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Health Affairs Reaches 25: How It All Got StartedTHE YEAR WAS 1981, and Ronald Reagan had just been elected president, dashing the hopes of Democrats, who controlled Congress, to press ahead with legislation that would reform the health care system, enlarging the role of government in the process. William B. Walsh, an entrepreneurial cardiologist and founder of Project HOPE, broached an idea to me: that HOPE, a nonprofit organization that sponsored international health education activities in thirty countries, would start a health policy journal aimed at provoking a constructive domestic U.S. dialogue between the warring political parties and countless private stakeholders. At the time, I was in search of a route back to health policy writing. I had spent a decade (1969–1979) at National Journal, joining its original staff and pursuing a career in health and social policy writing. Before that, I had spent six years with the Associated Press and a year on Capitol Hill on a Congressional Fellowship. I relished the work at National Journal, but after holding the editorship there, and virtually every other editorial post, I grew restless for a new challenge. At the time, the "HMO model" was flourishing, and its exemplar was the Kaiser Permanente Medical Care Program. I was intrigued by a program that operated within a budget and provided high-quality care to millions of voluntarily enrolled members. For two years (1979–1981) I directed its Washington office, advocating on its behalf before the federal government. Although my time there was relatively short (the role of advocate did not match my journalistic instincts), the experience proved invaluable because it convinced me that my professional niche was health policy journalism; I have never looked back. When I began my discussions with Dr. Walsh, I was skeptical about starting a journal because the health field was littered with publications. But Dr. Walsh was a persuasive figure, and he convinced me to take on the challenge. He set out just two requirements as I embarked on this new venture: The journal should not be "glitzy," and its type size should resemble that of Foreign Affairs—large enough to be an easy read for people with bifocals. I adopted that journal as a model, not only for its type size and typeface but for its physical shape, readable form, and name. I set out two requirements of my own: All papers considered for publication had to be subject to external peer review, and the journal had to publish all views relevant to the ongoing dialogue, rather than advocating a particular ideology. Dr. Walsh’s politics were quite conservative, but he agreed to both conditions. In his first "Publisher’s Letter" in Volume 1, Number 1 (Winter 1981), he wrote: "Health Affairs will not be a political instrument dedicated to one approach, but rather will publish views reflective of the broader body politic." To his lasting credit, Dr. Walsh never sought to intrude on the editorial independence of the journal, nor have his two successors: William B. Walsh Jr. and Project HOPE’s current CEO, Dr. John P. Howe III. My conviction that Health Affairs should be open to publishing all relevant views was born of a belief in the journalistic ethic of neutrality and my job experiences at the Associated Press and National Journal that swore by it. While Project HOPE provided the necessary venture capital, I had concluded early on that the greatest potential for developing an independent journal lay in having the journal raise its own money from outside sources. I turned to the private philanthropic community to secure continuing support. Initially, there were skeptics. A frequent question was, "How can you develop an independent journal when its publisher is a well-known conservative?" But after demonstrating through our pages that we were on our way down that path, we began to secure small grants from the Commonwealth Fund, John A. Hartford Foundation, Henry J. Kaiser Family Foundation, Pew Charitable Trusts, and Robert Wood Johnson Foundation (RWJF). Over our twenty-five years, the RWJF became our major benefactor, supporting many thematic issues, including the present one on vulnerable populations. In 2005 the Bill and Melinda Gates Foundation awarded us a five-year grant to publish more content on global health issues and to better align the journal’s interests with that of Project HOPE’s mission to sponsor international health education activities in thirty countries. Our last issue, July/August 2007, focused on financing issues in low- and middle-income countries. Next year we will publish a theme issue on health in China and India. Over the past decade, the California HealthCare Foundation also has been a steadfast supporter, encouraging us to identify innovative ways to improve the troubled U.S. health care system. Perhaps the most important contribution that Health Affairs has made to the health policy dialogue is that of serving as a bridge between the disparate worlds of academic disciplines, between health services researchers and the broader communities of government and private business, and between political parties. We have sought to accentuate this dialogue by inviting Perspectives from a wide variety of stakeholders on new proposals or on papers that are bound to be controversial. Although our mission as a translational journal remains, we have also evolved to accommodate the growing appetite for more timely health policy information, to exploit the power of the World Wide Web, and to publish more of the unsolicited papers we receive each year (from 200 papers in the early 1990s to more than 1,000 in 2007). Among the most important changes we have made is increasing the frequency