Public policy and health in the Trump era

The Lancet Commissions
Lancet Commission on Public Policy and Health in the Trump Era,
Published: February 10, 2021

Executive Summary

  • Trump exploited low and middle-income white people’s anger over their deteriorating life prospects to mobilise racial animus and xenophobia and enlist their support for policies that benefit high-income people and corporations and threaten health.
  • His signature legislative achievement, a trillion-dollar tax cut for corporations and high-income individuals, opened a budget hole that he used to justify cutting food subsidies and health care.
  • His appeals to racism, nativism, and religious bigotry have emboldened white nationalists and vigilantes, and encouraged police violence and, at the end of his term in office, insurrection.
  • He chose judges for US courts who are dismissive of affirmative action and reproductive, labour, civil, and voting rights; ordered the mass detention of immigrants in hazardous conditions; and promulgated regulations that reduce access to abortion and contraception in the USA and globally.
  • Although his effort to repeal the Affordable Care Act failed, he weakened its coverage and increased the number of uninsured people by 2·3 million, even before the mass dislocation of the COVID-19 pandemic, and has accelerated the privatisation of government health programmes.
  • Trump’s hostility to environmental regulations has already worsened pollution-resulting in more than 22 000 extra deaths in 2019 alone-hastened global warming, and despoiled national monuments and lands sacred to Native people.
  • Disdain for science and cuts to global health programmes and public health agencies have impeded the response to the COVID-19 pandemic, causing tens of thousands of unnecessary deaths, and imperil advances against HIV and other diseases.
  • And Trump’s bellicose trade, defence, and foreign policies have led to economic disruption and threaten an upswing in armed conflict.

Although Trump’s actions were singularly damaging, many of them represent an aggressive acceleration of neoliberal policies that date back 40 years.
These policies reversed New Deal and civil rights-era advances in economic and racial equality. Subsequently, inequality widened, with many people in the USA being denied the benefits of economic growth.

  • US life expectancy, which was similar to other high-income nations’ in 1980, trailed the G7 average by 3·4 years in 2018 (equivalent to 461 000 excess US deaths in that year alone).
  • The so-called war on drugs initiated by President Richard Nixon widened racial inequities and led to the mass incarceration of Black, Latinx, and Indigenous people.
  • Overdose deaths soared, spurred by drug firms’ profit-driven promotion of opioids and the spread of despair in long-afflicted communities of colour and among working-class white people.
  • Market-oriented health policies shifted medical resources toward high-income people, burdened the middle class with unaffordable out-of-pocket costs and deployed public money to stimulate the corporate takeover of vital health resources.

The Commission applauds President Joe Biden and Vice President Kamala Harris for rejoining WHO and the Paris Climate Agreement, and for other steps they have taken to rescind some of President Trump’s health-harming executive actions.
But the new administration and Congress must go beyond simply repairing Trump’s damage.
They must initiate thoroughgoing reforms to reverse widening economic inequality and the neoliberal policy drift that pre-dated Trump, and redress long-standing racism — root problems that harm health and have fomented threats to US democracy.
Additionally, forceful action is needed to forestall environmental disaster and strengthen public health infrastructure.

Reducing economic inequality will require raising taxes on the wealthy and using the proceeds to strengthen social, education, nutrition, and health programmes.
Those programmes should avoid segregating the poor, and instead encompass all people in the USA to bolster the solidarity that is key to securing broad and continuing popular support. Government should stop funnelling expenditures through private firms whose profit-seeking boosts costs and distorts priorities. Hence, a single payer health-care reform offers the fairest, most effective, and most efficient route to universal health coverage.

Censure of Trump’s virulent brand of racism is imperative but insufficient.
US leaders must embrace emphatically anti-racist politics and programmes to dismantle the centuries-old structures that reproduce racial inequity in health and all other spheres. Ending mass incarceration and reforming the execrable policing and criminal justice systems that oppress communities of colour and fill prisons are essential for racial justice. Additional steps must include vigorous enforcement of voting and civil rights; large new investments in educational equity, the Indian Health Service, and minority-serving health and educational institutions; and compensation for wealth denied to and confiscated from communities of colour in the past.

