Health Letter, July 2021
By Michael T. Abrams, M.P.H., Ph.D.
From climate change to COVID-19, few issues better define the legacy of President Donald Trump than his policies pertaining to human health. Since the early stages of his candidacy, for example, Trump voiced full-throated criticism of the Paris Agreement on climate change and the Affordable Care Act (ACA) — policies that are aimed distinctively at improving human health. But were Trump’s tweets, executive actions and legislative proposals on matters of human health helpful or harmful?
In April 2017, soon after Trump’s inauguration, the prestigious medical journal Lancet formed an expert commission of 33 scholars to evaluate Trump’s health-related policies and actions and to chart a course for that broad collection of governmental activities. In February 2021, Lancet published the commission’s report, “Public policy and health in the Trump era,” a 49-page critique of Trump’s actions regarding health.
To follow is a summary of facts and broader discourse of that ambitious Lancet publication.
Trump’s public statements and policies throughout the COVID-19 pandemic were dismissive of the threat; discouraged national and international cooperation; and politicized mask-wearing, school reopenings and large gatherings — all factors that certainly contributed to spread of the coronavirus. If Trump’s COVID-19 mitigation strategies had instead been similar to those of other developed countries, an estimated 40% fewer Americans (180,000 people) would have died from the virus as of February 2021.
The waves of avoidable COVID-19 deaths flooded the U.S. when it was already experiencing separate crises of “deaths of despair and structural racism” characterized by drug overdoses, suicides and the highest mortality rates among non-White minorities. In 1980, life expectancy in the U.S. was similar to that of other developed nations. By 2018, U.S. life expectancy was 3.4 years shorter than in other G7 nations, and death rates for Black and Indigenous Americans age 25–29 years were 4 to 7 times higher than the analogous G7 averages. During the COVID-19 pandemic, Black and Latinx Americans have lost more total years of potential life than White Americans even though the White population is three to four times larger.
Racism and white supremacy
The Lancet Commission report offers many details about the history that preceded Trump’s presidency. Well before Trump ran for that office, racism in the U.S. had a strong and negative impact on human well-being. Post-Civil War vagrancy statutes criminalized unemployment, forcing many Black people to return to their former owners under servitude leasing agreements. During the same period, firearm use among southern police emerged to enforce Jim Crow laws and to expropriate Native American land. In 1935 President Roosevelt’s Social Security Act excluded farm laborers and domestic workers (most of whom were Black). The 1946 Hill-Burton Act to fund hospital construction included a separate-but-equal provision to maintain racially segregated facilities. Until the mid-20th century, the American Medical Association (the preeminent physician’s guild) barred Black doctors from membership, and as of 2018 only 5% of physicians were Black even as 13% of the U.S. population was classified as that race.
The origins of the Medicare and Medicaid health insurance programs are stained by racism as Medicare (designed to serve older White people) is bolstered by essentially 100% federal funding and oversight, whereas Medicaid (which disproportionately serves Black people) is largely under the less predictable and often blatantly racist control of each state.
Historical review of the 1971 “war on drugs” shows it was instead a stealth and discriminatory campaign against President Nixon’s political enemies. Nixon’s chief domestic policy analyst later said the following:
We knew we couldn’t make it illegal to be either against the [Vietnam] war or black, but by getting the public to associate hippies with marijuana and black people with heroin, and then criminali[z]ing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about drugs? Of course we did.
Soon thereafter, Ronald Reagan promoted the myth of the so-called “welfare queens,” fictional lazy Black mothers milking the social welfare system. This framing helped Reagan get elected and then dismantle safety-net programs after assuming the presidency in 1980. One effect of Reagan’s actions was increasing Black infant death rates (relative to mortality among White babies).
A 1994 law authored by then-Senator Joe Biden and signed by President Bill Clinton — legislation both Democrats later came to regret — intensified a justice system that currently imprisons over 2.2 million people. The U.S. houses 22% of the world’s prisoners but has only 4.5% of the world’s population. Additionally, more than 20% of all Black men and nearly 60% of Black men without a high school diploma experience incarceration by their 34th birthday. The negative health correlates of imprisonment are many and include smoking, cardiovascular disease, serious mental illness and premature death from overdose or suicide. Current estimates show that Black men are killed by police 2.5 times more often than White men.
