America’s Poor Health Is an Invitation to Tyranny

The lack of universal care has made the U.S. more vulnerable to Trump’s demagogic appeals.

A health-care worker in a hospital.
David Ryder / Getty

President Donald Trump’s chief of staff stated plainly on Sunday that the administration does not intend to stop the spread of the coronavirus. “We are not going to control the pandemic,” Mark Meadows told CNN’s Jake Tapper. This approach is consistent with the president's own experience: He did not observe standard public-health measures, he caught the virus, and he received excellent care free of charge. The rest of the country has suffered, and will suffer, in an entirely different way.

In normal democracies, health care is not the preserve of an elite, and citizens count on both the prevention and the treatment of disease. Universal health care serves as the moral bridge between citizens and their governments. In this sense, the United States is not a normal democracy. Untreated illness and uncertain care fill our politics with unnecessary fear and rage. Our president pushes this logic by offering insecurity instead of security as the aim of politics. Meadows only clarified what has been true all along: Trump’s form of politics works with a plague, not against it. Among the president’s notable responses to the COVID-19 pandemic have been the withdrawal from the World Health Organization and his persistent attempt to take health insurance away from tens of millions of Americans. This is not inefficiency or neglect. It is a pattern evident all across the Trump administration: Governing is not about problems to be solved, but emergencies to be magnified.

Health care is always political, but the politics can confirm or deny democratic norms and practices. A democratic country that handles a pandemic well generates trust in government, and even national pride. If care is not universal, then the political equation, especially during a pandemic, is entirely different. When citizens cannot imagine security, politics becomes the distribution of insecurity, the allocation of fears and anxieties that push us away from an idea of common citizenship and toward authoritarianism. What is lethal for Americans is also lethal for our democracy.

I am an American historian who has seen the pandemic from both sides of the Atlantic, and who has just written a book about health care in the United States. When journalists from other countries ask me why so many Americans have died during the coronavirus pandemic, they phrase the question actively: “What have Americans done to bring about such needless mayhem?” And that is the right way to think about our COVID-19 policy. It is not a blundering, but a bludgeoning.

In other rich nations, it is easier to see a doctor and harder to die than in the United States. As I write these lines, I am sick in Austria. That means that if I call a doctor, I see her the same day, get tests right away, fill out no forms, and pay no fees. Without worries about access to care, I am a freer person. On the scale of a whole society, the gain in liberty is extraordinary.

Even before the pandemic, even before Trump, Americans were killing one another in huge numbers in the service of dogma. Too many of us take for granted that health and freedom are somehow in contradiction—and so we exclude our own bodies from our notion of rights. We treat as normal a system of commercial medicine in which decisions about life and death are made on the basis of profit. Our babies and their mothers die at rates that Europeans find unbelievable. American Millennials will likely pay more for health care yet die younger than their parents and grandparents did. Life expectancy peaked here in 2014, even as it continues to rise elsewhere. Americans pay twice as much per capita for health care as the citizens of peer countries do, for the privilege of dying years younger.

Americans have internalized entirely unnecessary inequalities in access to care—to the point that they run deep into our souls. Many of us, by some calculations nearly half, simply avoid care because it seems unaffordable. Those of us with insurance think about how good our insurance is, and where it will get us. Those of us who get access believe that we deserve it. It does not occur to us that the less-bad access we have is worse than what everyone has in countries with universal health care. Lost to us are the political consequences: If we take for granted radical inequality and repeated emergencies in the realm of health, we are primed for authoritarianism in the realm of life. In the health-care debate in the United States, proposals to extend coverage to all are decried as government overreach, socialism, even outright tyranny. But the lack of health security is what makes Americans vulnerable to demagogues and authoritarians.

Our sense that suffering is normal is also racial. Many white Americans regard their own suffering as virtuous, while maintaining that public health care would only be abused by Black people and immigrants. In other words, suffering is normal so long as others suffer more. During the pandemic, this everyday American sensibility has been on full display in widespread white indifference to a disease that has killed Black and Latino people disproportionately. Racial inequality brings unnecessary death. It also brings a sentiment that an authoritarian leader can exploit: Namely, that those who suffer the most are themselves at fault. When racism is a preexisting condition, the disproportionate death rates of Americans of color during a pandemic seem normal.

