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BUDGET RESOLUTIONS EMERGE FROM HOUSE, SENATE PANEL The Fiscal Year 2003 funding process recently advanced as the full House and the Senate Budget Committee moved their versions of the budget resolution that will guide appropriators when they make the actual allocation decisions later this year. With the House in Republican hands and the Senate led by Democrats, the resolutions make different assumptions about many things. However, both agree on the completion of the five-year doubling of the National Institutes of Health’s (NIH) budget and that funding for the National Science Foundation (NSF) should increase. On March 20, the House passed (by 221-209) H. Con. Res. 253, its budget outline for FY 2003. The resolution assumes a $46 billion deficit for next year, with $759 billion allocated for new discretionary spending. Of that total, $393 billion is for defense-related activities, and $366 billion is for non-defense agencies and programs. The House included language in the report accompanying the bill that assumes $4 billion for the NSF’s Research and Related Activities account, $217 million above the President’s request and $374 million more than FY 2002. This would also raise the total increase for the Foundation from five percent to over eight percent. On the Senate side, the resolution emerged from the Budget Committee, chaired by Senator Kent Conrad (D-ND), on March 21. On a straight party-line vote of 12-10, the Democrats pushed through FY 2003 total discretionary spending of $795 billion, with an anticipated deficit of $92 billion. The Senate resolution restores a number of cuts in the Bush-proposed budgets for job training and other programs, and provides increases to agencies such as the Centers for Disease Control and Prevention. Similar to the House resolution and the President’s budget, it assumes a $3.9 billion increase for NIH to complete the doubling. The Senate also pushes for a larger increase for NSF, assuming a total budget of $5.2 billion, close to the House number. This would represent a $500 million increase over FY 2002 and $261 million above the President’s request. The committee notes that the increase will cover “research activities in such areas as the physical sciences, engineering, and the social and behavioral sciences.” It also encourages increased funding for NSF’s education programs, including the Math & Science Partnerships and Graduate Education. The full Senate will take up the resolution when Congress returns from its “Spring break” on April 8. Early predictions assumed the House and Senate will not get together to produce a final resolution for use by the appropriations committees. Those panels are eager to begin their work as this congressional session will be shortened by election-year activities; if there is no agreed-upon budget resolution by April 15, the appropriators will proceed. At the same time Congress begins work on the FY 2003 budget, the President has asked for a supplemental appropriation to fund the continuing war and anti-terrorism efforts in FY 2002. In the proposed spending bill, NSF gets some funding for cyber-security. IMPROVEMENT OF EDUCATION RESEARCH GAINS MOMENTUM Researchers and policymakers continued in recent days to work towards improving education research. The House Education and the Workforce Committee reported favorably H.R. 3801, the bipartisan restructuring of the federal education research activity, on March 20 (see Update, March 18, 2002). And at the Academy for Educational Development, a nonprofit organization, nearly 200 researchers, advocates, officials, practitioners, and providers gathered to help lay the foundation for an improved system and culture for research in education. The March 26 conference was titled, “Research in Education: On the Leading Edge of School Improvement?” Coming on the heels of the President’s “No Child Left Behind Act,” which repeatedly called for scientifically-based programs and practices, the conference confronted such questions as, What are the guiding principles of scientific research? What is the nature of evidence? What do practitioners need from the research community? What is the appropriate federal role in education research? Steve Ross of the University of Memphis considered some aspects of research that scientists do not always reflect on. Perhaps most important is the fact that evidence and results are often difficult for policymakers to interpret. Particularly in the field of education, analyses can be complex, and results are often mixed or context-specific. This might help to explain, he implied, why policy often flows from sound bites. Ross suggested that expert, third-party review of research seems the best way to overcome these problems, in addition to educating the media and policymakers. It is also, he added, unproductive to ask which program or model is most effective. It is better, he corrected, to ask which can best be implemented in this particular context, and how effectively can it be implemented? “I look to the research for answers,” said Carmen Russo, Chief Executive Officer of the Baltimore Public Schools. Speaking for many school superintendents, Russo laid out what they need from the research community to improve their schools. Timely, accurate research that is meaningful to the practitioner, objective, accessible, and intelligible, is in demand, she said. Russo also suggested some topic areas where more