A Presidential Rx to Improve Health in the New Year

by Susan J. Blumenthal, M.D. and Yi-An Ko

Past U.S. Presidents have provided innovative leadership that shaped the landscape for our national health and science institutions. President Lincoln established the National Academy of Sciences; President Truman's foreign policies inspired the creation of the United States Agency for International Development (USAID); President Lyndon Johnson signed legislation that established Medicaid and Medicare; and President Clinton signed legislation that created the State Children's Health Insurance Program (SCHIP). Currently, our country faces significant health challenges including skyrocketing health care costs, declining funding for medical and scientific research, and a lack of effective coordination and innovation in the government's response to emerging health threats such as obesity and pandemic flu. Addressing these issues must be a top national and foreign policy priority for the next Administration. With transformational leadership, President-elect Barack Obama has the opportunity to build upon the legacies of his predecessors and write a new national prescription for improving the health of Americans.

A key component of this Presidential prescription is ensuring that all Americans have access to quality health care. 46 million Americans lack health insurance and, with the economic crisis on Wall Street and Main Street, 72 million working-age people in the United States report hardship in paying their medical bills. That's why an implementation strategy for the President's health care plan is urgently needed including the establishment of a National Health Insurance Exchange that will link individuals and businesses to public and private sector insurance plans that do not discriminate against pre-existing conditions; provide parity for coverage of mental illness; prioritize quality, prevention, and chronic disease management; and evaluate health outcomes through comparative effectiveness research. Furthermore, with 70% of the $2.4 trillion U.S. health care budget attributable to preventable causes and only 3-5% spent on prevention, our President must also emphasize the power of prevention by providing the leadership, role-modeling, and necessary funding as well as mobilize all Cabinet departments to develop strategies and utilize mechanisms within their agencies to advance health.

The new Administration must also find ways to apply information technology to improve health (e.g. electronic medical records, e-prescribing, telemedicine) while protecting the privacy of patients' health information. Today, only 10-20% of health professionals and 25% of hospitals use an electronic medical record, while an estimated 195,000 people die and 1.6 million are injured every year in the United States as a result of preventable medical errors. Information technology can accelerate access to life-saving resources, support evidenced-based care, empower patients, and improve the quality and efficiency of health care as well as decrease costs. While there has been an emphasis on the electronic medical record, social web-based media is also needed to empower people and practitioners with the information needed to improve health. For example, a "Health e-Commons" government website could be established where consumers and health care providers can find and share best practices about the diagnosis, treatment and prevention of diseases. In the spirit of participatory health care, this website would permit people to exchange information and submit innovative ideas for exploration and testing by the government and private sectors.

Another important priority is more effective coordination of Federal health initiatives to address the health challenges and opportunities ahead. With health programs spanning over 45 different Federal agencies, the next Administration and the American people would benefit from an independent office in the White House - paralleling the Office of Science and Technology Policy (OSTP) - that would support Presidential health and medicine initiatives, coordinate interagency health efforts, and build strong partnerships across the public and private sectors. Currently, health issues are addressed in OSTP, the National Security and Economic Councils, and the Domestic Policy Office. A White House Health Advisor would direct this office. The good news is that a White House Office on Health Care Reform will be established to address health care delivery issues. A President's Health Innovation Council might also be established with a multidisciplinary group of senior leaders from academia, the private sector and non-governmental organizations to provide insights and breakthrough recommendations on current and emerging health challenges as well as to identify opportunities that will keep America at the forefront of medical discovery and effective public health response.

Investing in biomedical, behavioral, epidemiologic, and health services research is another essential component of a national prescription to improve health. However, scientific research has been flat funded in recent years. In Fiscal year 2008, funding for the National Institutes of Health (NIH) is only $28.6 billion, which, when adjusted for inflation, is 18% below 2004 levels. These budget cuts have negatively impacted the conduct of research, the recruitment and retention of the next generation of scientists, and are threatening America's leadership, competitiveness and potential contributions to advancing health and medicine in the 21st century.

Another element should involve empowering the U.S. Surgeon General, the nation's top doctor, and expanding the U.S. Commissioned Corps. In the recent past, years have gone by without a Surgeon General in place. Filling this critical job swiftly should be a priority for the new Administration. The U.S. Commissioned Corps - a uniformed health service on duty 24 hours a day to fight international enemies including AIDS, chronic diseases and bioterrorism - should also be expanded to include a global division to provide expertise, technical assistance and rapid response on international health issues. An ROTC mechanism should be considered for the U.S. Public Health Service to foster recruitment of talented young people into this "special forces" of public health.

Lastly, investments in global health, which contribute to humanitarian, economic, and national security interests, can serve as an important foreign policy tool for the next Administration and should be significantly increased. While the United States is the world's biggest provider of foreign aid, it allocates only 0.16 of its gross national product to development aid, less than 15 other countries and the UN Millennium Development Goals target of 0.7 percent. While The President's Emergency Plan for AIDS Relief (PEPFAR) has saved millions of lives, now an evidence-based international as well as a domestic plan is urgently needed. It should be noted that besides PEPFAR, there is only minimal focus on global health within the U.S. Department of State, where health matters are largely concentrated in the Bureau of Oceans and International Environmental and Scientific Affairs. While a Science Advisor to the Secretary of the State Department exists, there is no equivalent post for health. Given the importance of health diplomacy to our nation's foreign policy, the new Administration should consider appointing a Coordinator for global health programs across the government as well as establishing an Assistant Secretary of Health with an Ambassadorial rank to serve as America's health diplomat. Other important steps include streamlining and better integrating funding mechanisms for global health programs that currently span many Federal agencies including restructuring USAID to increase its effectiveness.

By addressing these issues as well as ensuring that key Federal health positions are quickly filled with visionary, experienced and innovative leaders, our new President could write a transformative prescription to heal our country's sick care system, helping to ensure a healthier future for people in America and around the world.

Rear Admiral Susan Blumenthal, M.D. (ret.) is the Director of the Health and Medicine Program at the Center for the Study of the Presidency in Washington, D.C. and a Clinical Professor at Georgetown and Tufts University Schools of Medicine. She served for more than 20 years in health leadership positions in the Federal government, including as Assistant Surgeon General of the United States, the first Deputy Assistant Secretary of Women's Health, as a White House Advisor on Health, and as Chief of the Behavioral Medicine and Basic Prevention Research Branch at the National Institutes of Health. Dr. Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the US Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide.

Yi-An Ko, a recent graduate of Harvard University, served as a Health Policy Fellow at the Center for the Study of the Presidency in Washington D.C.