services researchers publish. The most spectacular example is Health Affairs: having begun as a quarterly journal with a dozen articles in each issue (a total of 560 pages in 1983), it is now published monthly with around twenty articles in each issue (a total of 2,208 pages in 2015).

A discipline tailored to health policy analysts

57The success of HSR with health policy analysts is also a result of the adaptation of its epistemological position to these experts’ professional activity in think tanks, foundations, some consulting firms, and, as we have seen, university centers that emphasize expertise production rather than that of properly academic knowledge. By emphasizing the production of a body of knowledge useful for political decision-makers, HSR took on both the constraints of expertise and its political dimension. For instance, no one challenged the place of feasibility as the primary criterion in producing recommendations. This relates to one of the main constraints for health policy analysts, who are required by the expert organizations that employ them to justify the “utility” and “impact” of the knowledge they produce. The issue of “feasibility” consequently became prominent in expert discourse. The ideas that circulated in expert forums were developed, discussed, and assessed in the light of this criterion. Any proposition that did not meet it was consigned to the margins of the space of expertise, outside the central forums offering access to the political world. During the period in question, I consistently observed strategies of compromise and adaptation on the part of experts who wanted to remain “in the game” in order to conform to what they perceived as politically in demand and “feasible.” In this sense, the professional ethos of health policy analysts is more one of feasibility than truth, setting it apart from the academic ethos.

58Another political constraint health policy analysts had to contend with was the extreme politicization of American health insurance. In a context of polarization and intense partisan battles, it was impossible to avoid receiving a political label. While very few were members of a party, they were all associated with one camp or another and, to an extent, played the partisan game. This state of affairs might have been embarrassing for someone claiming scientific autonomy, but was welcomed within health services research.

59Furthermore, insofar as the discipline promotes expertise, HSR places far greater value on the work of health policy analysts who have no interest in making it an autonomous discipline. As we have seen, the health policy analysts best connected to the political world were members of the AHSR’s board of directors, sometimes served as the association’s president, were often plenary speakers at the annual meeting, and received the discipline’s most prestigious prizes. Their expert work would never have enabled them to achieve such central positions in a discipline that desired autonomy. HSR allowed them to convert something that is typically little valued or discouraged in academia into a source of prestige. And they could place far greater emphasis on their publications—which, as we have seen, they produced in huge quantities. These appeared almost exclusively with presses and journals with expert audiences but little recognition in academia. [44]

60In return, health policy analysts allowed the discipline to profit from their close links with the political world. Lobbyists at AcademyHealth told us that they had been able to rely on health policy analysts who had strategic roles in Congress or the federal government. This was the case during Clinton’s reforms in 1993: “During the Clinton reforms, lots of our members were on the task force, either in the White House or in the federal government. That helped a lot!” [45] The same was true for Obama’s reforms: “I know a lot of people in the administration and the federal government who were close to AcademyHealth and lobbied for it [the creation of a dedicated institute for comparative effective research]: a former member of MedPAC, two White House staffers, and Nancy-Ann DeParle.” [46] The president of AcademyHealth also mentioned the names of three other members of the association who occupied strategic positions in the Obama administration during the reforms.

Does health services research have enough scientific authority?

61But this closely dependent relationship with the political world raised questions about the authority and legitimacy health services research had obtained as a specific, scientifically valuable discipline. Their status was challenged by those with a more orthodox conception of science. This was true for Newhouse who, as we have seen, had tried to institutionalize health economy on a far more academic model: as he said in an interview, “health services research is a little different in that it’s not really a discipline.” [47] He argued that the multidisciplinary character of this research, with no precise methodology and a purely operational purpose, does not meet the requirements of a scientific discipline.

62Following this line of thought, we should note the difficulty health services research has faced in policing the scholarly boundaries of the discipline—precisely because of its low level of autonomy, or closure, relative to other social spheres. This has been particularly remarkable since the early 2000s, when Republicans began to include health insurance experts with libertarian views in their teams, who generally did not have PhDs (unlike most health policy analysts) and argued that an unregulated free market was possible and desirable in the health insurance sector. Because this position contradicts many of the fundamental assumptions of health economics (like information imbalance and risk selection), many of the experts I spoke to wanted to exclude libertarians from health services research. But many libertarians were still members of Academy-Health, and still invited as “colleagues” to present their views in the main expert forums. This situation shows that the way the discipline has been positioned, in the service of expertise, makes it impossible to exclude those who now act as the primary experts for one of the nation’s two main parties. From this point of view, it has achieved a degree of “generosity” toward the political space that has not been reached even by European studies, discussed by Robert and Vauchez (2010), or Middle Eastern studies, discussed by Eyal (2002). Without taking on all of its characteristics, the situation resembles the extreme one described by Stampnitzky (2013) in terrorism studies, where definitions of fundamental concepts vary depending on political circumstances, and where there is no stable criterion for membership in or exclusion from the field.

