Public policy and health in the Trump era

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.
  • 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.

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
  • 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%
  • 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


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

  • Compensate Native Americans, Native Hawaiians, Puerto Ricans and African Americans for the wealth denied to and confiscated from those groups in the past
  • 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



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Joaquim Cardoso @ BCG

Joaquim Cardoso @ BCG

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