investigation is needed. She called for research on the middle and secondary levels, studies that assess the effectiveness of technology in the classroom, and answers about how best to restructure high schools. Mike Cohen of the non-profit Aspen Institute, and a key education official in the Clinton Administration, lamented the gap between research and its implementation. There are obstacles, he observed, that we need to determine how to overcome. Cohen also reminded researchers that they cannot study everything. A focused research program is needed, he asserted, with multiple research strategies that include both experimental and quasi-experimental research. Research and Reading G. Reid Lyon, Chief of the Child Development and Behavior Branch at the National Institute of Child Health and Human Development, delivered the day’s keynote luncheon. He tackled such issues as the nature of scientific research and the ways that children learn to read. While using the question of how children develop the capacity to read, Lyon’s remarks held lessons for conducting research on virtually any topic. For example, Lyon pointed to the observation that children develop language naturally, without direct instruction. However, he said, it was assumed that children would develop the ability to read in the same way. The mistake was that this assumption was not tested. He likened this to “pedagogical malpractice.” Lyon maintained that children will be best served when certain fundamental research principles are employed, like the formation and testing of falsifiable hypotheses. Like Cohen, Lyon also addressed the issue of research methodologies in education. The relative validity of experimental and quasi-experimental research has been a point of contention lately, with some claiming the superiority of experimental methods and others insisting on the validity of quasi-experimental or qualitative methods. The definition of science in the recent “No Child Left Behind” legislation and the proposed H.R. 3801 appears to favor experimental designs. Lyon sought to put the debate to rest, arguing that what is important is that the design is appropriate to the question, and that the application of the research is done well. For instance, if we are trying to determine what causes AIDS, he offered, the first studies would be descriptive – qualitative. Then, through randomized clinical trials, we would determine what works. In his discussion of how children learn to read, Lyon also sought to end the focus on another dichotomy – phonics versus whole language, which has appeared numerous times in the press. Phonemic awareness is one of many elements in learning to read, he said – it is necessary, but not sufficient. The conference sponsors expressed their hope that the recent momentum in the federal government towards improving education, and the interest and efforts of the attendees, was truly the leading edge of a historical improvement in our nation’s schools. The conference was sponsored by the Education Quality Institute, the National Education Knowledge Industry Association, and the Progressive Policy Institute.
LEADING ECONOMISTS BRIEF SENATE ON STATE OF ECONOMY Four prominent economists testified March 12 before the Senate Banking, Housing, and Urban Affairs Committee on the state of the U.S. economy. Nobel Laureates Robert Solow of MIT and Joseph Stiglitz of Columbia were joined on the panel by Alan Krueger of Princeton and David Malpass of Bear Stearns and Co. Solow opened his remarks by noting that while recession-like conditions have ceased, the current rebound may be sluggish, at least at first. He backed this assertion by pointing to several economic conditions he said will check growth, including weak markets in Europe and Japan, a continuing rise in unemployment rates, and falling corporate profits. Solow also critiqued the recently-passed but long debated stimulus package in his statement, saying, “If it had been a term paper, I would have graded it a strong B-plus, but I would have penalized it for being late.” As a remedy, he recommended that Congress develop a “standard stimulus package” that could also be reversed to cool a bullish economy. An up-or-down vote on the measure, he suggested, would be triggered by certain events or could also be proposed by the president. But he conceded that “no such thing is likely to happen.” Stiglitz, who served in the Clinton Administration, focused the first part of his testimony on current financial trends; he agreed with Solow’s analysis by noting that the economy will not soon return to robust growth. He explained that inventory cycles and overinvestment in capital and housing are largely to blame for the downturn, and these irritants will not be mitigated immediately. Stiglitz then went on to explain that the failure of “Enron and Global Crossing confirmed the suspicion of skeptics” that old accounting practices are no longer functional and that “this may dampen stock market prices, at least for a while.” He also noted that while this year’s increased military spending is a macro-economic positive, any benefit is negated because such expenditures do not contribute to long-term economic strength. In his conclusion, Stiglitz pointed out that the long-term effects of last year’s tax cut could do irreversible damage to the economy, unless its size and structure are revisited soon. Krueger’s statement centered on the labor market, his area of expertise. Using a variety of