This article is Part II of The Dubya Report's three-part response to Bush's State of the Union message. See also
Second only to "an economy that grows fast enough to employ every man and woman who seeks a job," (see Part I of The Dubya Report commentary on the State of the Union) Bush declared "Our ... goal is high-quality, affordable health for all Americans."
The American system of medicine is a model of skill and innovation with a pace of discovery that is adding good years to our lives. Yet for many people medical care costs too much and many have no health coverage at all. These problems will not be solved with a nationalized health care system that dictates coverage and rations care.
Health care reform must begin with Medicare. Medicare is the binding commitment of a caring society. We must renew that commitment by giving seniors access to preventive medicine and new drugs that are transforming health care in America.
Seniors happy with the current Medicare system should be able to keep their coverage just the way it is. And just like you, the members of Congress and your staffs and other federal employees, all seniors should have the choice of a health care plan that provides prescription drugs.
Except where noted, block quotes are excerpts from the Bush State of the Union message.
The importance given to health care issues in the State of the Union message reflected in part public concern, and in part the recommendations of advisory bodies to the administration. In November the National Academy of Sciences concluded that US healthcare system was in crisis and urged the administration to consider promoting universal health coverage and no-fault malpractice insurance. "The American health care system is confronting a crisis," said the report, from a panel of experts appointed by the academy's Institute of Medicine. "The health care delivery system is incapable of meeting the present, let alone the future, needs of the American public."
Yet while many members of Congress have promised a prescription drug plan to their constituents, there is not likely to be agreement on fundamental changes to Medicare. Critics have accused the administration of trying to use the popularity of prescription drug plans for the elderly to make long-term changes in the structure of Medicare.
Debbie Curtis, chief of staff to Representative Pete Stark, Democrat of California told the New York Times "If the price of a prescription drug benefit is the end of Medicare as we know it, that's not a price worth paying."
Groundwork has already been laid to force Medicare to compete with private health care plans, however. The Republican drug plan for the elderly, which passed the House in June 2002, contains an "experimental" provision under which Medicare would compete with private insurance plans in four metropolitan areas. Congressional Republicans are reportedly apprehensive about long term changes in Medicare, noting that older voters want drug benefits as soon as possible, but not necessarily "Medicare reform."
The administration often cites the Federal Employees Health Benefits Program as a model of the type of program they would like Medicare to become. In the federal employee program the government contributes a fixed amount for each employee, and employees can pay more for more expensive plans. "Plans should be allowed to bid to provide Medicare's required benefits at a competitive price," said assistant Health and Human Services (HHS) secretary Bobby Jindal. "[B]eneficiaries who elect a less costly option should be able to keep most of the savings."
Vicki Gottlich of the Center for Medicare Advocacy suggested that such an approach would not work well as a Medicare replacement. "It could shift costs to individual beneficiaries so that people with the greatest medical needs pay the most for their health care," she said.
Administration proposals encourage Medicare beneficiaries to enroll in an HMO or in a revised Medicare program to obtain prescription drug benefits. The new program would provide better coverage for preventive services -- such as mammogram and colon cancer tests -- as well as better protection against the costs of serious illnesses. But the additional coverage would likely entail higher Medicare premiums and co-payments, in addition to charges for prescription drug coverage.
The current Medicare premium, which is keyed to Medicare spending for doctors' services and outpatient hospital care, is $58.70 a month. The Congressional Budget Office estimates that the premium will reach $105 in 2012, even without prescription drug benefits. Drug coverage under plans most seriously considered by Congress last year, are likely to require an additional premium of $25 to $33 a month.
AIDS Proposal in Context
While his remarks concerning health care were a continuation of last year's congressional battles, Bush stunned liberals and conservatives alike with his announcement of $15 billion over five years "to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean."
The administration AIDS plan appears to be modeled after the ABC program in Uganda that emphasizes abstinence and "partner reduction," but does include condom distribution -- something Bush has opposed in other settings. ABC stands for: Abstain, Be Faithful, use a Condom.
