Abstract
David Mechanic has been a pioneering leader in the social and behavioral sciences of health, health services, and health and mental health policy for more than fifty years. One of David's most distinctive qualities has been his vision in identifying trends and defining new research areas and perspectives in health care policy. His early work on how methods of physician payment by capitation and fee-for-service in England and the United States affected physicians' responses to patients and patient care addressed present challenges and many ongoing studies of payment mechanisms. His papers on rationing of health care established a framework for examining alternative allocation mechanisms and just decision making. Influential papers dealt with risk selection, policy challenges in managed care, reducing racial disparities, trust relationships between patients, doctors, and the public and health institutions, and the predicaments of health reform. Focusing on the implementation of the Affordable Care Act, David explored its opportunities and challenges especially in providing comprehensive and effective behavioral health services. A hallmark of his work has been his redirecting our attention to the most severely ill and those in greatest need. Less visible is the leadership and institution building endeavors and the many honors David has received.
Why a special issue of the Journal of Health Politics, Policy and Law in recognition of the work and influence of David Mechanic? Our simple answer is that no other medical sociologist has had a greater and more enduring impact on health policy–related scholarship than David Mechanic.
The diversity of paths by which David has influenced policy is quite remarkable. His highly cited publications on health and health policy include thirty-one authored or edited books and more than four hundred articles. He has been involved for over half a century in a variety of roles and policy-relevant activities in academia, government committees, foundations, the Institute of Medicine (IOM; now the National Academy of Medicine), and professional organizations. He inspired the education, training, professional socialization, and career development of generations of medical sociologists, health services researchers, and other social scientists. His leadership advanced the thinking of investigators from multiple disciplines in addressing critical health policy issues. His work often anticipated crucial research and policy questions.
In one of the conversations that led to this article, Paul Cleary observed that “David was breaking down professional silos before we even started worrying about the siloed nature of our work, and he worked tirelessly to have an impact on policy and practice before we had even begun using the terms translation and implementation research” (personal communication, August 3, 2015). David's many colleagues know him as a caring and persistent source of guidance and stimulation for their own work. One rarely finds a scholar with the breadth and interdisciplinary perspective that David provides on health, health care, and policy. Appropriately, the contributors to this special issue come from more than a half dozen scholarly disciplines.
Pivotal Influences on Medical Sociology with Interdisciplinary Perspectives
David displayed his social science intellect early in his educational career, graduating magna cum laude from the City College of New York in 1956 and receiving the Ward Medal in Sociology. Encouraged by his mentors to choose Stanford University for graduate work, as well as its offer of a Ford Foundation Behavioral Sciences Fellowship and an academic setting that would provide endless opportunities for a self-directed student, David bought a 1951 DeSoto he describes as “a lemon if there ever was one” and headed with two friends to the West Coast. He planned to pursue a PhD in sociology with a minor in anthropology and sought research opportunities in health-related topics before a defined area of medical sociology existed. Beyond the sociology department he found a home as a research assistant at the Center for Advanced Study in the Behavioral Sciences and gained experience studying with major figures in sociology, social psychology, anthropology, and psychiatry.
His early encounters in anthropology were with Gregory Bateson, who had a schizophrenia research unit at Palo Alto Veterans Hospital and a research group exploring “double binds” in interviews of families who had a child with alleged schizophrenia. Questioning the consistency of identifying double binds, David attempted a reliability assessment of the double binds identified by Bateson's team members in their taped interview sessions, but he could not gain the needed cooperation of the team or of Bateson, who told David, “I can't agree with myself, much less with others” (personal communication, August 3, 2015). David came to think that he had not been persistent enough, since years later someone actually carried out such a study and documented the lack of reliability. He found Bateson brilliant, interesting, kind, and friendly, but his sort of science was not what David sought. His interests turned to the more rigorous field of experimental social psychology and the excitement generated by Leon Festinger's theory of cognitive dissonance. David worked with Festinger's assistants, Judson Mills and Elliot Aronson, designing a study testing dissonance theory. As a project assistant with John W. Thibaut and Harold H. Kelley (who were then visiting the Center for Advanced Study), David spent a good part of the year reading and integrating relevant literature for their forthcoming book. Thibaut and Kelley were developing their influential theory on the interdependence in interpersonal interactions based on utilitarian concepts, and the book they wrote that year, The Social Psychology of Groups (Thibaut and Kelley 1959), became a classic.
Through his involvement at the Center for Advanced Study, David encountered a star-studded group of distinguished scholars including Kenneth Arrow, George Homans, Stuart Hughes, Joshua Lederberg, Theodore Newcomb, Talcott Parsons, and John Whiting and notable visitors including Alfred Kroeber and Adlai Stevenson. Social interactions at the center ranged from intellectually gratifying seminars to volleyball. David Hamburg, then a young psychiatrist at the center, hired David to analyze taped interviews in a study of stress and successful coping in applicants to a distinguished psychoanalytic institute where a demanding inquisition with faculty was required for admission. Ideas developed from this project were eventually incorporated into David's studies of stress and coping, the subject of his first book, Students under Stress: A Study in the Social Psychology of Adaptation (Mechanic 1962d).
While at Stanford, David also arranged for internships at contrasting psychiatric institutions, Agnew State Hospital, a large custodial mental hospital, and an innovative inpatient psychiatric unit for acute care at San Mateo General Hospital. His experiences with the admissions process at Agnew stimulated his early publication on the identification of mental illness (Mechanic 1962b), a topic later explored by labeling theorists.
