The Lancet – by Prof Martin McKee, DSc; Scott L Greer, PhD; Prof David Stuckler, PhD
US Presidents make their mark on health, for better or worse. Donald Trump campaigned on a populist platform to “make America great again”. While the actual policies his administration will pursue—and the priority he will place on each of them—remain in many ways uncertain, both his statements and his nominations for key government posts suggest that his presidency could have profound implications for health. His proposal to repeal and replace the Affordable Care Act with a “better reform”, his stance on reproductive rights, and his approaches to other areas, such as science policy and climate change, coupled with his stated intention to put “America first” are creating anxiety and uncertainty about America’s domestic health policies and its global leadership role in areas such as security and development. We propose criteria on which the global health community can judge the success or failure of a Trump presidency, based on a selection of the 17 Sustainable Development Goals that apply to health.
The USA, along with every other country in the world, signed up to the United Nations’ 17 Sustainable Development Goals (SDGs).1 We assessed these goal to develop a scorecard, as set out by Beaglehole and Bonita,2 that can form the basis of a system to monitor and hold accountable global health leaders (figure). In the system, red indicates a high risk to health, amber a medium risk, and green a low risk. We applied these criteria to a subset of the 17 policy areas covered by the SDGs. We do not see this scorecard as being definitive, and indeed it cannot be until there is greater certainty about what policies will be pursued, but we offer it as a basis for further discussion.
Predicting the consequences of a Trump presidency is difficult, for several reasons. One is that there is considerable uncertainty, and little sign of a coherent plan from Trump’s transition staff and appointees. The President-elect’s views are inconsistent and have shifted on many key issues, sometimes within hours. Another reason is that achieving real change requires skill, yet Trump assumes the office of President with no government experience and concerns about his understanding of the role.3, 4 As a business leader at The Trump Organization, he operated a distinct family operation with a close-knit group of loyal supporters, giving him virtually absolute control over operations.5 As President, his actions will be constrained by the Constitution, centuries of legislation, and numerous checks and balances created by the formal separation of powers.6
His ability to pass legislation will depend on support of others, particularly the Republican Party who control Congress. During his campaign, Trump vilified several key party leaders, including the Speaker of the House of Representatives, Paul Ryan. Other prominent Republicans, including George W Bush and Jeb Bush, refused to support Trump, taking fundamentally different stances on core issues. They argued that true conservatives would prefer a smaller government role to Trump’s proposed fiscal largesse. Further questions exist about Trump’s links to Russia, including evidence of Russian interference in the election7 and his proposed nomination as Secretary of State of Rex Tillerson, an oil company executive with close Russian ties.8
One scenario is that Trump simply signs the overall Republican agenda, as summarised by House Speaker Paul Ryan’s “A Better Way” plan. Another is that the Republican Party’s legislative agenda, which is often quite radical, fails to be enacted because of tensions within the party. A third is that Trump develops his own, more populist, approach (as he suggested during the campaign, when he correctly said he was the only candidate defending Medicare). Regardless of Trump’s personal agenda, the preferences of his party will necessarily drive the legislative agenda, and give us insight into the likely direction of policy.
Much will also depend on his nominees for federal agencies. So far Trump’s appointments, including Scott Pruitt to the Environmental Protection Agency who is currently suing the Agency, take strikingly differing stances on the importance of evidence-based policy and role of international law than that of their staff. Likewise, his nominee to head the Department of Health and Human Services, Tom Price, is a Congressman who authored a bill repealing the Affordable Care Act (ACA).9 These conflicts within departments and agencies could pave the way for resignations or dismissal of career civil servants, including those with specialist expertise and lengthy and complex disputes over policy; there is some evidence that this conflict is already happening.10 Such disagreements will also make it more difficult for these appointed leaders to implement those policies that they favour.
Finally, there are wildcards. Any presidency can be overtaken by events, such as the Cuban Missile Crisis or the events of Sept 11, 2001. Quite how Trump would react in such crises has, inevitably, been the subject of extensive speculation,11 especially among those who seek insights as to his propensity to use nuclear weapons or the spontaneity of his approach to Twitter.
Yet while there are serious concerns, the public health community needs to focus on actual policy changes, not just the often confusing statements and tweets of the President-elect.
