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Vast power and wealth can damage welfare
Budget numbers often seem dull and confusing. But they can test the promises of political leaders against financial realities. Government budgetary spending, which underpins national policies, indicates a nation's true priorities. The US Bush Administration reveals its aims in its 5‐year budget plan. Totalling US$2.7 trillion for 2007 alone, the plan augurs grave effects on the nation's health and international well‐being, and adds over $1 trillion to the $5 trillion national debt.1
These priorities are misplaced because they are creating vulnerabilities for the US. The effects include its decline in world opinion, limits on its ability to address major global issues such as global warming, growing US wealth gaps and poverty, a weakening of science and education, and massive foreign debt, increasingly held by volatile nations such as China.2 Within this brief space, I focus on health and welfare.
The priorities are clear. Of available budgeted funds, the plan projects rises for defence (10.8%) and homeland security, mainly anti‐terrorism (4.6%), and sharp cuts in domestic social programmes (over 16%). When defence, as well as off‐budget military funds and nuclear weapons programmes are included, these funds will reach at least $600 billion next year alone. Ongoing costs of America's wars are now running at $10 billion monthly. Social programmes, by comparison, will get about $370 billion next year. Furthermore, proposed tax cuts are mainly for millionaires—who this year get over $110000 in benefits from previous cuts—whereas the poorest fifth of tax payers get $23 this year. Tax cuts will cost a quarter trillion dollars during the budget plan, to be paid in cuts to social programmes, or more debt.3
Defence funds for Iraqi reconstruction are being shifted to pay for armed private security guards, taking $6 billion of the total $19 billion appropriated for rebuilding. One effect, for example, is that only 20 of the promised 150 health centres were built.4 A recent study concluded that the single most important condition for people's support and stability among Iraqis is access to healthcare and environmental health, which would encourage confidence in the government and drain support for the insurgents.5 This under‐funding contributes to health risks in Iraq, where one‐third of the children are chronically malnourished, and infant and maternal mortality are 3–5 times higher than its neighbour Jordan.6
The health implications of the budget plan are grim for Americans. The growing debt burden is likely to curtail essential programmes. For example, 47 million people—many of whom are children—have no health insurance, and employers are providing less each year—now only 59% of employers provide health insurance to their workers. Medicare, the universal programme for elders and disabled, and social security retirement pensions face long‐term deficits. The Bush Administration failed to privatise this widely popular programme, preserving its low‐cost administration and equity.7 A secure, minimally adequate income or its equivalent is fundamental to all other determinants of health, as is well known, but this is almost never acknowledged in the US.
The budget proposal specifically reduces programmes for the poorest people, now rising to 37 million. The services include financial aid, child care, housing, transportation subsidies and food aid to be cut by 13% or $24 billion. It also cuts health programmes by another $24 billion, including research funds and monies for the Centers for Disease Control and Prevention, and ends entire preventive and medical services grants to states. Veterans' healthcare will be cut too, even as thousands of wounded military personnel will need long‐term care.7
Reduced public funding for contraceptives for low‐income women—available since the 1960s—was accompanied by 13% more funds for teen “abstinence‐only” education, rising to $200 million. This is despite research showing its lack of efficacy in delaying teen sex or participants' rates of sexually transmitted diseases, whether or not they had “abstained”.8,9,10 Several states have now refused federal funds for such programmes, citing their ineffectiveness. Most of the courses have also been found to provide misleading information.11 Moreover, a recent court ruling ordered the government to stop funding a $1 million grant to a faith‐based organisation which taught that Jesus Christ would help teens abstain, in a suit filed by the American Civil Liberties Union.12
Breaking a pre‐election pledge to maintain international family planning programmes, President Bush plans to cut them by 16% next year, down to $357 million.13
US foreign aid generally has taken on a different character under the current government, moving towards bilateral rather than multilateral and United Nations support. It is provided under criteria that are no longer based primarily on need. The lead aid agency, the United States Agency for International Development, no longer addresses poverty reduction as the thrust of its mission. Rather, it aims at democracy, free markets and human rights. A federal court ruled that the United States Agency for International Development violated the US Constitution when it required public health groups to pledge their “opposition to prostitution” before obtaining federal grants. The effect was to stop them from working with prostitutes, including young girls, by promoting condom use as a means of preventing the spread of AIDS—an indication of how US international health programmes are affected by evangelical Christian supporters of the Bush Administration.14
The US spent $2.6 billion for global AIDS, billions less than promised, and requires a third of preventive funds to advocate abstinence but not the use of condoms. It limits its funding of the United Nations Global Fund for AIDS to $200 million yearly, whereas the Fund will need over $20 billion in 2010 alone.15 The US provides only about half as much per capita overseas aid as the European Union.16
