Throughout the first months of President Donald Trump's second term in office, his administration has taken swift action to undermine the role that government health agencies play in the health policy-making process. This article makes the case that the Trump administration's efforts to undermine government health agencies' regulatory authority reflect a dislike and distrust of the people who serve in key civil service roles. It also provides evidence that efforts to roll back regulatory authority are part of a long-standing political strategy to cater to public dislike and distrust of scientific, medical, and academic experts. While the public could provide policy makers with an incentive to protect public health agencies and the people who staff them, recent public opinion research shows that many Americans simply do not know or do not care enough about the Trump administration's actions to call for their elected officials to stop them. This article concludes by offering several health communication strategies and directions for future research (the "science of standing up for science") that might inspire public concern about efforts to roll back government health agencies' regulatory authority and might motivate people to show support for the civil servants who staff those agencies.
Public health is under siege in the United States-particularly the parts of the field that focus on health equity. Although it may be tempting to abandon health equity efforts during this siege, this article argues that would be a mistake for the field. Research on the history of public health has shown that health equity pursuits were essential for building the field, and contemporary research continues to find that health equity pursuits remain popular and are effective for mobilizing large and diverse segments of the population to engage in individual and collective actions that advance the field's goals. The pursuit of equitable and healthy futures may be one of the effective pathways for sustaining the field's future.
In 2022, 48.7 million people in the United States (17.3% of the population aged 12 or older) met the criteria for substance use disorder (SUD). Nearly 40% of people with opioid use disorder (OUD) are Medicaid recipients, making Medicaid the largest single source of OUD treatment insurance coverage. Despite this crucial importance, two major barriers to expanding access to treatment for persons with SUD are baked into the program: the institutions for mental diseases (IMD) exclusion and the Medicaid inmate exclusion. This article first provides a timeline of these two waiver reforms to illustrate the variation in waivers over time and across states. Then it assesses the evidence to date on how well the SUD waivers are working to accomplish these goals in states that have adopted them. This review will focus on the SUD waivers that address the IMD exclusion, because the Medicaid inmate exclusion waivers are too new for any systematic evidence. It will then consider outstanding implementation challenges and policy risks associated with the IMD and Medicaid inmate exclusion waivers, and it will conclude by considering challenges that these waivers do not address and that therefore demand particular attention to properly serve persons living with SUD.
Since Congress enacted Medicaid estate recovery into law in 1993, there have been few changes to the policy and little research to investigate its effectiveness. Under Medicaid estate recovery-a response to the rising and uncertain costs associated with long-term custodial care among a rapidly aging American population-states have the right to track former Medicaid beneficiaries' assets and seek recovery from their estate after their death. Although it makes an insignificant dent in state budgets, Medicaid estate recovery can nonetheless have a lasting impact on the lives of families subject to its repayment requirements. For low-income families where homeownership is their primary source of wealth, policies aimed at homeowners may exacerbate longstanding disparities in wealth and disproportionately burden Black and Hispanic families. Recently, some states have initiated policy changes to address problems with Medicaid estate recovery, and similar legislation has also been introduced in Congress. Such reforms, if more widely adopted, may improve the financial circumstances of surviving family members of deceased Medicaid beneficiaries.
A core mission of the US Food and Drug Administration (FDA) is to advance public health through regulatory decision-making, demanding both scientific expertise and political judgment. Since its inception, the FDA has undergone frequent reform intended to better position the agency to fulfill its mission with attention to evidentiary standards, patient autonomy and protection, innovation and access, transparency, and independence. The FDA is situated within the executive branch, so it is reasonable for the agency's priorities and approach to change with administrations. However, the scope, number, and magnitude of changes in the second Trump administration have been extraordinary, including tremendous loss of expert staff and leadership, proposals for rushed reviews and approvals based on little evidence, "expert panels" lacking public input and conflict-of-interest vetting, and political interference in lieu of established science and procedures. Scientific rigor and public trust in the FDA's decisions are at stake. Yet this crisis may offer an opportunity to rebuild and reenvision the FDA for the future. This article proposes that developing a core set of principles and associated metrics can shape rebuilding and reform by providing a framework for guiding FDA policy choices, a shared evaluative structure for assessing agency actions, and parameters for differentiating reasonable policy changes from unreasonable ones.
