Rising Inequality: the ‘Pre-Existing Condition’ That Doomed the U.S. COVID Response

Photograph by Nathaniel St. Clair

Back in April 2017, only a few months after Donald Trump’s inauguration, one of world’s most prestigious medical journals, the London-based Lancet, established a special commission to keep tabs on “Public Policy and Health in the Trump Era.”

The panel’s 33 commissioners — medical professionals of all sorts, along with assorted notables in legal and economic circles — have just delivered their final report, and media outlets worldwide are taking notice. They’re headlining the commission’s most stunning stat: that some 200,000 fewer Americans would have diedfrom the coronavirus if the United States had treated Covid with the same level of public health competence that its peer developed nations have demonstrated.

“President Trump’s time in office,” the Lancet commission charges, “brought misfortune to the USA and the planet.”

The 45th president, the commission adds, expedited the spread of Covid with his “contempt for science, facts, and equity.”

The Lancet commission analysis abounds in the particulars. Pre-pandemic, for instance, Trump eliminated the National Security Council’s global health security team. His 2017 hiring freeze left almost 700 federal disease-control positions vacant. That “compromised preparedness,” as did his administration’s move, early on, to halt a “nearly completed effort by the Occupational Safety and Health Administration to develop airborne infection control standards for workplaces.”

Few Americans will find the commission’s core charge — that the Trump years undercut American public health — particularly surprising. But the Lancetcommissioners also have a deeper point to make: The health of the American people was hurtling “on a downward trajectory” even before Trump took office. Between 2014 and 2018, well before the coronavirus, the United States experienced the first three-year decline in life expectancy since World War I and the 1918 flu pandemic.

“Stagnating longevity,” the Lancet commission notes, has always “signaled grave societal problems.” In the United States, most of those problems revolve around our staggering inequality. Since the 1980s, the commission details, “the disparity between social and economic classes has widened” as unions have lost clout, trade policies have disappeared high-paying jobs, and tax and social policies have “increasingly favored the wealthy.”

“This widening income inequality,” the commission posits, “has widened inequalities in health.”

Adds the panel: “Many of President Trump’s policies do not represent a radical break with the past but have merely accelerated the decades-long trend of lagging life expectancy that reflects deep and long-standing flaws in U.S. economic, health, and social policy.”

Even President Barack Obama’s landmark health care achievement, the Affordable Care Act, “owed more to neoliberal tenets than to the progressive precepts of the Roosevelt era,” the commission argues. The ACA left “nearly 30 million uninsured” and funneled new public dollars “through private insurers whose exorbitant overhead and profits drain funds before they reach the clinic.”

These arrangements, the Lancet commission continues, “reinforced decades of market-oriented reforms that made profitability the fundamental measure of performance, drove the commodification of care, and increasingly vested control in investor-owned conglomerates.”

Trump’s policies, in short, have been no aberration. They represent instead “an aggressive acceleration of decades-old trends toward deregulation and market-based reforms” that have helped massive investor-run health-care systems buy up independent hospitals and physician practices and use “their monopoly power to leverage higher fees.”

“Venture capital and private equity firms,” the commission notes, “have pushed dermatologists they employ to boost revenues by promoting cosmetic procedures, implemented billing practices that saddle emergency patients with surprise bills, and closed urban hospitals sitting on valuable real estate.”

For-profit hospitals overall, meanwhile, “often select services on the basis of profitability, resulting in loss of emergency services and harm to communities.”

The resulting “lagging life expectancy” has “coincided with growing income-based and education-based mortality gaps among adults.”  By 2014, well before Donald Trump, the nation’s wealthiest 1 percent were living, on average, 15 years longer than the poorest 1 percent.

Mortality numbers like these helped move the White House to Donald Trump in 2016. His county-level vote share in 2016 closely correlates, the Lancet commission points out, “with mortality trends.” Counties where over 60 percent of locals voted for Trump had higher life expectancy in 1980 than those counties where over 60 percent went for Hillary Clinton. But by 2014 these same Trump counties lagged more than two years “behind counties that had voted for Clinton.”

“The suffering and dislocation inflicted by Covid-19,” the Lancet commission sums up, “has exposed the frailty of the U.S. social and medical order.”

We need, the commission concludes, “a new politics” that “rests on a vision of shared prosperity and a kind society.”

A sensible prescription.

Sam Pizzigati writes on inequality for the Institute for Policy Studies. His latest book: The Case for a Maximum Wage (Polity). Among his other books on maldistributed income and wealth: The Rich Don’t Always Win: The Forgotten Triumph over Plutocracy that Created the American Middle Class, 1900-1970  (Seven Stories Press).