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June 2017 (Volume 95)
Since this past November, when Donald J. Trump was elected to become the nation’s 45th president, there has been substantial and justifiable concern about the impact that his administration may have on health. Much of that public conversation has focused on the impact of the administration’s rollback of the Affordable Care Act (ACA). Perhaps the most significant consequence of repealing the ACA would be the potential loss of insurance coverage for 18 million Americans,1,2 which would effectively roll back hard-fought gains that finally brought the United States into the same ballpark with other high-income countries in providing basic health insurance coverage for most (even if still not all) of its citizens. Beyond the consequences of losing health care coverage is the possibility that Trump’s health policies would have a far greater impact on the public’s health.
In order to understand these consequences, we need to acknowledge that much of health is based on non-health-care-related factors. Although the public discourse around health focuses on medicine and health care, social, economic, cultural, and structural conditions have a far greater impact on overall health.3 For example, the United States has enjoyed an unprecedented improvement in health over the last hundred years. In 1900, US life expectancy was 47. Remarkably, by 1950, life expectancy had climbed to 68, a gain of 21 years. This improvement in health was driven in large part by a reduction in mortality from infectious disease. It is important to realize, however, that this improvement in life expectancy preceded the widespread use of antibiotics, beginning with penicillin in the late 1940s. Rather, this gain in life expectancy can be traced to the introduction of such measures as the use of chlorine in municipal water, effective sewage systems, and the systematization of health departments and regulations to ensure safer food, water, and sanitation. Underscoring this point, the United States gained only 9 years in life expectancy in the second half of the twentieth century, rising from 68 to 77 in 1999.
Although there was a rapid acceleration of investment in the US health care system during this period, much of that spending was on individual health care and most of it on the last 120 to 170 days of life. Health care spending as a percentage of gross domestic product (GDP) doubled from just over 8% to more than 17% between 1980 and 2013 alone.4
The story of health improvement in the United States over the twentieth century illustrates that overall health improvement requires investment in the social structures that keep us healthy and that those structures have little to do with the health care and medicine that restore us to health when we become sick.5 With this backdrop and understanding of the production of health in mind, there are two core pathways through which the Trump administration, if it continues down the current path of action, will affect the population’s health.
First, this administration, like many of the Republican presidential administrations that preceded it, is animated by one central ideology: reducing the government’s size and influence on and role in the lives of Americans. President Trump has appointed cabinet secretaries who are clearly committing to shrinking the role of government and to introducing deregulatory policies that would allow the private sector to act in a far more unfettered manner than it has previously. To pick but two examples, the president’s choice for secretary of housing and urban development (HUD), Ben Carson, is on the record as being skeptical, at best, about several of President Barack Obama’s efforts to provide affordable housing to low-income families. Similarly, Betsy DeVos, the secretary of education, has long been a proponent of school choice, which, unfortunately, comes with the likely disinvestment from public education in favor of programs that encourage school choice and manifestly disadvantage low-income communities, who have little real choice in how their children are educated. These appointments suggest that in the coming months and years, we will see a pullback from the government’s engagement in programs that aim to promote public goods—the environment, affordable housing, quality public schools—in the name of private choice. These actions would have many consequences for American society and could be ruinous to health. They would accelerate the overall slowing of health gains and widen health gaps, in which the “health haves”—an ever-shrinking minority of the US population who can afford to buy the resources that create health—leave the “health have-nots” further behind, reversing the recent narrowing of rich-poor and racial and ethnic gaps in health.
Second, the health of populations rests in no small part on our collective behaviors, influenced by shared social norms. This influence was starkly evident in the decline in cigarette smoking and motor vehicle deaths in the United States during the latter half of the twentieth century. The former was attributable to change in public perceptions of smoking, and the latter, to a widespread acceptance of vehicular and road safety measures. Changing norms and behaviors rest on the interplay between formal social controls and the growing adoption of these norms as informal changes in cultural preferences.
It is precisely these cultural preferences for several hard-fought health gains that the actions by the Trump administration threaten to weaken. For example, the administration’s attempt to ban immigration from predominantly Muslim countries and its rescinding of the Obama administration’s guidance to schools to enforce the right of transgender children to use whichever bathroom they choose may, at face value, affect only a small number of people. But they enable the chiseling away at social norms that value inclusiveness and diversity, tolerance, and accommodation of those who are otherwise different from the mainstream.
They once again make discrimination acceptable and cruelty mainstream. They create a shift in culture away from pro-social behavior that promotes our collective well-being toward the population’s health as a marginal concern, leaving positive health as an asset that can be bought by the few who have resources and are part of the in-group favored by the administration. While this administration’s effort to rewrite the access to health insurance for millions will have implications for those affected, we may be on track for something worse: an erosion of the country’s health gains over the past century. Sadly, these efforts by the Trump administration would take years and decades to undo, long after this administration gives way to its successor.
Sandro Galea, MD, DrPH, a physician and an epidemiologist, is dean and Robert A. Knox Professor at Boston University School of Public Health. He previously held academic and leadership positions at Columbia University, the University of Michigan, and the New York Academy of Medicine. Galea’s scholarship has been at the intersection of social and psychiatric epidemiology with a focus on the behavioral health consequences of trauma. He has published more than 700 scientific journal articles, 50 chapters, and 13 books, and his research has been featured extensively in current periodicals and newspapers. His latest book, Healthier: Fifty Thoughts on the Foundations of Population Health was published by Oxford University Press in 2017. Galea holds a medical degree from the University of Toronto and graduate degrees from Harvard University and Columbia University. He also holds an honorary doctorate from the University of Glasgow.
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