Universal health coverage
The USA is the only advanced industrialised country without universal health care. The consequences are well known. The health of Americans lags far behind that of their counterparts in otherwise similar countries.12 Medical expenses are the most common cause of personal bankruptcy, with implications for the wellbeing of families and communities.13However, much has been achieved. The ACA, in particular, has provided insurance to more than 20 million Americans, reducing the prevalence of uninsurance to less than 10%.14 Notwithstanding this progress, much more could be done to catch up with other industrialised countries.15
Trump’s proposed reforms to the ACA are unclear. He has committed to repealing and replacing the act. Some of his proposals to replace it coincide with existing Republican Party proposals. Such proposals include greater use of health savings accounts, characterised by high deductibles and the ability to roll forward unspent funds to future years, creating concerns that necessary care might be deterred,16 and the use of block grants from the Federal Government to the States to fund Medicaid, expected to lead to reduced eligibility. However, he has also proposed retaining some safeguards in the ACA, including coverage of pre-existing conditions and of dependents up to age 26 years. The situation is complicated further by the nomination of Tom Price, as Secretary for Health and Human Services. Price has consistently supported reducing entitlements to health care and favoured the providers of care (Price is an orthopaedic surgeon).9 Price’s most recent proposals to repeal the ACA would remove these safeguards and would also increase the cost of coverage substantially for those on low incomes.
A major challenge will be to find a workable replacement for the ACA. As has been noted by Gostin and colleagues,17 if the existing safeguards are retained they must continue to be accompanied by an individual obligation to purchase insurance (or pay a penalty) or risk destabilisation of the insurance market. A continuing obligation to obtain coverage would conflict with an emerging emphasis among Republicans on access to coverage rather than actual coverage.18 Yet if these safeguards are abandoned they risk a political backlash from the many Trump supporters who benefit from them. Thus, there is considerable scope for a split between populists and anti-government conservatives within the party. The risk is increased by Republican proposals for reform of the Medicare programme, which provides coverage for older people, and the Medicaid programme, which finances much long term care for the poor. During the campaign, Trump spoke favourably of Medicare and it is clearly an important social programme for his voters. However, House Republicans, including Secretary-Elect Price, support turning it into a voucher programme, increasing costs for most recipients.
The combined issues of the ACA, Medicare, and Medicaid might be the iceberg that sinks the Republican coalition. Given the financial impact on many of his supporters, Trump might not choose to support such an extensive attack on them. As many previous presidents have discovered, health care reform is easy to propose but much more difficult to achieve.
Overall, we score proposals on this issues as red, because any of the elements being proposed would move backwards on SDG indicator 3.8, to “Achieve universal health coverage”.
Evidence-based health policy
The scientific community has expressed great concerns about Trump’s approach to evidence. In a paper entitled “Shockingly Ignorant”, the editors of Scientific American have listed a series of his more extreme comments, including his endorsement of the theory that vaccines cause autism and his denial of man-made climate change.19 His Vice-President Mike Pence, when Governor of Indiana, initially opposed needle exchange at a time when an outbreak of HIV was spreading rapidly among intravenous drug users,20 although Pence eventually changed his mind.
Shortly after the election, more than 2000 American scientists signed an open letter,21 including many health researchers, calling on President-elect Trump to maintain a strong and open culture of science, ensure that public safeguards remain strongly grounded in science, adhere to high standards of scientific integrity and independence, and provide adequate resources to enable federal scientists to do their vitally important jobs.
Trump will face longstanding challenges in the pharmaceutical sector. He has called for “reform [of] the Food and Drug Administration, to put greater focus on the need of patients for new and innovative medical products”. This language suggests a policy of deregulation. It comes after the passage of the 21st Century CURES Act, which was passed with majority support from Democrats and Republicans. The Act enables the US Food and Drugs Administration (FDA) to rely less on randomised clinical trials in approving new indications for drugs and more on observational studies and pharmaceutical companies’ summaries of research,22 a highly controversial measure also being promoted by the pharmaceutical industry in Europe.23
Scientists are likely to experience reduced federal research funding, at least in some areas. Although the CURES Act increased funding to the National Institutes of Health (NIH) and allocated additional funds to addressing mental health and opioid addiction, the Agency for Healthcare Research and Quality (AHRQ), which finances health services research, is politically vulnerable because its research can easily anger industry lobbies. Moreover, reduced government spending overall is likely to hit research. In health, it should be noted that Secretary-Elect Price has consistently supported cuts to the NIH budget.9
In addition to budgetary threats, considerable risk exists that the administration and Congress will start to impose their own views on science, by for example driving scientists working on issues such as climate change out of the executive branch or discouraging research into certain topics. The demand by the Trump transition team for details of scientists working on such issues is an obvious reason for concern.24
We code this issue as red: not only is there is ample evidence of disrespect for science by Trump and many Republicans, and a strong risk of ideological interference in scientific work and findings, there is less clear evidence that it will translate into major policy or budget changes.
