What is the worst that could happen (for U.S. health)?

Thinking about the potential consequences of a policy landscape in flux

This piece was co-authored by Dr. Nason Maani.

The U.S. stands at a moment of uncertainty regarding its future health and well-being. The current administration has now sought to act on a range of fronts in advancing its policy agenda. These early actions have affected almost all levels of government, many of which will have an attendant impact on health. What this impact might be in the long term remains to be seen, a view that is complicated by both the speed and breadth of the federal actions, and the extent to which these actions are directly affecting our capacity to measure their effects — as in the case, for example, of enforced pauses on health agencies’ communication.

With this in mind, we ask, considering what we know, what is the worst that could happen to U.S. health, what challenges should we be most aware of and anticipating? In asking this question, it is important to note the importance of adjusting for our biases and avoiding a reflexive engagement with the emotions of the moment. It is on us to make an effort to be dispassionate, because dispassion supports the reasoned, fair-minded perspective that helps us to do and say only what is constructive at a time that calls for approaches that build, not break. We have written before about the importance of maintaining this perspective, recognizing that we have just had an election in which the American people chose a particular vision for the US and—while they could not have foreseen all of what has happened since and may well not support much of it—we need to recognize that many of the policy changes of the moment would likely be considered at least directionally correct by roughly fifty percent of the country.

At the same time, we speak from a particular perspective—that of working to create a healthier world—and this perspective entails evaluating as best we can the likelihood of a particular policy approach to get us closer to, or farther from, better health for all. That is what we are aiming to do in this essay, as we tackle the question, “what is the worst that can happen for health?”

Now, to the question. Answering this question it turns out, is complicated, in part because we are often not very good at prediction.

Perhaps we can take a step back and learn from the most recent crisis to face health in this country: COVID-19. The pandemic was a powerful lesson for the U.S., an instructive grounding to help us answer the questions we now pose concerning our immediate future. Although the U.S. had invested substantially in pandemic surveillance and preparedness, the country fared far worse than its peers during the pandemic. Why did that happen?

First, the U.S. population was already in poor health, with substantial health gaps driven by social inequality and low levels of social protections. This meant that the pandemic affected a country characterized by a substantial proportion of its population living in cramped low-income homes; a large undocumented worker population that feared contact with authorities; a sizeable number of single-parent households; poor internet connectivity; a large segment of the population with little savings to weather gaps in employment; and the ability to work remotely strongly patterned by education and income, race and ethnicity. These patterns increased the spread of COVID-19 and the impact of that spread. They reduced the inability of those with fewer resources to socially distance and increased the costs of that social distancing for children and adults, in both the short and long term.

Second, while the U.S. spends enormous amounts of money on treatments and cures, it has underinvested in public health infrastructure and capacity. This has meant that while the country had world-leading biomedical research capacity during COVID, there was no flexible, well-trained, well-resourced, adaptable public health workforce ready to do the work of data collection, contact tracing, linking data together, and identifying viral hot spots. The U.S. had for decades underinvested in its public health infrastructure, with large state-by-state variation in capacity and data, and such long-term declines and patchiness in coverage and capacity could not be reversed by urgent, short-term funding.

While these issues were exposed during COVID-19, they had been festering long before then and have been leading causes of poor life expectancy in the U.S. for decades. This means that the U.S. was already in poor health, substantially lagging behind its peers, when the pandemic struck. COVID did not create the problem — it merely exacerbated it.

This vulnerability has not gone away.

Any current pressures on health sit atop a foundation with deep cracks and fissures. In asking, then, what is the worst that could happen in the current moment, we need to look beyond the headlines about changes to Medicare provisions, or cuts to specific health research budgets. Instead, we need to consider what these changes mean for the health of the U.S. population as a result of all the wider forces that shape health.

Social Security offers an example of how this can manifest. While Social Security cuts have not formally been announced, efforts are being made to decrease staff at the Social Security Administration, even though staffing levels were already at 50-year lows. Evidence from austerity policies in the UK suggests that when access to social security benefits is further restricted, there is a corresponding drop in life expectancy. Currently, about 69 million Americans receive monthly Social Security benefits and stand to be affected by challenges to access.