Finally, the president and the Congress must mobilise massive resources to avert climate catastrophe, address the calamities caused by COVID-19, and attenuate global inequality.
The 3·4% of GDP the USA currently spends on troops and armaments should be reduced to the 1·4% average of other G-7 nations, with the savings redeployed to address urgent health, social, and environmental problems at home; reinvigorate the scientific efforts that are vital to global progress; and fund the four-times increase in foreign aid needed to reach the level recommended by the UN.

Key Messages

  • Politicised and repudiated science, leaving the USA unprepared and exposed to the COVID-19 pandemic
  • Eviscerated environmental regulation, hastening global warming
  • Incited racial, nativist, and religious hatred, provoking vigilante and police violence
  • Denied refuge to migrants fleeing violence and oppression, and abused immigrant detainees
  • Undermined health coverage
  • Weakened food assistance programmes
  • Curtailed reproductive rights
  • Undermined global cooperation for health, and triggered trade wars
  • Shifted resources from social programmes to military spending and tax windfalls for corporations and the wealthy
  • Subverted democracy both nationally and internationally

Although the Trump administration policies posed a uniquely urgent threat to health, damaging neoliberal policies predated and abetted his ascendance:

  • Life expectancy in the USA has lagged behind other wealthy nations since 1980 and began falling in 2014
  • The chronically high mortality of Native Americans started rising in 1999, while yawning disparities between Black and white people persisted and progress on racial equity in other domains (eg, education, housing, income and policing) halted or reversed
  • Substance abuse deaths greatly increased
  • Income and wealth inequality widened
  • Incarceration increased four-fold, initiated by President Nixon’s racially motivated war on drugs and compounded by harsh laws enacted under Presidents Reagan and Clinton
  • Welfare eligibility restrictions implemented by President Clinton removed benefits from millions
  • Deindustrialisation spurred by trade agreements that favoured corporate interests over labour protections reduced economic opportunity in many regions of the USA, damaging health and increasing receptivity to racist and xenophobic appeals
  • Market-based reforms commercialised and bureaucratised medical care, raised costs, and shifted care toward high-income US residents
  • Despite the Affordable Care Act, nearly 30 million people in the USA remained uninsured and many more were covered but still unable to afford care
  • Funding cuts reduced the front-line public health workforce by 20%

The Biden administration must cancel Trump’s actions and also address the health-damaging structural problems that were present before Trump’s presidency:

  • Raise taxes on high-income people and use the proceeds to bolster social, educational, and health programmes, and address urgent environmental problems
  • Mobilise against the structural racism and police violence that shorten the lives of people of colour
  • Replace means-tested programmes such as Medicaid that segregate low-income people, with unified programmes such as national health insurance that serve all US residents, aligning the interests of the middle class and the poor in maintaining excellence
  • Reclaim the US Government’s role in delivering health and social services, and stop channelling public funds through private firms whose profit-seeking skews priorities
  • Redirect public investments from militarism, corporate subsidies, and distorted medical priorities to domestic and global fairness, environmental protection, and neglected public health and social interventions
  • Reinvigorate US democracy by reforming campaign financing, reinforcing voting, immigration, and labour rights, and restoring oversight of presidential prerogatives

COVID-19’s facile breach of national boundaries is a reminder of the vulnerability of even the most powerful nations in an interconnected world, and the folly of contempt for science, facts, and equity. In years past, the USA deployed its economic power and scientific prowess in important, although imperfect, efforts to advance global health. It must rejoin the global community in a spirit of collaboration, rejecting the notion that others must fail in order for the USA to succeed.


Unfortunately, Trump’s politics and policies are not an isolated US aberration.

Authoritarian agendas are spreading worldwide, as politicians mobilise people unsettled by their declining prospects to go against those below them in racial, religious, or social hierarchies. Leaders with agendas similar to Trump’s already hold sway in many places — eg, Turkey, India, Hungary, the Philippines, and Brazil. In many other countries such leaders are gaining influence.