Despite President Barack Obama’s success in passing the Affordable Care Act (ACA) — a policy change that greatly expanded health care access to minorities in many states — racial disparities in health care have endured. Nine southern states with large Black populations refused generous federal subsidies to expand their Medicaid programs, and Medicaid reimbursement for services also remains below that of private coverage. The Indian Health Service, mandated to serve 2.2 million Native Americans, is supported by a budget that offers about $3,000 per capita per year — only a quarter of what the average American spends on health care.
President Trump from 2017 to 2020 used racial animus to denigrate public health. For example, he frequently stereotyped people of color as “freeloaders” in his push to impose new work requirements for Medicaid and food assistance. Trump also labeled COVID-19 the “kung flu,” denied federal aid to Puerto Rico following Hurricane Maria (in contrast to providing massive federal storm aid to Texas and Florida) and threatened Black Lives Matter protesters in the wake of George Floyd’s death. Prior to Floyd’s murder, Trump expanded use of the death penalty — especially for drug crimes — and ended federal oversight of civil rights abuse by local police.
Among the few positive health policy actions by President Trump was his support and eventual signing of the bipartisan 2018 First Step Act, which shortened sentences for some federal crimes and increased educational and job-training services for inmates and former inmates.
Incendiary language about immigrants was a staple of Trump’s campaign and presidency. During his presidential campaign he branded immigrants from Mexico as criminals, rapists and drug dealers, among other things. Such language was cited directly by the shooter who, in August 2019, indiscriminately murdered shoppers at a Texas Walmart.
During the first year of the Trump presidency, the number of detained immigrants increased by 40% to an all-time high of 55,000 daily. Moreover, Trump’s policies were typically discriminatory and draconian, including the Muslim ban and the forcible separation of at least 3,000 children from their parents under a zero-tolerance immigration policy. As of September 2019, at least seven children died in U.S. custody as a result of such detentions, and research — not surprisingly — shows that the detention of migrating children increased their risk of serious behavioral and psychological problems.
Emerging research also has revealed an association between Trump’s election (and his anti-immigrant rhetoric and policies) and the seeking of health care by immigrants and their families, especially among Latinx people. For example, one study of nearly 25,000 deliveries in Texas revealed that Trump’s rhetoric had discouraged pregnant Latinx women from seeking prenatal care — an important primary care/preventive service.
Tragically, opioid overdose deaths have increased in 40 of 50 states during the COVID-19 pandemic. Both Donald and Melania Trump at least rhetorically tried to expand treatment for opioid use disorder, but their efforts were weakened by poor framing and the neglect of harm-reduction approaches, such as needle exchange programs and medication-assisted treatment programs using methadone or buprenorphine. Melania Trump’s “Be Best” campaign, for example, lumped prenatal exposure to illicit opioids like heroin together with prenatal exposure to opioid use disorder treatment drugs like buprenorphine, even as such treatment is desirable and manageable for the mother and newborn.
Universal health care
Trump’s pronouncements and policy initiatives regarding the ACA were aimed at dismantling the law that between 2014 and 2017 expanded health insurance coverage to 20 million Americans. Trump was likely motivated in part by the fact that the ACA is partially funded by redistributing wealth from the rich to the poor via a 3.8% investment income tax.
Trump’s assault upon the ACA was further likely inspired by Reagan-era policies that aimed to privatize government programs towards the maximization of corporate profits. Such “free-market” policies (encouraged by Trump) have allowed elite coverage schemes like Medicare Advantage plans to thrive by limiting coverage to the healthiest among us while also allowing substantial administrative fees. In 2019, Advantage plans derived $371 billion from Medicare, including overhead and profits estimated at $1,360 to $1,608 per enrollee year. Trump further worked to privatize health care for military veterans as another way to prop up the for-profit health care enterprise over the development of government medical programs generally and equitable coverage expansions more specifically.