Food security and potential upcoming restrictions on the Supplemental Nutrition Assistance Program (SNAP) in the current House Farm Bill offer another example where proposed policies could have a range of negative health effects. According to the U.S. Department of Agriculture, 18 million households, or 13.5% of all U.S. households, experienced food insecurity (in other words, not having access to enough food for an active, healthy life) in 2023. This included 6.5 million households with children, a significant increase from 2022, part of a rising trend since the pandemic. Proper nutrition during early years is one of the foundations for health throughout the life course, and food insecurity during childhood has been found to have long-term negative effects on learning, behavior, and interpersonal skills. Food insecurity also has direct implications for health outcomes, with a large cohort study finding food insecurity in the U.S. to be associated with a higher risk of premature mortality. Any restriction on SNAP benefits, which served about 42 million participants in 2023, is therefore likely to have acute and long-term consequences for health and development for millions of Americans.

These are but two examples — we could consider many more. Proposed large-scale cuts of some 80,000 jobs at the Department of Veterans Affairs may mean a further increase in deaths of veterans from suicide; in 2022, there were almost 18 such deaths per day in the U.S. Proposed reversals on background checks on private gun sales may lead to an increase in gun-related deaths; about 47,000 people died from gun-related injury in the U.S. in 2023. Removing the rules allowing for revocations of licenses for firearm dealers found to have broken federal laws and regulations may lead to an increase in children’s and adolescents’ access to firearms, and therefore further embed firearms as the leading cause of deaths among children.

While each of these represent perhaps worst-case scenarios (albeit all based on stated policy proposals, some of which have already been enacted or formally announced), we would argue that the worst that could happen is not just that any of these could materialize, but that as part of wider policy initiatives, we would grow numb to their effects, accepting them as a new, unfortunate normal.

Compounding the problem is that the large-scale defunding of research on health inequalities may mean we, in the future, will not understand the cascading effects of the above initiatives on health, and how these might be shaped by income, race, ethnicity, age, gender, or geographic location. The proposed downsizing of the Centers for Disease Control and Prevention (CDC) budget, which accounts for much of the federal funding of state and local health departments, and therefore a large portion of the U.S. public health workforce, means that we will be less equipped to measure and report what the health consequences of such policy change will be. The reduction by nearly a quarter of the Department of Health and Human Services workforce is likely to compound such effects, as will the reported removal of datasets and government websites on the grounds of reversing diversity, equity and inclusion efforts. Sites such as the CDC’s Behavioral Risk Factor Surveillance System (BRFSS) now include a disclaimer that “CDC's website is being modified to comply with President Trump's Executive Orders,” and some datasets and tools are simply no longer accessible, such as a tool that assesses the social factors that render communities vulnerable in times of disaster.

So, what is the worst that could happen with respect to U.S. health?

Not any specific new health crisis, although that could happen and is terrifying to contemplate. Rather, the worst that could happen is that our collective health will move in a downward trajectory, and we may not even notice until we realize, a decade from now, how far worse our health as a country is than it should be. We may come to a point where a decline in our health may feel inexorable, inevitable, and invisible to those with the wealth and privilege to remain isolated from this reality. Our view of these effects could be further obscured because we lose our data and ability to track what is happening in a way that lets us meaningfully influence any conversation about the trade-offs inherent in our policy choices.

We can agree or disagree on the merits of a particular policy, but, in population health science, our fundamental role is to bear witness to the forces shaping population health, and to be able to anticipate and map out a worst-case scenario so that we can avoid it. At the moment, it is hard not to think that we are going down a path that does the opposite.

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Also this week

New in JAMA Health Forum: Our team examined the link between medical debt and forgone mental health care due to cost. We found medical debt was linked to a 17.3 percent increase in the probability of forgone mental health care due to cost. Thank you, Kate Miller and Catherine Ettman, for your partnership on this research, and Kyle Moon, for leading this work.

In Observing Science, with Michael Stein: on advancing reliable science to support better policymaking.