There were no organized medical sociology programs in the 1950s, but David's mentor in sociology at Stanford was Edmund H. Volkart, one of the first sociologists to apply sociological concepts and analysis to health issues, and who became a lifelong colleague and friend. David's dissertation was where he first proposed the concept of illness behavior to explain the factors influencing how individuals responded to illness, how they variously perceived, identified, and attributed bodily signs and symptoms, and what actions they took, including (but not limited to) seeking treatment (Mechanic 1959, 1961a).
Prior work on patient behavior used medical record data, implicitly assuming that people invariably sought treatment when they felt ill. David argued that people's response to illness was a more complex process. His concept of illness behavior (Mechanic 1963) subsequently informed countless studies of pain, disability, and use of health services, and his own further studies of various aspects of illness behavior, including how children acquired their health behaviors, resulted in many highly cited publications in sociological, psychiatric, and medical journals.
In David's dissertation he prospectively studied Stanford's students' varying views about using student health services for symptoms and stress and their actual use of health services over a year. (The survey for his project had a 94 percent response rate.) Analyses showed that both inclination to use health services and stress predicted utilization, with an interaction whereby stress was more influential in students' accessing care when their inclination was high. As a graduate student, David was not permitted to abstract the students' medical records for linkage to their survey data. His supportive mentor, Volkart, did the abstracting and became a collaborator on articles resulting from his dissertation (Mechanic and Volkart 1960, 1961). Years later, modeling on Volkart's superb mentorship, David was a mentor to a University of Wisconsin sociology doctoral student, William James Bogdanow, who, with his dissertation unfinished, was tragically killed in a boating accident. David completed “Predicting Rehospitalization among Mental Patients” to meet the degree requirement, a fine tribute to the student's legacy and a much treasured gift to his mother. This is but one example of David's generosity as a scholar and mentor.
There are many other examples of how David routinely helped other scholars. Bradford Gray recalls sending his 1973 Yale University doctoral dissertation on informed consent in biomedical research to David (then at Wisconsin) at the suggestion of Bernard Barber. David's response to the unsolicited request for advice from a stranger was typically quick and helpful. He offered a revision strategy and later accepted the resulting manuscript for publication in a series that he was editing for Wiley-Interscience (Gray 1975).
After David's dissertation was accepted with distinction and he had completed his doctorate (and all the work we have described) in three years, at age twenty-three, he accepted a National Institute of Mental Health (NIMH) postdoctoral traineeship at the University of North Carolina at Chapel Hill. His connections to multiple disciplines continued with the university's superb faculty in sociology, psychology, and public health including researchers such as Thibaut and John Cassell.
David's year in Chapel Hill was highly productive. He continued his research on stress and coping by collecting interview, survey, sociometric, and other data on graduate students preparing for and taking their preliminary PhD examinations. This research, along with his earlier work on stress and coping, resulted in his book Students under Stress: A Study in the Social Psychology of Adaptation (Mechanic 1962d), which remains a landmark in the field. The book established an important role for sociology in an area previously dominated by biologists and psychologists, offering a critique and an alternative interpretation of Freud's psychodynamic theory of defense mechanisms and adaptation, and becoming the dominant stress paradigm of today.
Continuing with his interest in how large psychiatric institutions functioned, he collected data at the Dorothea Dix Hospital, the state mental institution in Raleigh, and in a treatment unit for patients with substance abuse, work that resulted in articles in the Quarterly Journal of Studies on Alcohol (Mechanic 1961b, 1962a). In his experiences with attendants and lower-status staff at Dorothea Dix, David recognized the importance of validating their work with gestures of recognition and affirming symbols in his own data collection. His analysis of what he called the sources of power of lower participants in complex organizations resulted in an article in the Administrative Science Quarterly (Mechanic 1962c), a publication that has received more than 690 citations.
David's theoretical contributions about illness behavior, stress, and organizational behavior gave him early visibility in the emerging field of medical sociology, and his influence continued to grow after he joined the Department of Sociology at the University of Wisconsin in 1960. An interdisciplinary approach continued to be a hallmark of his work.
Institutionalizing Medical Sociology
Under Robert Felix, a psychiatrist and the first director of the NIMH, substantial funding had become available for research and training in the social and behavioral sciences related to mental health. The sociology department at Wisconsin, among other enterprising academic settings, was interested in capitalizing on this funding by starting a medical sociology program and recruited David, who eventually developed one of the outstanding programs in the country. Soon after arriving in Madison, he set to work on beginning a social psychology training program focusing on mental health research. He teamed with sociologist William Sewell, whose research centered on personality and social structure, and they wrote a successful NIMH predoctoral training grant, which was continually renewed until David left Wisconsin in 1979.
While at Wisconsin, David also established the Center for Medical Sociology and Health Services Research and Development with training funds from the National Center for Health Services Research (NCHSR), a predecessor to the Agency for Healthcare Research and Quality, and funding from several NIMH and NCHSR research grants. David also obtained Robert Wood Johnson Foundation (RWJF) funding for postdoctoral training in the Center for Medical Sociology and Health Services Research and Development. Linda H. Aiken, one of the first postdoctoral trainees in the program, later became vice president for research and evaluation at RWJF before going on to a distinguished health services research career in nursing at the University of Pennsylvania.