Despite its success at expanding health care access and quality, the ACA still had left 28 million people uninsured by Trump’s inauguration and many others underinsured — in 2017 there were 37,000 premature deaths attributed to a lack of insurance, and in 2016 one-quarter of adults younger than 65 with insurance reported challenges paying medical bills. In response to these challenges, Trump promised to repeal the ACA but to protect Medicaid and Medicare. The threat to repeal was narrowly averted by a single vote in the U.S. Senate (John McCain, Republican-Arizona), and Trump’s promise to protect existing governmental health insurance programs for seniors and the poor was just another lie.
A Republican-proposed bill to repeal the ACA, the American Health Care Act, that was introduced in March 2017 would have cut federal Medicaid spending by $839 billion over the subsequent decade, cut subsidies to low-income individuals for purchasing private health insurance and allowed insurers to deny coverage to people with pre-existing conditions or those who exceeded a lifetime cap on covered health care expenses. The bill to kill the ACA also would have given a $172-billion windfall to high-income earners by eliminating the 3.8% tax on investment income.
Trump’s near-miss failure to repeal the ACA did not deter him from many other actions that sought to weaken the law, including the following:
- abruptly suspending advertising to encourage enrollment in ACA plans
- making more than 300 documented false statements about the stability or repeal of the ACA
- dramatically shortening the open enrollment periods for ACA plans
- encouraging states to require Medicaid enrollees to work (provisions ultimately blocked by the courts)
- enacting legislation that eliminated a small tax penalty for those who do not obtain health insurance
- directing the U.S. Department of Justice to support a Texas lawsuit that resulted in a federal judge and appeals court declaring the ACA unconstitutional because the small tax penalty for not obtaining insurance was removed. (The U.S. Supreme Court recently decided against Trump’s position in this case, leaving the ACA intact.)
There is nothing about these actions by President Trump that “protected” Medicaid or human health. Mostly because of reductions in Medicaid coverage during Trump’s first three years in office, the number of uninsured Americans rose by 2.3 million.
In the U.S. before the COVID-19 pandemic, 11% of residents were food insecure and more than 19% of youths and 42% of adults were obese. Foodborne illness caused 128,000 hospitalizations per year and 3,000 deaths. Accordingly, the federal government has an ongoing interest in promoting health through sound food and nutrition policies. Trump’s presidential record on such policies consistently placed corporate interests over consumer and broad public health interests. For example, the Trump administration weakened standards for organic foods, permitted the acceleration of slaughterhouse production lines, delayed menu-labeling rules, and blocked a United Nations panel endorsement of taxes on sodas designed to combat obesity.
In a troubling assault on scientific inquiry at the U.S. Department of Agriculture (USDA), the Trump administration in 2018 abruptly announced plans to move that agency’s Economic Research Service from Washington, D.C., to Kansas City, Missouri. In response, 70% of the scientific staff resigned, thereby greatly diminishing the USDA’s ability to conduct its own food and nutrition policy research. One administration official maintained that this action “drained the swamp,” but the scientists involved and others perceived the move as a cynical means to silence the agency’s experts.
As of December 2019, the U.S. Supplemental Nutrition Assistance Program (SNAP) provided $126 per person per month in food aid to just over 37 million adults and children. Plausibly inspired by President Clinton’s actions to curtail SNAP’s generosity in the 1990s, President Trump sought to further weaken this safety-net program by tightening work requirements for SNAP beneficiaries and eliminating auto-enrollment for families once they qualify for cash assistance.
In direct contradiction to Obama’s policies (for example, Michelle Obama’s “Let’s Move!” campaign), the Trump administration allowed schools to ignore federal requirements that promote healthy eating by youths, including restrictions on sugary drinks and snacks and provision of more fresh fruits, vegetables and whole grains on school lunch menus.
As with health insurance and nutritional policies, Trump’s approach to global environmental policies and workplace safety issues largely favored corporate interests over public health. The fossil fuel industry has been a main beneficiary of that approach.