Harvard medical anthropologist Edward C. Green who has studied the Ugandan program, which began in 1986, reports a 15% reduction in AIDS infection in Uganda between 1991 and 2001. Observers note that those figures include a large number people who died.
And as Bob Herbert has written in the New York Times, "Alarm bells automatically go off" when the administration appears to be helping those in need. Viewing the AIDS proposal in the context of the administration's overall record on reproductive health seems to justify caution if not skepticism.
One of Bush's first actions after his anointing was to reinstate the "global gag rule," disqualifying humanitarian organizations from US aid if they provided abortion counseling to clients. Subsequently he held up $3 million of the World Health Organization's Human Reproduction Program, and is redirecting $33 million of the US contribution to the UN Population Fund budget to pay instead for domestic abstinence counseling.
Despite administration assurances that the AIDS funding would not come from existing health programs, Bush budget proposals would reduce spending for child survival and maternal health from $495 million to $384.6 million -- a reduction of more than $110 million. Moreover, funding for non-AIDS infectious disease prevention would drop from $185 million to $104.4 million. Senior health policy adviser at the US Agency for International Development, Felice M. Apter, said that the funding reduction could eliminate programs, including routine vaccinations "It depends upon what Congress will do," she said.
The US has supported child health programs abroad for 30 years, and the proposed funding reductions disappointed health care workers at USAID and elsewhere. Speaking to the Boston Globe, Nils Daulaire of the independent Global Health Council said "The bottom line is with 10.5 million children dying around the world each year from easily preventable causes -- things that could be stopped at very low costs -- this is an area where the world community has really dropped the ball over the last decade. When you recognize that you have dropped the ball, you don't drop it even further." "[S]imply shifting money into AIDS is at very best a neutral shift, or a relabeling of money, which is contrary to the intent of the president to provide additional funding. It also could make the situation worse by undermining the ability of health delivery systems to get the jobs done."
Daulaire observed that while the administration had originally pledged $2 billion in AIDS funding for the current fiscal year, the budget only contained $1.86 billion.
Noting that pharmaceutical companies were among Bush's largest campaign contributors, Kenneth Davidson, writing in the Australian newspaper The Age, speculated that much of the Bush AIDS funding will find its way into the coffers of US pharmaceutical companies as subsidies to protect their markets in developing countries.
Bush's proposed $15 billion in aid was met with cautious optimism by some AIDS care workers. Jose Zuniga, president and CEO of the International Association of Physicians in AIDS Care, issued a statement saying in part, "If President Bush's call for significantly increased resources with which to treat and prevent AIDS around the world comes to fruition -- and if the plan is as straightforward as it appears -- this may represent one of the largest steps taken in the history of this struggle."
On conservative Internet message boards, some participants suspected Bush was playing to liberal voters. "I'm not calling Bush a leftist, (but) I don't take him seriously on this AIDS racket," a poster on the FreeRepublic conservative activist web site wrote. "I think he was trying to score points with the left."
The Right-wing Evangelical Agenda in Action
Tripp Baird of the conservative Heritage foundation suggested that Bush's proposal to ban so-called "partial birth abortions" as well as human cloning would pacify conservatives. But he implied that conservatives in Congress might defeat the AIDS initiative under the cover of fiscal restraint, or have designs on the AIDS funding for faith-based programs. ""I think what maybe conservatives are thinking is that in time of deficit you don't want to propose more spending. But my hunch is that they're also concerned about how you spend that $15 billion," he said.
The White House has indicated that religious groups will be eligible for some of the AIDS funding. The Rev. Franklin Graham, who runs the Christian relief organization, Samaritan's Purse, (and delivered the invocation at Bush's inauguration) responded enthusiastically to the AIDS proposal, noting that much relief work in Africa is already sponsored by churches. Graham attained notoriety recently for on more than one occasion denouncing Islam as a "very evil and wicked religion." His comments on the AIDS funding plan prompted a response by Islamic organizations. Ibrahim Hooper, a spokesman for the Council on American-Islamic Relations, said "We are in favor of increased spending on AIDS drugs for those who can't afford them. But we would be greatly concerned if taxpayer money goes to a group headed by Franklin Graham, who has a long history of hostility toward Muslims and Islam."
