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After a long and contentious national debate, and after many failed attempts over the course of decades, health-care reform was signed into law on March 23, 2010. The goals of reform were twofold: to extend health care to the vast majority of U.S. citizens and to start to control health-care costs.
The need to reform the publication and distribution of academic journals is also great, and for the same reasons: scholarship should reach all who need it and be affordable. The central elements of the health-care debate can frame how the academic community approaches widening and accelerating the flow of scholarly journal content so all can benefit from it. In this article, we identify lessons from health-care reform and show how these lessons might be applied to periodical publishing and distribution.
The United States spent $2.4 trillion on health care in 2008, according to National Health Expenditure Projections, 2008–2018, a report issued by the U.S. Department of Health and Human Services. Almost $50 billion was spent on subscriptions to academic periodicals, according to the U.S. Economic Census. In both cases, over the course of decades, the rate of increase exceeded the consumer price index (CPI). Surely these industries differ in scope, size, and utilization. But there are three noteworthy parallels between them. First, both are vital to any advanced society. Second, we spend vast sums for their products and services. Third, similar forces and dynamics drove these industries to a place beyond the reach of many people who need their products and services.
Peer-reviewed scholarly journals remain principal repositories of research. Largely invisible to the general public, the publication and distribution of journal content have been at the center of a tug of war between cost and access; however, because subscription fees have been escalating for years, the balance has been shifting demonstrably toward cost, with less wealthy academics and colleges losing access. This is akin to the argument over whether health care is a “right” or a “privilege.” Also, like managed-care companies in the health-care industry, publishers, aggregators, and distributors of scholarship have had a powerful influence on both prices and the scope of dissemination of published products, while profiting overwhelmingly from this arrangement. A brief examination of how health-care reform came to be urgently needed helps set the stage for how to reform academic periodical publishing.
The Health-Care Context
Since the end of World War II, costs for health care have escalated faster than the inflation rate and the CPI. In Health Care USA: Understanding Its Organization and Delivery, epidemiologist Harry Sultz and public-health instructor Kristina Young, both of the State University of New York at Buffalo, demonstrate that efforts to manage costs have been secondary to expanding coverage and maintaining standards of quality care. Reimbursement formulas placed an emphasis on capital development in which hospitals continuously acquired more technology. In Improving Health Policy and Management, Kenneth Thorpe explored health-care costs during the past twenty years and found that efforts to suppress health-care inflation were largely unsuccessful. For example, the Diagnostic Related Groups program, instituted in 1983 by Medicare to curb inflationary spending growth, established fixed fees for hundreds of diagnoses without meaningfully reducing costs. Comprehensive efforts to reform the health-care system, such as the Clinton initiative in the early 1990s, also failed. By the 1990s, health care had become intolerably unaffordable, with “employer-sponsored health insurance premiums . . . increasing 119 percent” between 1997 and 2006. It became evident that a reduction in the rate of cost increase, accompanied by better access to health care, would not be brought about by a publicly or federally driven plan. Thus, opportunities opened for models that could steer patients through health-care systems and help them avoid needless and expensive costs—a premise employed by managed care (for example, through health-maintenance and preferred-provider organizations [HMOs and PPOs]) to establish a ubiquitous presence in health care.
Is Managed Care an Effective Solution?
When managed care emerged on the scene, it had broad appeal. It promised something for just about everyone: for example, patients would receive all the care they needed, and providers would be protected from excessive government intrusion. Managed care swooped into the health-care market aggressively; as Shawn Tully observed in Fortune in 1992, 38 percent of Americans were covered by managed-care plans in 1992. By 2007, the percentage of workers covered by commercial HMOs and PPOs had more than doubled, according to the Kaiser Family Foundation. But such growth raises the question of whether managed care contained costs for the nation. According to the Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999–2009, during the past decade, health-care premiums have outpaced inflation. Premiums have increased a total of 131 percent, which is more than workers’ wages (up only 38 percent) and inflation (up 28 percent). And yet, access to health care during this period declined. According to the U.S. Census Bureau, in 2000, 38.7 million Americans were without health insurance; this number swelled to 47 million by 2006. So, from the time the Clinton plan failed, managed-care penetration doubled, health-care expenses outpaced inflation by two to one, and a large number of Americans lost access to the system.
