Details. You can find both God and the devil in them, depending on your vantage. Consider medieval gargoyles, whose grotesque features evoked demons, but also drained water off roofs.
In our decidedly non-medieval age, a swathe of us have cast Uncle Sam as a modern-day demon. He hampers our freedom with his strictures, his omniscience, his taxes. Conservatives lob special disdain on the hugely expensive Affordable Care Act, on Medicaid, and on Medicare (until they need it). They yearn to topple Uncle Sam, replacing him with the 50 State Houses - an enthusiasm for state power that we haven’t seen since the ante-bellum South.
Yet the micro-details, the budgetary blips, also reveal Uncle Sam’s power, health-wise. In a $3.8 trillion federal budget, where roughly one-third is “discretionary spending” (and the military consumes the bulk of that), you don’t notice these small line-items; but, like gargoyles’ maws, they matter.
Here are a few blips-that-matter.
Most of us won’t need transplants of bone marrow or umbilical cord blood. But those who do – patients with cancer, with metabolic disorders, and/or immune system disorders - can benefit from transplanted healthy cells. Those patients depend upon Uncle Sam, represented by the Stem Cell Therapeutic and Research Act of 2005, the Reauthorization Act of 2010, and now another reauthorization Act. Two senators co-sponsored it: Orrin Hatch (R-Utah) and Jack Reed (D-R.I.). President Obama signed it. Thanks to that reauthorization, the National Marrow Donor Program and the National Cord Blood Inventory will stay afloat until 2020, when, optimistically, two more bipartisan Senators will re-introduce a re-authorization and a new President will sign the bill. The tab, $24 million, is funneled through Division of Transplantation (DoT) within the Health Resources and Services Administration (HRSA).
Remember Ryan White? In the mid 1980s the AIDS epidemic had turned patients into pariahs, shunned for contagion, and blamed for a profligate lifestyle. By 1988 though, 652 people with hemophilia had developed AIDS and 386 had died. More people harbored the HIV virus. The cause: tainted blood from donors. (By 1985 a screening test assured the safety of transfusions.) Ryan White, from Indiana, was a 13 year-old boy with hemophilia, diagnosed with AIDS in 1985. When his middle school denied him admission, Ryan’s mother broadcast his desire to go to school. His story changed the public’s perception of AIDS, and nudged Uncle Sam to open up a spigot to pay for treatment. In 2014, Uncle Sam spent $2.32 billion on this program, funneled through a bogglingly complex route, including the Department of Health and Human Services (HHS), the Health Resources and Services Administration (HRSA), and the HIV/AIDS Bureau (HAB). This program helps pay for drugs ($900 million for Ryan White’s AIDS Drug Assistance Program (ADAP), treatment, housing, and support. Overall, Uncle Sam spends $25.3 billion on domestic HIV, including care, prevention, and research.
Tuberculosis has shrunk in this country – fewer than 10,000 new cases in 2012, most diagnosed in people born outside the United States. We can’t erect a wall, or a disease immigration-screen, to bar this airborne virus, which wafts across national boundaries. So Uncle Sam has joined the worldwide battle to find new screening tests and new drugs, since some strains have grown resistant to existing drugs. In 2009, Uncle Sam spent $255 million for TB Research and Development, up to $268 million in 2010 (thanks to the American Recovery and Reinvestment Act, which unleashed funds for research), down to $248 million in 2011 (the ARRA expired), up to $256 million in 2012, then, in 2013, sequestration and a mandated 5% cut to the National Institutes of Health budget, forced TB funding down. NIH cut funding for the Tuberculosis Trials Consortium (TBTC) by 13%; three sites for clinical trials closed. The route for Uncle Sam’s spigot is complex: the Global Health Programs (GHP) account at USAID (an agency not beloved of political isolationists) along with the Economic Support Fund.
Some Presidential candidates pledge to slash Uncle Sam down to micro-size, to transfer money back to us the taxpayers, and back to states. Yet if we decimated this demon-from-DC, would we have a National Cord Blood Inventory? Would we help people living with AIDS? Would we eradicate tuberculosis?
Medievalists erected gargoyles for a reason; the “details” protected the buildings. So too Uncle Sam, however ugly we find him, however atrocious we find his trillion dollar budget, protects us.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.
From The Progressive Populist, February 15, 2016
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