America’s poor health helped elect Donald Trump.
The United States has the worst health indicators among its peer nations, even though it spends far more money on health than any of those countries. Much of this health burden is borne by the same marginalized groups that found hope in the message of the president-elect.
The new administration should seize the opportunity to be bold and inventive and to take steps that can actually make a difference in the lives and the health of the people who elevated Trump to power. My own work, and that of others, suggests 10 key ways to accomplish such change.
Improve early education
Education is a fundamental determinant of health. The more education we receive, the healthier we are likely to be, with early education playing a key role. Take, for example, the Brookline Early Education Project. Between 1972 and 1983 it provided health and developmental services to Boston-area children from birth until kindergarten. A 25-year follow-up study showed the program to be associated with a range of positive health outcomes, including lower rates of depression, compared to individuals who did not receive the intervention. Given how profoundly early-life experiences can shape health later on, improving early and pre-kindergarten education nationwide stands to make a tremendous, potentially intergenerational difference in the health of Americans.
Control the opioid epidemic
Driven in part by greater access to prescription opioids and to heroin, opioid overdose deaths more than doubled between 2000 and 2014. Many attempts have been made to solve the problem of opioid addiction, with little success. That may be changing. Last March, Massachusetts Governor Charlie Baker signed into law an innovative new program designed to tackle the opioid crisis on multiple fronts. Components of the law include limits on opiate prescriptions, a database to monitor these prescriptions, and a variety of strategies to identify those at risk of abuse and to provide them with the necessary support services. A similarly comprehensive approach at the national level could make real headway against the misuse of these deadly drugs.
Create health impact assessments
The World Health Organization defines health impact assessments (HIA) as “a combination of procedures, methods, and tools used to evaluate the potential health effects of a policy, programme or project.” HIAs reflect data gathered through various methods to provide recommendations to stakeholders across economic and political sectors. These stakeholders can then apply this information toward better health interventions. For example, city officials looking to promote urban fitness through a bicycle sharing program could conduct their own HIA using an assessment of Barcelona’s program as a template. Data-driven policy planning that is informed by a broader adoption of HIAs stands to be more efficient and, ultimately, more effective.
Increase support for episodes of special need
There are certain times in everyone’s life — childbearing, unemployment, caregiving for sick family members, and the like — when health is particularly vulnerable. They happen to almost everyone, which is why structures of support should be in place to provide assistance during them. Sadly, the US often lacks this structure. For example, ours is one of the few countries in the world, and the only high-income country, that does not guarantee paid parental leave for its citizens, despite the fact that paid leave benefits the health of both parents and children. Guaranteeing financial help during these episodes is good for all Americans.
The effects of violence — be it physical, sexual, psychological, or deprivation-based — can touch anyone, regardless of gender or age, often with lifelong repercussions. The Adverse Childhood Experiences Study and others have demonstrated an association between childhood abuse and poor health later in life. Intimate partner violence is another dimension of this problem. An estimated 8.8 percent of women and 0.5 percent of men have experienced intimate partner rape over their lifetimes, while lifetime experiences of other sexual violence perpetrated by an intimate partner has been estimated at 15.8 percent among women and 9.5 percent among men. It is possible to mitigate this cycle of violence with strategies such as those developed for the Centers for Disease Control and Prevention’s DELTA FOCUS Program, which promotes “healthy, respectful, nonviolent relationships” and works to mobilize communities against intimate partner violence. A nationwide rollout of similar programs could extend the reach of these critical interventions.
Do more to control tobacco use
Success in the fight against tobacco is one of the preeminent public health achievements of the 20th century. However, not all populations have benefitted from overall reductions in cigarette use. People who are uninsured are more likely to smoke, as are those living below the poverty line, those on Medicaid, and those without a college degree. We must use proven strategies — like better access to smoking cessation materials, and an expansion of tobacco taxation — to level the health playing field for those groups in danger of being left behind.
Put earned income tax credits to work
Poverty is unquestionably bad for health. The earned income tax credit is a cash-transfer benefit for the working poor, ranging from $500 a year to $6,200, a sum large enough to make a measurable difference in the lives of those who need it. This tax credit has been shown to mitigate the effects of poverty through reductions in maternal smoking during pregnancy, low birthweight, childhood behavior problems, and improvements in term birth, breastfeeding, and maternal health. Given the positive difference it has already made, extending the coverage of the earned income tax credit would do much to improve the health of families in poverty.
Reform the criminal justice system
The US has the highest incarceration rate in the world, a rate that has risen dramatically since the mid-1970s. The health effects of mass incarceration are varied and destructive. Compared to the general population, prisoners tend to have poorer mental and physical health, and are at risk of infectious diseases like HIV and tuberculosis. Mass incarceration also damages communities, with ripple effects extending to families that suffer from the lack of a caregiver or spouse. Worst of all, perhaps, are the racial disparities reflected by incarceration rates. Black Americans are about five times likelier to be incarcerated than whites. Eliminating mandatory minimum sentencing and reducing drug-related prison terms would go far toward addressing the problem of mass incarceration, as would greater attention to race-based unfairness in our justice system.
Limit alcohol misuse through taxation
The misuse of alcohol has been linked to a range of health hazards, including liver disease, cancer, and poisoning, as well as mental health challenges like depression and suicidality. Taxing alcoholic beverages, though underutilized in the US, is a well-established tool to improve public health. A 2010 analysis estimated that doubling the alcohol tax would reduce alcohol-related deaths in the US by 35 percent, traffic deaths by 11 percent, sexually transmitted disease by 6 percent, and violence by 2 percent.
Hands off the Affordable Care Act
I leave this for last because I realize that the new administration is determined to change Obamacare. But the ACA clearly represents an enormous triumph of social legislation, improving health care access for millions. The most recent numbers show that 17.6 million previously uninsured Americans gained coverage since October 2013, when the ACA took effect, and about 10.5 million more Americans are currently eligible for marketplace coverage in the upcoming enrollment. Meddling with the ACA will once again leave millions of Americans underinsured or without health insurance altogether. That would be a disaster.
We as a nation are about to turn the page on a challenging and, in many ways, unprecedented election year. Many difficulties, political and otherwise, stand in the way of progress on health and health care issues. With the historical winds at its back, will the Trump administration have the courage to think big, seize the moment, and implement commonsense solutions that will improve the health of all? We can only hope so.
Sandro Galea, MD, is the dean of the Boston University School of Public Health.