The Bush Administration continues to address the problem of Americans' increasing loss of healthcare insurance by privatising tax‐supported programmes while cutting the large Medicaid federal‐state health insurance programme for the poorest Americans.17 This marketplace solution centres on high deductible insurance for coverage of catastrophic illness. It does little to encourage preventive care and little for most uninsured people, mainly benefiting the healthy and wealthy—and the for‐profit insurance industry.18
The new Medicare prescription drug programme, with its subsidised, industry‐oriented design, is now judged too costly at $700 billion. It is incomplete—it does not cover all who need it—and complex. A congressional study reports that the government website, aimed to help older people choose a commercial drug plan (up to 40 are available per state), is not understood by almost half of them; older people are unable to perform over half the online tasks, and the hotline gives inaccurate, incomplete or inappropriate responses to questions.19
Numerous budgeted terminations include a national disaster relief corps, and community policing and state grants, costing states $235 billion in the next 5 years. These funds will either be made up in state regressive property and value‐added‐type taxes, which disproportionately affect low‐income people, or government funding will vanish, to be replaced by higher risks to health. Although states are responsible for the welfare of their citizens, they fulfil this task unevenly, depending on their wealth and political climate. For example, Mississippi requires a person to have less than $1000 annual income before becoming eligible for state aid, while Alaska provides aid to a three‐person family when they have a yearly income of about $13000. Moreover, states have become dependent on federal funds for most of their ever‐rising healthcare spending for the poor, as well as for higher‐education subsidies, and many other public health programmes.7
The US spends more on healthcare than the wealthiest nations. Yet, it has poorer outcomes, in life expectancy and rates of infant mortality, maternal mortality and obesity, implying inefficient financing, and delivery of health, welfare and environmental programmes. It remains the only member in the Organization for Economic Cooperation and Development (OECD) without universal health insurance and the most unequal in incomes between the rich and the poor among those wealthiest nations. The US has less adult employment than many northern European countries, and more recently, lower college access and completion rates than members of the OECD.20 This is because of rising tuition costs and diminishing federal student aid, especially for poorer young people. Students now borrow a total $14 billion yearly, 10 times more than a decade ago; the majority leave college with debts of $20000.21
In meeting the worst American natural disaster ever—Hurricane Katrina that destroyed New Orleans in September 2005—the Department of Homeland Security has had several scathing official reviews.22 Even with increased funds, it continues to be ill prepared.23
Lack of coordination among health and disaster relief agencies resulted in health threats to New Orleans, hurricane evacuees. Almost half of the displaced victims, mainly poor and black, lost their health insurance because there was no ready access to Medicaid. Displaced children's chronic diseases, mental health and behavioural problems increased from the pre‐Katrina period. Children were also many times more likely to lack prescribed medications, and missed months of schooling because families were forced to move three or four times.24
The 2007 budget will slow down health and safety regulations, alternative energy and transportation development, while giving heavy subsidies to fossil fuel and nuclear power industries—$13 billion. Agencies such as the Occupational Safety and Health Administration and Environmental Protection Agency are to be cut.7 Moreover, the US Superfund, an industry‐tax mandated facility to clean up toxic sites and prepare for the first permanent nuclear waste site, will soon be depleted; the site will not be ready when needed in 2012.25
Although recent studies are warning that the US may lose its edge in science and technology, the plan calls for cuts of up to 20% in education. Beyond diminishing access to education, basic science in primary and secondary schools is being challenged. Religious fundamentalists, elected to local boards of education that control curricula, have succeeded in making textbook, library and course changes to conform to their biblical interpretations of evolution and moral values. A third of science teachers say they have been confronted for their classroom instruction.26 Other surveys of government scientists in environmental, food and drug, and climate sciences reveal being pressurised by their political superiors to change conclusions from their study data.27 The Bush Administration's refusal to fund stem cell research is leading the top genetic scientists to work in more supportive countries such as Singapore.28
The US's power and wealth means that its policy choices affect the planet. It is also clear that a sole superpower cannot impose its choices effectively. Collaboration with the international community could help lead the world in facing and containing global threats through, for example, coordination of intelligence and policing of terrorists and crime; strengthening constraints on proliferation of weapons of mass destruction; and reducing poverty and oppression, pandemics, environmental degradation, global warming and violent conflict. Too many recent US policies are weakening its capacity to address urgent issues. The new 2007 Congress will signal how much hope there is for the US to move towards a more constructive leadership role for the benefit of global welfare.
Competing interests: None declared.