Trump’s election was enabled by the failures of his predecessors. A four-decade long drift toward neoliberal policies bolstered corporate prerogatives, privatised government services, reinforced racism, and imposed public austerity. The rich got much richer while their taxes were halved. Workers’ earnings stagnated, welfare programmes shrank, prison populations greatly increased, and millions were priced out of health care even as government payments enriched medical investors. GDP grew but longevity lagged, a sign of profound social dysfunction.

The path away from Trump’s politics of anger and despair cannot lead through past policies. President Biden must act for the people, not for the wealthy and the corporations they control. Resources to combat climate change, raise living standards, drop financial barriers to higher education and medical care, meet global aid responsibilities, and empower oppressed communities within the USA must come from taxes on the rich, and deep cuts in military spending (panel 6). For health care, overreliance on the private sector raises costs and distorts priorities, government must be a doer, not just a funder — eg, directly providing health coverage and engaging in drug development rather than paying private firms to carry out such functions.

Panel 6 — Commission recommendations

  • Implement a nationwide, science-led response to the COVID-19 pandemic * *Action taken by President Biden in January, 2021.
  • Enforce civil rights, voting rights, and fair-housing laws
  • Include medical institutions’ progress on diversity in grant or contract review criteria for US National Institutes for Health, US Centers for Disease Control (CDC), and other federal agencies
  • Reinvigorate Justice Department oversight of discriminatory policing and end transfers of surplus military equipment to police departments
  • Recommit to the Paris Climate Agreement * and reinstate occupational and environmental protections and funding
  • Curtail federal prosecutions of substance use and pardon people previously convicted for such use
  • Ban for-profit prisons and immigration detention facilities
  • Revoke Trump’s anti-immigrant executive orders * and policies and assure humane treatment of migrants and people fleeing persecution
  • Deliver fully adequate disaster aid to Puerto Rico
  • Align US foreign and trade policy with measures to promote the Sustainable Development Goals
  • Abolish regulations that treat sexual-health services differently from other health services
  • Reverse the Justice Department’s support for lawsuits seeking to overturn the Affordable Care Act

Recommendations for legislative action

  • Implement the Green New Deal, end subsidies and tax breaks for fossil fuels, and ban coal mining and single-use plastics
  • Repeal the 2017 tax cuts on corporations and the wealthy, implement new taxes on assets, and increase taxes on capital gains and high earnings
  • Increase public expenditures for social programmes, currently 18·7% of gross domestic product (GDP), to 24·2% (the average of other G7 nations), and repeal time limits and immigration restrictions on welfare and nutrition programmes
  • Cut defence spending from the current 3·4% of GDP to 1·4% (the average of other G7 nations) and increase foreign development aid from 0·18% at present to the UN target of 0·7%
  • Comply with long unmet obligations under treaties between the governments of the US and American Indian Nations, including boosting the funding of the Indian Health Service to levels commensurate with need
  • Implement single-payer national health insurance and regulate drug prices
  • Double federal public health spending, and reverse funding cuts to the CDC and global health programmes
  • Guarantee shelter and increase funding for public and subsidised housing
  • Prioritise funding for substance use treatment integrated with harm reduction and social services
  • Make free school meals universal and implement policies to improve their nutritional quality
  • Raise the minimum wage and strengthen labour protections
  • Enact immigration reforms based on an inclusive vision of national identity, including: a realistic path for those seeking to immigrate; a roadmap to citizenship for undocumented individuals; and human rights protections for detainees and other vulnerable migrants †Legislative proposal introduced by President Biden in January, 2021.
  • Restrict gun sales
  • Eliminate patents, trade agreement restrictions, and treaties that impede global access to vital generic drugs
  • Implement criminal justice reform through community control of the police, ending cash bail, shifting funds for public safety to mental health and social intervention, and ending special legal immunity for policy
  • Upgrade Puerto Rico’s status to assure equal treatment to US states
  • Protect democracy by implementing campaign finance reform, easing voter registration, and facilitating voting

Senior Advisor for Health Care Strategy to BCG — Boston Consulting Group