The recent report by the National Center for Health Statistics showing a decline in life expectancy in the U.S. in 2015 highlights a point largely overlooked in post-election discussions about health policy under the Trump Administration. The significant increases in health insurance coverage under the ACA have not resulted in population-wide improvements in life expectancy. This is not because the coverage increases aren’t important; without question they have made a difference in the lives of millions. Rather, it’s because health care plays a relatively small role in determining population-level health outcomes. More important are the so-called social determinants of health, the “conditions in which people are born, grow, work, live and age, and the wider forces and systems shaping the conditions of daily life.” This suggests that the new Administration’s economic, educational, environmental, labor, and housing policies will have more to say about the health of Americans than its proposals for replacing the ACA or reforming Medicare and Medicaid.
Public health policies, and public health law, can also have a major impact on population health. Several years ago, the CDC published a list of the “Ten Great Public Health Achievements in the 20th Century,” which it credited with adding 25 years to life expectancy in the U.S. The list included immunizations, control of infectious diseases, family planning, reductions in tobacco use, work-place and motor-vehicular safety and safer and healthier foods. These goals and other public health objectives, including reductions in opioid use and obesity, remain paramount to preventing further reductions in life expectancy.
To date, little attention has been paid to the incoming administration’s views on most of these issues. Although Trump has nominated Rep. Tom Price to be Secretary of HHS, he has yet to name his picks for the head of CDC or for Surgeon General. The Trump transition website does not mention public health; nor did many public health issues, other than the opioid epidemic, receive much notice during the election.
Given the rising death rates among working class whites, Trump’s core constituency, it is possible that the new Administration will take public health seriously. In addition, because many public health activities are vested with local governments, public health law is unlikely to change as dramatically as many other areas of health law. Still, there are some reasons for concern.
In future postings, I hope to discuss some of the specific public health law issues that the new Administration will face. For now, three general points merit consideration. The first is that public health protection relies significantly on regulation. To the extent that Trump Administration carries out its vow to impose a moratorium on all new regulations, and cut many existing regulations, a wide swath of federal regulations that affect health may be imperiled. More worrisome is the President-elect’s attitude towards science. Public health law and practice are inextricably dependent upon public health science. Effective public health protection is based on the best, although inevitably incomplete, scientific evidence. Unfortunately, the President-elect has shown little respect for scientific opinion, either with respect to climate science or regarding the safety of vaccines. If science is to be ignored, public health policies will fail to achieve their goal. Finally, history teaches us that societies often respond to public health crises by introducing tough-looking but counter-productive coercive measures, and scapegoating already marginalized populations. We saw that in the early years of the AIDS epidemic, and more recently in response to SARS and Ebola. During the 2014 Ebola outbreak, Trump showed his fondness for tough-looking, but ineffective measures. When U.S. missionaries infected with Ebola were to be flown to the US, Trump tweeted “Ebola patient will brought to the U.S. in a few days – now I know for sure that our leaders our incompetent. KEEP THEM OUT OF HERE!” He also argued that people from West Africa should be kept of the U.S. and that the disease was more easily transmitted than the CDC was admitting.
During the next four years a public health emergency, as yet unforeseen, will likely occur. Even if it does not, the health of Americans will remain threatened by the common scourges of the 21st century – unhealthy foods, opioids, and tobacco. Effective responses to all of these threats will require public health protection that is based on the best science available. Whether the new Administration will undertake and support such approaches remains to be seen.