What We're Reading

Health Policy Journal Club, April 2021
Public Policy and Health under the Trump Administration

Readings

1.     Woolhandler S, Himmelstein DU, Ahmed S, et al. Public policy and health in the Trump era. Lancet. 2021;397:705-753.

Key takeaways from the readings

The Trump presidency was preceded by 40 years of conservative and neoliberal policies that led to increased inequities and declines in health. 

While there were significant expansions of civil rights and poverty reduction programs in the 1960s, progress slowed or reversed in subsequent decades.  This period saw the growth of enormous inequities in income and wealth, the worst in 100 years. At the same time, health costs skyrocketed, accounting for almost 18% of the GDP.

• Richard Nixon (in office 1969-74) called for a “war on drugs” and “law and order” policies that spurred mass incarceration.
• Jimmy Carter (in office 1977-81) cut spending to reduce government deficits and declined to pursue expansion of social programs.
• Ronald Reagan (in office 1981-89) and George H.W. Bush (1989-1993) weakened labor and environmental protections, privatized social programs, and intensified the war on drugs.
• Bill Clinton (in office 1993-2001) and George W. Bush (2001-2009) removed trade protections, weakened unions, and imposed restrictions on receiving benefits from social programs.

The Lancet Commission on Public Policy and Health in the Trump Era concluded that a wide array of policies put in place by President Trump accelerated the decline in the health and wellbeing of Americans.

The Commission delineated categories of public policy changes impacting health from the Trump era:

• Health insurance
  • Shortened Affordable Care Act (ACA) enrollment periods, decreased funding for insurance navigators, and decreased funding for advertising on ACA plan enrollment
  • Expanded loopholes to increase exemptions from ACA requirements for private insurers on essential health benefits
  • Encouraged state officials to make restrictive changes to Medicaid plans such as imposing work requirements
• Pandemic preparedness and response
  • Eliminated the National Security Council’s Directorate for Global Health Security and Biodefense
  • Confused public health messaging about the seriousness of COVID-19, did not follow recommended public health measures and criticized Governors who did
  • Promoted unproven treatments
• Food and nutrition
  • Reversed increased nutritional standards put in place by the Health Hunger Free Kids Act
  • Removed automatic enrollment for food assistance when qualifying for cash assistance
• Environment
  • Withdrew from the Paris Agreement on climate change
  • Rolled back air pollution and air emissions standards, including reduced fuel efficiency standards for automobiles
  • Reduced protective standards for water pollution and toxic chemicals
  • Decreased health and safety standards for miners and terminated a silicosis prevention program
  • Reduced environmental protections for resource extraction on federal land
• Reproductive rights
  • Prohibited referrals for abortions from clinics receiving Title X funds
  • Appointed US Supreme Court justices against abortion
  • Reinstated the “Mexico City policy” which bans US funding for organizations that provide abortions or refer women for abortions
• Immigration
  • Increased detainment of undocumented immigrants and separated detained children from their parents  
  • Widely broadened the public charge rule which made immigrants receiving publicly funded services ineligible for upgrading their immigration status  or re-entering the US; caused reduction in use of Medicaid, CHIP, and SNAP, and thus negatively impacted child health
  • Reduced the number of refugees admitted into the US to less than 1/10 of the last year of the Obama administration.
  • Banned people from Muslim-majority countries from entering the US
• Criminal justice
  • Ended specific programs of federal oversight of local police implicated in civil rights abuses
  • Reversed a ban on for-profit prisons
  • Expanded the use of the death penalty
  • Supported the First Step Act (noted for positive impact) which shortens sentences for some federal crimes and increases educational and vocational services

Comments from discussion participants:

• Many Americans would say we have the best health care system, but it is simply not true
• This report is a good compilation of policies impacting health in the last 4 years in one place, within the context of broader trends, but the messaging has a clear bias. It is not designed to persuade.
• Politics has radically changed; less potential for bipartisanship, particularly since George HW Bush’s presidency. Parties no longer overlap in ideologies.
• The overwhelming consensus of economists is that immigration (legal and undocumented) is beneficial to our economy
• The food section does not include the history of agricultural subsidies and policy changes that have led to ultraprocessed foods and environmental harm
• When you cut costs somewhere in healthcare, you are cutting someone’s paycheck. Everyone is willing to come to a meeting about controlling costs, but no one is willing to come to a meeting about cutting their own revenues

The Commission offers the Biden administration recommendations to not only reverse the negative impacts of adverse public policy changes but also to address pre-existing structural issues.

The Commission calls on the Biden administration to:

• Raise taxes on high-income people and redirect public investments from militarism and corporate subsidies to improve social, educational, and health programs
• Mobilize against structural racism and police violence
• Implement a national health insurance program
• Stop directing public funds for health and social services through private firms
• Reform campaign financing, reinforce voting and labor rights, and restore oversight of presidential executive action.