Reproductive health is area where the situation is especially unclear. Trump has long shown little sign of caring about abortion. He has reportedly dodged questions about whether he paid for abortions after impregnating women25 and has previously said that he was “pro-choice in every respect”.26 However, during the campaign, he expressed support for some restrictions on abortion. A subsequent interview, which probed him on this issue in detail, provided little clarity.27 In contrast, Mike Pence, his Vice-President, has co-sponsored a bill that would distinguish “forcible” from other forms of rape and signed an Act, later ruled unconstitutional, that would have mandated funerals for all foetuses. Price holds similar views, consistently opposing any measure that improves access to abortions. In this respect, Pence and Price are closer to the Republican Party in Congress and in the country. Republicans are overwhelmingly committed to defunding Planned Parenthood and other reproductive health care providers, reversing the Roe v Wade decision that legalised abortion across the USA, and reducing access to birth control and sex education.
Trump will be able to make at least one appointment to the Supreme Court. His nominees to the hundreds of federal judicial posts that are now or will be open during his term will almost certainly oppose abortion rights. They will be able to work with a majority of state governments that oppose them and which are already constraining them further.28 Importantly, support for abortion rights has been drifting downward among younger cohorts of Americans (along with rates of sexual activity).29However, the scale of the changes proposed by Republicans would have a major impact on access to abortion, risking a backlash among a sizeable section of the Republican Party.
We score this issue as red. It is almost impossible to see a scenario in which the US will not lose ground vis-à-vis SDG 3.7, ensuring access to reproductive health care. Regardless of what Trump really thinks, opposition to abortion rights is one of the unifying views of the Republican Party.
The USA incarcerates a higher share of its population than almost any other country, with almost one in every 100 Americans in prison. This situation has many consequences for American society, but especially for health, both of prisoners and of the wider population.30 The arguments for reducing this population, on moral, criminal justice, and health grounds are overwhelming. 31
Owners of private prisons are a powerful US lobby group. Although it is difficult to find specific pronouncements by Trump, there is a widely held view that his presidency will remove the pressure that the Obama administration had exerted on private prison operators and, potentially, lead to even higher prison numbers. This is illustrated by soaring share values of CoreCivic (formerly the Corrections Corporation of America), who operate detention facilities and benefit from private prisons along the Mexican border.32 Although the President has little direct influence on the prison population, his overall approach to law and order risks creating a climate that further empowers these corporations as they lobby at state level for policies that benefit them financially.33 However, the expectations of the markets are also being driven by anticipation of the consequences of Trump’s proposal to round up and deport large numbers of illegal migrants. It also seems likely that the decision by the federal government to end private contracts for public correction and detention facilities, following evidence of profiteering and mismanagement, will be reversed.
Incarceration fails in almost every respect to achieve its stated goals.31 There are many arguments for the US prison population to be reduced but, regrettably, progress seems unlikely. For these reasons we score it red.
Security and foreign policy
The Ottawa Charter places peace first in its list of prerequisites for health.34 As the world’s remaining superpower, the USA plays a key role in global security. Trump’s inflammatory comments have given rise to concerns across the globe.35
European leaders voice concerns about Trump’s questioning America’s commitment to aide its allies under article 5 of the NATO Treaty.36 This questioning has caused particular anxiety in the Baltic states and Nordic countries, which perceive a growing threat from their neighbour, Russia. This concern is exacerbated by the closeness of Donald Trump and his new Secretary of State to the Russian President.
Trump’s foreign policy could further destabilise the Middle East. In Syria, Trump has expressed a willingness to work more closely with Russia, while in Israel, he has already entered into the fray with his comments on UN Security Council Resolution 2334 and his stated intention to move the American Embassy from Tel Aviv to Jerusalem. This position is contrary to an earlier Security Council resolution dating from 1947 and will be seen as a severe provocation by Palestinians.37
Trump also has made inflammatory comments towards China. By taking a telephone call from the President of Taiwan, he challenged the One China policy. Initially dismissed as a mistake, his subsequent actions have inflamed tensions in the region.38
However, these issues might be revisited in the light of changing circumstances. However, if change is enacted, given the enormous sensitivities involved, it seems appropriate for any decisions to be based on a detailed policy analysis. The President Elect often appears to be acting on his own accord, ignoring the caution that would be advised by seasoned diplomats. Indeed, as he commented in relation to intelligence briefings, “I don’t have to be told—you know, I’m, like, a smart person”.39
The UN, and its specialised agencies, play a key role in the global health architecture. But Trump’s views are difficult to discern. Insiders are reported to have expressed relief that, during the campaign, he did not promise to dismantle it altogether. At times he has praised it, and especially its presence in New York, even offering a cut price deal to rebuild its headquarters. However, he has also criticised it, especially in relation to decisions on Israel’s occupation of Palestinian territories,40tweeting “As to the U.N., things will be different after Jan. 20th”.41
At least for now, many foreign governments are suspending judgement, hoping that the responsibility of office will lead to a more measured approach. However, as history has shown, wars can easily be incited and, when they do, the consequences for health can be terrifying. Consequently, given the uncertainty, we score security and foreign policy as amber against SDG indicators related to Goal 16, on Peace, Justice, and Strong Institutions.
