An agenda to fight inequality.

1376 www.thelancet.com Vol 389 April 8, 2017 The USA is one of the richest countries in the world, but that reality means very little for most people because so much of that wealth is controlled by a tiny sliver of Americans. During the past 35 years, there has been a massive transfer of wealth away from the middle class and the poor to the top 0·1% of the US population. Despite advancements in technology and productivity, millions of Americans are working longer hours for lower wages. Since 1999, real median household income in the USA declined by nearly US$1400. According to a report by the Hudson Institute, middle-class net worth plummeted by 43% from 2007 to 2013. But not everyone is hurting. Over the past year alone, the ten richest Americans saw their wealth increase by more than $109 billion. In 1 year. Such inequality continues to be one of the greatest moral and economic issues of our time. It is also a huge health issue. As Pope Francis has reminded us, to follow the commandment “thou shalt not kill” we must “also say ‘thou shalt not’ to an economy of exclusion and inequality. Such an economy kills.” The America: Equity and Equality in Health Series in The Lancet provides an abundance of evidence that confirms the view of Pope Francis. Life expectancy in the USA is far lower than in most other wealthy nations, largely because of the widening health gap between rich and poor Americans, and stark and persistent racial inequalities. The wealthiest Americans now live about 10–15 years longer than the poorest. The USA’s dysfunctional health-care system is a major contributor to the nation’s health inequalities. Despite the substantial improvements made by the Affordable Care Act (ACA) since its full implementation in 2014, more than 28 million Americans still have no health insurance and millions more are underinsured. Meanwhile, since 2009, the profits of the top five insurance companies have almost doubled, while five major drug companies made more than $50 billion in profits in 2016 alone. Today, the US health-care system too often serves to enrich wealthy investors and executives, while impoverishing, and even bankrupting, many working families. In my home state of Vermont and around the country, doctors and nurses have told me about patients who have died unnecessarily because they put off their medical visits until it was too late. These were people who had no insurance or could not afford the payments their insurance plans required them to pay. Unfortunately, President Donald Trump and the Republicans in Washington tried—and may well try again—to take a major step backwards by repealing the ACA. Their plan in the American Health Care Act would have removed health insurance for 24 million Americans, dramatically increased healthcare premiums for low-income senior citizens on fixed incomes, and provided more than $300 billion in tax breaks to the wealthiest 2% of Americans in the next decade. Today, we must do everything we can to prevent the repeal of the ACA and oppose attempts by the Trump administration to undermine it by failing to enforce the law or promulgating regulations that would sabotage it. Tomorrow, we must work to join the rest of the industrialised world and guarantee health care to all citizens through a Medicare-for-all single-payer system. Health care is not a commodity. It is a human right. The goal of a health-care system should be to keep people well, not to make stockholders rich. The USA has the most expensive, bureaucratic, wasteful, and ineffective health-care system in the world. Medicarefor-all would change that by eliminating private health insurers’ profits and overhead costs, and much of the An agenda to fight inequality