Monday, April 10, 2006

Rats and their packs

I've been trying to clean out some papers lately. It's amazing to realize how much paper we can accumulate over the years. Add to that the problem of being something of a pack rat, and you can see that this could be a major chore.

The job is slowed down by finding such interesting things in the files (or out the files when they should have been filed [sigh]). A recent batch found me at the level of excavation that we can date around 1996-1997. Then, as now, we were looking forward toward the coming legislative session and appropriations that would be made for the next biennium. (Texas does two-year budgets.) Then, as now, we were faced with shortfalls in our HIV medications program and looking to the legislature to provide some relief.

For some reason I had, in my pack-rat ways, printed out and saved an email exchange from that time with an official in the state health department about the necessary appropriation. His replies were a virtual gold mine in their description of intradepartmental politics and the perpetual standoff between the state and federal governments.

Imagine, if you will, a situation in which virtually all levels of the state bureaucracy (in the stove pipe that would go from the then HIV Bureau to the highest level) were supportive of additional funding for HIV medications. Imagine that the metaphorical buck stopped at that highest level of the bureaucracy with an appointed official, not an elected official. And it was the appointed official who was required to face off against the federal appropriations process, to attempt to predict future appropriations cycles, and balance the need to fund the medication program against the need to convince the federal government that it was their responsibility to come up with the funds and not the state's.

That was the year that HIV was a footnote in the health department's legislative appropriations request. I recall having to work with that footnote as the primary support from the department for any increase in funding. It was also the year in which we first needed such major increases to fund the new medications that were to become so important to HIV therapy.

Several things ran through my mind in reading those emails: Bet that official wouldn't send such an explicit discussion of politics these days. Is it ironic or tragic that the life-saving breakthrough of protease inhibitors had to be a footnote in state funding? Gee, those were the good old days.

We face the same issues today: There are important new medications that we need to add to our formulary. How can we pay for them? Which of our pockets should the money come from (it being our money in each of our pockets)?

As it turns out, those were just old days, nothing to be nostalgic for. Maybe that's why being a pack rat is useful--there are plenty of reminders that the old days were just as tough as the new days. Of course, walking around the piles of files is not as easy as it was in the old days . . .

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