This blog post is part of a series entitled Global Agenda, in which experts will identify major global challenges facing President-Elect Trump, the options available to him, and what is at stake for the United States and its partners. This following post is authored by Laurie Garrett, senior fellow for global health at the Council on Foreign Relations.
When United Nations Ambassador Samantha Power speaks about health issues, she often notes with pride that nearly 4,000 United States military personnel did battle against Ebola in West Africa, along with 165 Cuban doctors. It’s a Barack Obama-era linkage not likely to be repeated in the new Donald J. Trump administration, tying together an outbreak on foreign soil, U.S. soldiers, and physicians from, of all places, Cuba.
Concern runs high in global health, research, and development circles all over the world about changes expected in 2017, though to date neither President-Elect Trump nor his transition team have offered any indication that such things as malaria control, rising diabetes levels in nearly all societies, access to medical care in poor countries, or pandemic preparedness are on their radar. The stakes for people all over the world, however, are terribly high. The U.S. government, through a variety of agencies and programs, is by far the most generous donor in the world, and plays an active, often dominant, role in defining health, development, and food policies for the entire planet. Whether viewed as global dependency upon the U.S. government, or responsible generosity from the richest nation on Earth, the programs are enormous, and their impact also huge. For example:
- Food For Peace, founded by the Eisenhower administration in 1954, claims to have “brought food to three billion hungry people” over the last sixty years;
- The $6.8 billion President’s Emergency Program for AIDS Relief (PEPFAR), launched in 2003 by George W. Bush, is keeping more than 10 million people alive, subsidizing their treatments, mostly in Africa;
- The United States is assessed more than any other nation for its membership in the World Health Organization, this year paying $28.6 million. It voluntarily gives another $305 million, which is $110 million more than the next most generous nation, the United Kingdom.
- The Global Fund to Fight AIDS, Tuberculosis and Malaria received $40.9 billion in donor pledges to date—32.5 percent of that ($13.2 billion) was promised by the U.S. government.
- The Obama administration in 2014 created the Global Health Security Agenda (GHSA), which was later endorsed by fifty nations, and aims to build a worldwide web of disease surveillance and rapid response to head off pandemics in people, food plants, and livestock. The United States is the primary driver and donor behind GHSA, spending more than $1 billion to bolster disease detection and response capacity, mostly in Africa.
Compared to American domestic spending on health, these foreign outlays are trivial, but the dependency at the receiving end is tremendous because the U.S. pieces of the programs’ small pies are overwhelming. Trump administration cuts, should they transpire, would be devastating.
The U.S. 2017 federal budget is $3.8 trillion, with 28 percent of that going towards health care, more than defense spending. Combined federal, state, and local FY 2017 healthcare spending is estimated at $1.5 trillion. President-Elect Trump has focused his attention on reducing government spending on health through elimination of the Affordable Care Act, or “Obamacare,” that currently provides insurance and added coverage for more than 36 million people, and overhaul of Medicaid (currently covering 72.5 million Americans under 65 years old) and Medicare (covering 53.9 million people over 65 years old). On November 29, he named private medical cost consultant, Seema Verma, to head Medicare and Medicaid, and Georgia Congressman Tom Price, an orthopedic surgeon, to be secretary of health and human services (HHS). Calling the duo his “dream team,” Trump vowed Verma and Price will turn domestic health programs upside down, drop immigrants from government-financed services, promote private insurance and payment programs, and provide financing for individuals through a combination of vouchers and tax write-offs, neither of which are likely to be useful to those currently covered by Obamacare. Price has promoted the Empowering Patients First Act in the House, which would lift most regulations on medical practices and let patients shop for care financed by health savings accounts (vouchers) and tax credits.
But while Verma and Price, in close collaboration with House Speaker Paul Ryan, are busy shifting American healthcare into the private sector, and deregulating the pharmaceutical and medical industries, what will the administration be doing on the global scale? Asked if PEPFAR should aim to double by 2020 the number of people worldwide who receive anti-HIV medicines with U.S. taxpayer support, then-candidate Trump responded, "Yes, I believe so strongly in that, and we’re going to lead the way." Impact2016 notes, however, that Trump was not a fan of foreign assistance programs.
