Recovering from Trump: Biden's first 100 days

US President Joe Biden's initial actions stayed Donald Trump's assault on health and the new administration has begun to redress injustices and flawed social policies that set the stage for Trump's ascendance. These long-standing policy failures contributed to US life expectancy falling 3·4 years behind that of other G7 nations over the past four decades.¹

Before assuming office, Biden announced a diverse cabinet; nearly half women and more than half people of colour, including Deb Haaland, the cabinet's first Native American, who heads the Department of the Interior, which oversees the Bureau of Indian Affairs. In his inaugural address, Biden became the first US President to utter the words white supremacy and systemic racism. Soon after assuming office, Biden reversed some of Trump's noxious executive actions (panel ), restoring respect for facts, science, and global cooperation; mobilising against COVID-19; rejoining WHO and the Paris Agreement; reinstating environmental and workplace protections; rescinding some inhumane and racist immigration policies; rolling back restrictions on reproductive health care; encouraging health coverage expansion; and reversing Trump's hostile stance towards gender equity, LGBTQ rights, and racial justice.²

Panel. Biden administration's executive actions on health and social justice.

COVID-19 response

• •Invoked the Defense Production Act to increase supplies of COVID-19 vaccines, testing materials, and personal protective equipment
• •Established programmes to speed development of COVID-19 therapies and tests and recommend steps to bolster health system capacity
• •Directed agencies to develop guidance for safely reopening schools, child-care centres, colleges, and universities
• •Required mask wearing on federally regulated public transportation, on federal property, and for federal contractors; asked all Americans to wear masks for 100 days
• •Reimbursed states for some pandemic-related costs
• •Ramped up COVID-19 vaccine distribution efforts

Respect for science

• •Re-established the President's Council of Advisors on Science and Technology, and instructed officials to ensure scientific integrity across federal agencies

Global health

• •Stopped US withdrawal from WHO
• •Announced an additional US$2 billion in funding for COVAX, bringing the total to $4 billion
• •Rescinded the Mexico City Policy (Global Gag Rule) that had banned US Government funding for non-governmental organisations that perform or counsel about abortions

Environmental and occupational protections

• •Rejoined the Paris Agreement; promised new, more stringent greenhouse gas and particulate matter emission reduction targets
• •Authorised the Occupational Safety and Health Administration to release guidance on preventing workplace COVID-19 transmission
• •Cancelled the Keystone XL pipeline; paused new oil and gas leases on federal lands and waters; and instructed federal agencies to eliminate fossil-fuel subsidies when legal and to procure carbon-pollution-free electricity and vehicles
• •Initiated reversal of more than 100 Trump rollbacks of environmental and workplace protections

Anti-racism

• •Reactivated federal government commitment to racial equality; ordered all agencies to perform equity audits
• •Centers for Disease Control and Prevention initiative on Racism in Health
• •Committed to enforcement of fair housing laws and extended them to cover LGBTQ persons
• •Moved to end federal contracting with private prisons (but not private immigrant detention centres)
• •Instructed federal agencies to “engage in regular, robust and meaningful consultation with Tribal governments”
• •Denounced rising discrimination against Asian Americans and Pacific Islanders, and initiated collaboration with Asian Americans and Pacific Islander communities to reduce hate crimes and harassment
• •Created a task force to promote equitable pandemic response and recovery and ordered new guidance on ending discrimination in the COVID-19 response
• •Terminated the 1776 Commission, which Trump had created to design patriotic school curricula that deny the legacies of slavery and genocide
• •Reversed Trump's efforts to withhold funding from cities allowing protests in support of the Black Lives Matter movement

Voting rights

• •Ordered actions to facilitate voting overall, and particularly for federal workers, military personnel, incarcerated persons, and Native Americans

