Peer reviewed / Review and opinion
- First comprehensive assessment of damage to health inflicted by former President Trump cites decades of policy failures made worse by the Trump administration, resulting in 461,000 unnecessary US deaths annually before the COVID-19 pandemic, and tens of thousands of unnecessary COVID-19 and pollution-related deaths attributable to his actions.
- Lancet Commission calls for immediate rollback of Trump's health-harming policies and additional sweeping reforms to reverse the deteriorating health of the US population: "The path away from Trump's politics of anger and despair cannot lead through past policies."
The first comprehensive assessment of the health effects of Donald Trump's presidency is published today in The Lancet revealing devastating impacts on every aspect of health in the USA. The Lancet Commission on Public Policy and Health in the Trump Era  also traces the policy failures that preceded and fueled Trump's ascent and left the USA lagging behind other high-income nations on life expectancy.
In new analyses, the Commission finds that 461,000 fewer Americans would have died in 2018, and 40% of US deaths during 2020 from COVID-19 would have been averted if the USA had death rates equivalent to those of the other G7 nations (Canada, France, Germany, Italy, Japan, and the United Kingdom). The report also estimates that Trump's rollbacks of environmental protections led to 22,000 excess deaths in 2019 alone.
The Commission finds that US life expectancy began trailing other high-income nations' in about 1980 as President Ronald Reagan initiated anti-government, wealth-concentrating policies that reversed many of the advances of the New Deal and Civil Rights eras. Reagan's political philosophy, known as neo-liberalism, has continued to influence US health and economic policy under both Republican and Democratic administrations. Many Trump policies, including tax cuts and deregulation that benefit the wealthy and corporations, austerity for the poor, and privatization of Medicare, emulate Reagan's.
The report warns that a return to pre-Trump era policies is not enough to protect health. Instead, sweeping reforms are needed to redress long-standing racism, and the four-decades of policy failures that weakened social and health safety nets and led to widened inequality.
The Commission emphasizes that these failures left the USA particularly vulnerable to the COVID-19 pandemic. Cuts in funding for public health agencies led to the loss of 50,000 front line staff vital to fighting epidemics between 2008 and 2016. The fragmented and profit-oriented health-care system was ill-prepared to prioritize and coordinate pandemic response. Nearly 11% of Americans suffered food insecurity, increasing their risk of obesity and diabetes, and hence death from COVID-19. And housing crowding due to poverty helped spread infection in communities of color with poor access to medical care.
The report notes that prior to the pandemic, midlife mortality for Native and Black Americans was 59% and 42% higher, respectively, than for non-Hispanic white people. The pandemic has widened the Black:white mortality gap by 50%, and has cut Latinx life expectancy by more than 3.5 years. Mortality rates from COVID-19 for people of color are 1.2-3.6 times higher than for non-Hispanic white people. Opioid deaths, a leading cause of death prior to the pandemic that was increasing fastest among middle-aged Black men, have increased in 40 out of 50 states since the emergence of COVID-19.
The report also condemns Trump's withdrawal from the World Health Organization (WHO) and defunding of the Pan American Health Organization (PAHO) - bodies critical for pandemic response globally - and his undermining of global health efforts prior to the pandemic.
"While the USA ranks highly in its global health security index, the COVID-19 pandemic has shown how woefully inadequate the country's health care 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 USA. At moments of instability, the world needs a strong USA, bolstered by a healthy population, to lead a global response," says Dr Richard Horton, Editor-in-Chief, The Lancet. 
"Americans' health was deteriorating even as our economy was booming," says Dr Steffie Woolhandler, who co-chairs the Commission with Dr David U. Himmelstein, and who both serve as Distinguished Professors at the City University of New York at Hunter College and Lecturers in Medicine at Harvard. "This unprecedented decoupling of health from national wealth signals that our society is sick. While the wealthy have thrived, most Americans have lost ground, both economically and medically. The Biden administration must reboot democracy and implement the progressive social and health policies needed to put the country on the road to better health." 
President Trump exploited chronic ill health and deeply entrenched inequalities
The Lancet Commission on Public Policy and Health in the Trump Era , formed in April 2017, brings together 33 leading experts from the United States, United Kingdom and Canada, with backgrounds in clinical medicine, public health, epidemiology, medical care policy, community medicine, economics, nutrition, law, and politics.
While the Commission initially intended to focus narrowly on the health effects of the Trump administration, its analyses revealed that deep-seated problems that preceded Trump had undermined health and set the stage for his political ascent. Trump gained his largest 2016 electoral margins in counties with the worst economic and mortality trends; in counties where Trump got more than 60% of the vote, life expectancy had been better in 1980 than in those where he was soundly defeated. By the time of his presidential run, life expectancy in the pro-Trump counties was 2 years shorter than in counties where he was defeated (fig. 4 )
The Commission concludes that Trump exploited low- and middle-income white people's anger over their deteriorating life prospects to mobilize racial animus and xenophobia; he then enlisted their support for policies that benefit wealthy individuals and corporations and threaten the health of most Americans, including Trump's supporters.
Trump's policies, while injurious to many non-wealthy people, brought particular harm to people of color. The Commission outlines how he undermined civil rights enforcement, encouraged repressive policing and voter suppression, implemented harsh and racist immigration policies, and pursued housing and medical care policies that encouraged segregation and cut health coverage.