statistics, he showed that the private sector job market was hurt more by this recent economic downturn than by the recession of the early 1990s. While unemployment figures may continue to rise slightly in the coming months, he explained, underlying data indicate that the economy has stabilized and will strengthen soon. Krueger continued by explicating the labor market patterns that were prevalent throughout the recent slump. During the early part of the downturn (March to July 2001), unemployment figures were most pronounced for skilled workers with at least a high school degree – an unusual trend. Since then, however, unemployment levels have risen most sharply for workers with a high school degree or less. He concluded by urging Congress to study long-term unemployment insurance issues and pressures facing the American economy expected to result from the upcoming Baby Boom retirements. Malpass, who serves as Chief Global Economist at Bear Stearns and held a series of appointments in the Reagan and Bush I Administrations, presented last. He opened by predicting “a broad-based U.S. recovery in 2002, with support from consumption, inventories, government purchases, and second-half strength in business investment.” He then pointed to reasons why steps should be taken to stabilize the value of the dollar, including the need to control inflation, deflation, and price stability. Finally, Malpass shared his thoughts on international economic policy. He stated that the U.S. continues to hold too big a share of the world’s GDP. This is the result of the underperformance of foreign economies, especially those in developing nations. He explained that this is widening the gap in living standards and holding down the world’s poorer individuals. Committee Chairman Paul Sarbanes (D-MD) opened the question phase of the hearing by asserting that the federal government does not spend enough on economic statistics analysis, and asked the witness to comment. Solow replied that while more resources should be allocated to the Bureau of Labor Statistics and the Bureau of Economic Analysis, a major reason for error in projection is the demand for immediate release of economic data and indicators. Stiglitz suggested that the government create an independent agency devoted to statistics collection, as exists in Canada. The other panelists stated that more money should be devoted to these government functions largely due to the vital role that government data play in economic decisionmaking. Senator Robert Bennett (R-UT) questioned the panelists on tax rates. Stiglitz responded by stressing that a higher tax burden allows the government to invest in research and development and other accounts that spur long-term economic growth. A protracted debate on the estate tax ensued, during which Krueger pointed out that charitable donations would be greatly reduced as the result of an estate tax repeal. Stiglitz followed this comment by noting that a cut in charitable giving would have major economic repercussions by hurting the non-profit sector. This conversation carried on to the end of the hearing in a debate between Bennett, who favors a repeal, and Sen. Jon Corzine (D-NJ), who stands in opposition. BUSH ADMINISTRATION CONVENES ITS FIRST HIV/AIDS COUNCIL MEETING For the first time since President Bush took office over a year ago, the Presidential Advisory Council on HIV/AIDS (PACHA) met, on March 14 and 15. The Council was created in 1995 during former President Clinton’s administration, and it was renewed by Bush last year. Under the Council’s charter, the members and chair are chosen by the Secretary of Health and Human Services (HHS). Secretary Tommy Thompson named 34 individuals to the panel last month, including former Congressman Tom Coburn (R-OK) and former HHS Secretary Louis Sullivan, who will serve as co-chairs. Coburn is currently a family physician, and Sullivan serves as President of the Morehouse School of Medicine. Nine of the members are holdovers from the last Clinton Council, including former PACHA Chair and former Congressman Ron Dellums (D-CA). The Council’s first session served primarily as an opportunity for various officials to brief the members on the status of the federal government’s response to the epidemic. Thompson opened the presentations by expressing the Administration’s will to combat the disease, both on a national and international level. Several members questioned him on this front, particularly on the amount of the U.S. contribution to the Global AIDS Fund, which is currently set at $500 million. The Secretary defended the amount, but it now appears that this figure could be doubled, largely as a result of unexpected support by conservative Senators Jesse Helms (R-NC) and Bill Frist (R-TN). Thompson was followed in turn by a slew of HHS representatives, including Claude Allen, Deputy Secretary; Joe O’Neill, Acting Director of the Office of HIV/AIDS Policy; and Robert Janssen, Director of the Division of HIV/AIDS Prevention at the U.S. Centers for Disease Control. O’Neill focused his remarks on an ongoing HHS management review of HIV/AIDS programs that is aimed at ensuring funds are well spent. Other presenters included Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, Dellums, who led a review of the final report issued by the Clinton Council, and Scott Evertz, Director of the White House Office of National AIDS Policy. The members had ample opportunity to ask questions and weigh in on