Congressman Price has consistently voted against the Affordable Care Act, all forms of funding for family planning or abortions, expansion of federal healthcare funding for children and poor single mothers, the Global Food Security Act, the Obama administration request for $1.9 billion in emergency Zika funds, the United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act, and opposed every piece of legislation favored by Planned Parenthood, earning a 100 percent rating from National Right to Life.
Andrew Bremberg, policy advisor to Senate Majority Leader Mitch McConnell, is leading the Trump transition team’s health effort, and will make many of the changes and appointments within HHS, including leadership of the Food and Drug Administration, the Centers for Disease Control and Prevention, and the National Institutes of Health. He served a number of policy roles inside HHS during the George W. Bush administration, but his views of global health programs are not known. Trump’s choice for secretary of state will be critical, as the U.S. Agency for International Development and PEPFAR programs are handled through U.S. embassies.
Tea leaf reading renders the Trump global health scorecard for 2017–2018 as:
- PEPFAR: Authorized through 2018, not likely to see its budget touched. But Price and Vice President Mike Pence may impose provisions akin to those used by the Bush administration, forbidding use of federal funds overseas for family planning, abortion services, and prevention programs targeting sex workers and intravenous drug users, thereby limiting spending on prevention.
- Maternal and child health: Over the last year, strong partisan rifts have developed, as faith-based groups have objected to family planning programs. The Trump administration will likely kill REACH, Republican Susan Collins’ Senate Bill 1911 aimed at creating a ten-year program for maternal and child health in USAID.
- Bureau for Global Health in USAID: Responsible for many vital overseas programs, the bureau is vulnerable to budget cuts, especially in its offices of health systems, of maternal and child health, and of population and reproductive health. Likely to remain untouched is the Office of Infectious Disease, which handles epidemic threats.
- GHSA: The Obama notion of health security was never congressionally authorized or earmarked under USAID. It was created by executive order, nested inside HHS, and is highly vulnerable.
- Centers for Disease Control and Prevention: The FY2017 budget of $6.98 billion will not be touched. Director Tom Frieden may be replaced by a leader more likely to enforce policies in keeping with Trump supporters’ beliefs that feature opposition to vaccination, opposition to family planning, claims that condoms don’t work, and insistence that CDC should never investigate gun-related violence.
- Food and Drug Administration: Republicans on the Hill, including Price, back the Twenty-first Century Cures Act, which was overwhelmingly approved by the House and is now moving on to a vote in the Senate. The act would severely deregulate the FDA, pushing new drugs to the marketplace with far less pretesting for efficacy and safety. Opposed by Democrats, the act would effectively gut FDA authority to prevent release of dubious or unproven drugs, or off-label use of existing drugs. The Obama administration recognized that most of the world’s supply of active ingredients used to formulate medicines come from China and India, which also produce most of the world’s fake, counterfeit, and substandard medicines that are used by patients inside the United States and all over the world, often with deadly outcomes. Since 2009, the FDA has engaged in global diplomacy and surveillance, trying to identify fraud and track false and dangerous As FDA personnel and budgets diminish, these programs will suffer, and may be eliminated.
- WHO: The Executive Board of WHO will vote on six candidates for the next director-general in January, around Inauguration Day. CDC Director Tom Frieden will cast the U.S. vote, though it’s unlikely the Trump administration will have had time to consider the American choice. Donald Trump isn’t a fan of the United Nations system, and claims it overspends $1 billion
The only time Donald Trump addressed a global health issue at length—well, in a Tweet storm— was in 2014 when physician Kent Brantly and nurse Nancy Writebol acquired Ebola infections while working in the Liberian epidemic, and were scheduled to be airlifted to Georgia for emergency care. “KEEP THEM OUT OF HERE!” he tweeted, in all-caps, calling President Obama a “Psycho!” for allowing the ailing health workers’ return to America. Clearly then-realtor Trump didn’t share Ambassador Power’s enthusiasm, linking Ebola, U.S. troops, and Cuban doctors.