Gender equity and LGBTQ rights

• •Established the Gender Policy Council to advance gender equity in the USA and globally
• •Moved to rescind the Trump-imposed rule barring Planned Parenthood and other clinics that refer patients for abortions from receiving federal funding for other family planning services
• •Directed federal agencies to support LGBTQ and gender equity in education, the refugee and asylum system and globally, and to enforce laws that ban discrimination
• •Reinstated the right of transgender people to serve in the US militaryImmigration
• •Revoked the ban on entry of persons holding passports from seven majority Muslim nations
• •Rescinded Trump's limit on refugee admissions (although Biden subsequently postponed this rescission) and on legal immigration during the COVID-19 pandemic
• •Moved to reunite families separated at the border
• •Reinstated the right of central Americans to seek asylum
• •Removed “public charge” penalties on immigrants for enrolling in public benefits
• •Fortified Delayed Action for Childhood Arrivals that allows some young adults brought to the USA as children to remain
• •Revoked policy of harsh immigration enforcement within the USA
• •Halted construction of the border wall between the USA and Mexico
• •Ended exclusion of non-citizens from the census data used to apportion congressional representation

Economic relief

• •Extended the moratorium on evictions and foreclosures until June 30, 2020, and on federal student loan repayments until Sept 30, 2021
• •Expanded eligibility for food assistance

Labour rights

• •Restored federal workers' collective bargaining rights
• •Revoked a Trump administration order creating an industry-led apprenticeship programme exempt from many wage and safety regulations

Health coverage

• •Reopened enrolment in health coverage through the Affordable Care Act's marketplaces

These executive actions were followed by a forward looking legislative programme. The first bills introduced, although not yet passed, in US Congress would outlaw Republican-led states' moves to impose voting restrictions redolent of racist Jim Crow-era laws.3, 4 Soon thereafter, on March 11, 2021, Congress enacted a US$1·9 trillion pandemic relief bill⁵ that improved on the two previous COVID-19 stimulus bills in several respects. The American Rescue Plan Act of 2021 increases support for lower-income Americans and the racial and minority ethnic communities hit hardest by the pandemic; provides funding for state, local, and tribal governments whose tax revenues have plummeted during the pandemic; and offers some, although inadequate, funding for global health programmes over the next 18 months.

Under the American Rescue Plan Act of 2021, individuals earning less than $75 000 have received one-time payments of $1400 and most families qualify for additional tax credits in 2021 of up to $3600 per child, which will temporarily lift 4·1 million children out of poverty and particularly benefit Black and Latinx families.⁶ The legislation also boosts unemployment and nutrition assistance benefits in 2021; provides $40 billion in emergency rental and mortgage assistance and homelessness relief; and includes $5 billion in aid and debt relief for Black farmers.

State, local, tribal, and territorial governments, including Puerto Rico's, will receive about $350 billion by the end of 2024 for COVID-19-related costs and revenue losses,⁷ with $20 billion earmarked for tribal governments. Native American communities will receive an additional $6 billion for health systems, $1·2 billion for housing, and $1·1 billion for education programmes.⁸ Nationwide, $170 billion is set aside to assist schools and colleges to reopen, and $7·6 billion to hire 100 000 public health workers.

The American Rescue Plan Act of 2021 will boost global health funding this year and next by a total of $11 billion, including $3·5 billion for the Global Fund to Fight AIDS, Tuberculosis and Malaria, $4 billion for USAID's global health and COVID-19 response activities, and smaller amounts for the US Centers for Disease Control and Prevention's global efforts, the US President's Emergency Plan for AIDS Relief (PEPFAR), and the UN's COVID-19 Global Humanitarian Response Plan.

Although previous relief bills provided some funds for domestic health coverage, the new legislation goes further. The American Rescue Plan Act of 2021 will pay private insurance premiums for laid-off workers and offers financial incentives for 12, mostly southern, states to reverse their rejection of the Affordable Care Act's (ACA) Medicaid expansion. Additionally, subsidies are increased for purchase of private coverage through the ACA exchanges and there is a one-time infusion of funds for rural hospitals.

The legislation adds funding for behavioural health and substance use programmes, but does not incorporate needed changes to current approaches. Deaths from drug overdoses increased by 29% between October, 2019, and September, 2020, in the USA, particularly among Black and Latinx people.9, 10, 11 Policies must address the social determinants of substance use, prioritise harm reduction and destigmatisation, and engage marginalised communities and people with substance use in decision making.