The Rise of Commercial Publishers and Distributors
Similarly, in the publishing and distribution of scholarly journals, commercial intermediaries (publishers, aggregators, and distributors) have established substantial influence over the industry, jeopardizing both product affordability and consumer access. An examination of pricing trends in scholarly journal publishing reveals a pattern of considerable inflation. Since 1990, average price increases exceeded 500 percent (see figure 1), while the CPI increased by only 41 percent; at the same time, the expense ratio for publishing remained steady. Moreover, with the shift from paper to electronic modes, material and distribution costs could hardly account for the increases in cost. Also, according to Costs and Business Models in Scientific Research Publishing, a 2004 report commissioned by the Wellcome Trust, the fees paid to authors and reviewers by some journals have not risen enough to drive up publishing costs by even modest amounts.
In addition to raising subscription fees, commercial publishers, aggregators, and distributors exerted a dominant presence remarkably similar to that of managed-care organizations. Consider the field of communication studies. In a 2005 Library Journal article, Lee C. Van Orsdel, dean of libraries at Eastern Kentucky University, and Kathleen Born, director of the Academic Division at EBSCO Information Services, point out that social science and humanities periodicals experienced the largest price increases among the disciplines between 2001 and 2005. More particularly, in “Confirming Suspicions,” an article in Collection Management by one of the present article’s authors, Lisa Romero, demonstrates that the number and price of communication studies periodicals grew more than for any other social science field between 2001 and 2004; average price increases exceeded 11.5 percent, compared to just over 8 percent for journals in all other subject areas. Commercial publishers expanded their ownership stake of communication journals by 78 percent from 1994 to 2008 (see figure 2). That is astonishingly close to the rate of increase of managed-care penetration in the health-care industry.
While the addition of new titles is responsible for some of the expansion of commercial entities, the acquisition of existing titles accounts for the significant increase in control and anticipated profits. For example, 22 percent of titles from nonprofit professional and academic associations and 8 percent of titles owned by universities were purchased by commercial publishers. This surge toward commercial publishers continued relatively uninterrupted from 1994 to 2008, leaving only 12 percent of the titles published by noncommercial entities. As Richard Edwards, senior vice chancellor at the University of Nebraska–Lincoln, and David Shulenburger, executive vice chancellor at the University of Kansas, detail in their article in Change, “The High Cost of Scholarly Journals,” commercial publishers seek to acquire top-quality journals (published by universities and professional and scholarly associations) and dramatically increase subscriptions to solidify future revenues. So it is no surprise to learn from the OneSource Global Business Browser database that in 2008, the larger commercial publishers boasted hefty revenues: Reed Elsevier, more than $5 billion; Taylor and Francis, more than $48 million; Routledge, more than $45 million; and Wiley-Blackwell, more than $87 million. In fact, Reed Elsevier’s operating profit margin for 2008 was 17.28 percent (the overall operating profit margin for the industry was 14.04 percent).
What Academia Can Learn from Health-Care Reform
Organizations with a commanding presence in an industry naturally seek to institutionalize their indispensability. They finance strategies that strengthen their position and challenge efforts to contain their power and influence. The insurance and pharmaceutical industries had great success in marshalling opposition to the Clinton health initiative. We see the same situation today in academic publishing, with nonprofit publishers and distributors yielding leverage to commercial entities. If it is to reverse trends of rising costs and limited access to journal content, academia would benefit from studying health-care reform in a quest to fulfill its purpose of advancing knowledge by making scholarship widely available. We posit that there are five questions central to the health-care debate that could be adapted to the scholarly periodical industry. The answers to these questions can help begin a reform of this industry.