63But if we look at membership numbers and the institutional recognition it has received, it does not seem that these phenomena have hindered the ability of health services research to gain recognition as a discipline by many actors. As Newhouse himself continued: “but still there are a number of people around the country who view that as their professional home.” [48] What gives a discipline its status is not just the nature of the knowledge and the analytical categories it produces. As Fabienne Pavis (2008) writes, it is also “an academic organization with links to degrees, jobs, and academic careers,” as well as “cultural production with a value in the marketplace for goods and services.” While health services research has chosen an epistemological position that does not correspond to academic standards of autonomization from other social spheres, it appears that its growth in terms of university courses, official recognition, and publications has confirmed its status as a discipline. Health policy analysts can claim that health services research is a discipline, and it can serve as a reference body of knowledge for the expert world. Such research therefore guarantees researchers sufficient scholarly authority with journalists and decision-makers who are seeking technical information, ideas for programs and reforms, and arguments to support their point of view.

64* * *

65In the 1970s, specialists in health insurance affiliated to a number of non-governmental expert organizations made the decision—constrained by the academic labor market—to embrace careers as health policy analysts. They thereby undertook a new sort of professional activity, in which expert activity became a job in its own right, rather than work carried out as part of another job.

66But while they enjoyed regular access to the political world, their status in the early 1980s was still relatively unstable. This was a result of the financial insecurity of the organizations employing them, which were entirely dependent on political decisions on whether to continue funding health insurance research. It was a result, too, of the low level of academic recognition enjoyed by health economics, the body of knowledge they principally laid claim to. I have shown in this article how health policy analysts resolved this problem by investing in a particular discipline, health services research. They constructed this discipline so that it was adapted to their own professional activity, carried out in organizations (think tanks, foundations, consulting firms, higher education schools) whose aim was to produce expertise rather than academic knowledge. It was not just that health services research was defined above all as a practical knowledge aimed at efficiency. Contrary to what has been observed in most other applied disciplines that initially emerged “in an applied context” (Benamouzig 2005; Desrosières [1993] 2002; Grossetti 2000; Ihl et al. 2003), when health services research was being formed, the actors most heavily involved did not try to reinforce their autonomy from other social spheres, particularly politics and economics. Instead, they tried to maintain such research as a “hybrid space,” giving practitioners a great deal of room (Robert and Vauchez 2010) and placing value on the feasibility of recommendations as a criterion for evaluating any work produced. On the other hand, they paid little attention to health economics, the discipline they were initially trained in but that, as in France (Benamouzig 2005), had developed according to the model of scientific autonomy. They created a discipline in their own image that allowed them to consolidate a space of professionalized expertise constructed around the non-governmental expert organizations that employed them.

67This hybrid position was not a barrier to the development of university courses that claimed to be part of health services research. Far from it. Health services research has benefited from a marked tendency since the 1980s toward courses that emphasize the “concrete” aspect of the knowledge taught and the opportunities provided (Gibbons et al. 1994; Pavis 2008). The steady growth of the healthcare sector in the American economy only strengthens the appeal of courses that offer training for management roles in hospitals, insurance firms, public administration, and the medical industry. This hybrid position has also encouraged financial support from foundations and government agencies who want to produce directly “useful” knowledge, particularly since leaders in health services research have deliberately chosen to emphasize consensus-based work, accommodating interest groups and political parties. Furthermore, the jobs that health policy analysts involved with the association occupy in government and foundations puts them in a good position to defend the discipline’s interests, primarily through attracting funding for its members.

