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Double the Health Budget? Think Again

Policy: More cash for NIH would benefit managed care firms; there are better ways to spend public dollars.

April 15, 1998|MICHAEL D. REAGAN | Michael D. Reagan is an emeritus professor of public policy at UC Riverside

President Clinton wants to add 10%, or $1.15 billion, to the National Institutes of Health budget for fiscal 1999, bringing the total to $14.8 billion. And doubling the NIH budget in five years is being seriously discussed in Congress. That's a no-brainer, a great idea, right? But compared with other needs? Maybe not.

Some of those other needs are within medical care:

* The 1997 Balanced Budget Act included more than $20 billion to develop health coverage for perhaps half of the country's uninsured children; that leaves 5 million other children uninsured. Can we assume that all of the $14 billion it will take to double NIH's budget will be better spent than if some or all of it were spent on coverage for more kids?

* Congress and the administration are hellbent on reducing the cost of Medicare by shoving seniors into HMOs. Maybe some of the money could be used to lessen the pressure on seniors to give up their longtime family physicians in order to accept cheaper care through managed care organizations.

* California has led the way in showing that sophisticated, strongly phrased anti-smoking messages can markedly reduce that drug's contribution to sickness and death rates. Might not a national campaign built on this state's model (that is, the model in operation when Gov. Pete Wilson was not curbing the anti-tobacco campaign in the mass media) be a better use of some of that money, conceivably preventing millions of cancers?

* More testing might be a competitive use of a chunk of money. This was a bad flu year, yet only half of Americans over 65 get annual flu shots. Insulin-dependent diabetes mellitus patients are susceptible to a condition that is the leading cause of blindness. Yet a survey of a few years ago found that only half of patients had the recommended dilated eye exam within the surveyed year and 20% had had no eye exam in two years.

* Better medical care can be obtained, with less waste, if we devote more funding to clinical evaluation of existing treatments, procedures and off-label uses of approved drugs. Only about one-eighth of 1% of U.S. health spending supports that kind of health services research, which is needed to develop cost-effective guidelines and reduce inappropriate and ineffective treatments. That work is done not in NIH but in the meagerly funded Agency for Health Care Policy and Research in the Public Health Service.

If $14 billion is added to NIH, while Congress requires itself not to unbalance the budget, we need to ask what alternative uses outside of medicine might well be worth consideration?

* President Clinton has again proposed budgeting $5 billion for school modernization, after abandoning an earlier version last year. That's nice--but the General Accounting Office estimated the national need at $112 billion. And early Head Start, combined with food and health treatment for very young children, is a winner in usefulness, but still greatly underfunded.

* An Alameda County research study in the New England Journal of Medicine confirmed that long-term poverty is a causative factor in depression and other mental problems. Perhaps more money should be pumped into the federally funded but locally operated community development programs that are reviving economically depressed inner cities. And into sadly neglected vocational education for non-college-bound youth.

* Environmental protection programs are producing cleaner air and water and are beneficial both to the economy and to the nation's health. Their slow pace could be picked up with more money.

Are all of these needs less urgent than increasing medical technology expenditures at the rate of 15% a year? Imagine what could be done with schools, inner city housing and economic development, public transportation so that ex-welfare clients can get to the suburban jobs in need of workers and other urban and rural infrastructure needs if we increased their budgets 15% a year.

The NIH budget proposals are being justified in part as needed to make up a shortfall caused by managed care companies' reluctance to pay routine costs of patients in early clinical trials and by academic medical centers' deteriorating financial situations (also partly caused by the economics of managed care competition). Consider this irony: Because the companies paying extraordinarily high executive salaries and squeezing patient expenses to keep Wall Street happy don't want to continue contributing to clinical trials, we taxpayers are to give No. 1 budget priority to NIH.

Because health plans are immediate beneficiaries of federally funded medical research, why shouldn't Congress legislate instead that these firms set aside some small percentage of income to continue contributing to research? In short, why should medical research win the budget sweepstakes without even having to competes?

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