That the American healthcare system is in a mess has long been apparent, write Professors Martin McKee and Susan Foster. Although the country spends almost 15% of its national income on health care, its outcomes are appalling, with death rates among young people from some common chronic diseases three or four times higher than in European countries.

The reforms that are being proposed contain some potentially good ideas, such as reform of the law on malpractice claims and expansion of community health centres, but others are seriously misguided, most notably the concept of health savings accounts.

Several other domestic policies are likely to prove controversial, write the authors. The expected change in the composition of the Supreme Court will facilitate a review of the legality of abortion, while social policies will emphasise fundamentalist views on sexuality and family relationships. As a result, the already high rate of teenage pregnancies is likely to increase further.

Policies adopted in Washington also have implications for the world, they add. The Bush administration has pursued a sustained campaign against multilateralism, seeking to block action on issues as diverse as global warming and landmines.

An example is the President's Emergency Plan for AIDS Relief, which exists in parallel with, and arguably undermines, the Global Fund to fight AIDS, Tuberculosis, and Malaria by diverting needed resources.

"Like other second term presidents George W Bush will have one eye on his place in history," say the authors. "The greatest epitaph for a politician is that they leave the world in a better state than they found it. History will be the judge."

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Contact: Emma Dickinson
edickinson@bmj.com
44-207-383-6529
BMJ-British Medical Journal
20-Jan-2005