issues that were raised by the presenters, but there was little substantive discussion. The Panel’s work will seemingly get underway at the next meeting, which has yet to be scheduled. The Council can be accessed on the web at www.pacha.gov. Patricia Ware, a leading teen pregnancy prevention advocate who served in the first Bush Administration, will serve as PACHA’s Executive Director. PRESIDENT AND HHS SECRETARY MAKE KEY HEALTH APPOINTMENTS NIH and Surgeon General Nominations More than a year into the administration, the National Institutes of Health (NIH) finally has a nominee for the top spot, and President Bush has signaled his choice for the office of the Surgeon General. On March 26, Bush announced his intention to nominate Elias A. Zerhouni of Johns Hopkins University as the next director of NIH and Richard Carmona as the next Surgeon General. “These are distinguished physicians who have worked tirelessly to save lives, and to improve lives. They bring exceptional knowledge and skill to these critical jobs,” Bush extolled. Richard Carmona, an Army Green Beret in Vietnam, decorated police officer, SWAT team member, nurse, and physician, has “redefined the term, hands-on medicine,” Bush joked. After earning a GED, Carmona received his bachelor and medical degrees from the University of California, San Francisco, where he graduated at the top of his medical school class. The National Association of Police Organizations named him the nation’s Top Cop in 2000. (See Update, March 18, 2002, for information on Zerhouni). According to Bush, the next Surgeon General will address “three particularly urgent issues:” administering the 5,600 member Public Health Services Commission Corps, leading important initiatives focusing on prevention and healthy living as a key component to medical care, and having regular conversations with the nation about alcohol and drug abuse and the tremendous toll they take on society. “Alcohol is a prime cause of many of our society’s ills, not the least of which is domestic violence,” Bush observed. Addressing healthy living, the President said, “The research is overwhelming that simple improvements in diet and exercise should result in dramatic improvements in America’s health . . . Fitness and a healthy lifestyle are a priority for me.” Both positions require Senate confirmation. Senator Edward Kennedy, Chairman of the Senate Health, Education, Labor and Pensions Committee, indicated he intends to promptly hold hearings on the nominations. But given the nature of the confirmation process, it could take four months or longer before either is voted on by the Senate. Acting Director of AHRQ Named Carolyn Clancy, the Agency for Healthcare Research and Quality’s (AHRQ) Director of the Center for Outcomes and Effectiveness Research, has been named Acting Director of the agency by Secretary of Health and Human Services Tommy Thompson. AHRQ’s long-time director John Eisenberg died in March after a year-long battle with brain cancer (see Update, March 18, 2002). Clancy is a general internist and health services researcher. Her major research interests include women’s health, primary care, the impact of financial incentives on physicians’ decisions, and access to care. Clancy graduated from Boston College and the University of Massachusetts Medical School. After her clinical training in internal medicine, she was a Henry Kaiser Family Foundation Fellow at the University of Pennsylvania and an assistant professor in the Department of Internal Medicine at the Medical College of Virginia in Richmond. She joined AHRQ in 1990. IOM REPORT ISSUES ‘WAKE-UP CALL’ TO HEALTH CARE SYSTEM Racial and ethnic minorities are more likely to receive lower quality health care than whites, even when insurance status, income, age, and severity of conditions are comparable, according to a recently-released Institute of Medicine (IOM) report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The National Academies’ IOM Committee on Understanding and Eliminating Racial and Ethnic Health Disparities in Health Care found that differences in treating heart disease, cancer, and HIV infection partly contribute to higher death rates for minorities. Two of the report’s findings are: racial and ethnic disparities exist in healthcare, and because they are associated with worse outcomes in many cases, are unacceptable; and racial and ethnic disparities in healthcare occur in the context of broader historic and contemporary social and economic inequality, and persistent racial and ethnic discrimination in many sectors of American life. “Disparities in health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases,” declared committee chair Alan Nelson, a retired physician, former president of the American Medical Association, and current special adviser to the chief executive officer of the American College of Physicians-American Society of Internal Medicine. The Congressionally mandated report assesses the extent of racial and ethnic differences in the quality of health care received by patients, not attributable to known factors such as access to care, ability to pay, or insurance coverage; evaluates potential sources of these disparities, including the role of bias, discrimination, and stereotyping at the provider, patient, institutional, and health systems levels; and provides recommendations regarding interventions to eliminate health care differences. “We have a health care system that is the pride of the