Health data linkage systems are essential for understanding and addressing health inequalities, yet the US system-already constrained by legal and institutional limitations-has been further eroded by the second Trump administration's policies. These include defunding data collection, politicizing inequality-related research, and breaching privacy rules that protect personal data. This article draws on documentary analysis, secondary data, and comparative institutional review to document recent changes to US health data infrastructure and evaluate alternative models from France, Sweden, and England. The authors find that the Trump administration's actions have severely undermined the US health data linkage system, disrupting the production of data and undermining public trust. A centralized system like Sweden's offers broad data linkage capacity but may not be feasible in the United States because of privacy concerns. France's tight controls on access limit usability to elite analysts, exacerbating inequality. England's nascent system offers a model for equitable access to data on social, economic, and political determinants of health. Rebuilding the US health data linkage infrastructure after Trump will require restoring public trust, restoring collection of key sociodemographic indicators, and ensuring equity in access. International examples provide guidance for a more politically sustainable, inclusive system.
This article examines the implications of recent and proposed reductions in federal public health funding with a focus on how these cuts disproportionately impact rural and low-resource communities. Drawing insight from national datasets, the authors document the increasing reliance of state and local public health systems on federal funds, particularly in the aftermath of COVID-19. Scenario modeling reveals that a rollback to pre-COVID federal funding levels would likely leave many local jurisdictions unable to sustain core public health services, especially where local fiscal capacity is limited. The authors argue that, while some communities may be able to partially offset federal losses with local revenues, most lack the means to do so at scale, particularly in rural areas already strained by limited infrastructure. This article offers empirical estimates of federal support, evaluates the plausibility of local revenue substitution, and analyzes the consequences of federal disinvestment for the Foundational Public Health Services. These findings underscore a key tension in federalism in which calls for local autonomy amid shrinking federal support risk exacerbating health inequities and eroding core protections, both of which lead to critical questions about the federal government's role and responsibility in ensuring a resilient and equitable public health system.
American public health is in crisis. The second Trump administration has imposed sweeping budget cuts and staff layoffs on federal health agencies, eroded the nation's public health infrastructure, and pursued myriad policies that imperil population health both in the United States and across the world. Why is public health under siege, and what does this tumultuous moment reveal about the politics of public health? This article chronicles the damage to public health caused by the Trump administration; analyzes the sources of public health's current predicament, including rising partisan polarization, the COVID-19 backlash, and a shifting political environment; and explores the challenges that lie ahead if public health is to surmount the turmoil that now engulfs it.
The Trump administration is restructuring federal health agencies to implement a new policy agenda. Central to this agenda is the Make America Healthy Again movement, which prioritizes individual solutions to broader public health problems, disregards science and scientific institutions, and aligns closely with the "wellness" industry. While it is normal for each administration to establish its own public health priorities, previous administrations did not dismantle existing institutions to do so. In contrast, this administration is consolidating power and actively politicizing the federal health bureaucracy, undermining scientific expertise and agency independence in the process. These changes are likely to have lasting impacts on both federal health agencies and public health that will extend well beyond the current administration.
Since the election of President Donald J. Trump to his second term in office, his administration has taken many steps to weaken public health infrastructure and agencies, which is likely to have an impact on population health. Less discussed have been the health impacts of ostensibly "nonhealth" policies that the administration is also implementing. Drawing on the social determinants of health framework, the authors analyze how policies across the domains of environmental regulations, food assistance, housing, immigration, and economic policy fundamentally shape population health outcomes. The administration's sweeping deregulatory agenda-including rollbacks of environmental protections, cuts to nutrition assistance programs, and immigration enforcement policies-represents a systematic threat to the policy infrastructure that supports population health. These changes threaten to widen health gaps and undermine decades of progress in addressing the root causes of poor health. The analysis demonstrates that in evaluating contemporary threats to population health, we must look beyond traditional health sector policies to understand how the broader policy environment shapes the conditions in which people live, work, and thrive.
