US elections: treating the acute-on-chronic decompensation.

As the USA nears the 2020 presidential election, the country remains confounded by a confluence of population health and economic issues. There are regional epidemics of unsuppressed severe COVID-19. The country is experiencing a sustained period of economic contraction resulting from local policy (eg, stay-at-home orders) and spontaneous collective physical distancing responses to the COVID-19 epidemic. Both of these burdens are inequitably borne by Black, Latin, and American Indian communities, whose disproportionate killings by police have been widely known but only recently highlighted in the sustained, widespread protests in support of the Black Lives Matter movement sparked by George Floyd's killing earlier this year. Whether US citizens choose to re-elect President Donald Trump or replace him with former Vice President Joseph Biden, the next president faces an overwhelming amount of work.

The next presidential administration needs to recognise that the COVID-19 pandemic in the USA represents a set of acute derangements overlaid upon a chronic erosion of health and wellbeing. The USA is currently in the middle of a 40-year population health crisis, having long ago diverged from the population health trajectories of other high-income countries. Unprecedented socioeconomic and racial/ethnic disparities in population health decline are occurring in tandem with stagnating economic outcomes as well as spiking income and wealth inequality.3, 4 A burgeoning literature identifies restricted economic opportunities—the fading of the American Dream—and growing economic insecurity as the primary reasons for the worsening metrics in population health and economic wellbeing.

As in clinical medicine, such acute-on-chronic decompensation is potentially reversible when identified early and treated aggressively. Reversing the underlying chronic decline in population health and economic wellbeing will require either legislative solutions or executive orders to enhance economic opportunity and promote population health. To continue the analogy from clinical medicine, evidence-based treatment would include raising the minimum wage, strengthening labour unions, and providing affordable childcare, health insurance, and paid parental or medical leave that are not contingent on employment.3, 5 These evidence-based approaches have been shown to broadly improve health and economic outcomes. More substantive changes to labour and housing markets, immigration policy, and the carceral system will be needed to directly benefit Black, Latin, and American Indian populations, who have long borne the brunt of deeply entrenched structural racism in the USA.6, 7

Such policies would substantially support the acute COVID-19 response in the USA. A patchwork of state and local social distancing measures has filled the void left by the current administration's leadership failure. This state of affairs has led to economic problems among individuals with unstable, low-paying, and low-quality jobs that offer neither paid medical leave nor work-from-home possibilities and among individuals whose living arrangements do not lend themselves to social distancing or isolation. People in stable, high-paying occupations have, by contrast, continued to accumulate wealth through savings and capital gains while safely working from home and relying on so-called essential workers for delivery of their basic needs.

Looking beyond the COVID-19 pandemic, we call on the next administration to enact structural changes to ensure that the patterns of the past are not repeated in the future. Universal access to primary education, in which quality of education is not conditioned on one's zip code of residence, will be needed to close persistent racial and socioeconomic gaps in economic, health, and social outcomes. For people who choose not to obtain a secondary education, the quality of manufacturing and other jobs needs to be strengthened, so that meaningful participation in the economy is not conditional on having a college degree.3, 10 Furthermore, more federal investments are needed to expand the supply of affordable housing—particularly in rural areas, in formerly redlined neighborhoods, and on tribal lands—so that more people have access to this primary engine of intergenerational wealth creation.

Unfortunately, the costs of policy implementation will be incurred immediately, whereas the economic, health, and social benefits will not be realised until years later. Our recommendations therefore run counter to existing political incentives and will admittedly require boldness and courage, motivated by outrage, to enact. But from the perspective of economic wellbeing and population health, both acutely and chronically, none of our suggestions are discretionary. We need opportunity for health—for all.