Who Gets What Slice of the President's First Federal Budget Pie

The New York Times
April 10, 2001

Health By Robin Toner

"The department's (Health and Human Services) discretionary spending (outside the entitlement programs like Medicare and Medicaid) would grow by 5 percent under the Bush proposal, an increase of $2.7 billion over the 2001 fiscal year's. The National Institutes of Health was the major winner in this 'redirection of resources,' as the budget called the shifting of money among programs."

Ron Pollack, Executive Director of Families USA:

"The president's budget proposal literally shortchanges Americans' health care by providing too little support and reaching too few people."

Tommy G. Thompson, Secretary of Health and Human Services:

"What's more important than finding a cure for cancer? What's more important than finding a cure for Alzheimer's?"

Comment: What's more important? Applying the knowledge and resources that we do have to improve the health of the American people that are funding the National Institutes of Health (NIH).

Much of the blame for runaway health care costs in America rests with the special privileged position that we have given our health care technology and pharmaceutical industries. Through the NIH, the taxpayers fund much of the research that is used by these industries to develop new products. These products are granted patent protections, and yet have not been subjected to the same degree of cost controls that the providers of health care are now facing. Many of the products, such as copycat drugs and scanners with more colorful images, have not demonstrated their value but have significantly added to costs.

In shifting health care dollars from care for the less fortunate in our society to the NIH, the administration is tacitly supporting their friends in the technological and pharmaceutical industries with free, taxpayer funded research. The taxpayers have a vested interest in this research and should directly benefit in the form of a return on our investment through lower costs and rational spending. Each other nation controls drug costs; we should as well. Although we need to fund new research, we should not fund the market applications until real value is demonstrated by pilot studies. We also need to recognize that increasing expenditures in technology reduces expenditures in other sectors. Since we are near the limit of what we will tolerate in health care expenditures, we need to place these industries under an implicit global budget. This would be automatic if we were to establish a publicly administered, universal risk pool. Only then could we be assured that everyone benefits from the public funding of health care research.

Response to Uwe Reinhardt by Philip Pollner, M.D. & Nancy Wooten, Ph.D. April 10, 2001

Dear Dr. Reinhardt:

We were saddened to read your email letter <2_27_01.htm> "To my Gentle Critics," (February 27, 2001). You argue that "We can never have a health care system that balances the dignity and freedom sought by doctors and patients with society's desire to have the system operated with some larger constraints. We can never have it, not under our system of governance. There is nothing that you or your patients can do about it. Your voices do not count, and you are powerless and must get used to it."

Dr. Reinhardt, perhaps your dismal opinion regarding the prospect for reform reflects your disappointment and despair with what seems a futile process at this point in time, but coming from a revered ally and a respected scholar this conveys a sense of hopelessness and surrender to many of us who have been committed for years to the attainment of health care for all Americans. Worse, at a time when we are facing both conflict and challenge in trying to improve the health care system, your commentary lends neither new ideas, strategies, encouragement nor moral support - any of which would be at least helpful as we try to keep the faith.

Most important, when viewed from the perspective of history your statement on the prospects for ultimate victory loses credence. Time and again we have witnessed what was considered to be unimaginable goals or unexpected institutional and legislative metamorphoses become reality. Who, for example, would have thought in 1982 as the Cold War raged that a decade later the Soviet Union would cease to exist, that the Berlin Wall would be toppled and the two Germanys would reunite? What black person in the 1970s living in Johannesburg would have dared to dream that apartheid would be abolished and representative government established in South Africa by the 1990s? Few men or women alive in nineteenth century America could imagine that there would ever be a Constitutional amendment guaranteeing women the right to vote, or foresee that there would be federal and multistate statutes enforcing the abolition of child labor. Nearly any observer in 1910 would have thought it impossible "not under our system of governance" that black Mississippians would be free from fear of lynching, be free to vote, and have gained in general their civil rights. In each of these examples, institutional, cultural, legal and diverse other barriers existed, powerful or wealthy interests were in place to halt change, yet profound change did come for many reasons including the hard, patient and persistent energies of activists who fortunately did not subscribe to your fatalism.

History speaks for itself; these are facts and not fantasies - although fantasies they seemed to be at some point in time. Dr. King once said, "Every time I look into the pages of history, change was never initiated by protocol, it was initiated by dreamers." We understand that the journey ahead is difficult, but we persevere, as we know such "dreams" over time can be shaped into reality. The indecency of the American health care system, the suffering of those without health or health care, is the constant reminder to us that the struggle is a critical one, worthy of keeping the faith even when prospects seem dim. As a prominent spokesperson, we need your understanding, commitment and support as we continue to fight for justice and equality in health care.

In another echo from history, Frederick Douglass perhaps expressed it best when he wrote in 1853, "If there is no struggle, there is no progress. Power concedes nothing without a demand. It never did and it never will."

Your gentle critics,

Philip Pollner, M.D. Nancy Wooten, Ph.D. National Leadership Coalition for Health Care Newark, Delaware

Prof. Uwe Reinhardt responds to Drs. Pollner and Wooten April 10, 2001

Dear Dr. Pollner and Wooten:

Many thanks for your response to my dismal letter. It is hard to disagree with your historical sweep. It happened, and major things are likely to happen in the future. Empires rose and fell. For all I know, we will be a Chinese colony in 2100. (China and India actually have enough people to occupy the U.S.)

You know, of course, the old joke about Congressman Claude Pepper's ascent to heaven. He asked God whether there would ever be universal health insurance in America. Whereupon God answered: "Probably, yes. But not in my lifetime." In that sense, of course, you are right. It may come. How soon is another question. Boot up, and read David Brooks' article on "Our Future Leaders," an essay based on a month's sojourn at Princeton. Perhaps you see hope for the underclass in that essay. I see the opposite.

I come at the topic the way I do these days not to discourage progress, but instead to annoy the opponents of universal coverage. In case you have not seen it, I attach a paper delivered to the US Chamber of Commerce a while ago. These days I say the crudest things about the poor to my students and to my audiences, mainly to shock people. I am holding up a mirror to these people to tell them: this is the kind of people you are.

Tomorrow I shall lecture on the income distribution in my freshman class. I'll make the point that our extraordinarily wide income distribution can be maintained only by tightly controlling the lower end of the income distribution. We do this by jailing more people per capita than any other industrialized nation (possibly excluding Russia) and by spending, in California, more on jails than on education. That is the kind of people we are. I say this in a natural tone, without raising my voice, as if that were reasonable, just perhaps, possibly to arouse at least one student under 400.

As I point out in my speeches and in the attached paper, the uninsured are, by and large, disposable people whose income is low (which means that we consider their social contribution low). Because we do not have to be nice to these people to have them work like hell for us in taxicabs, restaurants etc., we are not nice to them. We can, economically, take them for granted, and so we do.

I think 30 years of pretending that by good cheer and hoping we shall solve this problem have not yielded any fruit. Perhaps anger will. I am angry and disgusted.

You can keep on struggling. I would not want to discourage you. I'll keep on annoying the good Judeo-Christians. It's just another form of that struggle.

I also attach a homework assignment that you may find interesting. I bet you it moved no soul in my class.

Best regards,


<2001ec102ps5ANSX.doc>Homework assignment.doc