The Irreplaceable Public Sector

Much has justifiably been made of the embrace by the Biden administration of the levers at its disposal to bring about a latter day version of FDR’s New Deal. President Biden in his first 100 days launched unprecedented, large-scale efforts to rebuild national infrastructure and to implement programs to support those most affected by the Covid-19 pandemic. This comes as a dramatic contrast with his predecessor whose efforts were much more in line with Republican administrations dating back to President Reagan, aiming to reduce the size of government and to limit the scope of the public sector as much as possible.

In the wake of a global pandemic that froze the world in its tracks for more than a year and resulted in nearly 600,000 American lives lost, the return to an engaged, muscular public sector is a welcome shift indeed. From the point of view of the decision-making that is needed to create health, we think that greater engagement of the public sector is not only welcome but essential, both to mitigate the current pandemic and to help us prevent a future one.

In March 2021, President Biden introduced his “Build Back Better” proposal, a $2.3 trillion once-in-a-generation investment, the largest government intervention since the 1960’s. To be spread over eight years, this proposal overtly tackles “infrastructure”—roads, bridges, utilities—and was not framed as an effort to address the nation’s health.  But to our minds, this bill addresses many of the drivers of health that shape the world where Covid-19 emerged. By attending to child care ($25 billion), affordable housing ($213 billion), home care for seniors ($400 billion), public transportation, and even the removal of all lead water pipes in the country, the legislation takes on the conditions and structures that create poor health. All these efforts can improve the situations of millions and address the vulnerabilities that Covid-19 exposed.

In the end, the states, not Congress or the president, will decide where most of any Federal infrastructure funds get spent (although comprehensive oversight would help). We leave it to others to argue about the political merits of President Biden’s approach. One could argue that the spread of funds is too broad even for the expansive scope of infrastructure. But regardless of the plan’s objectives, its outcome is almost certainly to be that the quality of life of citizens is likely to improve. There will be jobs created and some of the work that is too costly or unprofitable for the private sector to do—water and sewer system repair for example—will be accomplished. This work has direct health effects.

Certain problems have been neglected for too long.  The Covid-19 moment has helped sharpen the mind about much. It has also shown us how irreplaceable a public sector might be in moving forward to strengthen the foundations of the public’s health.


Michael Stein & Sandro Galea

As we re-emerge from the pandemic, 2021 stands to be a turning point year for public health. In The Turning Point’s weekly essays, we reflect on what we learned during 2020, and what we are learning during 2021, that can guide us to the creation of a better, healthier world.