Donald Trump's healthcare, racial and environmental policies were killing hundreds of thousands of Americans annually even before the COVID-19 pandemic hit, researchers say.
A new study published this week in prestigious medical journal The Lancet says his presidency was "injurious to many non-wealthy", particularly people of colour and his own supporters.
"While the wealthy have thrived, most Americans have lost ground, both economically and medically," said Steffie Woolhandler, co-chair of The Lancet Commission on Public Policy and Health in the Trump Era, which was formed in 2017 to monitor the impact of the former reality TV star's administration.
Their analysis found 461,000 "unnecessary" deaths happened each year of his presidency thanks to his policies - almost as many as have died in the nation's COVID-19 outbreak to date.
And the COVID-19 death toll would have been 40 percent smaller if the US suffered a death rate equivalent to other G7 nations - Canada, France, Germany, Italy, Japan and the United Kingdom.
"Americans' health was deteriorating even as our economy was booming," said Dr Woolhandler. "This unprecedented decoupling of health from national wealth signals that our society is sick."
Specifically, the commission found Trump's policies "added 2.3 million to the 28 million US residents who were uninsured when he took office, with coverage losses concentrated in minority communities and among children".
"Meanwhile, he augmented the flow of public funds through private insurers, who now derive most of their revenues from government programs, raise Medicare's costs by an estimated US$24 billion annually, and have garnered record profits during the COVID-19 pandemic."
Trump regularly boasted of rolling back environmental protections and withdrew the US from the landmark climate agreement struck in Paris under his predecessor, Barack Obama.
"Ironically, US states that Trump won in 2016 and 2020 have suffered the greatest increases in pollution and in deaths from environmental and occupational causes," The Lancet noted.
2019 was the first year deaths caused by environmental and occupationally related causes had risen in 15 years. The result of the damage Trump did to the country's health system and environment hit his own supporters hard.
"Trump gained his largest 2016 electoral margins in counties with the worst economic and mortality trends; in counties where Trump got more than 60 percent of the vote, life expectancy had been better in 1980 than in those where he was soundly defeated. By the time of his presidential run, life expectancy in the pro-Trump counties was two years shorter than in counties where he was defeated."
The commission also found Trump "undermined civil rights enforcement, encouraged repressive policing and voter suppression, implemented harsh and racist immigration policies, and pursued housing and medical care policies that encouraged segregation and cut health coverage", taking a toll on "Black, Latinx and indigenous people".
"The disastrous, bungled response to the pandemic made clear how existing, longstanding racial inequities simply have not been addressed," said Harvard University epidemiologist Mary T Bassett. "It's time to stop saying these preventable gaps cannot be eliminated."
Harvard Medical School specialist Adam Gaffney, a member of the commission, decried Trump's "disdain for facts, science, and compassion", but added that "decades of health care inequality, privatisation and profiteering set the stage for these tragedies".
The commission said simply reverting to pre-Trump era policies would not be enough, calling for sweeping reforms - including reversing tax cuts for the wealthy, banning coal mining, justice reform, more than halving military spending and having a New Zealand-style single-payer medical system.
"Trump's disastrous actions compounded longstanding failures in health policy in the US," said University of California medical professor Kevin Grumbach. "We know what it will take to create a healthy society. We just need the political will to do it."
The commission's full report can be read in The Lancet.
