Millions of women in India give birth at home, where they don’t have easy access to medical help if things go wrong. And things go wrong often. The country has one of the world’s highest rates of maternal and neonatal deaths.

To curb this problem, the government pays eligible pregnant women to deliver their babies in an accredited medical facility. With both a financial incentive and the promise of a safer childbirth, it would stand to reason that most Indian women should choose to deliver their babies in a hospital.

But that’s not the case.

Most babies are still born in homes. Early numbers from the financial incentive programs show less than half of eligible women are choosing to participate.

Stanford researchers Grant Miller and Nomita Divi think the answer to this quandary—and so many other well-intentioned policies that fall short—needs to first be considered from the perspective of patients, doctors and other health care providers. And that, they say, is a different approach than most health interventions take.

Miller and Divi are spearheading the Stanford India Health Policy Initiative, a program that seeks to rethink health interventions based on Indian health care users’ and providers’ motivations for seeking care. And to get there, the initiative’s focus comes from the people who confront these problems every day.

The program, which is connected to the International Policy Implementation Lab at Stanford’s Freeman Spogli Institute, first brings together community leaders for an in-depth discussion of where best to focus efforts. Next, teams (including students) take these recommendations and spend several months conducting fieldwork to understand health care decision-making, both from the side of patients and providers.  From this foundation, the initiative produces reports detailing the behavioral motivations for why certain dimensions of health care are or are not working.

“To really understand why health policies succeed or fail, you have to see the world through the eyes of the providers and patients,” said Miller, an associate professor of medicine and a core faculty member of FSI’s Center for Health Policy and Primary Care Outcome Research. “A lot of programs are created because they seem logical from the outside. But if you don't understand a patient’s priorities or motives, your program may not work.”

Miller and Divi first applied this approach to the very issue of childbirth in India. Why weren’t more women giving birth in hospitals when there were seemingly logical reasons to do so?

Over the summer, Miller, Divi, their Indian partners, and Stanford graduate and medical students set out to answer this question. During seven weeks of field interviews and subsequent analysis, the students—with guidance from Miller and Divi —identified reasons for why Indian women weren’t accepting a stipend to have their babies in the hospital. Some of these reasons included hidden costs of delivering a baby (like the transportation cost to the hospital or unexpected medical expenses), pressure from mothers-in-law to follow tradition and deliver at home, and fear of unwanted medical procedures like Caesarean sections or sterilization.

This understanding of why patients and providers don’t always make seemingly logical health care decisions is exactly what the India Health Policy Initiative is after.

“So much academic research is driven by donors or journal articles that we read,” Miller said. “So it seemed like we were starting from the wrong place in identifying health policy challenges that we should work on.”

In January, Miller and Divi convened a group of Indian health policy leaders, health care workers, academics and entrepreneurs to understand the challenges they faced in their daily work, and what health care questions they would most like to know more about. From this two-day meeting, the group identified two focus areas for the India Health Policy Initiative over the coming year: understanding more deeply the motivations and activities of both formal and informal health care providers, and what Indians value about care from the informal sector. These informal providers are often doctors or nurses with little or no medical training that are used by many low-income Indians.

To help answer these questions and provide opportunities for students, the Stanford India Health Policy Initiative engages top students from across the university. “We want to provide our students with an experience that will hopefully shape the way they think in their future careers,” said Divi, the initiative's project manager. “And we try to achieve this by training our students to help make sense of urgent health delivery challenges, immersing them in an intensive field experience, and teaching them how to generate insights.”

To better understand providers’ motivations, as well as patients’ perspectives on both the informal and formal providers, Miller and Divi will work with this new team to carry out qualitative fieldwork this summer.

Miller explained that the approach is very anthropological.

”To be able to understand these issues, we all have to see the world through another person’s eyes, whether that be a formal or informal health provider or a patient,” he said. “This approach fundamentally relies on strong collaboration with Indian partners.”

The initiative’s teams will spend their weeks interviewing different health care providers and patients in a handful of Indian villages, taking copious notes and ultimately translating hundreds of interviews into findings.

Roshan Shankar, MS/MPP ’14, worked as part of the initiative’s team last summer, focusing on understanding pregnant women’s decisions about where to deliver their babies. After considering several summer internships with consulting firms and international organizations, Shankar declined these opportunities, instead opting to work with the Stanford India Health Policy Initiative.

Shankar is from New Delhi and has always planned to move back to his home country and work in government after school. He said the India Health Policy Initiative was a way to better understand his nation and the pressing challenges facing it.

“I’m used to sitting at a table and not venturing out,” Shankar said. “This experience showed me that things are much more different on the ground than on paper.”

