George W Bush's second term

When George W Bush returns to the White House after his inauguration ceremony, health is unlikely to be at the top of his agenda. In the months ahead he must devise strategies that will tackle record budget and trade deficits and pave the way for an exit from an increasingly unpopular war in Iraq. Yet many of the other decisions that he and his administration must make will have profound consequences for the health of America's people and for those in many other countries.

That the American healthcare system is in a mess has long been apparent. Despite spending vast and ever increasing amounts of money (now over a third more per person than Switzerland, the next highest spender), uniquely among industrialised countries the United States does not attempt to provide cover for all its citizens, and the number of uninsured people has increased from 42 million to 45 million in the past four years. Although the country spends almost 15% of its national income on health care, its outcomes are appalling, with death rates among young people from some common chronic diseases three or four times higher than in European countries.¹ The reforms that are being proposed contain some potentially good ideas, such as reform of the law on malpractice claims, expansion of community health centres, and help for small businesses to become more effective purchasers of insurance.² Others are seriously misguided, most notably the concept of health savings accounts.

An individual enrolled in a health savings account receives coverage for catastrophic illness. Other health care must be paid first by the individual, up to a defined limit (typically several thousand dollars), after which they can draw on the tax free fund into which they and their employer have paid. Any money in this fund that is unspent at the end of the year is rolled over to provide, hopefully, a reasonable pool for any future needs. Accounts appeal to wealthy people, who are likely to leave existing schemes.³ Those remaining will be disproportionately poor and unhealthy⁴ and will face higher premiums because of the loss of cross subsidy, which will further increase the number of uninsured people.

Several other domestic policies are likely to prove controversial. The expected change in the composition of the Supreme Court will facilitate a review of the legality of abortion. Social policies will emphasise fundamentalist views on sexuality and family relationships,⁵ with sex education based on the ineffective model of promoting abstinence.⁶ As a consequence, the already high rate of teenage pregnancies is likely to increase further.

The ability to respond to the challenges ahead will be constrained by the growing politicisation of American science. The Union of Concerned Scientists has catalogued how the first Bush administration sought to suppress or distort research deemed unhelpful or out of line with its socially conservative policies.⁷ A congressional committee has documented how this degree of political interference is unprecedented in the United States, noting that the consequences of this process go far beyond the delivery of health care to affect policies on education, the environment, and many other areas.⁸

As the United States is the one remaining global superpower, policies adopted in Washington have implications for the world. The Bush administration has pursued a sustained campaign against multilateralism, seeking to block action on issues as diverse as global warming and landmines. It has decided that the Geneva conventions do not apply to some of its prisoners and has refused to accept the authority of the International Criminal Court. The United Nations has been subjected to vitriolic attacks in the American media, and the Bush administration has sought, where possible, to lead coalitions of the willing that bypass the UN and its specialised agencies. An example is the President's Emergency Plan for AIDS Relief, which exists in parallel with, and arguably undermines, the Global Fund to fight AIDS, Tuberculosis, and Malaria by diverting needed resources. The president's emergency plan has been slow in spending the money made available to it, and much of what has been spent has been used to purchase expensive patented drugs instead of cheaper generics.⁹

Such mechanisms are attractive to the administration as they provide a means of projecting domestic policies on, for example, sexuality, to many other countries, a process aided by the global gag rule in which any organisation receiving American government funds must agree not to provide counselling for those seeking abortion or lobby for its legalisation. Some signs, however, show that the administration is reviewing this approach as illustrated by its rapid abandonment of the four country coalition created to provide relief to the victims of the tsunami in the Indian Ocean.

Like other second term presidents George W Bush will have one eye on his place in history. The greatest epitaph for a politician is that they leave the world in a better state than they found it. History will be the judge.