Much of the Bush administration's agenda in the areas of social justice, human rights, and especially women's rights, has been determined by right-wing evangelical partisans, however. Some of the best evidence of this campaign is what the Nation calls replacing "career diplomats with career ideologues" at the United Nations. According to the Nation, under the Bush administration nearly every US delegation to any UN meeting has included:
- John Klink, a former chief negotiator for the Vatican
- Jeanne Head of the National Right to Life Committee (NRLC)
- Janice Crouse of Concerned Women for America --the group founded by Beverly LaHaye, wife of Tim LaHaye who authored the Left Behind series of religious right science fiction.
- Others from the so-called "pro-life" lobby.
The US delegation has brought negotiations to a halt at meetings of UN General Assembly Special Session on Children, the World Summit on Sustainable Development and the Fifth Asian and Pacific Population Conference, objecting to support of nearly universally accepted public health practices such as condom use for AIDS prevention, and medically safe abortions where legal.
In March 2001 the US delegation to the UN Commission on Human Rights was so disruptive that for the first time in history the US was not re-elected to the commission. (They were invited back after the attacks of September 11, 2001).
In May of that year, instead of the usual delegates from organizations such as the American Medical Association and the American Public Health Association, the administration sent Jeanne Head of the NRLC to represent US interests at the World Health Assembly.
A year later the US attracted international attention at the Special Session on Children when HHS Secretary Tommy Thompson joined Iran, Syria, Libya, Sudan and Iraq, along with the Vatican, in lobbying against comprehensive sex education for adolescents, advocating that information about contraception and the prevention of sexually-transmitted disease be restricted to married couples, and seeking to have the session adopt a definition of "reproductive health services" that did not include abortion. The alliance created an interesting counterpoint to Bush's war against Islamic fundamentalism in which he had declared nations were either "with us or against us."
Rather than focus on problems of improving health services for young people around the world, who, for example, are becoming infected with HIV at a rate of one every five every minutes, the US delegation appeared determined to try to rewrite terminology and definitions that had been agreed to in prior years. During a session on children in the aftermath of military conflict, the US objected to the language: "When there are children who have been victims of violence and trauma in war, we need to provide them with services." "Nobody could understand why the United States would oppose [that] language," Zonny Woods of Action Canada for Population and Development said. "But because among those victims of violence there might be girls who were victims of rape, who might be offered emergency contraception or an abortion, they were willing to throw away the whole concept of 'services.' It was just insane." The US also succeeded in preventing a consensus statement opposing the death penalty for adolescents.
Then on November 1, 2002 Bush announced that his administration was contemplating withdrawing from a 1994 agreement signed by representatives of 179 countries that established for the first time a connection between population control and the availability of information concerning contraception for women. Once again the US delegation wanted all references to "reproductive health services" and "reproductive rights" removed. In a regional meeting leading up to the Fifth Asian and Pacific Population Conference, a US delegate was ridiculed when she tried to insist from the podium that natural family-planning methods be emphasized in the conference statement. An Iranian ob-gyn pointed out that such methods have a high failure rate, "And by the way, it says so in all the textbooks that come from United States."
The US reportedly threatened small countries like the Philippines, Sri Lanka, and Nepal that their share of USAID funds would be withheld if they didn't vote with the US. "They really overplayed their hand," said Françoise Girard of the International Women's Health Coalition. "... the fringe who've taken over US policy on sexual and reproductive health. Some people asked me, 'Do you think they're doing this because they want to save our souls?'" With cowboy swagger characteristic of the Bush administration, the US delegation insisted on a roll-call vote on provisions of the agreement concerning reproductive rights and adolescent health. They lost the votes 31 to 1 and 32 to 1, with Nepal and Sri Lanka abstaining. The US statement dissenting from the conference agreement struggled to resolve the incompatibility between an avowed concern for women's rights and a self-evident opposition to free expression of -- or even the term -- reproductive rights. While claiming concern that "the promotion of women's full enjoyment of all human rights is not emphasized more often," the statement went on to say "Because the United States supports innocent life from conception to natural death, the United States does not support, promote, or endorse abortions, abortion-related services or the use of abortifacients." The statement also contained the curious locution, "The illegality of abortion cannot be construed as making it unsafe."