At Wisconsin, David engaged, inspired, and trained other future notable sociologists and health researchers including Cleary, Alex Portes, William Eaton, Philip Leaf, Lowell Hargens, Larry Linn, and Bonnie Svarstad. Sociologist James R. Greenley, who became a close colleague and collaborator, was recruited to the faculty in the early 1970s and took the lead in developing a new postdoctoral training program through the psychiatry department that recruited outstanding trainees including Ronald C. Kessler, Sue Estroff, and Ron Diamond.
David was among the small number of highly regarded scholars including Victor Fuchs, Eli Ginzberg, and William Schwartz to receive support in RWJF's initial movement in the early 1970s into research on health policy and health services. In later years, the “great men awards,” as they were called, evolved into the Investigator Awards in Health Policy Research (Colby 2003). David's funding began in 1973 and continued to 1987, extending through the period of his transition from Wisconsin to Rutgers University.
The medical sociology training programs at Wisconsin drew on the excellent infrastructure in theory and methodology in the sociology department, as well as David's intellectual influence in health research and policy and his caring, guidance, and stimulation of emerging scholars. His approach continued to be interdisciplinary and involved economists at the Institute for Research on Poverty as well as lawyers and psychiatrists. As chair, David led Wisconsin's sociology department during the difficult challenges of disruptive demonstrations and political chaos associated with the Vietnam War (including the fatal bombing of a campus building) of the late 1960s and early 1970s, using approaches such as a twenty-four-hour teach-in with faculty present to avoid violent confrontations in the department.
Developing an International Perspective on Health Care
In 1965–66 with an NIMH Special Fellowship and an invitation from John Wing, a psychiatrist and sociologist, David spent the year at the Medical Research Council Social Psychiatry Unit at the Maudsley Hospital in London. In addition, he studied general medical practice in the National Health Service and the provision of psychiatric services in England.
David's studies in England were the first of his several experiences abroad, reflecting the value he placed on international perspectives when studying health and social problems. There were earlier examples of this interest; for example, Mark Field (1957) and David, along with people such as Odin Anderson and William Glaser, were among the first researchers to study other countries' health care systems with an eye toward issues relevant to the United States.
Studying the National Health Service and general medical practice in England underscored the importance of testing assumptions, remaining open to new ideas, and being alert to possible misconceptions. According to David, “This was one of the important instances in my career where I learned that despite my assumptions, which seemed intuitively correct to me and many of my colleagues, the actual way that systems worked and people behaved led to very different outcomes than expected . . . and that's what research means, an opportunity to test ideas and identify when one's hypotheses are wrong. Inquiries that only seek to document what people believe to be the only truth is not research; it is advocacy under the guise of research” (pers. comm., August 3, 2015).
The stimulating intellectual environment of this early cross-national experience influenced his research for decades. His sabbatical year occurred at a high point in the history of the Maudsley, then the world's leader in the development of social psychiatry and rigorous training of psychiatrists, and during the last year of Sir Aubrey Lewis's reign as director of the Institute of Psychiatry. David had the opportunity to watch the succession in leadership, which he says resembled scenes from C. P. Snow's book The Masters. More important was his exposure to and learning about rigorous research in psychiatry. At the time, American psychiatry was dominated by psychoanalysis, with little rigorous research of the kind that David encountered at the Maudsley.
In addition to joining Wing's group, David encountered other accomplished scholars. Michael Shepherd's team in psychiatry and primary care was beginning to bring attention to that topic. Douglas Bennett, who administered the day treatment hospital, was developing with Wing a broad rehabilitative perspective that included employment for their patients. As David set out to conduct possibly the first national survey of more than a thousand English general practitioners, he had considerable difficulty employing assistants because of the regulations of the very bureaucratic English tax authorities. One of the innovative aspects of his survey is that he contracted with the hospital to have day hospital patients do paid clerical work in preparing the surveys for mailing, addressing and affixing stamps to envelopes, maintaining records of surveys sent, tracking surveys returned, and sending reminders to nonrespondents. Patients with different capacities did various tasks, and those working on the project were extremely proud of their responsibilities and extraordinarily careful in performing their tasks. The success of the project led the Maudsley to shift more clerical tasks to day hospital patients, giving them more diversified work experiences.
One of David's most important connections was made with medical sociologist George Brown, who with Wing was doing cutting-edge research with patients diagnosed with schizophrenia. Among his other scientific contributions, Brown developed the concept of “expressed emotion,” which became a central component of treatment and rehabilitation for patients with schizophrenia. David describes Brown as a “fascinating personality and one of the most talented and innovative sociologists working on mental illness that he has encountered over the past fifty years” (pers. comm., August 3, 2015). David and his family lived near Brown and his family in Dulwich, saw a lot of each other at work and socially, and developed a lifelong friendship.
David's other global experiences included stays in South Africa, where he started the first course in medical sociology in the medical school at the University of Witwatersrand, learned about medical care in South Africa, resulting in his publication “Apartheid Medicine” (Mechanic 1973), and was selected as the second human rights lecturer sponsored by the National Medical and Dental Association and the Colleges of Medicine of South Africa. On a research visit to post-Mao China, David and medical anthropologist Arthur Kleinman conducted a mental health survey of clients in outpatient departments, comparing their presenting complaints with American data from the 1976 US National Ambulatory Medical Care Survey (Mechanic and Kleinman 1980). As in other health care systems, utilization in the Chinese sample was influenced not only by the severity of symptoms but also by the way clients interpreted and responded to their symptoms and the convenience of clinics. Patients with somatic symptoms of personal distress—especially depression—were typically diagnosed with neurasthenia, which was viewed as a physical disorder. This diagnosis sanctioned a medical sick role for patients who otherwise would bear the stigma of mental illness.
