About 40% of coronavirus deaths under President Donald Trump were avoidable — but even the total number of U.S. pandemic deaths last year is dwarfed by the annual number of preventable deaths caused by four decades of racist and pro-corporate policies, according to a new Lancet Commission report.
Months into Trump's presidency, dozens of medical experts formed a commission to study the health impacts of his policies for The Lancet, a highly-respected British medical journal. The Lancet Commission on Public Policy and Health in the Trump Era found that roughly 40% of coronavirus deaths in the United States could have been prevented if the average death rate matched that of other wealthy nations.
"We became concerned that even within a few weeks of him coming into office he had started to implement policies which we thought would be deadly," Dr. Steffie Woolhandler, a health policy expert at the CUNY School of Public Health at Hunter College and co-chair of the commission, said in an interview with Salon. "And now that we're in 2021, we have actual data and, in fact, his policy has been very deadly."
Instead of galvanizing the public to fight the pandemic, the report said, Trump "publicly dismissed its threat (despite privately acknowledging it), discouraged action as infection spread, and eschewed international cooperation."
"His refusal to develop a national strategy worsened shortages of personal protective equipment and diagnostic tests," the researchers added. "President Trump politicized mask-wearing and school re-openings and convened indoor events attended by thousands, where masks were discouraged and physical distancing was impossible."
But the commission went further, finding that life expectancy in the U.S. has diverged from other major industrial nations since the 1980s, despite continuous economic growth. As a result, the country sees more unnecessary deaths each year than all the 2020 coronavirus deaths combined.
"In 2018, 461,000 Americans died who would still be alive if our life expectancy were as long as in other wealthy nations," Woolhandler said. "So COVID killed about 400,000 people in 2020, which was horrible. But every single year, the United States was losing that many people relative to other developed nations, because our policymakers had failed to create the conditions for health."
There's little doubt that the coronavirus pandemic and Trump's mismanagement has significantly worsened that trend, particularly in communities of color. The pandemic has increased the life expectancy gap between Black and white people by more than 50%, the report said. The average Latino life expectancy in the U.S. has fallen by 3.5 years since the start of the pandemic.
"Overall, in the USA, Black and Latinx people have incurred more total years of potential life lost than white people because of COVID-19, although the white population is three to four times larger," the researchers wrote.
"The strong focus on racism in all its forms and its impact on almost every area of public policy is very important," Richard Gottfried, chair of the New York State Assembly's health committee and a member of the commission, said in an interview with Salon, adding that many Americans "may not fully understand the all-pervasive nature of the impact of racism."
Even before the pandemic hit America, Trump's policies were linked to an increase in preventable deaths. Despite repeatedly failing to repeal Obamacare, Trump undermined the program in various ways and the number of uninsured Americans increased by 2.3 million before the pandemic, a number that rose further amid rampant job losses during the health crisis. He used the deficit caused by the 2017 tax cut that primarily benefited the wealthy and corporations to "justify cutting food subsidies and health care," the report said. His deregulation agenda worsened pollution, "resulting in more than 22,000 extra deaths in 2019 alone."
Trump's "disdain for science" and cuts to global health programs and public health agencies hampered the coronavirus response, "causing tens of thousands of unnecessary deaths," according to the report, and those cuts "imperil advances against HIV and other diseases."
But the researchers warned that "focusing narrowly on Trump's policies and rhetoric, while ignoring the failings that precipitated his election, risks obscuring the causes and remedies for the longterm downward trajectory of health" in the United States.
"The disturbing truth is that many of President Trump's policies do not represent a radical break with the past but merely accelerated the decades-long trend of lagging life expectancy that reflects deep and long-standing flaws in US economic, health, and social policy," the report said.
In fact, Trump's county-level vote share was closely correlated with worsening life expectancy trends. Counties where more than 60% of voters backed Trump had higher life expectancy in 1980 than counties where Clinton won more than 60% of the vote, according to a 2017 study. But in 2014, the Trump counties had an average life expectancy two years lower than the average Clinton county.
"People's deteriorating life prospects appeared to be feeding unhappiness and dissatisfaction that Trump was able to adequately cynically mobilize for his own purposes," Woolhandler said.
Many lower-income white people with "deteriorating life prospects" have gravitated toward Republican policies because they believe people of color disproportionately benefit from expansions of public health and social safety nets, even though they themselves would greatly benefit from policies that improve public health.
"Ironically, the ascendance of right-wing populism and Trump's weakening of the US Government's role in protecting health are likely to exacerbate the income and place-based health disparities that harm many of his voters," the report said. "A negative feedback loop — with low-income white people helping to stifle demands for vital public investments — risks inflicting additional and long-lasting damage to their health and wellbeing."