Women's health advocates see Bush's assault on reproductive rights concerns at the UN. as a convenient way of accomplishing two administration goals: reducing UN influence over militarism and the flow of capital while simultaneously delivering on the right-wing agenda. "The Bush Administration has been able to get away with what would be appalling to most moderate Republicans," Jennifer Butler, the Presbyterian Church's UN representative, told the Nation. Butler, who tracks the Christian right's activities at the UN, noted that the public and the press do not pay much attention to meetings at the UN. "Bush can throw a bone to the Christian right and score some points, and he can do that without a cost," she added.
The assault on reproductive rights has appeared on the domestic front, as well. In October an HHS panel was directed to study what protections were given to embryos during medical experiments. The public justification was that the study was aimed at providing additional protection to pregnant women. Only antiabortion groups applauded the directive, however, as it appeared to pro-choice advocates as merely another incremental attempt to establish personhood for fetuses and embryos.
Then in late January 2003 the HHS announced that it had developed a way to provide prenatal care to women who might not otherwise be eligible. The alleged solution: broaden the definition of a "child" eligible for coverage under the Children's Health Insurance Program -- a process that HHS officials referred to as "clarification." The new rules would define childhood as beginning not at birth, but at conception. The net effect of the "clarification" is that fetuses would become eligible for health coverage. HHS Secretary Tommy Thompson told the New York Times that the policy change "would help poor mothers be able to take care of their unborn children and get the medical care they absolutely, vitally need."
Abortion opponents celebrated the ruling as a step toward a goal they had been seeking for years. "We applaud this Bush administration proposal to recognize the existence of an unborn child in order to allow the baby, and the mother as well, to receive adequate prenatal care — a concept to which only the most extreme pro-abortion ideologues will object," said Douglas Johnson of the National Right to Life Committee.
The Times' Bob Herbert observed,
The truth is the [January] decision had little to do with the health care of women. It was a political move, pure and simple. It was the Bush administration's way of sending a message to the right- wingers of the Republican Party: Don't give up hope. We're committed to undermining abortion rights.
In fact, coverage under the Children's Health Insurance Program could have been extended to pregnant women by simply waiving some existing rules, or by a minor legislative change. Reproductive rights advocates noted that defining fetuses and embryos as persons could create tragic conflicts if preserving the health of the mother required treatment potentially harmful to the fetus. One example of such a situation would be a mother who required radiation or chemotherapy. "This is not about health care for women," said Kate Michelman, president of the National Abortion and Reproductive Rights Action League. "It's all about politics. It's about undermining a woman's right to choose, disguised as health policy."
Lynn Paltrow, director the National Advocates for Pregnant Women went further, describing the HHS policy move as a cynical attempt to divert attention from the administration's failure to support a wide range of initiatives to improve the delivery of health care to women and children. "This maneuver to create insurance for unborn children both personifies the fetus and accentuates the fact that women themselves are neither full persons under the law, nor valued enough to be funded themselves," she said.
Other critics noted that 11 million of the 40 million Americans without health insurance are children, and that if the administration wanted to do something to extend health coverage, it could direct some attention to those without it.
Ideological Litmus Tests at HHS
Like the systematic replacing of "career diplomats with career ideologues" at the UN, the Bush administration has been screening the political and ideological orientation of scientific consultants and appointees to try to ensure that their policy recommendations are consistent with the White House political agenda.
As reported by the LA Times in December 2002, psychologist and addiction expert William R. Miller was interviewed by a Bush staff member concerning participation in a panel that advises the National Institute on Drug Abuse. But the questions had nothing to do with Miller's expertise: Did Miller support abortion rights? The death penalty for major drug dealers? And had he voted for President Bush? Miller, who did not vote for Bush, was not asked to join the panel.
