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Democratic victory could fire up US health policy debates

The Lancet2006;368:2043-2044 DOI:10.1016/S0140-6736(06)69820-6

World Report by NellieBristol

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Since their November majority win, Democrats in Congress have been gearing up to reopen debates on health issues including stem-cell research, drug pricing, and intellectual property. But will this political shift bring positive changes for US citizens' health? Nellie Bristol reports.

Last month's election of a Democratic majority in Congress could force new policy on issues like federal support for stem-cell research, although the shift in political power is unlikely to prompt large changes in US domestic or global health programmes. The Democrats will also have a more public platform to challenge the Bush Administration's approaches to important issues such as health-insurance coverage, HIV/AIDS, and drug-related trade provisions.

In domestic health, action on stem-cell research and provisions allowing drugs bought at low prices abroad to be imported for the US consumers has stalled in Washington for years. Both initiatives have supporters among Democrats and Republicans and are considered good candidates for policy shifts next year when the Democrats assume Congressional leadership.

Current federal policy limits research to stem-cell lines created on or before Aug 9, 2001. President Bush vetoed a bill in July that would have expanded opportunities for research. Proponents, including the incoming chair of the Senate Health, Education, Labor, and Pensions Committee, Edward Kennedy (D-Massachusetts), indicate they will bring up the issue again now that the political environment is, at least in theory, more supportive.

Reimportation of drugs is another issue likely to be hotly debated. Many conservatives oppose the practice citing safety concerns, but enough Republicans support the move that next year's Congress could have the votes to overturn a Presidential veto.

Federal support for health information technology and expansion of a state-federal programme for children's health insurance are two other issues that might prompt further debate. But larger and more contentious topics, including coverage for American's 46 million uninsured, are not likely to gain much traction despite the new majority. This is not an election that is a big mandate for big health care ideas, says John Rother, Group Executive Officer of Policy and Strategy for AARP, an advocacy group.

Observers say progress is being stifled by age-old ideological differences. The Republicans' push toward market-based individual-focused policies will be curtailed by the new Congress. But the Democrats' tendency to encourage government involvement will be stymied both by the Bush White House and funding shortages. Money is going to sharply limit what Democrats can do this year, says Joseph Antos, a health policy expert at the American Enterprise Institute for Public Policy Research.

Despite pledges of bipartisanship and cooperation, Democrats and Republicans in Washington are already staking out irreconcilable positions on some key health policies. For example, a top priority for House Democrats is to force the federal government to negotiate discounts with drug manufacturers for the nation's Medicare programme, a suggestion the Bush Administration promptly denounced. The idea of the government negotiating drug prices really isn't about the government negotiating drug prices, says Health and Human Services Secretary Mike Leavitt. It's a surrogate for a much larger issuegovernment-run health care.

Democrats argue that the massive market share of 42 million elderly and disabled Medicare beneficiaries would force drug manufacturers to lower prices to a particularly vulnerable population. Resulting savings in programme expenditures would make money available to expand coverage.

But the Bush Administration argues that the current drug plan, run by private insurers, already negotiates lower drug prices more effectively than the government could. A robust marketplace with a lot of competitors has driven down prices, Leavitt told The New York Times. It's the magic of the market. To assume that the government, in our genius, could improve on this belies the reality of a complex task.

Similar dissent could persist in US global-health policy. Opportunities for meaningful change will depend on how much politicians want to use the issues to differentiate themselves from the opposition in advance of the 2008 presidential election, says Nils Daulaire, President and CEO of the Global Health Council.

There is a broad set of issues that really are bipartisan and non-ideological in nature, some of which have withered on the vine because there has been the political dynamic of looking for wedge issues, Daulaire explains. He cites child health programmes, which he says need US$68 billion annually in additional funding from all sources. The US share should be $2 billion, he argues.

On reproductive health, a magnet for religious and morality-driven rhetoric, Daulaire says, we're looking for moderate leaders on both sides who can move this out of the ideological war zone.

Daulaire also anticipates more questioning of foreign-aid reforms. In the interests of making foreign policy more cohesive, the Administration recently moved the US Agency for International Development to the State Department. As a result, Daulaire says, We've seen evidence of budget reconfigurations that have shifted significant funds out ofprogrammes that are targeted towards the poor and more to serve geopolitical considerations. Democrats in Congress will oppose White House funding proposals, Daulaire predicts. It's clear that this Congress is not going to give this Administration a blank check, he says.

On more specific issues, the Democratic Congress will protest several current aid policies. Incoming House Government Reform Committee Chairman Henry Waxman (D-California) told The Lancet he will conduct oversight activities on current US HIV/AIDS policies on condoms and restrictions on prevention activities involving prostitutes. He says he will also do whatever I can to change trade policies he and others say are restricting access to low-cost drugs in developing countries.

Waxman has been outspoken about what he says are Administration distortions on the effectiveness and safety of condoms and other family-planning methods. I don't think government funds ought to be misused to mislead, he says. Waxman adds that he will try to make sure that they stop the ideology and make policies based on evidence and fact.

AIDS activists would like to see more US support of multilateral organisations including the Global Fund to Fight AIDS, Tuberculosis and Malaria, rather than continuing with its hyper-unilateral approach, says Global AIDS Alliance Executive Director Paul Zeitz. The AIDS response worldwide is fragmented because of the way the US government is acting, he argues. Zeitz also called on the US to focus on broader health and welfare policies including education, support for AIDS orphans, and efforts to reduce violence against women and children.

Incoming Senate Appropriations/State Foreign Operations subcommittee Chairman Patrick Leahy (D-Vermont) says he sees positives in both multilateral and bilateral approaches. Multilateral organisations can be cumbersome and they can be less effective, but they are indispensable, Leahy says. Protecting global health requires the participation of all nations and these organisations enable us to work together with other countries that don't have their own bilateral programmes.

An aide to Senator Leahy, Tim Rieser, says bilateral groups often work more quickly than multilateral structures, adding, Wasted time means lost lives. Despite that, he agrees more US funds should be allocated to global groups. The Administration is not supporting the Global Fund as much as it should, he says.

The Bush approach to pharmaceutical access under trade provisions also will be challenged. I'm really concerned about it, Waxman says. He and health advocates, including medical aid group Medecins Sans Frontieres (MSF), say the policies allow pharmaceutical companies excessive patent protections. They're undercutting the ability of countries to get generic drugs, Waxman says. Waxman and Senator Kennedy have long been active on the trade issue, but their new leadership positions will give them a more powerful platform from which to address it.

The US needs to stop seeking higher levels of intellectual property protection than what is internationally agreed to because [this agreement] already derives from very high standards, adds Ellen t Hoen of MSF's Campaign for Access to Essential Medicines.

The United States Trade Representatives' office disputes the criticisms. Our free trade agreements do not prevent countries from protecting public health, it said in a statement. The US is creating flexibility in trade rules for public health.

Even while the two sides are lining up their arguments, the political shift in Washington offers health advocates reason for optimism. Perhaps some different winds will start to blow, MSF's t Hoen says.

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