Should health care be available to all?
Is access to health care a right or a privilege? Although the health-care debate underscored the complexity of this question, public sentiment during the debate leaned toward universal coverage. A principal goal of health-care reform was to expand access. At the very least this meant not permitting the economic interests of those who manage access to supersede the welfare of consumers.
Should the principle of universality apply to publishing and distributing scholarship? How should we balance such a goal against the rights of publishers and distributors to determine fees and sell their products and services in an open market? There are risks to blocking economic opportunity, not the least of which is the inconsistency with a capitalist ethic and its propensity to stimulate innovation. However, society progresses to the extent we can conduct, engage, and learn from research that is designed to help us understand and improve the human condition.
Lesson 1: Just as restricting access to health-care weakens our national health, restricting access to scholarship jeopardizes the scholar’s ability to advance our society. Therefore, we must protect the free flow of scholarship to all who may benefit before we protect the economic interests of those who profit from controlling that flow.
How might stakeholders work more collaboratively and serve common interests?
In his 1995 article in the American Prospect, “What Happened to Health Care Reform?” Princeton University sociologist Paul Starr points out that the insurance and pharmaceutical industries mounted powerful campaigns to deter reform movements of earlier decades, and coalitions of constituencies seeking reform did not organize effectively to collaborate in their responses. Consumers and providers did not join forces in a productive and influential manner to identify common interests and sway policy toward those interests.
What complement of stakeholders can advance the agenda of scholarly publishing reform? While many groups could and should play a role, a stronger bond between librarians and scholars is crucial. Librarians understand the universe of scholarly resources, while scholars define resource needs. Together, they constitute a potentially powerful force in determining library holdings and managing access to information. However, the failure of these two groups to establish a mutually supportive and sustained working relationship has allowed third parties to dominate the determination of price and scholarship repository composition. Libraries now face the daunting challenge of meeting demand while managing escalating costs for periodicals (see figure 3).
Lesson 2: Scholars and academic librarians should identify common interests and formulate a shared agenda. Discussions should occur systematically and regularly, for example, in strategic planning contexts and at professional conferences. These stakeholder groups can do together what neither can do alone to develop new ways of obtaining, managing, and spreading scholarship.
What is the influence of technology?
Emerging technologies are playing a vital role in health care, facilitating rapid progress in diagnosis, treatment, and information management and retrieval. Communication technologies permit health-care consumers to engage providers and gain access to information in ways not previously possible or even imaginable. For example, consider that an electronic, portable medical-record system can facilitate and extend care by enabling physicians anywhere to learn about a patient’s health history. Such technology can help keep patients more informed. It also can help reduce errors and costs by eliminating the need to duplicate the construction of a medical record each time a patient visits a provider.
Increasingly, journal content is being produced and made available in electronic form. At the same time, technology is advancing our ability to network. As these currents track toward one another, researchers are increasingly able to identify colleagues with common interests and explore opportunities for working together. As we speculate about where these trends lead in the not too distant future, we can envision virtual research communities for scholars whose participation is based on shared professional and research pursuits. Electronic information resources will create opportunities for scholars to build bridges toward one another, enabling them as well to review scholarly content together, synchronously and fluidly. Technology can help make the playing field limitless and level.
Lesson 3: Concerted and systematic efforts to identify, imagine, and harness the power of emerging technologies should be pursued for their capacity to disseminate scholarship and facilitate shared experiences in using it.
What regulatory controls could ensure a fair system?
The debate over health-care reform included a contentious discussion about the role of government. Some groups argued that a strong governmental presence was essential to ensure fairness, while others contended that such a presence would be stifling and costly. Would scholars and students benefit if the academic publishing field were more fully regulated? Would this help make scholarship more available? What would the goal be and how much oversight would be necessary? Who should be responsible for ensuring that practices and processes are fair and access to information does not take a back seat to profit?