The withdrawal of the United States from the World Health Organization (WHO) raises crucial questions about its future as the governing international organization for health. The executive order on withdrawal was one of President Donald Trump's first acts in his second term. Because the United States is WHO's biggest funder and most powerful state backer, withdrawal could indicate an existential threat. However, almost simultaneously member states passed a new international Pandemic Agreement expanding WHO's authority. How should these conflicting signals be understood? Analyzing WHO's decline in a context of broader US and geopolitical shifts, the authors find that withdrawal is the outcome of the end to broader political orders of neoliberal internationalism on which WHO depended for legitimacy rather than idiosyncratic Trump politics. WHO's reliance on certain international norms and power structures leave it compromised. US normative and institutional shifts are far more difficult for WHO to navigate than in past political eras. Therefore, international relations research suggests that avoiding catastrophic impacts depends on reform actions by WHO officials, other member states, and US actors. States and others in the United States will face harm from WHO decline, and the authors suggest that US actors have legal standing to challenge withdrawal. Complacency and inaction may be WHO's biggest risk.
How unprecedented is the current backlash against the public health enterprise? In this article, the author explores previous attacks against public health practice in three exemplary domains: mass vaccination programs, air pollution control, and occupational safety. The author argues that in all three, public health was remarkably durable throughout the 20th century, and that most controversies over its powers-or even direct onslaughts from hostile elected officials-have failed to overturn long-standing practices or institutions, even if implementation may be altered for the worse. Once public health traditions and the infrastructure that erects them become entrenched, they have remained difficult to fully eliminate. There are signs, however, that the second Trump administration's assault on public health is different, both in the ferocity and velocity of its actions and in the new 21st-century context it inhabits, with different legal precedents, cultural beliefs, communication practices, and political norms. Throughout, the author also identifies historical seeds of public health's current crisis in the late 20th and early 21st centuries.
This article addresses the unprecedented politicization of science and health institutions, which threatens the functional integrity of democratic governance itself. Regulatory measures have weakened the infrastructure for evidence generation, constrained the autonomy of scientific actors, and subordinated public health priorities to cultural grievance and political loyalty. False and misleading information about core scientific knowledge is amplified not only in social media but also by government itself. Disinvestment from the National Institutes of Health, advisory body sidelining, and public rhetoric casting science as elite overreach have together eroded the credibility of United States health leadership both domestically and abroad. Moreover, targeting policies in research portfolios designed to enhance diversity, equity, and inclusion jeopardizes both representational justice and the innovation capacity of American science at large. This article traces the historical and political structure of science-politics confrontations and details the damage to the public health and research ecosystem. It offers proposals to reconstruct the scientific enterprise in the next presidential administration.
CONTEXT:Target populations do not always recognize policy benefits. This may be particularly true when policy design, informational environment, or political conflict make a policy's benefits difficult to discern, which is the case for the Affordable Care Act (ACA). Although many groups benefited from the ACA, the attitudes of seniors-one important target population of the ACA-remain unexplored. METHODS:A survey of 1,206 Americans age 65 and older was fielded in the summer of 2021 to assess the effect of three informational treatments about the ACA's benefits-extending the life of the Medicare trust fund, filling the Medicare Part D donut hole, and reducing the number of uninsured people-on the ACA's favorability and on attitudes about its future and about party leadership in the domain of health care. FINDINGS:Priming individuals about the ACA's benefits improved its favorability, particularly for subgroups generally opposed to the ACA, such as Republicans and those high in racial resentment. Attitude changes about the future of the ACA were limited to benefits directly focused on seniors. There were no broader spillover effects on attitudes about partisan health care leadership. CONCLUSIONS:The findings have implications for research on the ACA, policy feedback effects, self-interest, and priming effects.
CONTEXT:In recent decades, many countries experienced a reduction in the quality and functioning of democratic institutions and norms accompanied by rising social distrust and opposing political views. The decline in vaccine confidence might be linked to these trends. This study explores the political factors influencing individual attitudes toward vaccination across 22 upper-middle-income and high-income countries, examining the interaction between political orientation, trust in public health authorities, and levels of democracy. METHODS:The authors used the VaxPref database, encompassing demographically representative data from 50,242 respondents collected between July 2022 and June 2023, to conduct an analysis on three levels: pooled sample, democracy groups, and country-specific analyses. RESULTS:The authors found that higher democracy scores generally correlated with lower levels of vaccine skepticism. People in the political center and on the political right expressed more skepticism toward vaccines overall. However, trust in public health authorities emerged as the determinant that explains the largest variation in vaccine attitudes. CONCLUSIONS:These findings suggest a greater effectiveness of democratic systems in fostering vaccine confidence and the need to depoliticize vaccination efforts. Building and maintaining trust in scientific information and technical expertise is critical. Blunt measures like vaccination mandates may not sustain long-term confidence, particularly in democratic contexts. Effective interventions should prioritize comprehensive school-based education to promote preventive health behaviors coupled with targeted trust-enhancing communication strategies.