"The Commission highlights how racial disparities in health have grown in the last four years, especially as COVID-19 has taken its grim and unequal toll in Black, Latinx and Indigenous people," says Dr Mary T. Bassett, Commission member and Director of the FXB Center for Health and Human Rights at Harvard University, "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 Trump's actions added 2.3 million to the 28 million US residents who were uninsured when he took office, with coverage losses concentrated in minority communities and among children. An additional 726,000 children became uninsured during his time in office. Meanwhile, he augmented the flow of public funds through private insurers, who now derive most of their revenues from government programs, raise Medicare's costs by an estimated $24 billion annually, and have garnered record profits during the COVID-19 pandemic.
"Our ICU is the last stop for many patients harmed by Trump's disdain for facts, science, and compassion," says Commission member Dr Adam Gaffney, a pulmonary and critical care specialist at Cambridge Health Alliance and Harvard Medical School "But decades of health care inequality, privatization and profiteering set the stage for these tragedies. Our Commission has concluded that single payer, Medicare for All reform is the only way forward." 
In addition to reviewing the widespread failings of the US health care system, the Commission highlights the egregious underfunding of the US Indian Health Service (IHS), which is obligated by treaties to provide care to 2.2 million tribal citizens. The IHS budget is approximately one quarter of the average per head health spending in the USA; an additional $2.7 billion would be needed to meet IHS' minimal operating needs and $37.6 billion would be required in 2021 to meet the high health needs of tribal populations.
The Commission cites Trump's acceleration of global warming through encouragement of fossil fuel combustion and withdrawal from the Paris Climate Agreement as perhaps his longest lasting harm. It details his roll back of at least 84 separate environmental and workplace protections. Ironically, US states that Trump won in 2016 and 2020 have suffered the greatest increases in pollution and in deaths from environmental and occupational causes. In 2019 alone, the Commission estimates that 22,000 more Americans died from environmental and occupationally related causes than in 2016, the first time such deaths have increased after 15 years of steady progress (fig 9).
Sweeping reforms needed to chart a healthy future for all Americans
As the new administration takes office, the Commission advocates widespread reform, holding that "The path away from Trump's politics of anger and despair cannot lead through past policies". The Commission recommends immediate executive actions, including some that President Biden has already taken, such as the revocation of Trump's Muslim ban and rejoining the WHO and Paris Climate Agreement.
Additional recommendations (panel 6), many of which will require Congressional approval, include calls for:
- Implementation of a nationwide, science-led response to the COVID-19 pandemic.
- Repeal the 2017 tax cuts on corporations and the wealthy, implement new taxes on assets, and increase taxes on capital gains and high earnings.
- Implementation of the Green New Deal, ending subsidies and tax breaks for fossil fuels, and banning coal mining and single use plastics.
- Increase public expenditures for social programs, currently 18.7% of gross domestic product, to 24.2% (the average of G7 nations), and repeal time limits and immigration restrictions on welfare and nutrition programs.
- Vigorous enforcement of voting and civil rights.
- Reforming the policing and criminal justice systems that oppress communities of color and have filled prisons.
- New investments in education and minority-serving health institutions, and compensation to communities of color for wealth denied to and confiscated from them in the past.
- Enactment of a single-payer system (Medicare for All) reform covering all US residents that would redirect the $626 billion currently wasted annually on billing and administration to patient care, and a direct role for government in drug development, rather than merely paying for research that subsequently brings profits to private firms.
- A reduction in military spending from the current level of 3.4% of GDP to the 1.4% average of other G-7 nations. About ¼ of this should be redirected to foreign aid in order to reach the level recommended by the United Nations. The rest should be used to address urgent social needs.
- Repeal the Hyde Amendment and regulations that treat sexual-health services differently from other health services.
- A massive mobilization of resources to avert climate catastrophe.
"Trump's disastrous actions compounded longstanding failures in health policy in the USA. We know what it will take to create a healthy society. We just need the political will to do it," says Commission member Dr Kevin Grumbach, Hellman Endowed Professor and Chair of the Department of Family and Community Medicine, University of California, San Francisco .
Writing in a linked Comment, David Blumenthal, President of the Commonwealth Fund and Margaret Hamburg, Vice President of the Nuclear Threat Initiative and former Commissioner of the U.S. Food and Drug Administration (FDA) (who were not involved in the report), write: "The Commission's critique of US health care is broad, deep, and innovative. It provides a thorough review of the presidency and administration of Donald Trump and the many destructive executive orders he signed, which have led to, among other things, loss of health coverage for millions of US residents. The report could serve as a starting point for the corrective actions and policies of the new administration of President Joseph Biden and Vice President Kamala Harris." They add: "The hard fact is that the way to health-care reform in the USA requires political activism of the most basic kind, something that is far beyond the comfort zone of many health professionals. Should that work--by health professionals and others--prove successful, buttressed by the copious and compelling evidence in this Commission's report, the USA could be repositioned to address the fundamental roots of our health-care crisis, which often arise from inequalities in income, education, nutrition, housing, justice, and employment opportunities available to Americans."
NOTES TO EDITORS
 The Lancet Commission on Public Policy and Health in the Trump Era was formed following the publication of The Lancet Series on US health and health care (April 2017)
The Commission used data from original analyses, published studies, legal documents, news reports, and government websites, and the report was peer reviewed and published in The Lancet. The Commission was supported by grants from the Doris Duke Charitable Foundation and the Open Society Foundations, which covered costs of some members' travel, lodging for Commission meetings, and some data purchases. The funders played no role in drafting the report or recommendations. A full list of declarations and acknowledgements is included in the Commission.
 Quotes are direct from authors and editor and cannot be found in the text of the Commission.
 Figure 4 - based on analyses performed by Commission member Jacob Bor, ScD of the Boston University School of Public Health.
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