68Health services research has been characterized over the last four decades by strong growth and a process of specialization accompanied by the construction of a specific academic space in higher education schools (primarily medical and public health schools and, to a lesser degree, public affairs and business schools). As in the case of European studies, which Robert and Vauchez have discussed, there has emerged “a set of institutions and journals where professional models of excellence, criteria of judgment, and specific representations and practices prevail” (2010, 20). This expansion and specialization have been very profitable for health policy analysts, who have more easily found stable posts and increased the security of their professional careers. It has also consolidated health services research as a discipline, particularly for a non-academic audience. As with European studies, however, “far from leading automatically to the autonomization of this academic space, specialization has instead gone hand in hand with the maintenance of substantial heteronomy” (Robert and Vauchez 2010).

69Contrary to the literature on expertise, which typically shows the importance for experts of building links to a body of scientific knowledge that is recognized as autonomous, the position of health services research has not stopped health policy analysts exerting political influence or gaining recognition as legitimate experts on issues relating to the healthcare system and health insurance. This situation resembles that of the fields (or spaces) some authors describe as “liminal” (Eyal 2002) or “interstitial” (Vauchez 2011; Medvetz 2012; Stampnitzky 2013)—that is, located at the intersection of multiple social spaces. For these authors, this position is far from being an obstacle to the institutionalization of a group of experts. Rather, it is an asset, giving them a chance to accumulate resources from these different spaces. An emphasis on useful, “feasible” knowledge, adapted to circumstance and “political demand,” is precisely what gives health services an advantage in its interactions with the political world over academic knowledge, which claims scientific autonomy. Dependence on the political world is a firm advantage in relationships with decision-makers, as clients are more likely to receive a timely response that is well adapted to their needs. In return, these close relations make it easier to defend the interests of the discipline, which partly relies on government agencies’ financial support. The same is true for relations with foundations, which see social impact as a priority. The experts themselves find they can considerably lessen the unpleasantness caused by situations where they find themselves in tension with, or transgressing, the norms of their initial professional network—something numerous studies have observed (Memmi 1989; Barthe and Gilbert 2005). By situating themselves from the outset in a space of expertise that is autonomous from the academic space, and that requires an applied “knowledge-action” to meet political and social demands, experts accept the political aspect of their work and openly play the political game. Because their knowledge is oriented toward expertise, their peers do not view their involvement in the political world and the compromises it demands with suspicion. Rather, these become a source of value.

70It is logical, then, that those who benefit most from this situation—the health policy analysts most connected to the political and/or economic world—are particularly involved in the leadership of health services research (through its professional association), and that these individuals receive the honors distributed by the field (through awards and nominations). By affiliating themselves with the discipline and presenting themselves as eminent figures, the most consulted health policy analysts have found their own sphere of scholarly legitimacy. Health services research gives them scientific credibility without forcing them to accept the heavy constraints of the academic field. Such research gives them a way of consolidating a space of professionalized expertise on health insurance free from the constraints of academic norms, but that still retains some of its characteristics of legitimacy. Health policy analysts have resolved the tension Medvetz (2010, 557) described as internal to the profession of policy expert, caught between “intellectual credibility” and “temporal power.”

71Compared to the research cited above on interstitial spaces, health services research seems to me a case of closure (understood as the ability to protect oneself from incursions by other social spaces) that sits between, on the one hand, Middle Eastern studies in Israel (Eyal 2002) and European studies (Robert and Vauchez 2010; Vauchez 2011), which are characterized by a slightly greater degree of autonomy, and terrorism studies on the other (Stampnitsky 2013), which is marked by complete generosity toward the outside world. Furthermore, the number of actors and institutions involved means the domain of study in question is far broader than that examined here, suggesting similar conclusions could be drawn at different scales. The case’s crucial distinguishing feature, I believe, is that it explains a deliberate approach or strategy on the part of the actors involved, and connects this to changes in public expertise, characterized by the rise of the profession of policy analyst and the institutions that employ them, which form the basis of what I have called the space of professionalized expertise.

72These sites of professionalized expertise—think tanks, foundations, some higher education institutions—have developed considerably in recent years in the United States and Europe. My conclusions invite broader discussion of the consequences for bodies of knowledge in public space brought about by contemporary shifts in their production and diffusion. Such space competes with academic space in its ambition to produce knowledge about society, and it is important to bear in mind that the norms and demands within each are very different. In particular, the priority given to “feasibility” limits the critical dimension of the knowledge produced, as well as the degree of risk taken in the propositions formulated, which must remain within what is felt to be the realm of the possible.