By David R. Riemer
I had a dream last night that I got a phone call from Barack Obama. It's the kind of dream that only a former city and state budget director could cook up.
B-r-r-i-n-n-g-g-g-g (Did telephones ever really go "b-r-r-i-n-g-g-g-g? Do they still?)
Me: "Hello? This is David Riemer. May I ask who's calling?"
Voice: "This is Barack Obama."
Me: "Is this a joke?"
Obama: "No, it's the President...of the United States."
Me (remember: it's a dream): "Good evening, Mr President. I think you're doing a great job. Especially with national health insurance, given the weak Congress you've got. How can I help?
Obama: "David, I'd like you to think about becoming the nation's budget director. The current director of OMB, Peter Orszag, is resigning. As I’m sure you know, he has been advocating a cross-sectoral Place Based Strategy for many of our federal investments. I just nominated Jacob Lew to replace him, but who knows what Congress will do. So I wanted a back-up. I hear you were successful budget directors for both Milwaukee Mayor John Norquist back in the late '80s and for Wisconsin Governor Doyle in Wisconsin in 2003. The nation' budget is a mess. If need be, I'd like you to come to Washington to fix it."
Me (please remember...a dream): "Mr. President, if called upon, I'd be happy to accept the challenge."
Obama: "Thanks. One more thing. The people of the United States are far less healthy than they we ought to be. You know a lot about health policy. I understand you helped design Wisconsin's wonderful BadgerCare program. And I just learned that in your current job at Community Advocates, you're helping to lead the Milwaukee Tobacco Prevention and Control Coalition. Good stuff! If you end up in DC, I'd want you to use the federal budget to make Americans healthier."
Me: "No problem."
Obama: "A lot healthier."
Me: "It can be done."
Obama: "I'd like a brief report from you on exactly how you'd make Americans healthier. OK?
Me: "You'll have it tomorrow...tomorrow...tomorrow..."
And the dream (or was it a nightmare) ends.
But if it were true--if I really did end up as new Director of OMB, and had the job of using the federal budget to make Americans healthier--what would I recommend to the President of the United States?
Poverty, unemployment, and other economic and social problems do far more damage to the health of the American people than the weaknesses in our public health system or the flaws in our so-called health care “delivery” system.
If we want to greatly improve the health of the US population, and if we’re serious about reducing racial and other forms of health inequality, we need to identify and implement changes in public policy--especially in budget policy, and especially in federal budget policy--that the evidence shows will greatly reduce poverty and joblessness, particularly among African-Americans and Hispanics, but also among many low-income Whites in both urban and rural areas.
But after that introduction, what are likely to be the specific policy changes--particularly, the federal budget changes--that the evidence shows will reduce poverty and joblessness, and improve Americans' health?
The evidence is unfortunately partial and limited.
One of our problems is that we don't have any kind of national strategy for finding out, through systematic testing and evaluation of different models, exactly which changes in policy (budget policy and otherwise) would improve the economic and social determinants of health, and thus greatly improve US population health.
Frankly, we don't even have a strategy for developing such a strategy. But from what partial and limited evidence we do have, here's what the rest of the memo to the President would look like:
Improving the health of the American people means augmenting the incomes of thousands who rely on Social Security and Supplemental Security Income (SSI), but who still live below the poverty line.
It also means transitioning the unemployed—now nearly 10% of the workforce—into stable jobs, which in turn means creating and funding large numbers of transitional jobs to carry out useful projects that meet public needs if the regular labor market continues to have a serious shortage of jobs.
Improving health outcomes also means raising the minimum wage, and strengthening our system of earning supplements and other work support, like the Earned Income Tax Credit and child care.
In short, we need federal budget policies that lift all American adults (and thus their children) well above a realistic poverty line by providing them--depending on whether they're seniors, have a disability, are unemployed, or are working in low-wage jobs--with the additional income they need to get well above that realistic poverty line. Only such a "package of policies" that effectively eliminates the worst economic determinants of bad health (poverty and unemployment) will put the US population on an upward path to decent health.
In addition, improving the health of the US population means reforming our primary and secondary (K12) education system so that all children learn to read, write, and work with numbers. We also need to drive down crime rates, and reduce domestic violence.
Unless federal policy and budget changes allow America's poor adults and their children to make dramatic gains across a broad front of economic and social determinants of health, we’ll make little progress in improving overall US population health outcomes or reducing racial disparities.
Thank you, Mr. President, for this opportunity to speak truth to power.
End of memo.
But I hope you're listening.
David R. Riemer is Director of Policy and Planning for the Community Advocates Public Policy Institute in Milwaukee, Wisconsin.
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