Trump, the researchers argued, used this racial animus to "deflect attention from policies that abet billionaires' accretion of wealth and power," arguing that his America First narrative "camouflaged policies that enriched people who were already very wealthy and gave corporations license to degrade the environment for financial gain."
Meanwhile, the report said, Trump "halted progress in almost every domain, undermined care for low-income people and the middle class, weakened pandemic preparedness; withheld food and shelter from those in need, and persecuted those who were vulnerable and oppressed."
But Trump is obviously not the first president to push the privatization of public services and deregulation aimed at helping corporations maximize profits. Arguably every president since at least Jimmy Carter has played a role in that process.
"Although Trump's actions were singularly damaging, many of them represent an aggressive acceleration of neoliberal policies that date back 40 years," the report said. As a result of policies that chipped away at New Deal and Civil Rights-era progress, the "widening income inequality has widened inequalities in health."
The deepening inequality began in earnest during the Reagan era as unions were "stifled," the tax code and government policies increasingly favored the wealthy, and high-paying manufacturing jobs began to disappear, the report said. Despite a booming stock market and low unemployment, the report added, many people have been "forced into precarious jobs that offered low pay and insufficient benefits."
After Reagan's election, "we saw U.S. life expectancy begin to lag [and] health care costs begin to soar," Woolhandler said. In 1980, American life expectancy was around the average for developed nations. By the time the pandemic hit, U.S. life expectancy was 3.4 years below the G7 average, according to the commission.
The damaging policies were not limited to Republicans. Through Bill Clinton rejected many Reagan-era policies, he expanded trade agreements that weakened protections and unions and imposed restrictions on welfare and food benefits. He also signed bills that expanded mass incarceration and worsened wealth and income inequality.
"A major problem with trade policies has been that they made drugs too expensive," Woolhandler said.
Though Barack Obama expanded health coverage, his signature health program funneled money through private profit-seeking companies and exploded out-of-pocket costs.
Between 2002 and 2019, the share of public health spending in the U.S. fell from around 3.1% of the GDP to 2.45%, roughly half the proportion in Canada and the U.K.
"Market-oriented health policies shifted medical resources toward high-income people, burdened the middle class with unaffordable out-of-pocket costs and deployed public money to stimulate the corporate takeover of vital health resources," the report said.
Although the Affordable Care Act expanded health coverage to tens of millions more people, the program still left between 25 million and 30 million uninsured before Trump took office. Despite the coverage expansion and a booming economy since 2010, "there's been essentially no improvement in Americans' life expectancy, which is all the more shocking," Woolhandler said.
"That is really historically unprecedented, because usually when the economy grows, life expectancy grows," she said. "It's good for you to have more resources. But in the United States, we actually have an uncoupling of life expectancy growth from economic growth."
The decline in life expectancy has been especially stark in communities of color. Life expectancy for Black Americans is about 3.4 years shorter than for white people. Life expectancy among Native Americans is poorest of all, Woolhandler observed, saying these statistics "are related to structural white supremacy."
The report found that all people of color except Asian Americans receive significantly less medical care than white Americans despite having worse life expectancy and seemingly greater need. Mass incarceration, the drug war and police violence are also major factors in the lagging life expectancy of people of color. The report cited estimates that roughly one in every 1,000 Black men will be killed by police, a rate 250% higher than that of white males. While discourse around the opioid epidemic has largely focused on drug use among white people, Black Americans saw the sharpest increase in opioid deaths between 2012 and 2018, a problem that has likely been exacerbated during the pandemic due to economic stress and social isolation.
"We still have an unequal society based on a history of white supremacy with discriminatory treatment continuing to this very day," Woolhandler said. "That's something that needs to be changed. We concluded that racism is obviously bad for the health of people of color, but also that we think it threatens everyone.
"Racism has been manipulated by cynical politicians like Trump to encourage low-income white people to oppose social services. They're opposing social services in the mistaken belief that they only benefit people of color. So low-income whites are often mobilized against their own self-interest on services that would benefit them personally, opposing it just for people of color. So racism harms health directly for people of color, but also harms health by poisoning the political climate that we need in order to get our government to act."
The commission's report included dozens of recommendations for President Biden's administration and lawmakers, many of them focused on addressing the racial inequities in public health. But the extent of these policies shows that Congress and Biden need to "go beyond simply repairing Trump's damage," the report said.
"Racism has a profound impact on what health care providers are available in communities of color and their access to it," Gottfried said. "It denies people full health coverage disproportionately and has an impact on the quality of care that's available in their neighborhoods. And you see the results in shocking data on infant and maternal mortality and life expectancy and almost every measure of health care quality and bad outcomes."