Context: Community Health Centers, a key part of the health safety net in the United States, have a long tradition of promoting political participation, but few studies have examined this influence. This paper fills the gap by examining how health centers influence election participation and outcomes. Methods: This paper develops an innovative county-level dataset on health center coverage from 2006 to 2022 using ZIP code-level patient data and examines how health center coverage is associated with voter registration, turnout, and the Democratic presidential candidate's vote share. It also examines whether these associations are stronger in high-poverty counties, where voting is more challenging. Findings: In most election years, health center coverage is positively associated with voter registration rates(except in 2018 and 2020) and turnout rates (after the ACA) in high-poverty counties, but not in other counties. There is no consistent evidence showing that higher health center coverage is associated with a higher Democratic vote share. Conclusions: Health centers appear to play a more consistent role in facilitating election participation than in shaping electoral outcomes, with stronger effects concentrated in high-poverty counties. Health centers' influence may vary with the broader political environment, such as the passage of the ACA.
Context: Attention to the potential impact of highly pathogenic avian influenza (H5N1, or “bird flu”) on human health increased following documentation of mammalian transmission in Spring 2024, and the prevalence of H5N1 in the commercial dairy supply. We aim to quantify (a) the prevalence and (b) socio-political correlates of public concern about H5N1, as well as support for policy action aimed at reducing its potential health risks. Methods: In a nationally representative survey of N = 831 US adults, we asked respondents to answer questions about their levels of concern about H5N1 transmission, beliefs about the safety of consuming unpasteurized milk products, and support for policy interventions. Results: Few Americans express high levels of concern about the H5N1 health risks. People who express lower levels of concern about H5N1 and those who hold inaccurate or uncertain views toward raw milk safety are in turn less supportive of policies aimed at mitigating the spread of H5N1; as is both anti-intellectual attitude endorsement and partisan identification with the Republican Party. Conclusions: Moderate levels of concern about H5N1 risks could undermine pandemic preparedness. Lacking strong signals from the public, policymakers may be reluctant to pursue policies that reduce avian influenza's pandemic potential.
Context: The COVID-19 pandemic highlighted the importance of public health programs in preventing diseases and providing health security for entire populations. Yet, governments invest very little in preventive health care. While it is generally assumed that this lack of public investment reflects individuals' lack of interest in public health, few studies have actually studied the public's preferences on this issue. Drawing on the literature on social investments, this article brings politics into the study of individuals' preferences for public health and curative care. Methods: We rely on an original survey conducted in four OECD countries among 8,000 respondents to assess how citizens trade off preventive and curative care. Findings: We show that higher trust and liberal social values are associated with support for preventive health care, as both variables correlate with support for policies whose benefits unfold in the long term. By contrast, individuals with poor self-rated health and low satisfaction with health care services prioritize expenditures in curative care that are beneficial to them in the short term. Conclusions: These findings advance previous research by identifying the groups that demand additional investments in public health and those who prefer to allocate more resources towards curative care.
Context: Despite precision medicine's promise to revolutionize healthcare, access remains uneven, and disparities persist. This study examines how conflicts between the institutional logics of genetic science (“discovering”) and market-based health insurance (“covering”) impede precision-driven health equity. Methods: We conducted 44 semi-structured, in-depth interviews with individuals at elevated risk for hereditary cancer. Data were analyzed using an abductive approach, combining thematic analysis with grounded theory tools. Findings: Analysis reveals seven “zones of conflict” where precision medicine's aspirations clash with insurance practices, creating barriers to genetic testing and related services. These zones span initial access barriers (e.g., complex billing, inconsistent guideline uptake) and downstream care factors (e.g., financial concerns, lack of retesting guidelines). The interplay between expanding genomic knowledge and the fragmented American healthcare system particularly disadvantages underrepresented and minority populations. Conclusions: Participant experiences reveal more unanticipated sources of inequity than precision medicine proponents anticipated. Incremental reforms targeting these conflict zones, such as guideline harmonization, expanding coverage mandates, and enhanced patient advocacy related to insurance coverage, could mitigate cascading disparities. This study highlights the importance of addressing institutional misalignments to realize the full equitable potential of precision medicine involving genetics.
