A key element of the plan is improved access to health care coverage as part of Obama’s goal of reforming the US health-care system. “His plan will ensure that people living with HIV have access to lifesaving treatment and care”, campaign documents indicate.

The US is grappling with an HIV annual incidence rate of 56 300—a number that is 40% higher than previously thought. The new figure is the result of new incidence testing methodologies developed by the Centers for Disease Control (CDC) that more accurately determine when an infection was contracted.

CDC officials say they hope the new tool can help pinpoint growth in the epidemic so resources can be marshaled more efficiently to where they are needed most. The test also is being tried in Africa under the PEPFAR programme.

Increased testing is likely to be among the key features of enhanced prevention strategies. Although routine HIV screening is recommended for Americans aged 13-64 years, compliance is uneven. A recent study showed that only about 5% of patients with serious illness are screened in hospital emergency rooms, one of the sites CDC recommends for the tests.

In Washington, DC, the US city with the highest HIV/AIDS rate, officials are working with physicians to improve testing compliance. Shannon Hader, director of the HIV/AIDS Administration for the city, calls physician reluctance the  ”core barrier” to more universal screening. “We’ve spent 25 years telling medical providers that HIV testing was something special….something they had to be very careful about and really not their job,” she said. DC is changing that message by encouraging providers to offer HIV tests as part of routine exams, something she says many patients thought already was happening. “When you’ve been going to the doctor and getting your pap smear and getting your mammogram and getting checked out for your heart disease and your doctors say ‘hey you check out well,’ it doesn’t occur to [patients] that they didn’t bother to check you for the number one cause of premature death in your city”, Hader commented.

See the World Report in this week’s print issue for more on this topic.

Nellie Bristol

After Senate confirmation, Daschle would oversee the Medicare and Medicaid programs, the Food and Drug Administration, the Centers for Disease Control, and the National Institutes of Health.

During the transition, Daschle is heading Obama’s health-care working group.

Although the economic crisis is expected to slow work on health care reform, Capitol Hill is starting to prepare for the process. Key health legislator Edward Kennedy, Democrat from Massachusetts, appointed former presidential candidate Senator Hillary Clinton to chair a task force on health insurance reform.

Kennedy, who chairs the Senate Health Education, Labor and Pensions Committee, also established two other health related panels, one on prevention and public health and another on quality of care. Kennedy and other lawmakers are working on health reform legislation for consideration early next year. Several versions being developed take an approach similar to that outlined by Obama, which builds on employer-based insurance systems.

In what some see as a stepping stone to more comprehensive reform, Congress is expected to pass an expansion of the Children’s Health Insurance Program early next year. Obama is a strong supporter of the programme and is expected to support extending it. Other health measures expected early in an Obama administration are executive orders expanding stem-cell research options and reversal of a policy that limits funding to some international family groups.

Pressure on Obama to stick to other pledges also is building. A rally was planned for Nov 20 by AIDS activists at the Obama transition office to urge him to “fulfill [his] campaign promises by developing and implementing a comprehensive, transparent and attainable national AIDS strategy, including reforms to HIV prevention, treatment, care, housing and global AIDS policies” within his first 100 days in office. 

In global health, advocates are not expecting much in the way of new money, but are pushing for full funding and broadening of the President’s Emergency Plan for AIDS Relief (PEPFAR). Development and global health experts also urging reform of US foreign assistance including a revitalisation of the US Agency for International Development (USAID). In a Nov 10 letter to Obama, a group calling itself the Modernizing Foreign Assistance Network called for creation of an “elevated, empowered, consolidated and streamlined US development agency” as a “top foreign policy priority” and empowering a single individual with responsibility over the now separate entities of USAID, the Millennium Challenge Corporation and PEPFAR.

A strengthened, more coordinated US development strategy has been called for not only by humanitarian and development experts, but also by Defense Secretary Robert Gates. Last year, he urged “a dramatic increase in spending on the civilian instruments of national security-diplomacy, strategic communications, foreign assistance, civil action and economic reconstruction and development”.

Nellie Bristol

“There’s a lot that the president can do using his executive authority without waiting for congressional action”, John Podesta, head of Obama’s transition team, told Fox News this week.

Just days after taking office in 2001, President George W Bush issued an executive order restoring the “Mexico City Policy” adopted in 1984 by then-president Ronald Reagan, which required non-governmental organisations who receive federal funding to agree not to promote abortion as a family-planning method. The policy has become known as the global “gag rule”.

Victims of the gag rule include the United Nations Population Fund, which lost some US$200 million in funding in 2002.

Bush also banned funding in 2001 for the harvesting of new stem cells, something he and other conservatives believe immoral. The ban essentially stagnated the country’s stem-cell research industry, which has been surpassed by research in less-regulated countries like China. Earlier this year, Bush vetoed a Senate bill to remove the restrictions.