While we encourage a vigorous discussion of this issue, it is beyond the scope of this article to define specific parameters of conduct for an industry or to advocate for regulations that could impair an organization’s opportunity to profit. However, in making health care more accessible, reformers removed certain barriers that limited consumer access. For example, broadening accessibility meant that insurance companies and other third parties would be regulated.
This issue of oversight is complex. But it is also essential to consider—for with each passing day periodicals become more expensive, putting them beyond the reach of users. One point of departure for the discussion may involve the role of publication boards for professional associations. Ordinarily, publication boards appoint editors for an association’s journals and develop policies related to the association’s published materials. In so doing, boards review and authorize contracts with publishers, aggregators, and distributors of journal content. Yet, it is not uncommon for board members to function as authors, reviewers, or editors of material published by these commercial entities and to receive compensation for such work. Such professional activity, and remuneration received for it, should be disclosed to the association’s membership. Board members who receive incentives for such work should recuse themselves from reviews of business arrangements between their associations and organizations with which they have an economic relationship. Professional associations should review their conflict-of-interest policies on publication board membership and ensure that these include effective enforcement mechanisms. Publication board members should not be enticed by incentives to act in any way other than in the best interests of the association’s membership.
Lesson 4: If it appears that the obstacles to obtaining scholarship are prohibitive, some regulation of publishers and distributors may be necessary to establish a system in which such scholarship is kept affordable and accessible.
Should reform be approached comprehensively?
Absent a comprehensive, nationwide approach to health care, individual states and regions would have been forced to take action. Indeed, several states, including Massachusetts and California, adopted or proposed reform initiatives prior to the enactment of national legislation. Such an incremental, patchwork approach would not have produced broad, consistent, and meaningful change. Instead, it would have favored different groups in different states, and the portability of coverage across states would have faced enormous obstacles.
Today, a Byzantine network of journal formats has been cobbled together, each with a cost. Current journals, available in print or electronic formats, are provided by subscription or included with an association membership. Historical content is available separately, usually from an aggregator and purchased by the institutional library. A third tier of content for older material may be available from yet another source, like JSTOR. Finally, abstracts and other metadata may be available from sources such as online indexes or abstracts. This multiplicity of subscriptions makes acquisition and access through libraries difficult to manage and maintain. Recently, challenges to this model have sprung up, including from nonprofit aggregators (such as BioOne), author Web sites (see the February 2008 Inside Higher Ed article “Harvard Opts In to ‘Opt Out’ Plan”), and burgeoning open-access projects (for example, see the efforts of the Scholarly Publishing and Academic Resources Coalition).
Lesson 5: Only through comprehensive reform will a model emerge that establishes the primacy of the consumer and unrestricted access to scholarship as its core elements.
A Look Back, a Look Ahead
In 1940, approximately 10 percent of employees in the United States were covered by employer-based health insurance. By 1950, that number skyrocketed to 50 percent, a trend that continued until recently. Along with the enactment of Medicare and Medicaid, the phenomenon of payment for care by third parties resulted in the majority of Americans being shielded from the real costs of medical care. Similarly, with scholars and students securing access to journal content through their university libraries, they, too, are generally unaware of the full cost of the information they consume.
But costs in both industries have gotten out of hand. The forces that sought to dampen health-care reform could no longer depend on consumer apathy. Premiums escalated too rapidly, producing too many have-nots. We may be nearing such a tipping point in the world of periodical publishing and distribution. As the price for scholarship exceeds what is affordable and reasonable, resulting in increased profits for publishers and diminished access to information for users, new models must emerge. Stakeholders with an interest in promoting the unfettered flow of scholarship must find common ground and restore this ethic to its proper place.
Barry Eisenberg is assistant professor in the MBA program of the School for Graduate Studies at the State University of New York Empire State College. His e-mail address is email@example.com. Lisa Romero is associate professor and head of the communications library at the University of Illinois at Urbana-Champaign. Her e-mail address is firstname.lastname@example.org.