What would it take to ‘Make America healthy again?’ Part 1 of 2

Thinking through the realities facing such a commitment

This piece was co-written with Dr. Nason Maani.

This week Robert F. Kennedy Jr. was confirmed as Department of Health and Human Services. The possibility of his appointment has not been without controversy, with his positions on a range of issues, notably his skepticism of some vaccines, facing justifiable scrutiny. This scrutiny reflects a reasonable response to Kennedy’s nomination, given his positions and statements. At the same time, it is worth trying to engage with the health policy goals of a new administration in good faith as it implements the policies that the president ran on, even as we call out bad policy when we see it. This reflects an acknowledgement that elections are a contest of ideas, and the American people have just unambiguously endorsed a particular vision for the country, revealing an appetite for widespread changes, including to the U.S. public health system.

Before taking office, President Trump publicly stated that his goal with respect to health and science agencies is to “restore these agencies to the traditions of Gold Standard Scientific Research, and beacons of Transparency, to end the Chronic Disease epidemic, and to Make America Great and Healthy Again!” This slogan is both welcome and somewhat perplexing, given the prior positions of both the president and his Republican party on a range of health-related issues, positions that, at first glance, do not seem to bode well for health in the U.S. This includes the efforts of the first Trump administration to repeal the Affordable Care Act, the administration’s recent actions in the area of global health, and its moves to cut NIH research funding, all of which raise concerns over the consequences of its actions around health. Early announcements and executive orders by the new administration, such as ceasing reviews and external communications at the National Institutes of Health, withdrawing the U.S. from the WHO, withdrawing the U.S. from the Paris Agreement and changing the rules governing civil servants have evoked serious concerns and merit scrutiny. Ultimately, health expertise and scientific evidence should not be partisan issues, and each policy choice involves long-tail consequences for all Americans, particularly the most vulnerable. It seems imperative, then, that the administration’s intentions be treated with the respect, caution and objectivity that administrative responsibility demands. The administration says it wants to make America healthy again. So, in this piece, we will try to take this sentiment at face value and ask:

What would it take to truly make America healthy again?

Where should this administration, or any administration, focus if it is to make significant strides in improving Americans’ health?

The challenge before us

An effort to Make America Healthy Again needs to start by acknowledging the scale of the challenges to health in this country. It has been said that “the first step to solving a problem is recognizing there is one,” and the U.S. has problems indeed when it comes to health. These problems are best understood through the lenses of comparison and cost. Indeed, were one to view U.S. health outcomes by almost any comparative metric relative to its peers, it would be world-leading in one central aspect: its enormous cost. It seems inarguable that compared to its peers, the U.S. has for decades failed in its duties to protect the health of a large swath of its population (at all ages), and remains a place of profound health inequalities.

This failure is long-term and has occurred under Democratic and Republican administrations alike. While it is therefore possible, and indeed understandable, to question the new administration’s commitment to health and raise concerns about the many likely negative consequences for health that may result from its agenda, that is separate from the fact that U.S. population health is indeed in a poor state at the outset, with deep inequalities that have persisted and grown under previous administrations. The comparative examples of many other high-income countries remind us that U.S. health could be far better than it currently is, and that it is reasonable, indeed a responsibility, for a new administration claiming to want to make America healthy again to engage with this reality.

So, with an awareness of these challenges, and informed by the aspirations that the new administration has expressed, we will explore its stated health priorities toward making America healthy again and offer suggestions about what meaningful steps might be taken to improve population health in the U.S. We offer here two main reflections on the foundational drivers of our national health failures, reflecting the goals of the administration. In this week’s essay, we will talk about prevention and population health — what it takes to make the population healthy and keep it so. Next week we will address the health-care industry, and how one might improve aspects of health-care delivery. By engaging with these focus areas, with commitment, investment, and data-informed action, we can indeed make America healthy again, an enviable legacy for any political movement.

What it will take to make and keep the population healthy

Making America healthy again is not just a matter of treating disease when it emerges — if it were, our astronomical investment in health care, far higher than that of any other country, would serve us much better than it does. Rather, creating a healthy country means preventing disease before it takes hold, which will take addressing the key drivers of premature mortality in the U.S. Preventing disease aligns with the stated goals of the administration, one of which has been to address America’s “chronic disease epidemic,” and another of which has been to improve efficiency, through the announcement of the creation of the Department of Government Efficiency. As we have outlined, the cost of treating illness, and the burden of illness itself, are both disproportionately high in the U.S., representing a double burden. While there are certainly a range of ways in which the treatment of illness could be more efficient in terms of cost and availability, the most efficient, cost-effective, and just route to a healthier America would be through an emphasis on prevention, rather than treatment.

What, then, are the main drivers of preventable disease in the U.S.? When considering the principal contributors to declines in life expectancy pre-COVID-19 in the U.S., “deaths of despair” loom large. These deaths are deeply patterned by income inequality and social mobility, as well as by the proximity of associated risk factors such as firearm availability in the case of suicide, opioid availability in the case of accidental overdoses, and increasing levels of high-risk drinking postpandemic in the case of liver disease. These are examples of the scale of the challenge in making America healthier in the current moment, as these are problems that speak to the need to consider the health consequences of large gaps in income, wealth and opportunity, combined with the need for stronger public health regulations and protections when it comes to product safety.

The same could be said for another significant cause of disease and premature mortality in the U.S., the disproportionately high rate of noncommunicable diseases (NCDs) such as mental health conditions, diabetes, cancer and cardiovascular disease. Some of the key drivers of NCDs in the U.S. are obesity, tobacco use, poor nutrition, alcohol, and a lack of physical activity opportunities. These, in turn, are shaped powerfully by government actions (or lack thereof), in areas such as product marketing, the continuation of subsidies that fuel greater levels of production and marketing of cheap, ultra-processed foods, and persistent, stark inequalities in working and living conditions that create environments in which there are few opportunities to access nutritious food, creating so-called “food deserts” or “food swamps.” It is widely acknowledged that these trends will only worsen over time if we do not address these structural drivers of NCDs.

These health challenges are a primary reason why the U.S. is not as healthy as its peers and why addressing the structural causes of these challenges are what would make the U.S. healthier. Of critical importance, this would require acknowledging that much action would be needed outside health policy itself, action that would intersect with factors like environmental and food regulation, subsidies, welfare, housing, and transportation. It is simply not possible to make America healthy again if the health effects of these foundational factors are not considered. While the early signs from the new administration do not appear to bode well for addressing these areas, and therefore may well exacerbate health inequalities and hamper progress in disease prevention and overall American life expectancy, we would argue that it is possible to envision a future in which regulatory processes are simpler, and government works more efficiently, yet both are constructed in ways that are able to meaningfully address the root causes of population ill-health in evidence-led ways. In truth, considering the economic cost alone of current and projected levels of poor health in the U.S., making America healthy again is a critical national priority demanding bold action across political divides and government departments. The administration has shown a taste for boldness, but boldness can be harmful if it is poorly applied. Making America healthy again will take boldness combined with thoughtful, data-informed action that addresses the root causes of our national poor health. If the new administration and its appointees can take these steps, if they can disrupt by way of making “good trouble” rather than for disruption’s sake alone, they can leave behind a healthier country and world.

Making a healthier country therefore means putting prevention at the heart of our health agenda. However, we also need to be able to treat disease when it emerges, delivering high-quality, accessible health care to all who need it. Next week we will address how we might improve health care in this country, and how committing to making America healthier can lead us to reframing the relationship between U.S. population health and our wider approach to prosperity and well-being.