Setting a baseline

The public might have a better idea of what's at stake in an election if we did a better job tracking key indicators of public health.

Here are my three touchstones for thinking about where Trump II will take America over the next four years. First, personnel is policy. Second, focus on what they do, not on what they say. Third, track outcomes closely.

If Trump gives Robert F. Kennedy, Jr., the president-elect’s new health guru, a czar-like role at the Health & Human Services department and allows him to “go wild” at the Food and Drug Administration, lobbyists for the pharmaceutical, vaccine and food industries will undoubtedly have something to say about it. They have unlimited cash to throw Trump’s and Congresspersons’ way to avoid the disruption it would cause for their business models.

A more likely outcome, given their insatiable greed for more profits, is that drug makers will become more like the $54 billion supplements industry, which peddles pills with zero evidence of efficacy to millions of Americans. In recent years (and with support from both sides of the aisle), the FDA caved to industry pressure to approve worthless drugs like aducanumab for Alzheimer's disease and eteplirsen for Duchenne muscular dystrophy.

Will Trump appoint someone to head the FDA who has a track record of adhering to scientific evidence? Or will he choose a hack willing to push accelerated new drug approvals based on flimsy data; back right-to-try of experimental therapies that may do more harm than good; and ignore the agency’s outside scientific advisors or loads the committees with industry flunkies.

Kennedy says he wants to abolish the nutrition department at the FDA because it’s not doing its job. I applaud his goal of reducing the sugar and salt content in processed food and restaurant offerings, which are major contributors to the nation’s high high blood pressure and obesity epidemics and contributes to excess heart attacks, strokes and diabetes. But a real answer to that problem is giving regulators more power to do their jobs, not eliminating their positions, which will only give free rein to the food processors.

Will Trump again pluck someone from the drug industry to head the Health and Human Services Department and allow that person to eviscerate drug price negotiations? Will he appoint another industry-oriented consultant (his first one, Seema Verma, now heads an electronic health record supplier) to run the Centers for Medicare and Medicaid Services? These would be relatively benign choices compared to nominating one of the Christian Nationalist authors of Project 2025, who have outlined their plan to ban abortion nationwide by prohibiting the mailing of mifepristone and misoprostol to desperate women in need.

ACA on the chopping block

Major changes in the Affordable Care Act will be on the table no matter which party gains control of the House. As I repeatedly pointed out before the election, the enhanced subsidies passed during the pandemic expire next year. Without them, millions of people will lose coverage.

Republican control of Congress will also put Medicaid in play. The GOP’s preferred “reform” is turning the program that now covers 85 million people into a block grant and eliminate some or all coverage requirements. The reduction in federal funding will be needed to help pay for renewing some or all of the Trump 2017 tax giveaways to big corporations and the wealthy, which also expire in 2025. The net effect in most states would be a sharp reduction in enrollment and a major spike in the number of uninsured.

The U.S. already has one of the weakest public health systems in the world. The Centers for Disease Control and Prevention is so underfunded that it cannot pursue population health goals like reducing substance abuse, obesity and gun violence. Its data collection system is scattershot and archaic.

Yet Kennedy, with Trump’s encouragement, says he wants to eliminate fluoride from the water supply and pull vaccines from the market. Clearly, neither he nor his enabler-in-chief knows how little authority the CDC has. It has no control over states. Placing a political loyalist at the top of the agency could lead to withdrawing some recommendations. But that wouldn’t stop states from maintaining this proven dental decay prevention strategy or continuing to mandate certain childhood vaccinations for school attendance.

The same is true for already approved vaccines. Any attempt to withdraw a product without scientific justification would be immediately challenged in court. This Science Magazine interview with Georgetown University law professor Lawrence Gostin gives a good overview of how career scientists and the law might respond to a worst case scenario.

Keeping track

But even if stymied from achieving their more outrageous goals, a second Trump administration will do enormous harm to public health. That’s why it’s important to measure where we things stand now. It will enable us to appropriately judge how things are faring when changes enacted during Trump’s first year in office take effect, which will be sometime before the 2026 midterms.

Here are a few key indicators:

• The uninsured rate in the U.S. now stands at 8.2%, less than half of where it was when the Affordable Care Act passed in 2010. The biggest jump came during Biden’s second and third years in office when an expansion in subsidies meant nearly 90% of people who bought plans on the exchanges received at least some government help. Should those subsidies lapse next fall, the uninsured rate will likely spike in early 2026.

• Life expectancy in the U.S. rebounded slightly from the Covid-era collapse and stood at 77.5 years in 2022 (74.8 for males and 80.2 for females). The OECD average for 38 industrialized countries in 2021 was 80.3, leaving the U.S. ranked 32^nd internationally. Its worst-off state, Mississippi, with a 71.9-year life expectancy, was nearly 1.2 years behind Latvia, which was ranked last in the OECD. African-American life expectancy was nearly five years behind whites and seven years behind Hispanics.  

• In 2023, the nation’s obesity rate stood at 32.8%. Of the 23 states that had obesity rates over 35%, 20 voted for Trump. Three states (Arkansas, Mississippi and West Virginia), had obesity rates over 40%.

• The U.S. infant mortality rate was 5.6 deaths per 1,000 live births in 2022. The OECD average was 4.0 deaths per 1,000 live births in 2021, leaving the U.S. ranked 33rd among the 38 countries.

• There were over 107,500 drug overdose deaths in 2023, a decrease of 3% from the previous year. Fully 75% of those overdoses involved opioids and virtually all of the decline in 2023 came from reduced exposure to fentanyl.

It may take more than two years to get a complete picture of how Trump II’s policies affect these five indicators. You may have a few you want added to the list. Let me know since I am thinking about putting together a Health Tracker based on trusted sources that can trace progress or setbacks in the nation’s march to better health. It could be a useful tool for evaluating not just Trump II but subsequent administrations.