As a Sir Edward Youde Memorial Fund visiting fellow in Hong Kong in 2000, David lectured at the Hospital Authority and the major universities there. At a meeting in Taiwan organized by economist William Hsiao of Harvard University, David was among an impressive group of experts who advised Taiwan on developing a universal health insurance system. David also made several visits to Japan, with his most extensive involvement occurring when the United Nations declared 1981 as the International Year of Disabled Persons. David spoke at a large symposium in Osaka about mental health and disability issues, along with psychiatrist Herbert Pardes, then director of the NIMH, and three other international speakers, who then traveled to other areas of Japan to speak on related topics. Other consultations or lectures and visits occurred throughout Asia including Thailand, Vietnam, Laos, Cambodia, India, and Nepal.
Although hardly a global experience, David had one of his more interesting consultations in health policy in Puerto Rico in 1975 when the government was moving to introduce a universal health system. David brought together an expert group from the United States who, in collaboration with a complementary group of health care leaders and administrators in Puerto Rico, recommended an incremental approach with additional financing and better coordination to enhance the public service system that was already in place alongside the private sector. Their recommendations were accepted, but Senate legislation based on the group's proposal led to charges of socialized medicine by physicians in Puerto Rico. David returned to Puerto Rico to hold a press conference to refute the charges of socialized medicine; it was reported by United Press International as “Expert Chides ‘Socialized Medicine’ Charge” (Pietri 1976). The health bills were enacted into law, but Puerto Rico subsequently experienced a deep recession, the governor and both houses of the legislature were defeated in the 1976 election, and few of the health provisions were implemented. Notably, many of the legislation's provisions regarding primary care initiatives, administration of health services, improved information systems, and the evaluation of service performance are similar to provisions later included in the Affordable Care Act (ACA).
Making Medical Sociology Relevant to Health Policy
While in England in the mid-1960s, David drafted what became Medical Sociology: A Selective View (Mechanic 1968), a modest title for a synthetic tour de force that became an Institute for Scientific Information (ISI) “citation classic.” The book provided a coherent and comprehensive presentation of the substantive range of medical sociology, locating it squarely within the dominant concerns of the sociological discipline, emphasizing how class, status, and power relationships, organizational dynamics, and cultural values belonged in the forefront of explanations for the health behaviors of laypeople as well as the behavior of health professionals. As David notes, “I guarded against my presumptuousness in trying to encompass such a vast range of intellectual activities by subtitling the book, A Selective View” (Mechanic 1985: 20). But his “selective view” also recognized that health policy and related issues were part of the purview of the field, although policy-related topics were developed in much greater detail in the book's second edition a decade later. (Notably, the words policy and government did not appear in the first two editions [1963 and 1972] of the Handbook of Medical Sociology [Gray and O'Leary 2000].)
Another of David's successful endeavors involved work in the early 1970s to enhance the visibility and recognition of medical sociology as a major subdiscipline in the American Sociological Association (ASA). Margaret E. Mahoney, then a senior executive in health care philanthropy at the Carnegie Corporation, had expressed interest in his research, and David, as chair of the ASA's Medical Sociology Section, sent Carnegie a proposal to facilitate a shift in the section's activities toward examining sociological and social psychological issues relevant to emerging health policy concerns and health services research. The eight committees established under this grant were probably the most active within the ASA at that time, and committee members collaborated with other social scientists, younger researchers in the section, health professionals, policy makers, and others interested in health policy. There was little precedent in the section for such work. The work of these committees moved well beyond the traditional boundaries of medical sociology, highlighting its relevance to services research and policy.
The committees' activities included meetings with policy makers; explorations of reorganization options for what was to become the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA); symposia at professional meetings including the American Association for the Advancement of Science, the American Statistical Association, and the American Public Health Association; interdisciplinary work groups on topics such as barriers to medical care among Chicanos, the practice of family medicine, and sociomedical health indicators; a national interdisciplinary conference on humanizing health care; and meetings with other professional work groups studying similar health issues including those at the IOM and the Social Science Research Council and the Office of Management and Budget's project on health indicators. Beyond books, peer-reviewed articles, reports, dissertations, and seed projects that received modest research support from, or were prompted by, the Carnegie grant, a special supplement of Medical Care, which David coedited with sociologist Sol Levine, included articles based on the activities of the eight committees (Mechanic and Levine 1977).
At about the same time, David entered the national rationing debate when the IOM asked him to make a presentation on the issue of guaranteeing medical care at its 1975 annual meeting. David argued that rationing should be “more equitable, more explicit, and under greater control of general guidelines than under control of the power of the purse” (Mechanic 1976a: 36; 1976b). David's dominant point made in other publications within a broader sociological perspective was that rationing of health care was pervasive and inevitable in the United States and that prudent public policy would acknowledge it and seek to insure that care was fairly rationed and consistent with the best evidence (Mechanic 1977, 1978, 1979). With the growing bureaucratization of medicine in the 1970s and thereafter, David did a number of studies of prepaid group practices and wrote about rationing in his books Future Issues in Health Care: Social Policy and the Rationing of Medical Services and From Advocacy to Allocation: The Evolving American Health Care System (Mechanic 1979, 1986).