David Boddiger

“In 2009, Congress must take up and act on meaningful health reform legislation that achieves coverage for every American while also addressing the underlying problems in our health system. The urgency of this task has become undeniable”, wrote Baucus.

Baucus and fellow members of the finance committee have already held nine hearings this year on health-care reform, and many experts suspect that early momentum is crucial going into the new presidential term. Still others believe reform impossible without a substantial economic turnaround, something that could take months, or longer.   Whether or not health care reform and economic recovery are mutually exclusive is a question that Congress and the new president will have to answer in-step and early in 2009. With so much at stake, delays could render reform terminally ill if Obama and Congress fail to act during what Senator Hillary Clinton—whose efforts at health care reform failed in the mid-nineties during husband Bill Clinton’s administration—has called “a honeymoon period”.

“The bottom line is that Americans are voting for change, and by that they mean they want to see a better life for themselves and their families and their country, and we’re going to have to produce that”, Clinton told reporter Karen Tumulty.          

Otherwise, the honeymoon between voters and their favourite new change agent could wind down – and rather quickly.

Obama has said he would first work toward creating economic stability and then on adopting a new renewable energy policy. Health-care reform would come third, he said. But Baucus’s new proposal, along with support of other senators— including Edward Kennedy, chairman of the Senate committee on health and a strong advocate for health care reform—may just be reason enough for the new president to take a second look at his list of short-term priorities. 

David Boddiger

In Chicago, hundreds of thousands of supporters young and old gathered in Grant Park to hear Obama deliver his victory speech on the same grounds as the tumultuous and violent events of the 1968 Democratic National Convention only four decades ago. Obama’s speech, which some commentators have compared to the language of former President Abraham Lincoln (also of Illinois) and with the cadence of civil rights leader Martin Luther King, Jr, moved most of the audience and many of those glued to television screens across the country to tears.

Congressman Jesse Jackson, Jr, son of civil rights leader and the former presidential candidate of the same name, called Obama’s sweeping victory a “peaceful revolution”.

www.barackobama.com

Across the USA, Obama supporters took to the streets in celebration. An impromptu crowd amassed in front of the White House in the nation’s capital. Obama’s successful bid to occupy that famous residency has been one of the most dynamic and unpredictable political events in the nation’s modern history.

Voters also gave Democrats solid control of both congressional chambers, electing 254 Democrats to the House of Representatives out of a total 435 seats, and 56 of 100 total Senate seats (just shy of the 60 seats needed to block Republican filibusters). Majority control of Congress and a voter-backed margin favouring Obama over McCain 52% to 46% give Obama a clear mandate to enact reform proposals and embark on a direction entirely different than that of the previous 8 years under George W Bush.

“It’s been a long time coming, but tonight, because of what we did on this day, in this election, at this defining moment, change has come to America”, Obama said on Tuesday night to a crowd that included celebrities, fellow politicians, and average Americans, some who had waited all day to hear the speech.

But despite the expanded congressional majorities and a voter-backed mandate for change, on Jan 20, 2009, Obama’s task will change from campaigning to governing as he inherits a country in the midst of the worst financial crisis since the Great Depression.

As The Lancet’s Bryant Furlow reports, the US government’s recent financial bailout package adds nearly US$1 trillion dollars to an already existing $500 billion budget deficit. Add to that two ongoing foreign wars and an economy that remains stagnant, and many campaign promises, including health-care reform, may be out of reach for some time to come. Obama has acknowledged that health-care reform could be postponed.

“The economy, of course transcends all the other issues”, House Speaker Nancy Pelosi told National Public Radio’s Robert Siegel the day after Obama’s election.

But legislators do seem poised to at least partially take up the matter almost instantly by passing a measure that was impossible just last month under the Bush administration.

“As far as Congress is concerned, there are some things that we can do quickly to signal change”, Pelosi said. “We can come right back in January with a children’s health initiative. President Bush vetoed it, (but) it will probably be one of the first bills we would put on President Obama’s desk”, she said.

The initiative is a $35 billion expansion of a programme to provide health insurance to children whose parents earn too much to qualify for Medicaid, but too little to afford insurance on their own. The bill would extend coverage to an estimated 10 million children, up from 6 million, and would dramatically reduce the number of uninsured children in the USA, supporters say. The vetoed bill had garnered support even from some congressional Republicans.

But other efforts to extend coverage to the millions of Americans without health insurance, to reduce costly premiums and guarantee access, as well as improve medical technology and preventive care-all initiatives promoted by Obama’s campaign-will prove costly and perhaps out of short-term reach given current budget restrictions.