of publication from quarterly to bimonthly in 1997, then in 2001 beginning to publish peer-reviewed content regularly on our Web site: http://www.healthaffairs.org. Now we publish more than one such paper a week, and fully a quarter of the material we publish every year is released first on the Web. Last October we launched a blog, which quickly became one of the most-read health care blogs, attracting readers from a wide swath of public and private interests. Despite a dramatic increase in the number of pages we publish (from 508 in Volume 1 to 2,652 pages in Volume 25), our acceptance rates have been declining regularly since the early 1990s—from about one-third to the current rate of about 10 percent for unsolicited manuscripts. The lower acceptance rates reflect not only the realities of space constraints but also the vigorous growth in the fields of health services research and health policy analysis. An external peer-review process helps ensure that only the best and most relevant of a large body of research is selected for publication. We acknowledge with deep gratitude the selfless devotion of time and thought that our reviewers and editorial advisers invest in strengthening our content. Among the most active reviewers are members of the Editorial Board of Health Affairs, to whom we owe a special debt of thanks. Until July 1999, Health Affairs was a journal devoted to health services research, commentaries on issues of the day, and a great deal of data and other policy-related material. At that point, we launched a new section in the journal that granted authors an opportunity to tell a personal story linked to a policy lesson. We called the section "Narrative Matters," and its "godfather" was contributing editor Fitzhugh Mullan, who wrote in the July/August 1999 issue about the importance of connecting the little story to the big one. Part of our rationale for offering this new section was to lend the voices of patients, their families, and their caregivers to the continuing saga over America’s medical economy. We have come to appreciate the power of the personal story. Well told, a personal story packs a wallop that far outstrips the impact of an empirical study or yet one more reform proposal. I no longer marvel at the number of times I have been praised by an appreciative reader because we decided to publish personal stories. The best of them were published last year by the Johns Hopkins University Press. The section is now edited by Ellen Ficklen, senior editor. We thank the W.K. Kellogg Foundation for its generosity in supporting this section of the journal. Beyond the success that Project HOPE’s journal has enjoyed, I am most proud of its dedicated staff and the collegiality they bring to their tasks. Over the years I have sought to foster a work environment in which people can spread their creative wings and thrive on a management style that reflects strong confidence in their ability to get the job done with minimal interference from on high. One of our deputy editors (Philip Musgrove), who has worked at the World Bank and the Pan American Health Organization, taught at several universities, and conducted research at a think tank, developed an index of job satisfaction. The numerator is the productivity of an organization’s staff, and the denominator is the level of work-place stress: the higher the ratio, the better a place is to work. Musgrove concluded—hands down—that Health Affairs is the most satisfying workplace that he has experienced in a long professional career. Another measure of the place is staff longevity—more than one-third of the staff has been with the journal for ten years or more. Jane Hiebert-White (executive publisher): twenty-two years. Andrea Zuercher (managing editor): twenty years. Sue Driesen (senior editor): eighteen years. Lee-Lee Prina (senior editor): sixteen years. Judie Tucker (customer service and marketing manager): fifteen years. Donald Metz (executive editor): fourteen years. Fitzhugh Mullan (contributing editor): eleven years. Jeanne Burke (assistant editor: ten and a half years. And now to the important thematic subject of this volume: vulnerable populations. The journal dedicated its fifth-anniversary issue to "health and poverty," and we remain committed to finding solutions to societal challenges facing the poor. This issue was underwritten by the Robert Wood Johnson Foundation, an organization that has been steadfast in its grant making on behalf of people of limited means and opportunities. Parmeeth Atwal, a deputy editor, took overall responsibility for development of this issue, and I commend him and the authors with whom he worked for strengthening the papers published here. On September 4, James C. Robinson assumes the editorship. Robinson comes to the journal from the University of California, Berkeley, where he holds the Kaiser Permanente Distinguished Professorship of Health Economics in the School of Public Health. Robinson is a familiar figure to both our staff and the journal’s readers. Over the past decade we have published thirty-three of his papers on subjects that range widely across the medical economy. Robinson combines the intellectual rigor of an economics professor with strong journalistic instincts that he has employed to conduct what he characterizes as "shoe-leather social science." I wish him well as he pursues this new challenge, and I acknowledge with great feeling the debt I owe to the staff of Health Affairs. Without its dedication, the journal would be a mere shadow of itself. Meantime, I am not retiring but am returning once again to my first professional love: writing and reporting on national health policy issues of concern to society.
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