Asked in a recent conversation to identify his favorite book, David struggled to answer and then cited a relatively recent one: The Truth about Health Care (Mechanic 2006). Written not only for scholars and students but also for the public, practitioners, and policy makers, and subtitled Why Reform Is Not Working in America, the book examines why this country, with its ample resources including our willingness to spend on medical care, sophisticated technologies, pathbreaking medical research, great educational institutions, and talented health care professionals, does not produce higher-quality care and better outcomes. The book is characteristically ambitious in scope, wide-ranging in cited evidence, and concise. It explains how historical and cultural factors (including faith in markets) make it difficult to reach policy solutions in which a governmental role is central. (His preferred title was The American Health Care Predicament.)
Pursuing the Challenges of Behavioral and Mental Health Policy
Perhaps the most consistent theme in David's research from the very beginning of his independently arranged internships in psychiatric hospitals and research as a graduate student was his persistent interest and endeavors in understanding the diagnosing and treating of individuals with severe mental illnesses, as well as issues in the delivery of the mental health and social services that they needed. Over time his studies have resulted in more focused scientific and policy concerns about improved behavioral and mental health services. David contributed to our historical, sociological, and organizational understanding of deinstitutionalization, community treatment, evolving issues in managed care, health care outcomes and performance, financing and reimbursement systems, socialization of mental health professionals, and parity of treatment, among other issues. Most recently, he has written about opportunities to improve the nation's highly flawed mental health system through the ACA's incentives, regulations, and new initiatives including the Medicaid expansion (Mechanic 2012, 2014; Mechanic and Olfson 2016).
David's long policy involvement with the NIMH began in 1968 when he joined and later chaired the NIMH's Epidemiological Studies Review Committee. He worked on large policy issues as coordinator of the President's Commission on Mental Health's Task Panel on the Nature and Scope of the Problem in 1977–78. The panel's report detailed the epidemiology of mental disorders and mental health services use, including data gaps and the need for more methodological rigor (President's Commission on Mental Health 1978). The commission's report advocated greater investment in mental health, especially better community mental health services and more research and training focused on people with severe mental illnesses. The legislation passed but was soon rescinded when President Ronald Reagan took office. Over time the general directions sought by the commission have moved forward (Koyanagi and Goldman 1991).
Another significant involvement with the NIMH began in 1989 when the institute sought to develop a national plan to improve services for individuals with severe mental illnesses. One of the three panels established to define the most critical needs of this population and design a research approach was a panel chaired by David on needed and targeted research resources. The panel's recommendations included establishing a stable infrastructure for mental health services research, facilitating a research agenda and demonstration projects, improving data sources and analytic capacity, and linking the work of federal and state agencies. The panel recognized the need to develop a critical mass of interdisciplinary mental health services researchers who could address and work within the complexity of the very underdeveloped mental health system, with its different levels of authority, varying funding streams, and various housing, disability, and other programs (Mechanic et al. 1992). The NIMH implemented many of the panel's recommendations including the funding of an additional number of collaborative mental health services research centers; by 2001 they totaled sixteen.
The first edition of David's book Mental Health and Social Policy (Mechanic 1969) reshaped the terms in which mental health issues were framed, examining services and policy from both sociological and interdisciplinary perspectives. Like earlier editions, the recent sixth (Mechanic, McAlpine, and Rochefort 2014) examines fundamental controversies and problems in the field with evidence, not ideology, and places challenges faced by people with severe and persistent mental illness at the center of arguments for needed policy changes. While acknowledging policy failures and the seeming intractability of fundamental issues, it conveys the potential of the ACA to make a difference for individuals and their families.
David's commitment and skills for translating research into practice and effective policy recommendations substantially advanced the care and treatment for individuals with severe and persistent mental illnesses and led, as we later describe, to his being honored by several organizations concerned with mental health. Even so, David underscores that social and treatment inequalities remain, and the outcomes of innovative behavioral health service strategies continue to be insufficiently implemented and studied.
In one of the largest national initiatives to improve mental health care, David served as mental health consultant for the Program for the Chronically Mentally Ill, a major endeavor by the RWJF to build more effective service capacities in major cities for persons with severe and persistent mental illness. Large cities face significant obstacles to providing and coordinating needed care for such persons, along with their comorbidities, disabilities, homelessness, and imprisonment. The program's underlying ideas were to improve care by developing mental health authorities for coordinating services across different sectors, creating closer linkage with Social Security for subsistence primarily through Supplemental Security Income (SSI), and providing appropriate housing for the most critically impaired and homeless people, who were offered Section 8 housing certificates from the Department of Housing and Urban Development (Shore and Cohen 1994). The results were mixed, with some tangible health system improvements, but as David recalls: “Most such large demonstrations of programs for persons with serious mental illness, while finding important positive effects such as prevention of hospitalization, increased access to care, and improved functioning in the community, have difficulty demonstrating significant clinical improvements” (pers. comm., August 3, 2015).
Expanding Interdisciplinary Research in Health and Health Policy
Shortly after his move to Rutgers in 1979, David became the first dean of the Faculty of Arts and Sciences. The position involved developing and overseeing the complex unification of what had been four administratively, geographically, and culturally separate colleges with thousands of faculty, staff, and students. Allan Horwitz, who observed the process from his faculty position, says (pers. comm., October 20, 2015): “Remarkably, David's administrative achievements match[ed] his prodigious scholarly attainments.” David's efforts at integration were uniformly regarded as highly successful and ultimately provided the foundation for Rutgers's entry into the prestigious Association of American Universities in 1989.