After his work with the Stanford Health Policy Initiative, Shankar said he is now certain he wants to return to India and work in government.

“It was a humbling and enlightening experience. I think the way we did this entire analysis will affect the way I do any work there,” he said. “It will ensure that I do a more effective evaluation of the policies and programs that I work on, and start by going to see people who use them.”

The Stanford India Health Policy Initiative is supported by several organizations including the Center for Innovation in Global Health and the Office of International Affairs.

Teal Pennebaker is a freelance writer.

Millions of Americans who need to buy health insurance are eligible for federal subsidies. But the government may have underfunded the expense by billions of dollars, according to Stanford researchers.

In a recent article published in Health Affairs, the researchers expose the remarkable control employers will soon have on federal revenue. Employers will soon decide whether to continue providing health insurance to their employees, cut their coverage or increase premiums that workers pay. 

These choices will in part determine whether it will be financially beneficial for workers to buy insurance through the government’s new health insurance exchanges, rather than be insured through their employers.  And such decisions could change government expenditures by billions of dollars– a potential spending increase that the federal government has likely not accounted for.

"There’s going to be a lot more federal money required for insurance subsidies than people are ready for," said Jay Bhattacharya, an associate professor of medicine at Stanford and a core faculty member of Stanford Health Policy, a center at the university’s Freeman Spogli Institute for International Studies. Bhattacharya co-authored the study with medical students Daniel Austin, Anna Luan and Louise Wang from Stanford.

Because a lot of employers and employees are going to realize that employer-provided coverage isn’t worth it – that it makes more economic sense for their employees to get health insurance through the exchanges,” Bhattacharya said.

As of Oct. 1, millions of Americans began receiving federal subsidies to buy health insurance under the Affordable Care Act. People are eligible for a subsidy if they earn between 133 and 400 percent of the poverty level. For individuals, that’s between $14,404 and $43,320. And for a family of four, the range is between $29,326 and $88,200. The subsidies from the government amount to $9,247 for a family of four living on $56,604 a year.

The new health care law assumes that workers who already have affordable insurance through their employers will not use the exchanges, though no mechanism is in place to check that a person using a subsidy isn’t already insured. And while there is a penalty – about $3,000 per employee after the first 50 employees – to  large employers who stop offering health insurance, it is often cheaper for an organization to pay the fine. Providing insurance to cover an employee’s family could cost a business $16,000 or more to cover an employee’s family.

Bhattacharya was interested in understanding the financial implications for the federal government should an employer decide to keep or end its health insurance coverage for employees eligible for subsidies. So he and his colleagues modeled how much the federal government would have to provide in subsidies if an employer stopped providing health insurance to workers, and those employees then used the federal subsidies to buy themselves insurance on the exchanges.  

“These decisions that employers are making about whether or not to provide their employees health insurance has a huge effect on federal government spending,” Bhattacharya said.  

According to the researchers’ calculations, if everyone who would benefit financially from receiving health insurance through the exchanges rather than from their employer chose to buy insurance on the exchanges, the federal government would be on the hook for $132 billion per year to pay for the subsidized insurance.  While not everyone who benefits financially from dropping employer-based coverage will do so, Bhattacharya estimates that federal costs would climb by nearly $7 billion if employers raise health insurance premiums by even just $100 because it would induce millions of employees to switch to exchange-based coverage.

In many instances, Bhattacharya pointed out, companies can still ensure their employees have benefits and make more money by cutting their workers’ health insurance if they’re eligible for subsidies, paying their employees a slightly higher salary and encouraging them to receive the federal subsidies and buy their own policies. But doing so puts a heavier financial burden on the government.

On the flip side, if more employers decide to offer health insurance – perhaps wanting to avoid the small penalty or because of the appearance of not offering a basic benefit – the government could end up spending a lot less on subsidies. But Bhattacharya expects that is unlikely.

The study used data from the Medical Expenditure Panel Survey Household Component – a national survey of household health care use, insurance status, and health expenses, as well as demographic and socioeconomic information – to construct a model.  The model revealed that as employees’ health insurance contributions rise (when their insurance is provided by an employer), employees are increasingly enticed to drop their employer coverage and buy insurance through the exchange. Among workers who qualify for a subsidy and see an increase of $100 in their employer-based premium contribution levels, 2.25 million individuals would choose to instead buy insurance on the exchanges – increasing federal spending for subsidies by $6.7 billion.

“In the model we assume that if there’s a $1 benefit, employees will drop their employer-sponsored coverage. In reality there’s a lot of inertia and you most likely won’t get that $1 increase,” Bhattacharya said. “On the other hand, in the medium run, employers might say ‘employees will benefit if I drop coverage. I can raise their wages, and they’ll get better coverage on the exchanges.’”