Unfortunately, a boost to the minimum wage was removed from the bill, and many provisions in the legislation will expire within 6 months, and almost all by the end of 2022. Biden supports making the child credits permanent, a first step toward cementing the social gains of the American Rescue Plan Act, but additional measures will be needed to reverse decades of widening income and health inequalities.

The American Jobs Plan, Biden's proposed follow-on bill that would shore up US infrastructure, includes spending for social supports that would advance equity.¹² The bill, if passed, would provide funding for transitioning to clean energy and electric automobiles, and investments in broadband internet access, public transportation, schools, and affordable housing, which would especially benefit low-income and minority individuals.¹² Over the 8-year time frame of the proposed infrastructure bill, $400 billion would go to upgrading community-based care for older people and individuals with disabilities; $50 billion to the National Science Foundation; $30 billion for pandemic preparedness; and $10 billion for research programmes at historically Black colleges and universities. These investments would be partly funded by increased corporate taxes that would reclaim about half of corporations' windfall from tax cuts made under the Trump administration. Biden subsequently floated an additional plan to increase taxes on wealthy Americans' investment gains.

The new administration's proposed budget would increase federal government spending on domestic programmes next year by 16%, including increases for low-income schools and public health and climate programmes.¹³

Yet crucial problems remain unaddressed by the new administration. Inhumane treatment of migrants at the southern border continues,14, 15 and although the ban on telemedicine-based medication abortions has been lifted temporarily,¹⁶ other restrictions on dispensing mifepristone¹⁷ and the prohibition on federal funding for abortion remain in effect. Biden has shown little appetite for deprivatising public services or curtailing corporate privileges that maldistribute wealth and undermine health in the USA and globally. Rather than directing the new billions for expansion of health insurance coverage through the popular and efficient public Medicare programme (whose overhead on administrative costs is about 2%),¹⁸ most funding will flow through the far less efficient private Medicaid managed care plans (overhead, about 15%) and commercial insurers (overhead, about 19%), augmenting their record profits during the pandemic.¹⁹ And the new administration has done nothing to slow the galloping corporate takeover by private equity firms of physicians' practices,²⁰ reverse the profit motive that raises death rates in investor-owned nursing homes²¹ and dialysis facilities,²² or lower unaffordable drug prices, copayments, and deductibles that obstruct care for many with health insurance coverage.

Biden, along with leaders of other high-income nations, refused to treat COVID-19 vaccines as a global public good, rejecting in February, 2021, waivers of intellectual property rules that obstruct widespread, low-cost vaccine manufacture. Although he appointed a senior official to help mobilise the global COVID-19 vaccine effort,²³ and pledged $4 billion to COVAX for vaccines to low-income and middle-income countries, the available funding is barely a third of what is needed.²⁴ Moreover, unlike Canada and many European nations, much US development, health, and food aid continues to be funnelled through US contractors and agribusiness firms,25, 26 bypassing national structures. Developments in the foreign policy arena are mixed. Despite ending support for Saudi-led bombing in Yemen and making tentative diplomatic overtures to Iran, under the new administration US air strikes were launched in Syria,²⁷ a bellicose stance continues towards China²⁸ and Venezuela,²⁹ the US Embassy to Israel will remain in Jerusalem,³⁰ and there are proposals for a 2% increase in military spending.¹³

Propelled into office by popular mobilisations against Trump's racist, sexist, and pro-rich policies, Biden has begun to remediate Trump's damage and renounce four decades of austerity that widened inequality, stoked racial animus, and undermined health. Yet reluctance to confront market-imposed inequities, corporate privileges, and the outsized power of wealthy campaign donors and of conservative states in the US Senate obstructs further progress.³¹ More powerful mobilisation will be needed to impel the administration and Congress to reorient health-care, trade, and aid policies to prioritise health over profit and the military; compensate Black and Indigenous Americans for the land and labour stolen from them; and empower all poor and working-class Americans to share in the prosperity and health gains that the USA's vast resources should enable.