Meanwhile, Obama began meetings this week with transition planners to start the task of naming members of his administration, one that is likely to draw heavily from his campaign and former President Bill Clinton’s administration.

David Boddiger

Obama said the remark confirmed that employer coverage would be better than that offered by McCain. “Now this is the point I’ve been making since Senator McCain unveiled his plan”, Obama said.

Holtz-Eakin said the quote was taken out of context and that he was arguing that the tax credit would not undermine employer sponsored care, which provides coverage for more than 60% of Americans under 65 years. Erosion of employer coverage under McCain’s plan is a major concern of some economists and health policy experts. The proposal “has the potential to reduce the incentive for many employers, particularly small employers, to continue providing health coverage to their employees”, argues the Commonwealth Fund, a Washington, DC, based think tank.

McCain is proposing elimination of the current tax exemptions offered to employers who provide coverage, replacing them with a refundable credit of $2500 for individuals and $5000 for families to purchase coverage in a proposed deregulated insurance market.

But Obama’s plan, which requires large employers to provide coverage or pay into a national coverage pool, is also found lacking by tax experts. It would offer tax incentives to small businesses to provide coverage, and claims it will reduce health payments by $2500 per person a year by improving technology and emphasising preventive care. “The numbers aren’t supported by anything”, commented Robertson Williams principal research associate at the Tax Policy Center, who finds the lack of specifics in Obama’s plan concerning.

Obama’s plan is expected to cost $50 billion to $65 billion when fully phased in, paid for by increased taxes on those making more than $250 000 a year. McCain says his plan would be budget neutral over 10 years.

Trying to lay some groundwork with Congress in case he does take the White House, Obama called fiscally conservative House Democrats known as the Blue Dogs.  The group, now counting 49 and expected to grow, could be significant voting block as the next President works to move health care changes through the legislative process. Wholesale reforms of the US health system have a dismal record in Congress and the new White House will need all the help it can get. Congress is expected to have a large influence on how health care reforms will look. Bills likely to influence the process already have been drafted, including several that make providing employee coverage more affordable for small businesses.

Long time health legislator Senator Ted Kennedy, Democrat of Massachusetts, is also said to be working on plan he hopes to introduce early next year. Kennedy provided a key endorsement for Obama when he was neck-in-neck with Senator Hillary Clinton for the Democratic nomination.

Nellie Bristol

But Biden’s physicians recorded little concern of a repeat cerebrovascular event. He’s never had a follow-up study to confirm that his arteries are clear. At the same time, Biden’s blood pressure is a relatively healthy 120/78, and he’s taking statins to control his cholesterol.

The corollary to all of this is that Governor Sarah Palin, who’s 44 and the Republican vice presidential nominee, has never disclosed any medical information to the public. She’s running to be second to a 72-year-old John McCain, who’s had two bouts of malignant melanoma (see Correspondence in the Oct 25 issue of The Lancet for more on McCain’s health).

Barack Obama, meanwhile, has released some medical information. He’s been deemed fit by his doctors, who note he’s tried several times to permanently quit smoking.

All of this was kind of a sideshow to the sickness in America’s health system itself.

The left-leaning consumer’s group Families USA released a report. Thursday with some alarming findings. Average family health insurance premiums had shot up more than five times faster than workers’ wages between 2000 and 2007. While premiums rose 78.5%, wages rose just 14.5%.

Ron Pollack, the group’s president said American workers are being hit by a “triple whammy”. While premiums keep going up, employers are gradually backing away from the comprehensive coverage they once freely offered employees. Meanwhile, rising health care costs mean bosses are holding back on pay for workers. “A bad situation is clearly growing worse”, Pollack told reporters.

Some results from the Henry J Kaiser Family Foundation’s political tracking poll this week seem to confirm it. While the economy remains voters’ number-one concern, their ability to pay for health care seems to be a major part of that. And nearly half say the crunch is hitting home in a very real way.

Nearly half of the respondents in said they’d skipped some needed medical care because of cost. More than a third said they’d postponed needed treatment, and about a quarter said they’d divided pills, skipped doses, or skipped filling a prescription because of the price.

Washington is asking whether the faltering economy means that John McCain or Barack Obama won’t really be able to address American health care in a substantial way next year. But this week’s news suggests the economic news may only get worse if they don’t.

Todd Zwillich

Although the large increases of recent years may be slowed, what this ultimately means for overseas funding aimed at combating HIV/AIDS, malaria, tuberculosis, and other health issues remains unclear.

Both McCain and Obama support continuing and expanding the President’s Emergency Plan for AIDS Relief (PEPFAR)—the primary vehicle for US HIV/AIDS funding overseas, the majority of which is spent in Africa. Obama wants the US Government to increase its focus on addressing health care infrastructure and health care worker training in African countries, and also appears to favor a stronger, more streamlined US Agency for International Development—the agency responsible for carrying out most PEPFAR-funded programmes.

