Trump’s health care disruption could pay off

Eric Reinhart, Tribune News Service

President Donald Trump’s nomination of Robert F. Kennedy Jr. reflects anger and frustration at the wanton greed underlying America’s health systems. Major changes are coming. But we must not let those changes leave us even worse off than we already are. For decades, our capitalist health systems shaped by for-profit insurance, physician interest groups and now private equity have been antithetical to effective public health. Despite spending two to three times more per capita on health care than other high-income nations, the U.S. lags far behind on outcomes, while trust in medicine and government have dropped precipitously to historic lows. As public health scholars have long observed, the root of our collective problem lies in gross overinvestment in profitable medical interventions, which account for only 10 — 20% of what shapes health in the US, alongside massive underinvestment in the far more consequential political and economic determinants of health: housing, working conditions, basic income, environmental and food regulation, and everyday social support. Yet following the worst of the COVID-19 pandemic, instead of newly prioritising these issues, the Biden administration called for a “return to normal” — a boon for the health care industry but a death sentence for the estimated 1 million US residents who die from preventable causes each year.

Trump, by contrast, has risen to power on the promise of wide-ranging disruption. Trump’s chosen health officials have shared militant critiques of these entrenched public health norms. But while Trump’s health nominees have been loud in their criticisms of the status quo, they have so far offered no coherent vision for rebuilding our public health. Many people worry their agenda will be purely destructive and further feed the private profit-making machine. If the Trump administration hopes to do more than simply destroy the current system and leave Americans even more vulnerable, then Trump’s health officials should combine their criticisms with critiques of health policy from the left to advance a truly populist model of public health. This approach prioritizes immediate, tangible benefits to working people and empowers them as both recipients and providers of care, rather than mere consumers inside a broken system.

A populist public health agenda could unite left and right by addressing the everyday needs of ordinary Americans while combating the elitism and shameless profiteering of our current health systems. For conservatives, it appeals to values of local control, personal liberty rather than restriction, and trust in local community actors rather than distant bureaucrats. For progressives, it offers a pathway to address economic inequality and to build systems of care that prioritize people over profits. For decades, US public health policy has focused on privatization, deregulation, “free” markets and the associated profits. This approach values experts at the expense of working people, reactive medical treatment over prevention through nonmedical social care, fickle philanthropy as a substitute for government-protected rights, and individual moral responsibility for health in place of public responsibility to address the systemic drivers of disease.

Illness is framed as a matter of personal failure — poor diet, sedentary lifestyles or smoking, for example — rather than the result of policies that undermine rights to healthy environments. For instance, debates about mask mandates and obesity in relation to COVID focused on personal behavior, ignoring structural failures such as unsafe workplaces, lack of air-quality regulation and cheap unhealthy foods that have crowded out affordable access to healthy alternatives. Meanwhile, social problems such as poverty, isolation and trauma are treated as individual pathologies requiring medical interventions, like often-ineffective pharmaceuticals or therapy. This diverts resources from community-based care and prevention, generating profits for industry while leaving patients with endless bills and disappointments. Populist public health, by contrast, promotes policies such as universal child care, housing-first initiatives and direct cash transfers to improve health outcomes while reducing poverty and economic insecurity. During the pandemic, the success of expanded child tax credits and direct payments offered proof that public investments can make enormous improvements for people’s health.

A populist approach emphasizes violence and disease prevention over reactive treatment. To reduce spread of infectious diseases, it invests in paid sick leave, air filtration in public spaces, cost-free vaccination provided by trusted neighborhood health workers — policies that enhance individual freedom. To promote healthier diets and prevent chronic diseases, this approach subsidizes small farmers, neighborhood grocery co-ops and fresh produce for working-class individuals and families instead of propping up multinational corporations and factory farms that flood our communities with designed-to-be-addictive ultra-processed foods.