One analysis found that over 100 environmental regulatory rollbacks had been instigated by the Trump administration, and at least 80% of these had been completed. These rollbacks included relaxing air and water pollution standards, lifting restrictions on the extraction and distribution of fossil fuels, and directing federal agencies to halt calculating the social cost of carbon emissions (such as costing out the impacts of pollution from a neighboring factory or other engine or chemical discharges).
The Trump administration, in January 2021, finalized a rule deceptively entitled “Strengthening Transparency in Regulatory Science.” The rule, developed by big tobacco, fossil fuel and chemical industry lobbyists, mandates that the Environmental Protection Agency use only data that is fully accessible to the public and affected industries, making most epidemiological datasets unusable for environmental regulatory purposes because they almost always require anonymity to protect individual patient confidentiality. One leading researcher called the rule “a direct assault” on the science of understanding disease and health.
The above policies are consequential manifestations of Trump’s climate change denialism. They additionally effectively ceded global environmental leadership, economic opportunities and political advantage to the European Union, as well as to mainland China and other authoritarian regimes. Accordingly, many state Governors and now President Biden are working to, in the words of the Lancet Commission, “do the opposite” of Trump with regards to environmental policy-making and stewardship.
Other health-related issues
In closing sections of its report, the Lancet Commission described several other issues of importance, including reproductive rights, gun control, militarism and isolationism.
The discourse is critical of Trump for flip-flopping from his previous “pro-choice” position on abortion and notes that his three Supreme Court and more than 200 federal court judge appointees have shifted the balance in favor of Trump’s current “pro-life” position. In tracking that highly charged issue, the following statistics and health correlates are useful: In the U.S., there are approximately 17 maternal deaths per 100,000 pregnancies. Each year in the U.S., more than 860,000 women obtain abortion services. Restrictions on such services correlate directly with female physical and behavioral health declines and with persistent poverty.
Regarding gun control, an extraordinary exchange between health care workers and gun advocates is instructive. In 2018, the National Rifle Association (NRA) chided the American College of Physicians (ACP) for an ACP position paper on gun control: “(S)omeone should tell self-important anti-gun doctors to stay in their lane,” the NRA tweeted. In response, more than 40,000 health care professionals (including surgeons who treat gunshot wounds and public health experts who know that firearms boost homicides and suicides) signed a petition declaring “this is our lane.” No doubt, the NRA’s crass response to health care professionals’ views regarding the ongoing scourge of firearm violence was emboldened by Trump’s strident pro-gun positioning throughout his presidency.
Finally, there are many examples of Trump’s militarism and broader antagonism of other countries. The example of Yemen is proffered by the Lancet Commission as especially clear. Against that small nation, the U.S. has supported Saudi-led bombings that have caused widespread malnutrition and a cholera outbreak. Almost 250,000 deaths have resulted. Still, Trump vetoed a set of bipartisan resolutions passed by Congress to halt support for these atrocities (Biden, in February 2021, announced he would reverse that decision).
Trump’s overall grade on fostering human health
Though the Lancet Commission on Public Policy and Health did not assign a grade to President Trump’s overall performance regarding human health, he almost certainly would have received an all-around “F” from this prodigious collection of professors. Simply stated, more Americans and others have and will continue to die prematurely and suffer from preventable illness and injury because of Trump’s reckless policies. Moreover, non-Hispanic, non-White populations are disproportionately and unfairly impacted.
That said, Trump did not emerge from the ether. He was instead following many policies and biases of earlier presidents, especially those of Nixon and Reagan, but also including sentiments of Democratic presidents with xenophobic and conservative tendencies (such as Clinton and welfare reform and Johnson regarding Vietnam). Even Obama’s ACA is rooted tightly in preserving the “medical-industrial complex” (controlled by profit-driven hospitals and health care systems, insurance companies, and pharmaceutical and medical device manufacturers) in the face of considerable evidence that a Medicare-for-All approach would not only be more economical, but also healthier and more equitable.