After leaving the deanship, David returned to the faculty, and prompted by a highly competitive offer elsewhere to build a program with many luminaries in health services and health policy, he was given resources to do the same at Rutgers. That was the beginning of the Institute for Health, Health Care Policy and Aging Research, the culmination of David's institution building. He led the institute for almost thirty years. David was also named the René Dubos Professor of Behavioral Sciences, a professorship that had special meaning because of Dubos's emphasis on the ever-changing adaptations to the environment required for biological success and prudent medical care. From its inception in 1985, the institute achieved national distinction through the research generated by its interdisciplinary faculty in the social and behavioral sciences along with clinical, policy, and law school faculty from nine schools and more than a dozen departments.
The institute spawned several specialized research centers. From 1988 to 2004, David directed an NIMH-funded Center for Research on the Organization and Financing of Care for the Severely Mentally Ill to understand and improve treatment programs for persons with the most severe mental illnesses. As NIMH priorities changed over the years, institute faculty established centers specifically dedicated to mental illness and criminal justice research and to pharmacotherapy and chronic disease management. A National Institute of Aging award funded a center grant for studies of biopsychosocial approaches to health behaviors in chronic illnesses. A nationally recognized undergraduate research training program, predoctoral fellowships, and an NIMH postdoctoral mental health training program from 1980 to 2014 bridged disciplines to provide rich and diverse opportunities for research on health, health care, and policy. But more was on the horizon in institution building.
Public universities have historically played important supporting roles in state policy making. In the 1980s and 1990s, New Jersey was in the vanguard of states experimenting with health policy initiatives such as all-payer rate setting and progressive regulation of health insurance markets. However, academic institutions in New Jersey had played only modest roles in informing and shaping the state's health policy initiatives. The failure of health care reform during the Clinton administration convinced David that responsibility and initiative in health policy making were increasingly going to reside with the states. Recognizing that his own state had limited expertise and capacity in this area, David worked to develop a state health policy center within the Institute for Health, Health Care Policy and Aging Research and the broader Rutgers community.
David envisioned a center that would be dedicated to helping leaders and decision makers examine complex state health policy issues and find solutions. Working with James R. Knickman, then vice president of the RWJF, David obtained a planning grant in 1998 to assess the need for a center in New Jersey and develop a plan for one. The planning effort revealed strong demand from a broad spectrum of New Jersey policy makers, administrators, and stakeholders, as well as broad bipartisan support among legislators. The commissioner of the New Jersey State Department of Health at the time, Len Fishman, was a particularly strong advocate for establishing the center.
Based on the results of the planning grant, in 1999 the RWJF awarded an $11 million grant to Rutgers to establish the Center for State Health Policy (CSHP) with a mission to inform, support, and stimulate state health policy in New Jersey and across the nation. Under Joel Cantor's leadership, the center has garnered broad respect from New Jersey policy makers and stakeholders as a producer of impartial, rigorous, and timely health policy research and analysis. Its important work has included ongoing studies about states' decisions to expand Medicaid under the ACA. An article by faculty at the center (Monheit et al. 2004) about the difficulty of sustaining individual health insurance markets was cited in oral arguments by US solicitor general Donald Verrilli in defense of the ACA's individual mandate before the Supreme Court in National Federation of Independent Business v. Sebelius (132 S. Ct. 2566 (2012)).
David Mechanic as Policy Activist
Not all of David's professional activities have been highly visible. He has served on countless scientific study and review groups and as an adviser to many federal agencies including the Executive Office of the President. Valued for his deep substantive and methodological expertise, he continually demonstrated the relevance of sociology and social science approaches to health and health policy. The list of advisory committees on which he has served takes up four single-spaced pages in his curriculum vitae. We will describe a few examples.
An advisory activity that David found particularly gratifying involved his service from 1988 to 1992 on the National Committee on Vital and Health Statistics (NCVHS). The committee is the statutory public advisory body to the secretary of the Department of Health and Human Services on health information and data policy. As chair of the mental health statistics subcommittee, David focused on the lack of inclusion of behavioral health items in the National Center for Health Statistics' (NCHS) household interview survey and other relevant surveys. He reasoned that since the NCHS was responsible for data about the nation's health, it should include questions about mental health and substance abuse disorders in view of their high prevalence, associated comorbid disabilities, and mortality rates. However, the NCHS staff saw measuring population mental health as the responsibility of the NIMH and argued further that measures of mental health were too “soft” to be included in its high-quality surveys.
The turning point in convincing the NCHS staff to include mental health content in NCHS surveys was a scientific meeting that David helped engineer to review the measurement issue. Ronald W. Manderscheid, the mental health staff person for the NCVHS, was a strong ally on this issue, and his presentation along with a number of others including Cleary and Kessler, who were conducting research on the measurement of mental health, convinced the NCHS that mental health questions belonged in their household surveys. Mental health measures, it was shown, were better studied psychometrically than most physical health measures and had high reliability and robustness.
Agreement about using the mental health measures was achieved with a two-pronged strategy. A small set of questions was added to the core survey on the occasion of the ten-year planning for the National Health Interview Survey. Kessler was conducting his National Comorbidity Survey at the time, and the Kessler-6 (K6) scale on psychological distress was added to the National Health Interview Survey and continues to this day. A special supplement on major mental disorders was also introduced. Ultimately, the NIMH was able to fund this supplement. Manderscheid (pers. comm., October 19, 2015) says that adding these questions was revolutionary because of the stigma surrounding mental illness, with many staff thinking that it was inappropriate in a government survey to ask about the topic. To cite one example of the worth of the supplement, Benjamin G. Druss used its data in a seventeen-year follow-up of mortality in people with mental illness (Druss et al. 2011). From Manderscheid's perspective (pers. comm., October 19, 2015): “The major lesson in all of this is persistence, persistence, persistence. David had persistence, and we were able to prevail. I always enjoyed working with David because he actually accomplished important goals!”
