Careful What You Wish For

But the next president may not have a choice; pressure to reform the system is growing. America spends about $2 trillion annually on health care, yet it ranks poorly on a variety of key health indices. The National Coalition on Health Care describes the system as "riddled with inefficiencies, excessive administrative expenses, inflated prices, poor management, and inappropriate care, waste and fraud."

Adding to the problem: concerns that funding for research is stagnating. Last year The New England Journal of Medicine reported that, after doubling between 1998 and 2003, the budget for the National Institutes of Health was expected to decrease 3 percent this fiscal year (after adjusting for inflation). That's the first true budget reduction for the NIH since 1970. Increasing funding will be hard, given budget deficits and costly wars. At the same time, there's more pressure to provide aid for global health concerns. Last year President Bush doubled U.S. spending to fight global HIV/AIDS to $30 billion. There's reason to expect further funding increases to help rehab America's image.

The next president will also have to tackle politically sensitive subjects like stem-cell research, family planning and drug safety and oversight. He or she will have to do this with a "Grand Canyon divide between the parties," says Altman. "The differences could not be more striking." And the challenges, it seems, more monumental.
—Jennifer Barrett

Environment: Ending The Holdout
In environmental terms, January 2009 doesn't just mark the start of a new administration in Washington, but the halfway point in the two-year process of coming up with a new international agreement to combat global warming. That clock was set at a meeting of 187 nations last month in Bali, which called for "deep cuts" in greenhouse-gas emissions—endorsed in principle by the United States, but with the caveat that the Bush administration would continue to oppose mandatory caps. So when U.N. Secretary General Ban Ki-moon said the scope of reductions "will have to be negotiated down the road," everyone knew what he meant: with a new president.

To take the lead on global warming, the new president must undo the skepticism and disdain toward American policy that was on display in Bali, and dates back to President Bush's renunciation in 2001 of the existing greenhouse-gas treaty, the Kyoto Protocol. And he or she will have to find a way to sell the necessary sacrifices to developing countries in a climate of diminished American political and economic clout. ("Lead, follow, or get out of the way!" the American delegation was admonished in Bali—by Papua New Guinea.) Bush at least has laid the groundwork for a reversal by his successor by finally admitting that global warming is happening and human activity plays a part in it. "I take the issue seriously," he told an end-of-year news conference, although environmental groups say that the only meaningful measure of seriousness is support for mandatory limits on greenhouse-gas emissions.

The next president's job will be easier, of course, if mandatory limits are already in place a year from now. In a historic first, the Lieberman-Warner Climate Security bill, which would impose most of what environmentalists say is needed—an 80 percent reduction in greenhouse emissions by 2050—passed a committee vote last month and may be taken up by the Senate later this year. It embodies a version of the market-based "cap and trade" system that has been successful in cutting other forms of air pollution. But the bill has roughly an iceberg's chance in Bali of being signed into law in anything like its present form this year—so it could well become part of the next president's agenda.

Even without a new law, the incoming administration will be able to wield regulatory authority over emissions. The Supreme Court ruled last year that the Clean Air Act covers carbon dioxide, clearing the way for the Environmental Protection Agency to regulate it. Bush quickly disavowed any such intention, but the authority is there for the next president to use. Similarly, the administration overruled an attempt by California to impose its own carbon dioxide emissions regulations. Bush's successor could reverse that decision also. As evidence grows of a warming climate, the next president will have an opportunity to move the world toward a more sustainable future. And, if the majority of climate scientists are right, it won't be just "an" opportunity. It may be the last opportunity.
—Jerry Adler

© 2008