Sweeping Policy Reforms Needed to Address U.S. Health Inequities, According to Lancet Commission
Miller School Researchers Emphasize Report’s Call for Action
After decades of policy failures, sweeping reforms are needed to address the nation’s serious health inequities, including racism, poverty and access to care, according to a comprehensive study by The Lancet Commission on Public Policy and Health in the Trump Era. Formed in April 2017 by one of the world’s most prestigious medical journals, the commission brought together 33 leading experts from the United States, United Kingdom and Canada.
“We have lost our global leadership in health care, and the COVID-19 pandemic highlighted that failure,” said commission member Olveen Carrasquillo, M.D., M.P.H., professor of medicine and public health science, and chief of the Division of General Internal Medicine at the University of Miami Miller School of Medicine. “The philosophy that health care should be allocated by one’s ability to pay is simply wrong.”
A second Miller School commission member, Zinzi Diana Bailey, Sc.D., M.S.P.H., research assistant professor, emphasized the importance of confronting structural racism. “We need to take an intentional approach to advancing health equity, particularly among the highly diverse populations of South Florida,” she said. “Now is the time to address issues that have been brewing for decades, by putting forth big ideas and capitalizing on the national momentum for change.”
The commission’s report, “Public Policy and Health in the Trump Era,” published February 11 in The Lancet, details how policy failures that began during the Reagan presidency were made worse by the Trump administration. It warned that major reforms are needed to redress long-standing racism, and policy failures that weakened social and health safety nets and led to widened inequality.
Miller School contributors
A national expert in minority health, health disparities, and access to care, Dr. Carrasquillo had collaborated with the commission’s co-chairs, David Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H., distinguished professors at the City University of New York, on prior studies. Dr. Bailey, whose research focuses on the health impacts of structural discrimination, contributed to The Lancet’s “America: Equity and Equality in Health” series in 2017, which was edited by Drs. Himmelstein and Woolhandler. All four researchers gave UM faculty a preview of the report’s findings during the Department of Medicine Grand Rounds held on December 16.
“We need a new approach to health care that does not leave large parts of our society behind,” said Dr. Carrasquillo. “Hopefully, this will be a wakeup call for many people on the need to address the underlying social determinants of health. In our community, the University of Miami and the Miller School must take a clear leadership position on addressing racism and health inequities.”
Dr. Bailey added that environmental concerns, such as climate change, also have public health implications, especially for marginalized groups, including Blacks, Native Americans and Hispanics. “While this report is a reflection of our past, it points the way toward policies we need to consider as we move forward,” she said.
Dr. Carrasquillo noted that “we highlighted Puerto Rico in the report as an example of how a century of colonial neglect left it absolutely unprepared for a global warming-fueled hurricane which killed 3,000 people and decimated the island’s infrastructure.”
Declining life expectancy
The Lancet Commission found that U.S. life expectancy began trailing other high-income nations after 1980. Since then, President Reagan’s political philosophy, known as neo-liberalism, has influenced health policies 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, said the report.
These failures left the U.S. particularly vulnerable to the COVID-19 pandemic, said the commission. 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 percent 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 commission found that 40 percent of U.S. deaths during 2020 from COVID-19 would have been averted if the nation’s death rates were equivalent to Canada, France, Germany, Italy, Japan, and the United Kingdom. The report also estimated that Trump’s rollbacks of environmental protections led to 22,000 excess deaths in 2019 alone.
Prior to the pandemic, midlife mortality for Native and Black Americans was 59 percent and 42 percent higher, respectively, than for non-Hispanic Whites. The pandemic widened the Black-White mortality gap by 50 percent and cut Hispanic life expectancy by more than 3.5 years. Mortality rates from COVID-19 for people of color are several times higher than for non-Hispanic Whites.
Recommendations for reform
With the Biden administration now in office, the commission recommended immediate executive actions, including rejoining the World Health Organization (WHO) and the Paris Climate Agreement. The commission also called on Washington to enact a single-payer system (Medicare for All) reform covering all U.S. residents. This would redirect the $626 billion currently wasted annually on billing and administration to patient care and allow the government to play a direct role in drug development, rather than merely paying for research.
Additional recommendations – many of which will require Congressional approval – included the following:
- Implement 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.
- Implement the Green New Deal, end subsidies and tax breaks for fossil fuels, and ban coal mining and single-use plastics.
- Increase public expenditures for social programs, and repeal restrictions on welfare and nutrition programs.
- Vigorously enforce voting and civil rights.
- Reform the policing and criminal justice systems.
- Make new investments in education and minority-serving health institutions.
- A reduction in military spending to free funds to address urgent social needs.
- Repeal of the Hyde Amendment and regulations that treat sexual-health services differently from other health services.
- A massive mobilization of resources to avert climate catastrophe.
“Americans’ health was deteriorating even as our economy was booming,” said Dr. Woolhandler. “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.”