WASHINGTON PERSPECTIVE

NEWS WASHINGTON PERSPECTIVE

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None of the stake holders in America’s trillion-dollar health industry is at ease about health-care reform, but a special case of jitters exists in the medical education and research sec-

: budgeted in the previous year. The increase was proposed denounced by the biomedical lobby as an insulting, ground-losing token. A sympathetic Congress then nearly tors. Heavily dependent on an doubled the amount of additional increasingly frugal Congress, neither funding, but even so, the NIH comhas received much attention from the munity felt abused. In the budget Clintons, and even less or none at all that he presented last month, Clinton from the authors of competing was a bit more generous, proposing a; health-care designs. With the White half-billion-dollar increase for NIH. House in need of all the support it That was less than the pouting health

for its embattled reform lobbies had declared to be the miniplan, Hillary Rodham Clinton went mum requirement for to the National Institutes of Health reversion to a biomedical dark age. on Feb 17 to persuade administrators Nonetheless, recognising that and researchers that the Clinton have fared better than most under health formula merits their Washington’s severe budget condiboth as professionals and recipients tions, the health-science mandarins of health care. prudently moderated their expresThe values they cherish in educasions of dismay this time. : tion and research, particularly basic Not so the guardians of the acaderesearch, she said, would flourish mic health centres, which, somewhat under the Administration’s plan. realistically, fear that fiscal "For much of the past decade", Mrs if not disaster, awaits them in the Clinton "biomedical Clinton reform plan. In Congressiondeclared, research has been neglected and al testimony in January, the Associaunderfunded and even unappreciattion of American Medical Colleges ed, and the President intends to fix (AAMC), which represents the that". The White House proposal, nation’s 126 medical schools and 400 she assured them, would underwrite teaching hospitals, candidly explained its anxieties about the the vitality of the nation’s many acadfiscal emic health centres. As Mrs Clinton ’. upheavals it foresees. The additional "the President’s dollars that the government now described it, all is to require plans that attaches to Medicare payments for approach provide health insurance coverage to patients in teaching hospitals "covers contract with such academic health only 20 to 33% of the costs associatcentres in order to preserve and ed with the academic mission", the protect that critical mission of these Senators were told by Stuart Boncentres". durant, chair of the AAMC and dean The message was respectfully of the University of North Carolina received but it did not put to rest the at Chapel Hill School of Medicine. anxieties that inspired Mrs Clinton’s The balance comes through "crossvisit because the Clinton record and subsidisation", he said, noting that the fine details of his health-reform "patient service revenues have supproposal are considerably out of harported graduate medical education with the First rendition. and other academic activities ... revmony Lady’s The biomedical research commuenues from high-volume services nity measures political affection in have supported low-volume services; money, not oratory. Clinton’s health and payments from paying patients legislation says little about research.have charity-care supported Where it does address the topic, the patients". context is preventive research and But the system is breaking down, he said, as private insurers "restrict public-health measures, not the subcellular studies that are the pride and their payments to cover only goods . ’ passion of NIH. Last year, in his first and services they believe are necesopportunity to improve the finances sary and of identifiable benefit to of NIH, President Clinton proposed their enrollees. Costs associated with only a modest increase, a mere the education and research missions $342 million atop the$10-3 billion of teaching hospitals generally are not can muster

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The Clinton plan anticipates these financial changes by proposing the creation of two special funds to finance residency training and to subsidise the operation of academic health centres. But, as proposed, both fall short by billions of dollars for sustaining these activities, the AAMC testified, representative adding: "Managed competition, the fundamental premise on which the [Health Security] Act is based, would unravel medical schools’ entire financing system of cross-subsidisation, but would make accommodation for only a portion of the system by replacing it with two funds". In her address to NIH, Mrs Clinton did not confront these detailed objections. Her talk was broadbush and intended to be inspirational. She and the President have often said that everything in their plan is negotiable, except irrevocable universal health The researchers and coverage. health-centre administrators are hoping for a better deal.

Daniel S

Greenberg

UK technology exercise

foresight

Think about what society will need in 10-20 years’ time. Think what areas of research are most likely to meet these needs and to yield the greatest economic benefits. Research users and providers all over the United Kingdom are going to be asked to do so over the coming months in the government’s first large-scale systematic technology foresight exercise. The fifteen sectors to be covered by the foresight programme were announced on Monday. Each will be taken forward by a group led by a chairman and a vice-chairman, one an industrialist, the other an academic, in keeping with an exercise intended to be market-led but well balanced by sciencepush. The technology foresight programme is one of the main features of the government’s science policy announced last May (see Lancet 1993; 341: 1441 and 1469) and aimed at fostering partnership between academia, government, and industry, to create wealth and improve quality of life. A foresight method’ used by other countries is to set up working groups to review and select the most promising technologies. Another method, designed to avoid the distortion effects of personality and peer pressure often encountered with small groups, is the Delphi technique, whereby large numbers of people

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