Members of the administration insist that they were only ensuring that their point of view was represented. Critics maintained, however, that Bushies were placing unprecedented emphasis on ideology over science. For example, ideological screening was applied to candidates for at least one panel that only gives technical advice on research proposals, and has no policy-making function. Donald Kennedy, past president of Stanford University and editor of the prestigious journal Science said "I don't think any administration has penetrated so deeply into the advisory committee structure as this one, and I think it matters. If you start picking people by their ideology instead of their scientific credentials, you are inevitably reducing the quality of the advisory group."
Recent complaints concerning HHS:
- Democrats and public health advocates allege that in the fall of 2002 the administration appointed industry advocates to panels at the Centers for Disease Control and Prevention that make recommendations concerning environmental toxins, bioterrorism preparations, and the prevention of lead poisoning in children. Appointees to the lead panel included Dr. William Banner Jr., an Oklahoma physician who reportedly has testified that lead is harmful only at levels well beyond the current government standards, and Dr. Sergio Piomelli of Columbia Presbyterian Medical Center in New York, who announced at the committee's first meeting in October that he had been nominated by "someone from the lead industry," whose name he could not remember.
- During the summer of 2002 the administration allowed the terms of 15 of the 18 members of the National Center for Environmental Health Advisory Committee to expire, without reappointing them. The committee advises the Centers for Disease Control concerning bioterrorism preparedness and safe drinking water standards among other matters. Senators Edward M. Kennedy (D-Massachusetts) and Hillary Rodham Clinton (D-New York) wrote Secretary Thompson to complain that one of the new appointees was formerly the president of a research firm funded by the chemical industry, and another "has made a career countering claims of links between pollutants and cancer."
- On December 10 the Food and Drug Administration (FDA) rejected a nominee to an advisory board who advocates the use of human cloning in medical research. The nominee had been approved by subject experts at the FDA but was rejected by higher officials. (Despite Bush's ambivalent statement concerning stemcell research in August 2001, the State of the Union message called on Congress to ban human cloning.)
- Thompson's office rejected three nominees to the Safety and Occupational Health Study Section, a panel that provides peer review of applications for research grants. The nominees had been chosen by the panel staff and other officials, and had been approved by the then-director of the occupational safety institute. Although the office gave no reason for the rejections, in a letter to Sen. Kennedy, Dana Loomis, of the University of North Carolina who is chairman of the panel, wrote that the reasons "seem clear enough in at least one case: One of the rejected nominees is a respected expert in ergonomics who has publicly supported a workplace ergonomics standard." Bush last year repealed a similar rule designed to require employers to take the initiative in reducing repetitive stress and other workplace injuries. The nominee Loomis was referring to, Laura Purnett of the University of Massachusetts in Lowell, said that she had been subjected to "an ideological litmus test" that implied that she could not be objective in her work on the panel. Catherine Heaney of Ohio State University, another of the rejected nominees said she did not know why she was rejected, either. Her most recent research concerned ergonomics, as well.
Applying ideological screening to peer review panels is particularly troublesome to scientists and researchers, because the function of such panels is not to make policy but solely to judge whether scientists seeking federal funding have designed experiments that can actually address the matters they are studying.
Anthony Mazzaschi, an assistant vice president at the Association of American Medical Colleges explained "The goal here is to fund the best science, the best-designed experiments. To stack peer-review panels based on political preferences rather than scientific competency is doing everyone a disservice."
Loomis, the occupation safety panel chairman, told the LA Times "Regardless of what the intention was, this creates the appearance that review panel members are being politically scrutinized, which is directly opposed to the philosophy of peer review, which is supposed to be nonpolitical and transparent." This, he asserted "tends to stifle the scientific spirit."
David Michaels, of George Washington University, a public health expert who served in the Clinton administration added "They're stacking committees to get the advice they know they want to hear, which is a charade," adding "Why have an advisory panel if you know what everyone is going to say, and they agree with you?"
Thomas Murray, president of the Hastings Center, a New York bioethics institute was nominated and subsequently rejected from the Biological Response Modifiers Advisory Committee, an FDA panel that makes recommendations concerning protein drugs, gene therapy and related topics. Concluding that there was a pattern to the rejections, Murray complained, "The fact that they would even bother to blacklist me is ... deeply sad. It portends a distortion of the process of determining what the facts are on a health topic or in environmental policy."