Given these grievous problems, America’s only hope of stopping the COVID-19 pandemic was to do so at the outset. Such efforts have been mounted before. Under George W. Bush, the number of SARS cases in the U.S. was limited, and no one died. In 2014, the Obama administration took the fight against Ebola to West Africa, a prudent step that was normal then but that seems like science fiction now.

Before the novel coronavirus arrived in the U.S., the Trump administration dismantled the institutions that were responsible for early warning and early action. By telling Americans in February what they wanted to hear about the virus—that it was not serious, that it would disappear, that everyone could get a test—Trump ensured that death would be widespread. By failing to institute a regime of testing, he made it normal for us to follow our own guesswork and emotions rather than dealing with facts. This was a profound choice, and Trump made it explicitly: For him to feel good personally about artificially low numbers was more important than for Americans to accumulate the knowledge that we would need to survive.

The Trump administration announced a kind of new federalism, in which governors would have to show their loyalty to get federal assistance, and in which the Democratic ones would be blamed regardless of what happened. The bluster shrouded the basic decision, which was not to launch a federal response to the pandemic. No nationwide lockdown, no national testing initiative, no national contact-tracing initiative, no nationwide signaling on wearing masks and washing hands. This set the United States apart from every other comparable country.

After first blaming Democrats for not doing enough, Trump switched to blaming them for doing too much. He placed himself on the side of those who opposed public-health protections, and helped to create a sense among some of his supporters that lockdowns and quarantines were a power grab by liberals. By tweeting in April that states should be “liberated” at a time when armed protesters were at statehouses, he encouraged violence. In June, according to the FBI, men gathered in Ohio to plot the kidnapping of Gretchen Whitmer, the governor of Michigan. When the plot was exposed, Trump suggested that Whitmer was herself responsible, because she “wants to be a dictator.”

Throughout the summer, as anxieties over the pandemic mixed with resurgent anger over racial injustice, Trump worked to make white people feel like victims. He used the Black Lives Matter protests to declare that Black people were actually the aggressors. By hiding in the White House bunker and using force to disperse a peaceful protest in nearby Lafayette Square on June 1, Trump defined himself as the real victim. He tried (and failed) to persuade the armed forces to view protesters as enemies. By issuing an executive order to protect monuments on June 26, he claimed that the real issue was the innocence of (white) American history. By sending unidentified federal agents to Portland, Oregon, he tried to create the impression that defenders of the rights of Black Americans were threats to American cities. The problem was not the shooting of civilians by police; it was that Black people were making trouble in cities for no good reason.

In the real world, Americans have been dying from the pandemic all summer and fall, in ever greater numbers in states with Republican governors. The whole time, COVID-19 has been the real danger to everyone involved. More police officers have been dying of coronavirus exposure while on duty than from all other causes combined. At the very moment when the disease is reaching those whom Trump calls “my people,” the White House admits that it has no plan to stop it.

This is America’s basic problem: Health care is not a promise for all, but rather an expectation of the rich that they will do relatively better than the poor, and of white people that they will do relatively better than Black people. Suffering can seem meaningful if it affirms this basic order, even if that suffering is one’s own. This is a posture of submission. Letting a disease play itself out is not the attitude of a free people. Nor is resentment against those who take the initiative.

Our politics were supposed to be about the pursuit of happiness; and, as the author of that phrase knew, happiness is impossible without health. Yet a democracy can become suffused with suffering, to the point where many voters do not even expect that policy might help them or loved ones stay well. An aspiring authoritarian such as Trump knows what to do: provide the emotional jolts of pleasure that distract from the general decline. “Winning” is no longer about gaining something for oneself, such as a healthier or longer life, but about taking pleasure in the suffering of others. This is a sensibility—the strong survive; the weak get what they deserve—that favors authoritarianism over democracy. Those who endorse it cannot win this year’s election for Trump, but they can wreak havoc in November.

When Trump stands on a balcony after receiving treatment that is out of reach for others, he is asking not just for submission but for sacrifice. After all, he looks strong in the foreground only if others die in the background. That Trump would maximize pain, divide people, and create emergencies should not surprise anyone. It is just the authoritarian alchemy that one should expect. The unpredictable part is how we choose to react. In this election, Americans face a choice not between individuals, but between regimes: between tyranny and a republic as forms of government, and between suffering and happiness as its aims. If Trump is defeated, our democracy should be reinforced by universal health care. Health and freedom collapse together, and they can be recovered together. We would be much freer as a people if we accorded ourselves health care as a right.