Teal Pennebaker is a Washgington, D.C.-based freelance writer and former information editor and external relations coorinator at Stanford Health Policy.

Mariano-Florentino Cuéllar, a Stanford law professor and expert on administrative law and governance, public organizations, and transnational security, will lead the university’s Freeman Spogli Institute for International Studies.

The announcement was made in Feb. 11 by Provost John Etchemendy and Ann Arvin, Stanford’s vice provost and dean of research.

“Professor Cuéllar brings a remarkable breadth of experience to his new role as FSI director, which is reflected in his many achievements as a legal scholar and his work on diverse federal policy initiatives over the past decade,” Arvin said. “He is deeply committed to enhancing FSI’s academic programs and ensuring that it remains an intellectually rich environment where faculty and students can pursue important interdisciplinary and policy-relevant research.”

Known to colleagues as “Tino,” Cuéllar starts his role as FSI director on July 1.

Cuéllar has been co-director of FSI’s Center for International Security and Cooperation (CISAC) since 2011, and has served in the Clinton and Obama administrations. In his role as FSI director, he’ll oversee 11 research centers and programs – including CISAC – along with a variety of undergraduate and graduate education initiatives on international affairs.  His move to the institute's helm will be marked by a commitment to build on FSI’s interdisciplinary approach to solving some of the world’s biggest problems.

“I am deeply honored to have been asked to lead FSI. The institute is in a unique position to help address some of our most pressing international challenges, in areas such as governance and development, health, technology, and security,” Cuéllar said. “FSI’s culture embodies the best of Stanford – a commitment to rigorous research, training leaders and engaging with the world – and excels at bringing together accomplished scholars from different disciplines.”

Cuéllar, 40, is a senior fellow at FSI and the Stanley Morrison Professor of Law at the law school, where he will continue to teach and conduct research. He succeeds Gerhard Casper, Stanford’s ninth president and a senior fellow at FSI.

“We are deeply indebted to former President Casper for accomplishing so much as FSI director this year and for overseeing the transition to new leadership so effectively,” Arvin said.

Casper was appointed to direct the institute for one year following the departure of Coit D. Blacker, who led FSI from 2003 to 2012 and oversaw significant growth in faculty appointments and research.

Casper, who chaired the search for a new director, said Cuéllar has a “profound understanding of institutions and policy issues, both nationally and internationally.”

“Stanford is very fortunate to have persuaded Tino to become director of the Freeman Spogli Institute for International Studies,” Casper said. “He will not only be an outstanding fiduciary of the institute, but with his considerable imagination, energy, and tenacity will develop collaborative and multidisciplinary approaches to problem-solving.”

Cuéllar – who did undergraduate work at Harvard, earned his law degree from Yale and received his PhD in political science at Stanford in 2000 – has had an extensive public service record since he began teaching at Stanford Law School in 2001.

Taking a leave of absence from Stanford during 2009 and 2010, he worked as special assistant to the president for justice and regulatory policy at the White House, where his responsibilities included justice and public safety, public health policy, borders and immigration, and regulatory reform.  Earlier, he co-chaired the presidential transition team responsible for immigration.

After returning to Stanford, he accepted a presidential appointment to the Council of the Administrative Conference of the United States, a nonpartisan agency charged with recommending improvements in the efficiency and fairness of federal regulatory programs.

Cuéllar also worked in the Treasury Department during the Clinton administration, focusing on fighting financial crime, improving border coordination and enhancing anti-corruption measures.

Since his appointment as co-director of CISAC, Cuéllar worked to expand the center’s agenda while continuing its strong focus on arms control, nuclear security and counterterrorism. During Cuéllar’s tenure, the center launched new projects on cybsersecurity, migration and refugees, as well as violence and governance in Latin America. CISAC also added six fellowships; recruited new faculty affiliates from engineering, medicine, and the social sciences; and forged ties with academic units across campus.

He said his focus as FSI’s director will be to strengthen the institute’s centers and programs and enhance its contributions to graduate education while fostering collaboration among faculty with varying academic backgrounds.

“FSI has much to contribute through its existing research centers and education programs,” he said. “But we will also need to forge new initiatives cutting across existing programs in order to understand more fully the complex risks and relationships shaping our world.”

In addition to Casper, the members of the search committee were Michael H. Armacost, Francis Fukuyama, Philip W. Halperin, David Holloway, Rosamond L. Naylor, Douglas K. Owens, and Elisabeth Paté-Cornell.