The US’s compromised vaccine rollout casts a harsh light on a healthcare system where most of the public funds flow to a private sector with little oversight, rational planning, or fairness, say David U Himmelstein and colleagues
It’s easy to blame Donald Trump, previous president of the US, and his legions for the many Americans hesitating to get covid-19 vaccinations—and they surely bear much blame. Trump’s denial and politicisation of the pandemic, his anti-science bent, and his embrace of conspiracy theories have poisoned the waters (and probably explain why Republicans are 37% less likely to be vaccinated than Democrats).  But the US’s compromised vaccine rollout has deeper roots, ones that preceded Trump.
Health policies pursued over four decades have left the US ill-prepared to fight pandemics. Following neoliberal orthodoxy, control of the healthcare system has been privatized, even as public funding has increased. Government spending now accounts for two thirds of all medical expenditures, and (on a per capita basis) exceeds total health spending (public+private) in every other nation.  Most of the public funds flow to a private sector with little public oversight, rational planning, or fairness.
Meanwhile, our public health infrastructure has been grossly neglected. Prior to the pandemic, spending on public health activities accounted for only 2.6% of total health funding, and had been declining for years. [3,4] The public health workforce fell from about 500,000 (220/100,000 population) in 1980 to 291,000 (93/100,000 population) in 2014.  Lacking the public sector capacity to efficiently and equitably administer vaccinations, most local areas instead relied heavily on a private health sector that routinely excludes those unable to pay, and whose transparent quest for profits undermines patients’ trust. 
Although the federal government made covid-19 vaccinations free, that’s an exception to the rule in American healthcare. Some 30 million Americans are uninsured, and mostly shunned by doctors and hospitals. Even those with insurance encounter ever-larger out-of-pocket costs. Having disciplined patients for decades to expect financial roadblocks, we now expect them to suddenly understand that covid-19 vaccination is different—a fact many apparently doubt.  Meanwhile, 1 in 4 Americans (and an even higher share of the uninsured) lack a primary care doctor—a trusted source of personal medical advice, including on vaccination.  Little wonder that vaccination rates are lowest in states with the highest uninsurance rates, and among racial/ethnic groups who have been most excluded from healthcare access. As of mid-August, about 40% of Black people and 45% of Hispanics, vs. 50% of White people have been vaccinated. 
Even as patients feel squeezed they witness the enrichment of those overseeing care, which undermines trust: the CEO of a concierge primary care start-up who pocketed $199 million last year (and whose clinics jumped VIPs to the front of the vaccination queue); insurance executives who took home tens of millions; and hospital managers and academic medical leaders who supplement multi-million dollar salaries from their day jobs with generous stipends and stock options from drug companies. [10,11,12] The financial ties between leading physicians and pharma are particularly damaging, breeding suspicion that medical advice is tainted. On social media, anti-vaxxers are encouraging people not to trust doctors, highlighting what they perceive to be “a corrupt profession of pill salespeople.”
Distrust in healthcare is particularly acute in the Black and Latinx communities that have suffered high covid-19 mortality, yet have been slowest to get vaccinated. The racism that disfigures US society and its healthcare deters vaccine uptake. Many Black Americans view US healthcare through the lens of historic and pervasive experiences of discrimination, exemplified by the infamous (U.S. Public Health Service-sponsored) Tuskegee Study. Yet discrimination is not a relic of the past: despite being sicker and dying younger than their White counterparts, Black Americans get far less care today, and the care they do get is more often delivered in crowded and dated facilities. [13,14]
Hence, for some Black people—and some Latinx people as well—the healthcare system remains a foreign land, alienation reinforced by the paucity of Black and Latinx physicians. As poet Nikki Giovanni noted, “The health care system never cared about my diabetes for 30 years. Why all of a sudden are they so concerned about vaccinating me?”  Distrust of healthcare, meanwhile, is compounded by other structural hurdles faced disproportionately by racial/ethnic minorities: lack of transportation, childcare options, and sick leave. 
The high vaccine uptake among Native Americans, a group that has also suffered greatly from both covid-19 and racism, gives reason for optimism.  Tribal governments and the Indian Health Service mobilized from their base within communities, offering care untainted by commerce, and convenient access to jabs. Vaccine refusal rates have also been low—and racial disparities in refusal rates non-existent—in the public system that cares for veterans.  In both instances care is free or nearly so, patients are treated as co-owners rather than customers, and special efforts have been made to address racism and the needs of the poor, and to surmount transportation difficulties.
The covid-19 pandemic casts a harsh light on America’s lethal inequalities, but also illuminates a path forward. Contending with tomorrow’s health emergencies will require reversing austerity and adequately funding public health agencies. We must go further to democratize care: implement universal coverage and abolish out-of-pocket costs; equalize the distribution of health infrastructure; and reverse the privatization and commodification of medical services.
David U Himmelstein, primary care physician, Distinguished Professor of Public Health at the City University of New York at Hunter College, Lecturer in Medicine at Harvard Medical School, and Research Associate at the Public Citizen Health Research Group.
Steffie Woolhandler, primary care physician, Distinguished Professor of Public Health at the City University of New York at Hunter College, Lecturer in Medicine at Harvard Medical School, and Research Associate at the Public Citizen Health Research Group.
Adam Gaffney is a pulmonary and critical care physician at Cambridge Health Alliance and an Assistant Professor of Medicine at Harvard Medical School.
Competing interests: none declared.
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