Senator Kennedy summarized the situation: "Advisory committees are supposed to give the government and the public expert, unbiased advice based on the best possible science. By stacking these important committees with right-wing ideologues instead of respected scientists, the administration is putting the health and well-being of the American public at risk."
But the reign of ideology over science is not confined to advisory panel appointments. Information given to the public has been subjected to ideological censorship, as well. Over the course of the year 2002 HHS quietly removed from its web sites information concerning:
- How using condoms protects against AIDS
- How abortion does not increase the risk of breast cancer
- How to run programs to reduce teenage sexual activity
Department spokesman Bill Pierce claimed that in all three cases the information had been removed so that it could be updated.
Terje Anderson of the National Association of People with AIDS, scoffed at Pierce's explanation. Referring to condom information, which was removed from the National Center for HIV, STD and TB Prevention Web site on July 23, 2001, she said, "Something doesn't need to disappear for a year and a half to be updated."
James Wagoner, president of Advocates for Youth, a public health organization dealing with adolescent sexual health, agreed, saying there "seems to be a concerted effort to censor science and research that supports contraception in favor of 'abstinence-only until marriage' programs."
Pierce also claimed that the CDC and NIH had removed the information without interference from HHS.
In the case of the condom information, however, he was contradicted by the responsible CDC official, Dr. Ron Valdiserri, deputy director of the center's program for HIV, STD and TB Prevention, who said at a news conference on October 31 that the removal had been a joint decision between CDC and HHS.
Representative Henry A. Waxman, the California Democrat, and other members of Congress complained in writing to Thompson about the removal of information. "We're concerned that their decisions are being driven by ideology and not science, particularly those who want to stop sex education. It appears that those who want to urge abstinence-only as a policy, whether it's effective or not, don't want to suggest that other programs work, too," Waxman told the New York Times.
The information that no link has been found between abortion and breast cancer was removed in June in response to a letter to Thompson from Representative Christopher H. Smith, the New Jersey Republican who is co-chairman of the House Pro-Life Caucus. In his letter Smith called the National Cancer Institute research "scientifically inaccurate and misleading to the public."
Smith further claimed that his objections were scientific and not political. The letter asserted that a majority of studies showed a relationship between abortion and breast cancer, and that the study which the National Cancer Institute reviewed "contains many significant flaws."
Gloria Feldt, president of the Planned Parenthood Federation of America, disagreed, saying "They are gagging scientists and doctors. They are censoring medical and scientific facts. It's ideology and not medicine. The consequences to the health and well-being of American citizens are secondary to this administration."
Summing up the Bush crusade against reproductive health and women's rights Terri Bartlett, of Population Action International concluded, "It's like Bush is sacrificing the women of the world to pay his political dues," A UN official added "We have got to figure out a way to avoid this.... Because AIDS won't wait. Unwanted pregnancies won't wait."
Davidson, Kenneth "The truth about George Bush's anti-AIDS push" The Age 10 Feb. 2003
Donnelly, John "US seeks cuts in health programs abroad" Boston Globe 5 Feb. 2003
Herbert, Bob "Sneak Attack" NY Times 4 Feb. 2002
Stolberg, Sheryl Gay "The White House Gets Religion on AIDS in Africa" NY Times 2 Feb. 2003
Philipkoski, Kristen "Bush AIDS Proposal Draws Fire" Wired News 30 Jan. 2003
Block, Jennifer "Christian Soldiers on the March" The Nation 16 Jan. 2003
Pear, Robert "Bush to Propose Changes in Medicare Plan" NY Times 3 Jan. 2003
Zitner, Aaron "Advisors Put Under a Microscope" LA Times 23 Dec. 2002
Pear, Robert "Federal Advisory Panel Warns of a Crisis in Health Care" NY Times 19 Nov. 2002
Clymer, Adam "Critics Say Government Deleted Web Site Material to Push Abstinence" NY Times 6 Nov.2002
- "Bush Proposes Major Changes in Medicare and Medicaid" from the NY Times (free registration required)
- "The Fakeout" from The American Prospect.