With congressional Democrats pledging to pass a second package of spending and tax breaks to stimulate the recession-bound American economy in a post-election “lame duck” session in November, additional funding for cash-strapped US states struggling to meet health care costs may be back on the table.

As part of an economic stimulus package passed in September, House Democrats proposed providing billions of dollars funding to help states with their funding for Medicaid—the US Government health care programme for low-income individuals and families. The bill died in the Senate, but could be revived, and expanded, if lawmakers return to Washington, DC after the election.

As part of a larger economic stimulus plan announced Oct 13, Obama signalled he would support federal aid to states and cities to support cash-strapped health care programmes. “And for all those cities and small towns that are facing a choice between cutting services like health care and education or raising property taxes, we will provide the funding to prevent those tax hikes from happening”, Obama said in Toledo, Ohio.

The tumultuous debate over a $700 billion economic bailout plan signed into law by President Bush 2 weeks ago brought with it an unexpected victory for advocates of greater funding for mental-health care. As congressional leaders sought to win support for the bailout, they attached it to legislation that requiring private health insurance companies to offer mental health benefits equivalent on par with traditional medical benefits. The bill’s passage was a victory for long time advocates like Democratic Senator Edward M Kennedy.

 Joseph Schatz

David Cutler, professor of Applied Economics at Harvard, warned that if present trends continue, US federal tax revenues will be spent entirely on Social Security and Medicare— the retirement and medical programmes for the elderly and people with certain chronic conditions.

Cutler estimated that Obama’s plan would cost the federal government US$50 billion to $65 billion annually, to be paid for largely by ending tax cuts President Bush enacted for individuals with annual incomes of $250 000 or more. All in all, a typical family of four would save about $2500 per year in medical costs under the plan, or roughly 8% of what it costs to cover that family today. At the same time, an Obama administration would lower medical costs by enlarging risk pools, and through investments in areas such as health-care infrastructure, public health, and preventive care. Doctors would be rewarded for good outcomes, and Medicare would offer incentive payments for activities such as following up with patients who miss appointments, electronic doctor-patient communication, and investing in information technology (IT). Indeed, IT would play a prominent role in Obama’s scheme. His team would have the federal government spend $50 billion to bring the USA up to speed. Much of that money would go towards helping smaller providers, such as community clinics, small group practices, and cash-strapped hospitals, invest in new IT systems. The importance of IT seems to be a rare area in which both candidates agree, because, according to Cutler, “John McCain’s heart also seems to be in electronic medical records”. 

The government is already nudging doctors toward incorporating more IT into their practices by offering bonuses to successful users of e-prescribing systems, beginning in 2009. On Tuesday, the Centers for Medicare and Medicaid Services (CMS) held a conference in Boston to promote this effort. In a press release, CMS noted that drug errors injure 1.5 million Americans annually. E-prescribing could help prevent these errors by warning of potential drug interactions, dosing problems, or duplications. The incentive payments will start at 2% and taper off to 0.5% by 2013. Prescribers who do not fulfill the standards by 2012 will see their payments go down. All in all, Medicare is expected to save $156 million over 5 years, just by avoiding adverse drug events. For more information about the conference, go to http://www.e-prescribeconference.com/.

Norra MacReady

She points out that women havemore than half of HIV infections in some regions. In addition, 200 million women yearly have unmet need for contraceptive services and there are 80 million unintended pregnancies each year, 60% of which end in abortion. Half a million women die each year from pregnancy related complications and 68000 die from unsafe abortions.

Despite these grime statistics and widespread acknowledgement of the need to address both gender equity and the effects of demographics on development, the issue has not been a hot topic on the campaign trail, to say the least. Even development groups haven’t pushed the issue in recommendations on foreign assistance reform aimed at the next president, Sippel said. 

Rachel Nugent, deputy director for global health at the Center for Global Development (CGD), agrees that the subject is intimidating for many, especially political candidates. For McCain, who is trying to court the conservative vote, issues surrounding reproduction are “radioactive”, she said. “There no way in the world he would want to get anywhere near this issue.” Obama also is walking a fine line, given that family planning and abortion are so emotionally charged in the USA. But Obama has taken more positions on global health, generally, than has McCain and he has specifically called for an end to US policies barring federal funding for non-governmental organisations that do abortions or provide abortion counselling. He also supports reinstating US funding for the UN family planning agency.

As for support for reproductive health among development groups, Nugent says CGD recommendations on foreign assistance reform are broad at this point and don’t include detailed policy recommendations.

But she says, development experts are advising the Obama campaign to take up the issue if he wins the White House. “I think the door’s open for further discussion”, she said.

Nellie Bristol