An Open Letter to President-Elect Biden

Building Back Better

This is part of the Building Back Better series.

Dear President-elect Biden:

As you well know, 2020 has been an unusually traumatic year for the United States.  COVID-19 has sickened more than 9 million Americans, claimed more than 233,000 lives, and exposed serious limitations in our public health preparedness and in our health care system’s ability to deliver health care effectively and equitably. The pandemic’s economic effects have cost millions of Americans their jobs, their livelihoods, and their health insurance. Thousands more have lost their homes and businesses to devastating hurricanes and unprecedented wildfires. And the senseless murders of Black citizens by police officers have sparked widespread protests and civil unrest, the likes of which the nation has not seen in almost 50 years.

These public health, economic, and racial injustice calamities pose existential threats to the security and well-being of the nation. As president, you will face the difficult task of charting a course by which the nation may tackle and overcome these threats. This includes restoring the public’s faith in science and its trust in government to serve and protect the American people. Americans expect their president to be an all-embracing leader who empowers them to live healthy, productive lives. Your message of unity, compassion, and perseverance in the face of these hardships demonstrates that you understand the dangers threatening our democracy, and your solemn pledge to serve as president to all Americans inspires hope for the future.

Building Back Better to Improve the Health of All Americans

The Milbank Quarterly is a multidisciplinary journal of population health and health policy. Our editorial team shares your desire to see evidence-based policies implemented that will help the nation “build back better.” In that spirit, we aim to share with you policy insights and recommendations from members of our Editorial Advisory Board, several of whom have had extensive experience in government, serving in Democratic as well as Republican administrations. Some also have held positions in state government, and many have served on national and state advisory committees and commissions. Their collective wisdom and insights on a number of critical health issues may benefit your transition team as it plans for the transfer of power on January 20, 2021.

Over the course of the transition period, we will present for your consideration policy ideas and strategies in three broad areas:

  1. Improving the health and wellbeing of the American people;
  2. Improving the public health infrastructure that is so critical in an era of COVID-19 and other emerging disease threats; and
  3. Improving the effectiveness, affordability, and equity of the US health care system on which we all rely.

In the coming weeks, these are just some of the topics that Editorial Advisory Board members will address:

  • Devising a national coordinated response to the COVID-19 pandemic
  • Implementing “upstream” policies to improve population health
  • Addressing social and non-medical drivers of health
  • Overcoming racial barriers to health equity
  • Strengthening the link between housing and health
  • Reforming and strengthening the FDA
  • Reforming and strengthening the CDC
  • Reexamining and reforming health care regulations
  • Strengthening and funding biomedical research through the NIH
  • Restoring trust in government
  • Building on the Medicaid program
  • Strengthening state health insurance marketplaces with a public option
  • Improving value-based payment methods
  • Improving long-term care and end-of-life care

We begin, however, by outlining the most urgent tasks requiring swift executive action, namely the reversal of Trump administration policies that threaten or harm vulnerable populations, especially minority communities and low-income individuals and families.

Reversing the Most Harmful Trump-Era Policies That Threaten Vulnerable Populations

As you know, over the past four years, the Trump administration has systematically dismantled Obama-era policies and programs across virtually all federal government agencies through a combination of executive orders, rule changes, policy statements, budget proposals, and major court challenges. While the net effect of these policy actions has been to strip away or nullify protections for all Americans, no group has been more disproportionately harmed or disadvantaged than communities of color, whose access to health care, fair housing, and safe environments has been severely curtailed.

For example, Black and Hispanic Americans gained the most in coverage, access, and utilization of health care through the Affordable Care Act (ACA).  Yet, despite these gains, the Trump administration has consistently supported policy actions intended to eliminate or weaken the law. Moreover, people of color historically have faced discrimination and segregation in housing, and tend to live in communities more vulnerable to environmental hazards. Nevertheless, the Trump administration has sought to overturn Obama-era rules supporting the Fair Housing Act, and has actively worked to rescind various environmental protections and safeguards. In fact, The New York Times has identified 100 instances of administration attempts to reverse environmental regulations, including clean air and clean water rules. Perhaps the most sweeping retreat from environmental safety has been the administration’s decision to withdraw the United States from the 2015 Paris Climate Agreement.

Former Vice President Hubert H. Humphrey said that the moral test of a government is how that government treats its most vulnerable citizens—the children, the elderly, the sick, and the disabled. In order for your vision of “build back better” to be realized, the harmful policies of the Trump administration across the full spectrum of the federal government must be reversed and replaced with evidence-based policies that respect the dignity of all Americans and protect the most vulnerable within society.

The COVID-19 pandemic is a public health emergency that requires a coordinated national response to contain and mitigate the virus. We applaud your commitment to fight the pandemic by instituting a national mandatory mask requirement, implementing more robust testing and contact tracing, limiting the size of public gatherings, reversing many of the steps taken to reopen local economies, enforcing penalties for non-compliance with mitigation measures, and working with state and local officials to distribute vital equipment and supplies. Restoring the economy to pre-pandemic levels is an important goal, but it is secondary to containing the virus in the absence of effective vaccines and therapeutics.

As you prepare to take office as the nation’s 46th President, we urge you to undertake other immediate actions to protect the health and well-being of all Americans, particularly those that have been disproportionately affected. The five most pressing needs, in our view, are these:

  • Individuals with pre-existing medical conditions, including COVID-19 infection, must be protected from the loss of their health insurance coverage;
  • Affordable health insurance coverage must be extended to more lower-income Americans through various mechanisms (e.g., stabilizing and strengthening the ACA’s marketplaces, raising federal premium subsidies and making eligibility more accessible, eliminating non-ACA compliant health plans, offering a public option to compete with private plans, and providing stronger incentives for non-expansion states to expand their Medicaid programs);
  • Financial support to the World Health Organization must be restored so that the organization may fulfill its role in coordinating world-wide emergency preparedness and disease surveillance, with the United States regaining its stature as a leader in global health affairs;
  • The United States must rejoin the Paris climate accord and become an active partner in the global collaboration to counter the effects of climate change, thereby securing a safe and healthy environment for all; and
  • The Fair Housing Act must be enforced and further augmented to protect minorities, particularly communities of color, from unjust discrimination and segregation in housing.

To your credit, you already have articulated your intention to pursue most, if not all, of these actions through executive orders on Inauguration Day. But reversal of the destructive Trump executive orders and administrative rule changes may not necessarily be enough. Additional remedial actions, including potential legislation, may be required to undo the damage already done and to prevent further harm. However, with your leadership on all of these fronts, the nation will be set upon a new path that ultimately will assure a brighter, healthier, and more just future for generations of Americans to come.

We wish you and Vice President-elect Harris great success in these endeavors, and we look forward to offering more ideas and suggestions to your team as it formulates and implements sound public policies.

About the Authors

Alan B. Cohen became editor of The Milbank Quarterly in August 2018. He currently is a research professor in the Markets, Public Policy, and Law Department at the Boston University Questrom School of Business, and professor of health law, policy and management at the Boston University School of Public Health. He previously directed the Scholars in Health Policy Research Program and the Investigator Awards in Health Policy Research for the Robert Wood Johnson Foundation. Earlier in his career, he held faculty positions at Johns Hopkins University and Brandeis University, and spent 8 years at the Robert Wood Johnson Foundation. He is a member of the National Academy of Social Insurance. He received his BA in psychology from the University of Rochester, and his MS and ScD in health policy and management from the Harvard School of Public Health.

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Amanda Katchmar is a Kilachand Honors College student and MPH candidate at Boston University.

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