I'm a nerd and I follow The Lancet

Obama's plans for US and global health, The Lancet, Volume 372, Issue 9652, Pages 1797 - 1798, 22 November 2008

Tough economic times will hamper the ability of Barack Obama, USPresident-elect, to deliver on his many domestic and global health-carep roposals. But experts still see ways for him to quickly make his mark on health policy. Nellie Bristol reports from Washington, DC.

Expanded health coverage for children, reversal of the Bush Administration'spolicies on stem-cell research, and the removal of funding restrictions forinternational family-planning agencies are among health policies likely to be enacted quickly by Barack Obama when he takes office in late January,2009, say experts.

Although Obama campaigned on a promise to expand health-care coverage tomost of the 45 million Americans without insurance, fiscal realities willlikely slow progress on his plan, which some estimate would cost the federalgovernment more than US$75 billion a year. But health policy andcongressional experts see the expansion of the State Children's HealthInsurance Program (SCHIP) as immediately feasible. Both houses of Congress passed expansion bills last year, but they were vetoed by President Bush.

The bill likely to pass next year would be based on legislation that would increase funding by $35 billion over 5 years to a total of $60 billion. Thebill would be paid for through an increase in cigarette taxes. It wouldcontinue coverage for the 6 million children currently enrolled and add 5·8million more children by raising the income eligibility level to 300% of thepoverty line, or $51 510 yearly for a single parent with two children and$61 950 for a family of four. Children make up 20% (8 million individuals)of the uninsured population, according to the Kaiser Family Foundation.

Karen Pollitz, of Georgetown University's Health Policy Institute, alsocalled for better insurance access for young adults aged 19—29 years, whomake up 29% of uninsured people and often lose coverage when they becomeineligible for their parents' plans.Other domestic health-care initiatives likely to be enacted early in the newadministration include reversing a federal ban on stem-cell research—a moveObama can make through an executive order.

The Bush Administration limited research to existing stem-cell lines but Obama has been a strong supporter of expanding research.

On Nov 9 Obama's transition team leader John Podesta said that thePresident-elect is reviewing all of Bush's Executive Orders and that therestrictions on stem-cell research will be reconsidered. "There's a lot thatthe President can do using his executive authority without waiting forcongressional action and I think we'll see the President do that to try torestore…a sense that the country is working on behalf of the common good",Podesta told *Fox News*.
Another executive order that could be subject to quick reversal in theso-called Mexico City policy. Instituted by President Reagan in 1984, thepolicy requires non-governmental organisations (NGOs) to "agree as acondition of their receipt of federal funds" that they will neither "perform nor actively promote abortion as a method of family planning in other nations", according to White House documents. The policy, also known as the global gag rule, was rescinded by President Bill Clinton in one of his first acts when he took office in 1993. It was restored by President Bush in 2001.

Other possible legislative moves early in Obama's administration include theestablishment of a comparative effectiveness mechanism for medical care anda revamping of the Medicare system for physician payment. Throughout hiscampaign, Obama supported establishment of an independent institute to guidereviews and research on the effectiveness of treatment. Gail Shearer,director of health policy analysis for the Consumers Union, said theinstitute could work similarly to the UK's National Institute for Health andClinical Excellence, which provides national advice and guidance onpublic-health technologies and clinical practice.Although the current fiscal crisis will be an issue, policy experts say alarger overhaul of the US health-care system may fare better this timearound than it has in the past. Several previous attempts at reform wentfamously flat, including a 1992 effort by the Clinton Administration.Working to Obama's advantage are his ties to Capitol Hill. "Obama is goingto relate to the Hill presumably better than his two Democratic predecessors neither of whom had set foot on the Hill as a member of Congress", said EdHoward, executive vice president of the Alliance for Health Reform. BothClinton and the previous Democratic President, Jimmy Carter, came to the office as governors whereas Obama served on Capitol Hill as a Senator from Illinois.

Congressional support for health-care reform is essential since it has to beenacted via legislation. The Clintons hampered their effort by developing acomplex proposal mostly with White House input. Although expected oppositionwas mounted by conservatives and the health insurance industry, essentialsupport from the Hill was lacking because lawmakers felt they had noownership of the plan.

Details of Obama's plan, which pledges to reduce health-care costs through better preventive care and more widely disseminated health informationtechnology, are scarce. For coverage expansion, it would rely principally onthe current system of employer-provided health benefit: employers wouldeither have to contribute to their employees' coverage or towards the costof a public plan. Other people would have access through a National HealthInsurance Exchange.

Despite a host of other pressing issues and lack of funding, pressure tomove on health-care reform is likely to be intense. Four key groupsrepresenting business interests, unions, and older Americans, announced a $1million media campaign on Nov 10 encouraging elected representatives to"keep their campaign promises, break Washington's gridlock and solve ourhealth care and financial security crises". As the US sheds jobs and relatedemployer-based insurance, a sharp increase in the number of uninsured couldalso add impetus for action.
Obama also will face intense pressure to live up to his promises on globalhealth, but fiscal realities are likely to impinge on these programmes too.Vice President-elect Joe Biden commented in October that Obama's promise todouble foreign assistance to $50 billion a year would be slowed givencurrent economic conditions. Global-health experts comment that although newmoney may not be available for programmes, the most important priority is tofully fund the President's Emergency Plan for AIDS Relief (PEPFAR).

Although 5 year funding of $48 billion was authorised by Congress for PEPFARand malaria and tuberculosis programmes, actual funding levels aredetermined on a year by year basis through a separate Congressional process.Advocates are pushing hard for full funding of the bill and use of funds toaddress broader health issues, such as food security and health-systemstrengthening, efforts that are supported by Obama. "President-elect Obamarecognises that HIV efforts in the long run aren't going to be sustained ifwe don't continue to build the broader health infrastructure and look atsome of the other issues like maternal and child health", said Helene Gayle,president and chief executive officer of the international NGO CARE and aformer official of the US Centers of Disease Control and Prevention.Nonetheless, she added, "It's going to be a difficult period to balance thekey economic priorities that face the country along with the things that hewould want to do more broadly."

The Obama Administration also may respond to strong bipartisan calls toreform US foreign assistance structure—a move that would signal a newemphasis in the area without spending a lot of money. A group of highpowered development and humanitarian aid experts calling itself theModernizing Foreign Assistance Network is working on a detailed plan tobring all US development and global-health entities under a commonleadership. The group and other global health and development advocates arepushing for a high-level foreign assistance leadership in theAdministration, a reinvigorated USAID, and better coordination and alignmentof global health and development policies.

"There needs to simply be true comprehensive global-health coordinationrather than disease specific programmes with different reporting mechanisms,different lines of authority", said Laura Barnitz, director of policycommunications for the Global Health Council.