US Health and Healthcare is a Chaos: Now What?

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The report of the lancet Public Order and Health Commission in the Trump Era
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  • Wool merchant S
  • Himmelstein YOU
  • Ahmed S.
  • et al.
Politics and Health in the Trump Era.

is a tour de force chronicle of the failures of both the US healthcare system and the society and public institutions that cause and perpetuate these failures. The Commission’s report is likely to serve as a reference document on these issues in the years to come. In exposing the ideological and systemic causes of US health problems, this commission faces the challenge of correcting them. In this respect, their analysis still leaves a deep uncertainty about the further path.

The Commission’s criticism of the US health care system is broad, profound, and innovative. It provides a thorough overview of Donald Trump’s presidency and administration and the many destructive executive orders he has signed, which, among other things, have resulted in the loss of health insurance for millions of US citizens. The report could serve as a starting point for corrective actions and guidelines for the new administration of President Joseph Biden and Vice President Kamala Harris.

The commissioners extensively document the inadequate support of the U.S. health care apparatus, including the fateful decline in public health funding between 2002 and 2019 from 3.21% to 2.45% of national health spending and the resulting loss of approximately 50,000 public health spending positions at national level Level, just when they were most needed to face COVID-19.

The reduced life expectancy formulated by the Commission in the USA compared to other high-income countries is also convincing. In 2018, the commission said 461,000 US citizens were “missing” due to the country’s lower life expectancy. This silent epidemic of shortened lives suggests that in addition to the nearly 500,000 deaths COVID-19 will have claimed in the U.S. by mid-February 2021, there could be hundreds of thousands of preventable deaths.
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US Centers for Disease Control and Prevention
COVID-19 predictions: deaths.

The commission also links deficiencies in U.S. health care to the country’s history of racism, economic inequality, and social policy choices that have failed to provide a minimally safe safety net for the U.S. population. The Commission rightly points out that changes in public policies on housing, food and income security, education and systemic racism are needed in order for the country to overcome its health deficits.

But if the commission correctly links the US health crisis to broader political and social causes, the commission is only implicitly asking for an in-depth analysis of how it can be addressed. It is no coincidence that the US is a runaway health care provider and there have been vigorous reform efforts in the past.
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United States Health Reform: Progress So Far and Next Steps.

Reformers face major obstacles, however. Some of these obstacles are political and cultural and none are easy to overcome. Voter suppression remains a major issue in the United States, having a detrimental effect on people of color voting, especially in the conservative southern states.

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Voter suppression is still one of the greatest obstacles to a fairer America.

The US electoral college and the allocation of two Senate seats to each state, regardless of population, give conservative, rural and sparsely populated parts of the country disproportionate political weight.

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Harvard Law Review
Pack the Union: a proposal to admit new states to amend the constitution to ensure equal representation.

The requirement of 60 Senate votes to overcome deliberate delays in advancing legislative work stands in the way of major social and political reforms. Changes in the composition of the U.S. Supreme Court during Trump’s presidency, which added more conservative judges, threaten any major reform and progressive initiatives that make it through the U.S. Congress.

Another obstacle is the fundamental moderation of US voters, who are consistently incremental and generally deeply suspicious of the government.
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Pew Research Center
American Views of the Government: Low Confidence, but Some Positive Performance Ratings.

Although surveys in the US show support for comprehensive health care, that support declines when the specifics of reform proposals, such as tax increases, are tested in the surveys.

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Survey: Support for Medicare-for-all varies with details.

Notably, many Americans with private health insurance are satisfied with their coverage.

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Americans are still quite happy with their private health insurance.

despite the many shortcomings that make a payer health system extremely controversial for voters.

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Why aren’t voters more willing to give up a failing health system?

These cultural and political realities have undone major changes in social and health policy throughout much of US history. Reforms, particularly the Patient Protection and Affordable Care Act (ACA) of 2010 during Barack Obama’s presidency, have usually been competitive, gradual, and unsatisfactory for progressives – the ACA did not go far enough to ensure general health insurance coverage, although this has significantly reduced the number of people without health insurance.
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We read 9 Democratic plans to expand health care. This is how they work.

The Commission proposes three ways to remove the obstacles to the political and social reforms it is seeking: better reasoning so as to get the maximum support possible; Cross-sectoral coalition building to strengthen political reform efforts; and the formulation of improved strategies and tactics, such as B. the use of social media for the organization. These ideas are all useful but barely match the powerful forces that are making the US an outlier in health and other areas.

Looking to the future, the health professionals have an obligation to be fully committed to health and political commitment is likely to be required. Indeed, health workers could be more effective in promoting health care improvements in the United States by engaging in voter registration and mobilization in the southern states than any kind of reshaping or coalitioning. The hard fact is that the road to health reform in the US requires political activism of the most basic kind, well beyond the comfort zone of many health professionals. Should this work prove successful – by health professionals and others – supported by the abundant and compelling evidence in this Commission report, the U.S. could be reorganized to address inequalities in income, education, nutrition, housing, Justice and employment opportunities addressing Americans, who are often the fundamental roots of our health crisis.

We do not declare any competing interests.

References

  1. 1.
    • Wool merchant S
    • Himmelstein YOU
    • Ahmed S.
    • et al.

    Politics and Health in the Trump Era.

    Lancet. 2021; ()

  2. 2.
    • US Centers for Disease Control and Prevention

    COVID-19 predictions: deaths.

  3. 3.

    United States Health Reform: Progress So Far and Next Steps.

    JAMA. 2016; 316: 525-532

  4. 4th

    Voter suppression is still one of the greatest obstacles to a fairer America.

    TIME. June 12, 2020;

  5. 5.

    Pack the Union: a proposal to admit new states to amend the constitution to ensure equal representation.

    Harv Law Rev. 2020; 133: 1049-1053

  6. 6th

    American Views of the Government: Low Confidence, but Some Positive Performance Ratings.

  7. 7th

    Survey: Support for Medicare-for-all varies with details.

    Associated press,
    01/23/2019

  8. 8th.

    Americans are still quite happy with their private health insurance.

    CNN,
    9 Dec 2019

  9. 9.

    Why aren’t voters more willing to give up a failing health system?

    Vox,
    29th July 2019

  10. 10.

    We read 9 Democrats’ plans to expand healthcare. This is how they work.

    Vox,
    June 21, 2019

Linked articles

  • Health in the US: under review and repair
    • Although the word “health” itself does not appear in the US Constitution, allusions to it are invited in the preamble from the start. The intent is, very clearly, “to build a more perfect union, to establish justice, to ensure peace of mind, to provide common defense, to promote common welfare and to secure the blessings of freedom for us and our descendants”. But health stands between the lines and comes as close to the strength, security and functionality of a country as it does to the integrity and physical condition of its people.

    • Full text

    • PDF

  • Public Order and Health in the Trump Era
    • This report of the lancet The Trump-era Public Order and Health Commission evaluates the impact of President Donald Trump’s health policies and examines the failures and social divisions that made his election possible. Trump took advantage of the anger of white low- and middle-income people about their deteriorating life prospects to mobilize racism and xenophobia and gain their support for policies that benefit high-income people, businesses and health threats. His signature legislative achievement, a trillion-dollar tax cut for businesses and high-income individuals, opened a budget gap that justified cuts in food subsidies and health care.

    • Full text

    • PDF

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