America’s Public Health Crisis Demands a Populist Solution
While Joe Biden protected a failed health care status quo, Donald Trump promises disruption. But we need more: a radical reimagining of public health that empowers working people as both recipients and providers, not consumers in a broken system.
Despite spending roughly two times more per capita on health care than other high-income countries, US health outcomes were far inferior. (Ridofranz / Getty Images)
National news is abuzz with Jay Bhattacharya’s nomination to director of the National Institutes of Health — the world’s preeminent health research agency with a $48 billion budget. Four years ago, Bhattacharya was widely denounced within professional medical and public health communities as a reckless, fringe figure. What has happened since in our national health landscape such that he could now be set to assume a position with such enormous influence over the nation’s health, and what does his nomination portend for its future?
When Joe Biden became president of the United States, an ongoing pandemic had exposed the nation’s public health and health care systems as failures. After decades of delusional thinking inside US medicine, media, and politics shaped by health care–industry propaganda that claimed Americans enjoyed “the best health care in the world,” no one could continue denying — not with a straight face, anyway — an obvious truth: health capitalism, in which profit rather than people is the priority and thus privatization rather than strong public institutions is the goal, is conducive to either good medical care or effective public health.
Despite spending roughly two times more per capita on health care than other high-income countries, US health outcomes were far inferior. Compared to peer nations, life expectancy was considerably worse. Our premature death rate topped the list. And public distrust of medicine, science, and government had reached historic highs. America’s deeply unpopular health systems were ripe for disruption and reconstitution on a fundamentally different model.
But at a moment when a progressive paradigm shift was obviously needed and could have generated broad popular support, Biden instead insisted on “a return to normal,” consistent with his 2020 private campaign promise to wealthy donors that nothing would fundamentally change if he were elected. Neither the deaths from COVID-19 of nearly a million US residents under his watch nor an historic drop in US life expectancy has been enough to deter him from this goal.
To achieve it, Biden oversaw the removal of over 25 million US residents from Medicaid. He also allowed the expanded child tax credit, which had cut child poverty in half and brought a host of health benefits to both children and adults, to expire. Changes like these, meant to dismantle public support programs rolled out amid COVID, led to the largest one-year increase in poverty in the nation’s history — a major public health problem when poverty is estimated to be the fourth-leading contributor to premature death in the United States.
When Kamala Harris took over as the Democratic nominee, she told us she could think of nothing she would change about Biden’s policies and almost entirely avoided the subjects of health care and public health during her campaign. Ultimately, perhaps the best one can say about Biden and Harris’s health legacy is that they made some marginal improvements to the Affordable Care Act and enabled limited Medicare negotiation of drug prices with pharmaceutical companies. However, they refused to even broach the subjects of single-payer universal health care or major reforms to US public health institutions. As a result, US mortality has continued to increase even after the decline of COVID-associated deaths — something not seen in any other wealthy nation. And distrust of public health has, justifiably, continued to mount.
Many Democrats explain away Biden and Harris’s failures by claiming that “political will” for progressive health policies was simply not there. But as the sociologist and cultural theorist Stuart Hall once observed, “Politics does not reflect majorities, it constructs them.” If ever there has been a period in US history when the construction of mass popular support for the progressive transformation of public health and health care could have been possible, the last four years was it. But rather than attempt to build such support, Biden and Harris instead devoted themselves to the defense of an indefensible status quo.
Trump and the American right, by contrast, are very well-attuned to the political fact that popular movements must be invented and public opinion shaped rather than regarded as simply given, static, or naturally occurring phenomena. And when liberals refuse to address the glaring failures of existing public systems and decline to hold their own leaders accountable for their abysmal health policies that constitute “an invitation to tyranny,” they should not be surprised when right-wing populists capitalize on the void they have left.
Trump’s Public Health Disruptors
In this context of the Democrats’ concession to their opponents of public health as a political rallying point, Donald Trump has ascended to power for the second time, promising generational disruption to US health systems by nominating a slew of unconventional figures to lead the federal government’s health agencies. Part of what sets these individuals apart from more typical nominees is their outspoken criticism of the institutions over which they are set to assume leadership and loud calls to upend their basic operations.
Many public health scholars and progressive activists have also asserted that US health agencies are all overdue for major reforms. It is not the high likelihood of impending changes, then, that is controversial or that has provoked alarm in response to Trump’s chosen officials; it is the unclear direction they will take a sector of government in which reckless attempts at “creative destruction” could lead to even more preventable death and disability than we already suffer.
This is a serious risk, given that Trump’s cadre of health contrarians have risen to prominence via calls for dismantling existing policies, regulations, and institutions while offering little detail regarding plans for the reconstruction of public health in another model. They have also, so far, provided limited evidence that they would push back against their boss — a man who once publicly suggested injecting humans with bleach to treat COVID — should he instruct them to implement harmful, scientifically deranged, or unethical ideas.
Criticizing others’ failures is always easier than implementing successful solutions of one’s own. And a reality facing Trump’s heads of health is that the consequences of their work will be readily measurable. If what they do does not improve the nation’s core health outcomes, they will and should be held to account. And to succeed in the realm of either public opinion or hard epidemiological statistics, they will need to make clear to the public, Congress, and the White House what exactly it is that constitutes the model of public health to which they are putting an end and what defines the alternative they must build in its place.
To do so, they would be wise to lean into the convergence between their own criticisms of existing US health norms and parallel critiques of neoliberal public health that have long emanated from the Left. Furthermore, they would benefit from embracing corresponding proposals for rebuilding public health on a populist model. This model has the potential to unite left and right in service of genuine public health — and in repudiation of elitist technocrats who have for so long allowed mass preventable death for corporate profits to be our national norm.
Moving from Neoliberal to Populist Public Health
Whether approaching our present problems from the left or right, to rebuild public health, we must first confront the failures of the dominant neoliberal model that has been promoted by both Democratic and Republican administrations since at least the 1980s under Ronald Reagan.
Neoliberal public health is characterized by antidemocratic rule by technocratic experts who prioritize privatization and reactive market solutions at the expense of robust care public systems, corporate regulations, and direct services for prevention. It assigns moral responsibility for health to individuals, portraying illness as a result of personal failure or bad luck. This viewpoint hides the structural inequalities caused by public policies that have cut essential services, replacing them with self-interested philanthropy and marketable commodities. This approach fuels moralistic health rhetoric and individualistic policing of behavior — think, for example, of the rhetorical wars over mask-wearing or fat-shaming — that condemn and alienate millions of people while neglecting the root causes of disease.
Public health in this failed mold medicalizes social distress and isolation, treating poverty, trauma, and exploitation as if simply neurobiological conditions to be managed primarily by mental health professionals and pharmaceuticals rather than problems requiring redress through reparative public policies for systemic change and supportive community. And it divests from community-based care based in trusted interpersonal relationships, leaving working-class people to navigate condescending, elitist health care institutions that rarely reflect their needs or values. Millions of Americans today know health care best through extravagant bills and threat of bankruptcy. None of this supports health, nor does it provide any basis for trust in public health institutions.
A populist public health model represents a profound departure from this paradigm and a return to what public health should always have been about: a project by and for the people. It begins by centering policies that deliver immediate, tangible benefits to working-class individuals and communities at the highest risk for preventable disease and death. This approach demands investments in direct public care services and jobs that address the political-economic determinants of health — housing, nutrition, community safety, workplace conditions, and economic security — rather than relying on punitive or coercive measures. Programs like universal childcare, housing-first initiatives, harm-reduction services rather than criminalization for people suffering from addiction, and direct cash transfers, such as those provided by the expanded child tax credit and the emergency checks sent to Americans during Trump’s first term, demonstrate how public health can be reoriented to meet people’s everyday needs.
Rather than just vainly demanding that people change their behaviors without support to do so, populist public health enables people to move freely and enjoy healthy environments by embracing policies that directly facilitate risk-reducing behaviors. To encourage people to stay home from work when sick with infectious illness, for example, it provides guaranteed paid sick leave. Rather than enforcing mask mandates or school closures, it requires and supports installation of high-quality air filtration systems in schools, restaurants, high-density workplaces, and other high-flow spaces while also supplying free masks.
To encourage healthier diets, it provides government subsidies to small farmers and to working-class consumers for purchasing fresh produce at neighborhood farmers’ markets — rather than giving tax breaks to corporations that sell cheap ultra-processed, designed-to-be-addictive foods while putting providers of healthier options out of business. To foster increased physical activity and neighborhood safety, it makes evidence-backed investments in public parks, greening urban spaces and repairing homes, installing better streetlights, and providing access to cost-free public reaction facilities. In sum, instead of helping people accommodate themselves to unhealthy environments while telling them to manage their own individual risk tolerance, populist public health uses the tools of government to make our environments healthier and safer for everyone, while maximizing individual freedom and collective well-being.
Central to this model of public health is a shift toward participatory care, whereby working-class people are empowered not just as recipients but also as providers of care to their own neighbors. Publicly funded programs to train and employ community care workers in properly compensated career positions offer a clear example: these nonprofessional workers, recruited from the same communities they serve, can provide essential services such as chronic disease prevention and management, mental health support, elder care, and assistance with the resolution of housing or food insecurity. And in exceptional times of epidemic crisis or natural disasters, the availability of a trusted relationship-based infrastructure like this is invaluable for contact tracing, supportive care, and rapid vaccination campaigns, for example. This is the kind of democratized, populist care infrastructure that earns trust in public systems by rooting them in the lived experiences of working-class people and providing mechanisms for their insights to shape the bottom-up design and delivery of care.
Unlike neoliberalism’s ever-growing reliance on profitable medical interventions as expensive Band-Aids for policy failures, this model prioritizes demedicalization by providing public funding for community-based, nonmedical services for prevention and care. By doing so, it reduces overreliance on America’s capitalist health care industry and diminishes its perverse political power that thrives on disease and professional hierarchies while — at a structural level — opposing prevention and the democratization of knowledge and care.
Health Politics Beyond Parties
Public health has the potential to be a unifying force in a nation riven by destructive partisan divisions and blind loyalties. It should be a project that brings people of all groups together in recognition of our inescapable interdependence such that neglect for any group eventually boomerangs back as harm for everyone. Public health should recruit us all into a common pursuit of shared well-being, safety, and positive freedoms via public protection for rights to care, housing, basic income, and community. But to realize this potential, we must abandon the punitive, profiteering, and elitist models of our present health systems and build a broad-based movement for public care.
A populist public health agenda is about more than preventing disease; it is about creating conditions for collective flourishing, mutual concern, and democratic participation in caring for one another. It is about ensuring that everyone, regardless of identity or class, is ensured the material and social resources to realize their own unique potential. It means reimagining public health not as something imposed on people but as something built with them — a project that earns trust by including those it serves in shaping the conditions of their own lives and communities.
This is the promise of populist public health: not rule by detached experts nor hollow appeals to individual responsibility, but care by and for the people. By embracing this vision and actively participating in it, we can transform public health into a force that unites rather than divides, empowers rather than punishes, and repairs rather than alienates.
There are abundant reasons to doubt that either Trump or his federal health nominees are sincerely interested in building a populist public health system. There is also a risk that they will cynically deploy some of its rhetoric to grease the wheels of yet deeper public abandonment and opportunities for private profits that could yield devastating consequences for the country. If they do this, we should do everything possible to oppose it. But they could also surprise millions who never would have voted for Trump by instead demonstrating that while public health is intrinsically deeply political, it need not be captive to petty partisan politics.
Regardless of the party affiliations of whoever finally takes on the necessary task of bucking the for-profit health care industry, transforming America’s health systems, and replacing them with actually effective public health infrastructure, we should all root for them — even if they come from the least expected corners of our increasingly bizarre reality. After all, as we have already seen, the changes that the US public so desperately needs are unlikely to be initiated by traditional medical and public health professionals who have slowly built careers within the current system by submitting to its existing neoliberal norms.