A contrast to his successful work on the NCVHS came about when David was a member of the Panel on Health Services Research and Development of the President's Science Advisory Committee in 1971–72, during the Nixon administration. David was asked to join a group of consultants to the Executive Office of the President to recommend proposals for the president's 1972 State of the Union address. This was a big deal (or so it seemed at the time). The charge was to use the technological innovations from the nation's space program as a model for improving access to and the quality of health care. After several intensive meetings, the group supplied a wide range of innovative ideas. David's excitement about his important behind-the-scenes role in policy making at the highest levels cooled quickly when the speech was delivered with little mention of the group's suggestions. The only recommendation included in the president's address seemed disappointingly minor at the time: it was to develop the medical emergency communications system now known as the 9-1-1 system. It was also not clear that the committee's report was the source or impetus of this recommendation.
In 1990 David was in the founding class of the National Academy of Social Insurance and participated as a member of the Disability Policy Panel that undertook a comprehensive review of the nation's Social Security benefit programs. Recommendations included incentives and rehabilitation for persons with disabilities to gain work capacity, without weakening the right to benefits for those not capable of working. Included in one of the reports was the return-to-work program that became law (Mashaw and Reno 1996). The legislation was launched as the Ticket to Work and Work Incentives Improvement Act of 1999 by the Clinton administration. Its implementation is still being fine-tuned based on studies of its uncertain impact.
For more than a quarter century, David has been among the preeminent academic diagnosticians of contemporary health and social policy. Although initially focused on mental health care, the scope of his attention grew over time to be far broader and his influence more pervasive. His thoughtful assessments and critiques helped illuminate the changing organizational arrangements within which health care is delivered, demonstrate the ways in which cross-national contexts shaped policy design, and clarify some fundamental aspirations for medical professionalism and health system performance.
What most characterized these contributions was David's careful, balanced assessment of policy making, as well as how that policy-making process might be improved. At a time when relatively few medical sociologists entered the policy fray, David brought conceptual perspectives that had previously been given short shrift in policy analysis. Mark Schlesinger, a colleague and coauthor with David, says (pers. comm., December 6, 2015): “At a time when most academics engaged with public policy largely through the lens of their favorite pet theories or narrowly defined methods, David brought to bear a more impartial, evenhanded assessment that added clarity, without pushing an agenda. That made his voice distinctive—and thereby all the more valuable.”
Leadership and Mentoring in Health Policy
David's strong leadership and mentoring in bringing more social scientists into health policy research and policy making have played out exceptionally in his long involvement with the RWJF. He became involved with the foundation from the very beginning of its transition from a small community foundation in New Brunswick that began in 1936 to the hugely endowed entity with headquarters in Princeton. In 1971 the foundation acquired more than $1 billion in securities from the estate of Robert Wood Johnson II, the former CEO of Johnson and Johnson, making it overnight the second-largest foundation in the country (Farber 1971). David's first contact was in 1972 when he was invited to join a panel headed by Robert J. Blendon, senior vice president of the RWJF. The panel met in the recently completed headquarters with boxes still unpacked to discuss RWJF's future programs.
David was actively involved in the RWJF human capital programs that brought social scientists including economists, political scientists, and sociologists into health policy research. They, in turn, would then train future cohorts of social scientists. He participated in the development of the Scholars in Health Policy Research Program, where he served on its national advisory committee from 1992 to 2012. He was involved in initiating the Health and Society Scholars Program, whose heterogeneous interdisciplinary awardees pursued research on the determinants of population health. He was a member of the program's technical advisory committee in 2001–2 and its national advisory committee from 2003 to 2010. Over the years, David was also involved in advisory committees or as a consultant to other RWJF programs including the Program to Consolidate Health Services for High-Risk Young People and the RWJF Commission on Medical Education.
David's mentoring skills moved to a much different level when, in 2000, he became director of RWJF's Investigator Awards in Health Policy Research Program, a position he held for thirteen years, during which the program provided support for innovative projects by some 148 researchers from at least twenty disciplines. David worked tirelessly to advance the program, leverage its influence and prestige nationally, and foster synergies and cross-fertilization among its network of scholars from diverse disciplines across the social sciences, the health professions, and other fields from history to journalism. Under David's leadership, the program's research portfolio achieved great breadth, depth, media attention, and policy impact. Working with the program's national advisory committee, on which he continues to serve, he identified innovative and productive lines of health policy–relevant inquiry in the social, behavioral, and clinical sciences and the humanities. He was especially skilled at finding intersections across fields.
As Lynn Rogut, deputy director of the program, recalls (pers. comm., October 17, 2015): “David ha[d] a knack for posing the most incisive question in the conference room, one of his many tactics for pushing intellectual boundaries and promoting research excellence.” Rosemary Stevens, who served on the program's national advisory committee, says (pers. comm., October 23, 2015): “David's work epitomizes the urgency and the importance for future scholars to think broadly about society, its messy health care system, how well (or ill) citizens are being served, and possible avenues for change.”
