Donald Trump will take office with a pledge to “make America healthy again”, even as growing evidence shows the president-elect’s conservative policy agenda is associated with worse health.
Population health scientists see Republican-led states, some of which have the worst health outcomes in the developed world, and Trump’s track record as warning signs for the future.
“We were looking at the policies other countries had adopted that allowed their populations to live longer and healthier,” said Dr Steven Woolf, a population health researcher and family doctor at Virginia Commonwealth University.
Those policies often included universal healthcare, educational support, gun violence prevention and laws that reduce smoking – many of which are opposed by the Trump administration or have been opposed by Republican state leaders.
“One of the immediate takeaways from the election is that policy agenda is now even more doubtful – essentially a political non-starter,” said Woolf. “Now, the bigger concern sweeping over all of this is we’re likely to see the heralding of a set of new policies that are going to compromise health even more.”
The foreboding future envisioned by researchers highlights the gulf between what decades of research show are the key drivers of poor health and the belief in alternative medicines (and sometimes outright quackery) supported by one of Trump’s key advisers, Robert F Kennedy Jr.
Kennedy, a longtime vaccine skeptic and former independent presidential candidate, laid out his policy agenda on social media two weeks ago, telling his supporters he would promote “stem cells, raw milk, hyperbaric therapies, chelating compounds, ivermectin, hydroxychloroquine, vitamins, clean foods, sunshine, exercise, nutraceuticals and anything else that advances human health and can’t be patented by Pharma”.
Without getting into the minutia of that list – some of which is actively harmful – the focus stands in contrast to what population health scientists see as the most effective ways to improve the nation’s health, from getting everyone health insurance to improving STD tracking and diagnostic programs to increasing tobacco taxes.
The US south paints one of the starkest examples of ignoring this evidence. This longtime conservative stronghold has among the highest rates of diabetes, obesity, infant mortality, maternal mortality, sexually transmitted diseases, cancer and self-reported poor health in the nation, and sometimes the developed world.
If West Virginia were a nation, it would have the worst rate of preventable deaths of any country in the 38-member OECD, a group of highly developed democracies. At 416 preventable deaths per 100,000 people, the state’s rate is on par with Latvia, Lithuania and Hungary, according to a Commonwealth Fund analysis that used 2018 data.
The south as a region also has the highest rates of people who lack health insurance, have less than a high school education and live in poverty – all associated with worse overall physical and behavioral health outcomes.
“The US is not doing well at protecting the health and welfare of its residents,” said Reginald Williams II, vice-president of international health policy at the Commonwealth Fund.
Researchers trace the beginning of a decades-long decline in US health and the growing gap between states to the Reagan era, when the administration cut funding to the Department of Health and Human Services (HHS) and the public health insurance program Medicaid – in effect eliminating many public health programs. States were expected to fill in the gap, resulting in some states doing better than others, with worse health nationally compared with peer wealthy nations.
“Now, you have some states that perform better like Massachusetts and Connecticut, and you have some states that perform rather poorly like Mississippi and West Virginia,” said Williams. “But when you even look at the best-performing states in the US they are still below other advanced economies.”
In other words, the concerns that drive Kennedy’s promises are legitimate: corporate profiteering and influence are real. But the Republican party has a track record of cutting regulations that protect health – like occupational health and safety standards – and opposing those that protect health – such as curbing cigarettes, alcohol, junk food or pollution.
These, in turn, are what researchers call the “political determinants of health”. And a growing body of research, including a study published as recently as September by Krieger, shows how the conservative policy agenda is associated with poor health outcomes.
“It’s the conditions of life, the air we breathe, the temperature of the planet, the nature of the qualities of the ecosystems in which we live – that’s fundamental to understanding population health,” said Nancy Krieger, a professor of epidemiology at Harvard’s TH Chan school of public health.
This area of research grew substantially after the Covid-19 pandemic, when the worst-affected populations moved from the poor and people of color early in the outbreak, to more affluent, white and conservative states where Republicans opposed masks and vaccines.
“So there’s one part [of political determinants of health] – what are the policies of the health insurance system?” said Krieger.
For instance, Republican-led South Dakota took steps to restrict insurance coverage this election cycle. There, voters approved a measure to add work requirements to Medicaid, the public health insurance program for low-income Americans.
The American Cancer Society called that change “dangerous and life-threatening”, and one that goes against research showing “time and again that access to health insurance is a significant determining factor in surviving a cancer diagnosis”. The measure still needs approval from the Centers for Medicare and Medicaid (CMS), which it is likely to get in a new Trump administration.
“On the other side”, Krieger said, are proposals by Trump’s supporters to dismantle the “regulatory state”. Trump supporters are “very keen on going after environmental regulations and occupational health protections – those kinds of things that really do matter”, she said.
That would include policies such as ending a Food and Drug Administration (FDA) effort to ban menthol cigarettes, now considered dead in the water by both supporters and opponents. Advocates believed the ban would reduce predatory marketing to Black youth. Black men have the highest rates of developing and dying from lung cancer in the country.
Taken together, these kinds of changes make “it very implausible there’s going to be a healthier nation”, during the second Trump term, Krieger said.
The Guardian reached out to a potential pick for Trump’s health and human services department, the former Louisiana governor Bobby Jindal, through the Trump-aligned America First Policy Institute. The thinktank did not respond to an interview request.