Aid and global health
International aid is a major component of the USA’s soft power. Historically, US aid has failed to meet pledges of 0·7% of gross national income (attaining 0·17% in 2015).42 Trump has pledged to stop sending foreign aid to countries that “hate Americans.”43 This position raises questions about the future of US engagement in global health initiatives.44 Although appointments to USAID have yet to be confirmed, Trump has considered Newt Gingrich, who proposed abolishing USAID altogether.45 Moreover, Trump’s choice of Mick Mulvaney, a fiscal conservative, as Director of the Office of Management and Budget, suggests those policies will dominate. Under such an approach, any discretionary federal spending is likely to be cut substantially, including foreign aid, as well as Medicaid and public health and support for the Centers for Disease Control and Prevention (CDC). Trump has said little on this subject, although he did express support for expanding access to AIDS treatment in a response to a student at a New Hampshire meeting.43 However, Vice-President-elect Pence has supported spending on global health, invoking biblical obligations. A recent, detailed analysis43 of what is known suggests that support may vary by disease, or more specifically, the characteristics of those most affected, as well as influencing the types of response that will be supported, something that has long characterised US aid.46 The uncertainty in this area was summarised by comments by Michele Barry, from Stanford University (CA, USA): “Well, he’s a germophobe, so that’s got to be good for the CDC”.43
We thus score this issue as amber, against SDG indicator 1a, to mobilise resources to end poverty, particularly in the poorest countries.
The final area we consider is climate change. 2016 was the hottest year on record and the world might be reaching a tipping point where melting Arctic ice and release of methane stores in permafrost create runaway global warming. Trump famously described climate change as a hoax, created by the Chinese to reduce the competitiveness of American manufacturing.47 His initial appointments strongly suggest a rolling back from President Obama’s position. Pruitt, Trump’s nominee for head of the Environmental Protection Agency has sued the Agency on several occasions in his role as Oklahoma’s Attorney General and is leading a 27 state coalition to overturn Obama’s clean power plan, a core element of his climate change strategy.48Trump’s transition team has also stated the intention to defund NASA’s monitoring of the global environment, thereby removing the most important source of information on climate change. Domestically, many Americans face the threat of extreme climatic events, with large areas of the Atlantic coast (including most of Florida), the South West, and the Mississippi under threat of climate change-related events, as well and increased transmission of vector-borne diseases such as Zika virus.49 The question is whether the American media and many of its politicians are willing to accept that these events are ultimately our collective responsibility and hold any politicians, past or present, to account.
This approach moves in the opposite direction to that envisaged in SDG indicator 13.2, to “Integrate climate change measures into national policies, strategies and planning”, thus scoring as red.
Role for public health
Trump will enter the Oval Office at the time of great uncertainty, not just for the USA, but also France, Germany, the Netherlands, the UK, and several other industrialised nations that face the rise of far-right parties and populist policies. Trump’s decisions will have profound implications for the health of Americans and others throughout the world. A large inconsistency exists between what can be ascertained about his stated intentions and US commitments to the SDGs. Several core areas, including those which we were unable to cover in detail in this Health Policy such as gun violence (which we score as red), employment and insecurity (amber), and social determinants of health (red), pose further threats to public health (figure), as do suggestions—still unconfirmed at the time of writing—that he might invite Robert F Kennedy junior, a known anti-vaccination campaigner to chair a commission on vaccine safety.50 At least so far, Trump’s policies and actions indicate a need for considerable concern.
Public health professionals have several responsibilities over the coming months and years. One is to monitor and hold accountable leaders for their actions. The SDG framework is a good place to start. National public health associations could pressure leaders to keep their promises for social development. The least the community can do is to assess rapidly proposals that emerge, such as any reform to the Affordable Care Act, to understand their consequences for health and health inequalities.
The second, deeper, responsibility, is to understand the sources of political unrest that are fuelling widespread discontent, and especially worsening health and living conditions,51, 52 which pave the way for the rise of populism and extreme nationalism. It is important not to overstate the parallels with the events of the Great Depression, where within one decade, the combination of debt politics, austerity, and economic hardship fuelled the rise of fascism. However, as Mark Twain is reputed to have said, history does not repeat itself but it does rhyme. The resonances are clear; the dangers are evident; and the role of public health is more important than ever.
All authors contributed equally to the writing of this Health Policy.
Declarations of interests
We declare no competing interests.
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