Investigators who were supported by the program while David was director not only produced an astonishing array of books and articles, but they also had a more direct impact on national health policy. For example, four investigators (David Blumenthal, Richard G. Frank, Sherry Glied, and Richard Kronick) subsequently served in senior positions in the Department of Health and Human Services, and Timothy Westmoreland was a consulting counsel for the US House of Representatives' Energy and Commerce Committee. Sara Rosenbaum played an important role from outside government in the design of federal Medicaid policy under the ACA, the creation of federal funding and policies related to the health care safety net, and the Department of Health and Human Services' application of civil rights policy to new health insurance markets. Forty investigators are members of the IOM (now the National Academy of Medicine), one of the highest honors a health scholar can earn, with twenty-five of them elected to the IOM after receiving their Investigator Award.
Recognition and Achievement in Honors and Awards
In view of the accomplishments that we have described, it should be no surprise that David received many honors and awards in recognition of his research contributions and his leadership in various organizations. A partial list of the honors he has received appears in table 1. Several points are notable about the list. One is that the honors took place over more than forty years. Another is the number of different disciplines whose organizations have given recognition to David.
His IOM involvement is particularly remarkable. Twelve years after completing his doctorate, David was in the first class elected to the newly created IOM in 1971. (Twenty years later, he was elected to the IOM's parent organization, the National Academy of Sciences, a rare honor for a sociologist.) Over the years, David has served on at least twenty IOM study and advisory committees, including the membership committee, the program committee, and the governing council. He also, perhaps uniquely, received two individual awards from the IOM. In 2008 he received the Adam Yarmolinsky Medal, given to an IOM member from a discipline outside the health and medical sciences “who has over a significant period of time contributed in multiple ways” to the IOM's mission. The next year, he received the IOM's Rhoda and Bernard Sarnat International Prize in Mental Health, awarded to individuals, groups, or organizations for outstanding achievement in improving mental health.
But four honors that are not listed in table 1, along with his doctoral involvement at the Center for Advanced Study, had perhaps the longest-lasting impact on his career and the accomplishments that we have described. While a doctoral student at Stanford, he was supported by a Ford Foundation Behavioral Sciences Fellowship, an A. E. Fowle Scholarship, and an NIMH research fellowship, and he also received NIMH support for his postdoctoral traineeship at the University of North Carolina at Chapel Hill. It is evident that David Mechanic would have succeeded in whatever direction he took with his career, but the early and continuing fellowships and NIMH grants including a NIMH Special Fellowship spent at the Maudsley in 1965–66 supported training and research activities that resulted in the astonishing set of accomplishments we have described and led to his career-long interest in finding ways to provide financial and intellectual support to younger scholars who became some of the most eminent medical sociologists and health services researchers in their fields. Financial support, along with exceptional leadership and guidance of young scholars, remains vitally important in developing and sustaining the next generation of innovators in health and health policy research. No finer model of a universally respected colleague and caring and relentless source of guidance and inspiration in the scholarly and policy research world is likely to be found.
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The authors in this collection of essays include friends and colleagues (and, in one instance, a son) who have worked with David in many different capacities—as students, collaborators, contributors to books that he edited, investigators in academic enterprises that he led, leaders of projects that he advised, fellow committee members, or recipients of financial support in programs in which he was involved. Four of us (Paul Cleary, Bradford Gray, James Morone, and Mark Schlesinger) also dealt as journal editors with David, both as an author and a reviewer. What perhaps might not be expected for an author of his eminence, he was always highly responsive to critical comments from reviewers or editors. And as a reviewer, he was an editor's dream, always providing thoughtful, incisive, and constructive comments long before the due date.
Dozens of other people have worked with David in one capacity or another and could have contributed suitable essays to this issue of JHPPL; space constraints required that we be selective. The essays themselves reflect the diversity of his policy-relevant interests—challenges in mental health care; population health; disparities in health and health care; trust in health care; the quest for quality health care; predicaments of health care reform; state-level health reforms; organization, financing, and delivery of long-term and end-of-life care; and the relevance of research to patient care and policy.
Our endeavor benefited from the contributions of many individuals. First and foremost, David shared his personal thoughts and reflections of his early academic background and his experiences and participation in various endeavors in research, policy making, institution building, and mentoring. He should not be held responsible for the prose that resulted from our conversations and the unpublished material he shared with us. Our advisory committee, Paul D. Cleary, Allan V. Horwitz, Rosemary Stevens, and Mark Schlesinger, offered valuable advice and strategic guidance throughout the project and provided their own perspectives about David's scholarship and leadership and their personal reflections about him in this article. Joel Cantor, Renée Fox, Ronald W. Manderscheid, and Lynn Rogut provided details of David's involvement in policy development and his pioneering work in medical sociology.
We are also grateful to the following people who reviewed draft essays and offered suggestions to the authors: Lisa F. Berkman, Donald Berwick, Elizabeth Bradley, Deborah Chollet, Patrick W. Corrigan, Frank deGruy, Judith Feder, David M. Frankford, Howard H. Goldman, Mark Hall, John Holahan, Timothy Jost, George Kaplan, Judith R. Lave, Ronald W. Manderscheid, Ramin Mojtabai, Mark Olfson, John Pachankis, Dana Gelb Safran, Edward Shorter, Stephen Somers, Michael Sparer, Katherine Swartz, Peter Ubel, Debra Umberson, Joseph White, and Matthew Wynia. These busy individuals responded instantly when told the nature of our request.
We are also grateful to Colleen M. Grogan, editor of JHPPL, for her quick and enthusiastic response to our proposal for this special issue; to Allison Stinson, assistant editor, for her guidance and accommodating the authors and editors in submitting their essays; Stacy Lavin, senior managing editor at Duke University Press, for her astute handling of editorial processes; and to David C. Colby and the Robert Wood Johnson Foundation for financial support for the project.
