Last week, The Lancet’s 33-member Commission on Public Policy and Health in the Trump Era (the Commission) issued its final report. In just 49 pages, it blasts the administration of Donald Trump for undermining US health and welfare and harming Black, Indigenous and People of Color (BIPOC) populations in particular. But the Commission also notes that Trump’s team built upon a foundation dating back to the Nixon years that has influenced the health policies of preceding administrations, liberal and conservative alike:
Trump’s election was enabled by the failures of his predecessors. A four-decade long drift toward neoliberal policies bolstered corporate prerogatives, privatized government services, reinforced racism, and imposed public austerity. The rich got much richer while their taxes were halved. Workers’ earnings stagnated, welfare programs 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.
This combination of racism, privatization, and privileging the needs of the wealthy has marked an evolution in public policy that has undermined US federal capacity in a range of areas, from healthcare to education, to housing, to the environment.
The COVID-19 pandemic and the inability of the US to handle it effectively provides one stark illustration. If the US had merely maintained the average COVID-19 mortality rate of the G-7 nations (namely, the US, Japan, Germany, Great Britain, France, Italy, and Canada), Americans would have lost 40 percent fewer lives. With deaths in the US from COVID-19 now in excess of 485,000, that translates into nearly 200,000 people.
The failures of the Trump administration in controlling the virus were exacerbated by a weak healthcare system that predated it. For example, The Lancet reports that between 2002 and 2019, the public health share of US health spending fell from 3.21 to 2.45 percent, leaving it at roughly half the Canadian level.
Dr. Richard Horton, The Lancet’s editor in chief, puts the Commission’s findings in a broader context: “The COVID-19 pandemic has shown how woefully inadequate the country’s healthcare and public health system has been in protecting the nation’s health. The COVID-19 pandemic has exploited existing health and social inequalities and nowhere is this more apparent than in the US.”
The Commission report also underscores how structural racism made COVID-19 health outcomes so much worse in BIPOC communities. According to Dr. Mary T. Bassett, Commission member and director of the FXB Center for Health and Human Rights at Harvard University, in comments reported by Medical Xpress, “The disastrous, bungled response to the pandemic made clear how existing, longstanding racial inequities simply have not been addressed. It’s time to stop saying these preventable gaps cannot be eliminated. The report calls for structural solutions, including reparations, to ensure everyone has the right to health.”
The Commission found that “death rates for Black people in the USA at ages 25–29 years are four times higher than the average of the other G7 nations and, for Native American and Alaska Native people deaths rates at ages 25–29 years are seven times higher than this average.”
As the authors point out, there were clear signs of decay in US public health before COVID-19. Take Puerto Rico. Although Hurricane Maria made headlines in 2017, decades of efforts prior to the storm to restrain the public sector had left the territory in bankruptcy. A once-robust Puerto Rican public health system had been sold off to private interests; the result, according to the Commission, was “more fragmented, inadequate, and costly than the public system it replaced, forcing the government further into debt.”
But the Commission also sees in this moment of crisis the potential for radical change. With the Trump era coming to an end, there’s the chance to undo not only what was done in the last four years, but the harms of the past 50 years.
The report recalls the words of activists and scholars Frances Fox Piven and Richard Cloward in 1977 when they “argued that sudden disruption to the status quo—whether by popular protests or changing electoral realignment—often cause big positive changes in public opinion and, subsequently, public policy.” At that time, they were looking at what allowed Lyndon Johnson to move forward on civil rights, voting rights, and anti-poverty programs that had failed to move for decades before he took office.
If Joe Biden’s administration can move boldly, The Lancet authors assert, it could reverse “decades of neoliberal policies seeking to privatize many public services and deregulate corporations to maximize profits” and “a brand of neoliberalism that particularly favors individual enrichment…over public goods and seeks to reduce the size and scope of US Government services and terminate US support for health abroad.”
The Commission also offers a series of recommendations. Beyond improving US pandemic response to mitigate immediate harm, the Commission echoes many items NPQ has emphasized: reparations for wealth denied to Native Americans, Native Hawaiians, Puerto Ricans, and African Americans; enacting the Green New Deal; revising tax systems to end wealth hoarding by the super-rich; significantly increasing public spending on social programs; establishing a single-payer health insurance program; creation of a new immigration system that embraces an inclusive, multiracial vision of national identity; instituting a living minimum wage; an end to the carceral-industrial complex and empowering communities to control their police forces; and protecting voting rights.
This is a big agenda. The nation’s shortcomings, as the Commission notes, are even larger. The nation is at a moment when it can continue on the path it has followed for administration after administration, Republican and Democratic alike, or it can change course to the direction that justice and good public health demand.—Martin Levine