The researchers called on lawmakers to address structural racism, decriminalize drug use, and reform policing and criminal justice systems that "oppress" communities of color and "fill prisons." The recommendations also include addressing policies that suppress voters, particularly voters of color, and creating a National Center on Anti-Racism and Health within the Centers for Disease Control and Prevention. The commission also called for reparations to African Americans, Native Americans and residents of Puerto Rico "for the wealth and education confiscated from (or denied to) those groups in the past."
"To repair health deficits in the USA, we must redistribute wealth and income through taxation, fortify social programmes and regulation, remediate the structural racism that afflicts Black, Latinx, and Indigenous people, and heal US democracy by eliminating obstructions to voting," the report said.
The report also called on lawmakers to address the worsening pollution caused by Trump's deregulation of environmental regulations and to mobilize "massive resources to avert climate catastrophe."
Funding for these major reforms could come from redirecting resources from the military, raising taxes on the wealthy, and ending corporate subsidies and programs that funnel public funds through private companies.
At the heart of the report's recommendations is the need for a universal health care program that does not allow tens of millions of people to be denied coverage while forcing tens of millions of others to pay skyrocketing out-of-pocket costs that lead to bankruptcies and avoidance of medical care.
"Almost every problem we face in health and health care, whether as patients or providers or employers or taxpayers, is made much worse and much harder to solve because of the way we pay for health care in America," said Gottfried.
Gottfried has sponsored a single-payer health care bill called the New York Health Act in the state legislature for nearly three full decades.
"Really the only solution to the coverage problem that is effective is a single-payer system," he said. "Everything else leaves us with gaps and a fragmented system and all the wasted spending that is caused by a fragmented system dominated by insurance companies. … Getting rid of that waste would generate enough money to provide complete coverage for everyone, including long-term care. Until we get rid of that waste, it is virtually impossible to achieve high-quality and equitable healthcare."
A study by Woolhandler and fellow commission co-chair Dr. David Himmelstein last year found that eliminating overhead and administration costs from health care spending by transitioning to a government-run health care program similar to Canada's would save enough money to pay for the entire cost of the program. Woolhandler and Himmelstein are also the co-founders of Physicians for a National Health Program, which has long advocated for a single-payer system. Their findings were echoed in another study published last year in The Lancet and a review of 22 studies published in PLOS Medicine.
Biden has made clear that he opposes a Medicare for All-style single-payer system, although he has vowed to expand Obamacare. Gottfried said that progress will first likely have to come at the state level if New York and others can pass bills like his single-payer proposal.
"I think the most we can expect from the Biden administration is cooperation with states that want to do single-payer systems," he said. "I believe New York can implement single-payer coverage even without federal cooperation. It would be more complicated, but we can do it."
In Canada, Gottfried observed, single-payer health insurance "began in one province and then another province joined in and in just a few years it became a provincial-based program but funded largely with federal money." He suggested that the same could happen in the U.S. "After one state enacts it, you'll see more states doing it. Eventually, either there will be a national program or there will be federal funding to help support state single-payer programs."
The commission's report included numerous immediate reforms the Biden administration could use to improve public health en route to an eventual single-payer system, including providing incentives for states to expand Medicaid if they have yet to do so — primarily in the South where half of America's Black population lives. The commission also recommended rolling back all Trump's efforts to undermine Obamacare and undoing his expansion of the public charge immigration rule.
"The public charge rule is a long-standing immigration term that originally just applied to people who receive cash benefits and who resided in long-term care institutions paid for at government expense," Woolhandler said. "Trump has expanded that rule so that it can encompass virtually any use of public benefits, and that has really frightened many people in immigrant communities. People are afraid to enroll themselves or their children in Medicaid. They're afraid to use nutrition benefits. They're afraid to seek housing benefits, and those things are very important for health."
Biden quickly signed dozens of executive actions to roll back many of Trump's policies related to health care, immigration, climate and racial equity, and plans additional executive orders and legislation to undo Trump's damage. But the commission emphasized that correcting inequity will require much more than rolling back four years of Republican policies.
"Policymakers are going to have to create the conditions that allow my patients to be healthy," said Woolhandler, who is also a practicing primary care physician. "We need to change the direction of American public policy to make sure that people's needs are met, and that the conditions for their health are met.
"If we fail to do that, we're going to continue to see people feeling desperate, see people feeling angry. Those are the conditions that allow the rise of autocratic leaders like Trump. So Trump may be gone, but Trumpism will come back and cause problems for us unless we build a society that actually takes care of people."