world, but this report documents that the playing field is not even,” stated University of Michigan sociologist David Williams. This report is “a wake-up call for every health care professional.” The Committee emphasized that bias among doctors and nurses, while not necessarily overt, contributes to health disparities, fostering distrust among minority patients that exacerbates the problem. The stereotyping process is unconscious and automatic, said Williams, explaining that many individuals committed to egalitarian values will nevertheless unconsciously treat minority patients differently. Other key findings of the report include: · Many sources B including health systems as a whole, health care providers, patients, and health care plan managers B contribute to the disparities in health care. · Bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care. · Racial and ethnic minority patients are more likely than white patients to refuse treatment, but differences in refusal rates are generally small. Minority patient refusal does not fully explain health care disparities. Needed Research Less clear than the disparities in care, however, is the evidence base to better understand and eliminate those disparities. Thus far, the report observes, “far greater research attention has been directed to documenting racial and ethnic disparities in care” than to discovering ways to eliminate them. Other areas where research is minimal or notably absent are: intervention research; research on disparities in care among non-African-American racial and ethnic minority populations; and research on the role of non-physician health care professions. The committee urged the creation of a more ambitious research agenda aimed at disentangling the many influences on the process, structure, and outcome of care for minority Americans. The members called for research to: · Better understand the relative contributions of patient, provider, and institutional characteristics of healthcare disparities. · Assess the relative contributions of provider biases, stereotyping, prejudice, and uncertainty in producing racial/ethnic disparities in diagnosis, treatment, and outcomes of care. · Further illuminate provider decision-making, heuristics employed in diagnostic evaluation, and how patients’ race, ethnicity, gender, and social class may influence these decisions. · Develop methods for monitoring progress toward eliminating these disparities. · Understand the relationship between healthcare disparities and the health gap between minority and non-minority Americans. Finally, Unequal Treatment encourages the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, and the National Institutes of Health to conduct research on the barriers to eliminating racial/ethnic disparities in care, including data-related concerns (especially those related to HIPAA privacy regulations) and ethical issues. The report and a RealPlayer file of the briefing are available at http://national-academies.org/webextra/minorityhealth .
REPORT CALLS HUMAN DIMENSIONS OF FIRE MANAGEMENT CRITICAL We need “as strong a science base in the human dimensions as we do in the physical and biological sciences” when it comes to wildfire management, according to Brian Wademan, Chief of Staff to Interior Secretary Gale Norton. Wademan made the comment at a March 21 briefing formally releasing the report, Burning Questions: A Social Science Research Plan for Federal Wildland Fire Management. The report, authored by Gary E. Machlis, Professor of Fire Resources and Sociology at the University of Idaho and Visiting Chief Social Scientist of the National Park Service and his colleagues, was commissioned by the National Wildfire Coordinating Group (NCWG). This group consists of representatives from various agencies in the Departments of Agriculture and the Interior, and is the umbrella organization for those concerned with wildland fire activity. Using the extraordinary fire season of 2000 as “compelling evidence of the relationship between wildland fire and people,” the report notes the challenges faced by fire management organizations with respect to the “human dimension.” These included Congressional policy debates, decisions about risk to firefighters and the public, allocating resources, communicating with the public, managing workforce issues, and coordination among those organizations. Machlis and his co-authors identify key elements that will create a research agenda. These include: reviewing existing requirements in laws, regulations, and policies that guide federal wildland fire management agencies; assessing the literature relevant to the human dimensions of fire management, such as studies of the socioeconomic factors contributing to these fires and their socioeconomic consequences; and determining the needs of fire management professionals, scientists, and stakeholders. The report calls for a broad, interdisciplinary research agenda on wildland fire management that would focus on: social, economic, and cultural variables as contributing factors; social, economic, and cultural impacts; firefighter health and safety; public health and safety; organizational capacity, decision-making, and coordination; public values, attitudes, and behaviors; and pathways of public communication. To obtain a copy of Burning Questions contact Sheila Williams, National Interagency Fire Center, 208/387-5203, Sheila_Williams@nps.gov .
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