What Will it Take to Achieve Better Health in a Divided America?

Can you solve this paradox? The U.S. spends more on healthcare than any other developed nation, yet Americans are falling farther behind when it comes to health status and life expectancy.

The paradox of the U.S. healthcare system lies in the contrast between its world-class capabilities and its mediocre population health outcomes. While our country is renowned for cutting-edge medical technology, groundbreaking research, and exceptional specialists, these strengths do not consistently translate into better health or longer life expectancy for the population as a whole.

Healthcare disparities remain at the heart of our poor population outcomes, yet I worry that the incoming Trump administration doesn’t have health equity anywhere on its agenda. Instead, I fear they are focused on advancing personal freedoms at the expense of collective well-being.

Limiting Factors to Good Health Outcomes

One significant issue is access. Many Americans face barriers to receiving care due to high costs, inadequate insurance, or geographic challenges. Additionally, the system tends to focus on treating diseases after they occur rather than prioritizing prevention and early intervention, often leaving chronic conditions poorly managed until they require intensive treatment.

Socioeconomic disparities further exacerbate the problem. Factors like income inequality, education gaps, and unstable housing create a wide gulf in health outcomes across different communities. At the same time, the fragmented and complex nature of the healthcare system adds inefficiencies and administrative burdens that inflate costs without improving care quality.

Public health initiatives in the U.S. are often underfunded compared to other countries, leaving gaps in disease prevention, mental health support, and health education. Cultural factors, such as a strong emphasis on individualism, also make it difficult to implement broad, systemic changes like universal healthcare.

Ultimately, while the U.S. excels at providing top-tier care for individuals with access to its resources, it struggles to ensure equitable, population-wide health benefits. Bridging this gap will require a shift toward prevention, equity, and addressing the broader social and economic factors that shape health outcomes.

A Poor Prognosis

A collection of studies featured in The Lancet (volume 404, December 7, 2024) recognized these issues and more. The research compiled the most robust evidence on the current state of health in the U.S. and proposed strategies for improvement. (I find it ironic that a British publication rather than a U.S.-led journal came forward in this manner.) The Lancet presented an assessment of current health in the U.S., highlighting what we’ve known for at least a decade: significant disparities rooted in geography, race, ethnicity, gender, and socioeconomic status are causing the U.S. healthcare system to backslide — and the outlook is “bleak.”

Why such a poor prognosis?

First, the good news. According to a commentary in The Lancet, the incoming Trump administration professes an interest in addressing chronic disease, promoting prevention, and mitigating harmful commercial influences on health. On paper, these goals align with a vision of improving health outcomes in the U.S.

But then The Lancet drops the hammer, critiquing these promises as inherently contradictory to the administration’s broader political ethos. It identifies a tension between the rhetoric of health improvement and the administration’s seeming hostility toward public health fundamentals, such as addressing inequality, upholding reproductive rights, and embracing regulation (for example, to promote vaccination and contain the spread of infectious diseases through other means).

The editorial’s sharp observation is that while the Trump administration will frame its policies under the banner of personal responsibility and freedom, this perspective will undermine the structural and communal supports necessary for equitable health. Public health, by nature, relies on a collective approach that transcends individualism, aiming to reduce disparities and create environments in which all people can thrive.

“Red” States Advance More Restrictive Policies

In fact, we are already witnessing “red” states advancing conservative, non-evidence-based healthcare agendas in anticipation of Trump’s return to office. Lawmakers in Oklahoma plan to further restrict abortion by limiting emergency exceptions. Arkansas is moving to establish “vaccine harm” as a criminal offense for pharmaceutical companies or their executives, potentially stymieing vaccine research. Tennessee’s prohibition of hormones and puberty blockers in transgender minors will likely be upheld by the Supreme Court, paving the way for other states to enact similar, restrictive laws. And Title IX provisions aiming to protect LGBTQ+ students from discrimination in schools may be rolled back due to the efforts of red states.

Obviously, the new administration has important choices to make about healthcare reform — not only the hot-button issues, but also disparities that have long existed in access and quality of care. The choices involve expanding insurance coverage, controlling costs, and improving healthcare outcomes for all citizens. The administration must decide how to best integrate public health measures with individual healthcare choices, ensuring that policies not only protect public health but also respect personal freedoms, as constituents have been promised.

Health and Society

Historian Timothy Snyder, DPhil, observed, “Modern public health and healthcare requires us to act together.”

Another quote, one that is often attributed to Gandhi but which he never actually said, is “A civilization is measured by how it treats its weakest members.”

Writer and Nobel Prize recipient Pearl Buck is credited with a similar quote: “The test of a civilization is the way that it cares for its helpless members.”

All reflect the idea that the moral and ethical strength of a society is revealed in how it treats its most vulnerable individuals. This principle underscores the importance of providing compassionate and equitable care to all patients, especially those who are marginalized or disadvantaged. The U.S. has fallen short of that goal.

Healthcare professionals must advocate for policies and practices that guarantee equitable access to quality care for all, irrespective of individual circumstances and free from political influence or interference. It would be deeply unfortunate if these noble aspirations were reduced to nothing more than reflections of a nation’s administrative priorities.

Arthur Lazarus, MD, MBA, is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia. He is the author of several books on narrative medicine, including Medicine on Fire: A Narrative Travelogue and Story Treasures: Medical Essays and Insights in the Narrative Tradition.

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