Map of life expectancy at birth from Global Education Project.

Thursday, November 09, 2006

Big changes?

So what can we hope for from the Democratic Congress between January, 2007, and the start of the next campaign season,* after which little will get done? I'm afraid we'll need to temper our expectations for a cornucopia of public health goodness.

As far as the political balance of power, even as the former world bestriding colossus and Emperor of Mesopotamia shrivels up like bacon, he still possesses the constitutional power of the veto, and under the new order, he may well use it. Just as important, the congressional Democrats are highly fractious, with nowhere near the unity and party discipline of what is now the opposition.

As far as the nation's circumstances are concerned, we're bankrupt. We can reasonably expect the new congress to be generally more inclined toward supporting essential public health infrastructure including CDC and its grants to the states for programs such as cancer control and emergency preparedness -- the latter, one hopes, with a more realistic focus on natural disasters and epidemics, rather than implausible bioterrorism scenarios. We can hope that programs of the Health Resources and Services Administration, such as the Ryan White CARE Act; the Substance Abuse and Mental Health Services Administration, including their formula grants to the states as well as support for community based treatment providers, will at least keep up with inflation and growing need, although the essential public interest in treatment on demand will not come close to being satisfied; and that formula grants to the states in these areas will also no longer be squeezed.

But even those modest improvements will be hard to achieve. The Democratic leadership has promised, quite appropriately, to institute pay-as-you-go financing. Any increases will have to be offset by cuts in spending elsewhere, or revenue increases. Whether they can stick to this pledge remains to be seen, but the fact is the country faces a long-term catastrophe if they can't, should the Chinese and Saudis decide to call in their loans. Stopping the hemmorhaging of billions of dollars every week in Iraq, starting to shut down the global military imperium and ending boondoogles on weapons systems designed to fight the Soviet Union in the 1980s would free up tons of money. But as the always on-target Tom Engelhardt spells it out, that is not likely, indeed, except for Iraq, it isn't even part of the public discourse. And no matter what the public mood and its expression in the election, we are going to be stuck right where we are in Iraq for a long time to come.

The Democrats have proposed to raise the minimum wage, and the Incredible Shrinking President has signaled he would sign a bill subject to certain conditions. The Dems also say they will give Medicare the power to negotiate directly with drug companies over price, but it isn't clear whether the veto pen comes out on that one. Even if it doesn't, presumably any savings go to shrink the doughnut hole, at best, or more likely just get written off to cost control, so there isn't going to be any free money coming out of that one. Whether it happens at all still depends on whether enough Democrats are sufficiently free of drug company entanglements to actually pass it.

Ted Kennedy will become chair of the Senatorial committee that oversees the FDA, and we may see some progress toward more effective drug regulation, although to give credit where it's due Sen. Grassley hasn't been bad in that area. The problem is that the agency needs a pretty radical redesign, which requires comprehensive legislation that the drug companies will fight with everything they've got; and new leadership, which only the White House occupant can appoint. It also needs, yup, more money, which has to come from somewhere.

The Dems are going to be extremely timid about any "revenue enhancements." As a matter of fact, they have proposed tax cuts. It is possible that some of the sunsetted cuts -- such as the estate tax and capital gains -- will be allowed to expire after all, but that won't help until 2010. So the kind of money needed to expand Medicare or Medicaid and insure more people, and to begin to solve their long-term financing problems, is nowhere to be seen.

The most important new policy of all, a carbon tax, which would help save the world while providing desperately needed revenue, is not even remotely possible. Other than that, it is conceivable that there could be legislative overrides of some of the EPA's most egregious rule making of the past few years -- on mercury, arsenic, particulate matter, etc. -- but even that would take a knock-down, drag-out fight.

So, except for some possible incremental benefits, the most I'm hoping for in the short term is that the space for public discussion of our real problems will begin to open up. If we can at least start to honestly confront the profound multiple crises before the nation, there is hope that in another two years, we will start to work on them seriously.

Don't get me wrong -- that's a hell of a lot better than the situation last week. We are no longer doomed. But we have taken only the first step on a long, hard march.

*Approximately February, 2007.

Addendum: I meant to mention rolling the pork barrel out of the Capitol. That would indeed free up a few bucks for better things, but I have no particular reason to expect the Dems to do that either. Bringing home the bacon gets the votes for both parties.

No comments: