Here’s what happened when Reagan went after healthcare programs. It’s not good.
The latest cuts have a less-than-stellar precedent
In the early 1980s, during President Ronald Reagan’s first few years in office, his administration slashed Medicaid expenditures by more than 18 percent. The Department of Health and Human Services budget was cut by 25 percent, essentially eliminating several public-health programs. Federal funding for maternal and child health was reduced by 18 percent — subsequent programming cuts ended up creating no administrative savings.
Sound eerily familiar? It should. President Trump’s budget also suggests social welfare program funding be reduced by $272 billion; the Department of Health and Human Services’ budget cut by 18 percent. This would mean funding for Supplemental Nutrition Assistance Program (SNAP), a.k.a. food stamps, would be reduced by a quarter and Temporary Assistance for Needy Families (TANF), a.k.a. welfare, by 13 percent. And even if republicans’ last-gasp effort to gut the Affordable Care Act fails, Medicaid still stands to see drastic cuts and changes at the state level.
If you’re wondering how these reductions might affect the nation’s health, public health experts say to look no further than what Reagan wrought. Over the summer, two prominent public health scholars raised the specter of Reagan in scientific papers as a harbinger of things to come if Republicans achieve their budgetary wishes.
Both David R. Williams, a professor of public health at Harvard University, and Sandro Galea, the dean of public health at Boston University, separately brought up the aftermath of Reagan’s similarly sweeping reductions to federal health and social welfare program funding as evidence of the potential public-health impacts of the current administration’s proposed budget cuts.
“For the past 35 years, the U.S. has fallen further behind in health. This coincides with the Reagan policies of greater disinvestment in public good,” Galea told Timeline. “We are now continuing along these lines — that’s what worries me.”
Trump’s current White House Budget Director Mick Mulvaney maintains that any cuts to health and safety net services would mean system streamlining, not ceasing to serve those in need. White House counselor Kellyanne Conway said adults cut from Medicaid can just go get jobs that offer health insurance.
The Reagan administration also repeatedly assured the public that their cuts wouldn’t result in actual harm — people would get jobs, get better jobs, or states would make up the funds. But we now know that this was largely not the case.
So what happened after Reagan’s budget cuts? A million children lost reduced-price school lunches, 600,000 people lost Medicaid, and a million lost food stamps. Women, Infants, and Children (WIC) could only serve a third of those eligible. WIC provides low-income pregnant women and children with formula and healthy food staples. Nearly 500,000 lost eligibility for Aid to Families with Dependent Children (a less-stringent precursor to TANF). This caused a two-percent increase in the total poverty rate, and the number of children in poverty rose nearly three percent.
Lack of funding meant Public Health Service Hospitals and programs that deployed physicians to rural and urban areas were shut down. More than 250 community health centers were closed. Between 1980 and 1991, 309 rural hospitals and 294 urban hospitals were shuttered. Nearly one million Native Americans lost access to Indian Health Service care when eligibility was narrowed.
“History has taught us that such cuts in health and social service programs can have pervasive negative effects on health,” Williams writes. “Negative effects were soon evident in the health of pregnant women, children, and adults with chronic disease. There was an increase in women receiving no prenatal care. The overall decline in infant mortality slowed, and an increase in infant mortality in poor areas of 20 states was evident between 1981 and 1982. There was also an increase in preventable childhood diseases in poor populations.”
From 1982 to 1987, unintended pregnancy rates increased by nearly 8 percent. The increases were especially pronounced among those living below the poverty line. The uninsured rate skyrocketed. By 1985, 15 percent of the population lacked health insurance. The health of those cut from Medicaid deteriorated.
Under Reagan, life-expectancy-at-birth of black Americans actually decreased. By 1988, a third of Native American deaths were of those younger than 45; Native Americans were 400 percent more likely than the rest of the U.S. population to die of tuberculosis and 438 percent more likely to die of alcoholism-related ailments.
Agencies were also woefully unprepared to tackle the burgeoning threats of HIV and E. coli. By 1988, the Institute of Medicine declared that the American public health system had fallen into disarray. The then-president of the American Public Health Association responded that public health activities had been “inappropriately politicized.”
The current administration’s push toward an individualistic, free-market model of government has definite echoes of Reagan, who cemented the notion of rugged individualism in American political rhetoric. Focus on how to benefit the collective good was falling out of fashion. When it came to health, this translated into a heightened sense of individual responsibility for disease.
Galea argues that while he has observed a further devolution in our sense of responsibility to the collective in recent years, the push toward individualist policies is not always motivated by a lack of concern for others. “It’s also a misunderstanding — that you can always buy your way out of something. But buying medicine does not equal buying health.”
Inequality doesn’t only affect the health of those who rely on welfare programs, it affects everyone. When funding is cut for programs that tackle public health issues — such as evidence-based sex education or addiction prevention and treatment — everyone loses.
“Wrapping your family in bubble wrap won’t protect them from the forces chipping away at the health of the group,” Galea said. “You cannot insulate yourself from everything. I cannot insulate myself from a drunk driver, from a stray bullet.”
When the gap between rich and poor widens in a country, the public’s health suffers. And boy did the gap widen during the Reagan era. Between 1982 and 1985, the poorest Americans lost 9 percent of their wealth while the wealthiest gained 9 percent. In Betrayal of Trust: The Collapse of Global Public Health, Pulitzer-prize winning journalist Laurie Garrett notes that “by April 15, 1985, for example, the poorest U.S. households — those that survived on less than $10,000 a year — were $2,490 poorer than they had been in 1982. In the same time span, the upper middle class, earning $40,000 to $80,000 per year, gained $8,620, and wealthy households taking in more than $80,000 a year netted $24,270.”
Another common misconception is that access to healthcare is the most important factor in determining an individual’s health. In the case of healthcare, however, more doesn’t always equal better. Despite spending the most on healthcare among 10 other similarly high-income countries, U.S. health outcomes currently rank worst.
“Overall health improvement requires investment in the social structures that keep us healthy and that those structures have little to do with the healthcare and medicine,” Galea explains, stressing that “although the public discourse around health focuses on medicine and health care, social, economic, cultural, and structural conditions have a far greater impact on overall health.”
Access to quality healthcare is just the tip of the iceberg: environmental protections, affordable housing, living wages, and good public schools all play an enormous role. Galea warns that if the federal government pulls back from supporting these endeavors, it “could be ruinous to health; accelerate the overall slowing of health gains and widen health gaps.” Trump’s budget suggests education spending be cut by $9.2 billion, or 13.5 percent.
“Ultimately, we need to invest in government at every level — invest in things that can make life better,” Galea said. “If things are privatized, they are run by market forces. You will have the haves and the have-nots, and the have-nots will get left behind.”
