On Thursday, the British medical journal The Lancet published its official report, three years in the making, on the Trump administration’s health care record.

The report is, appropriately, dominated by the COVID-19 pandemic. The Lancet found the Trump administration directly responsible for the deaths of tens of thousands of people during the pandemic, and that over 200,000 people would still be alive if the United States had a COVID-19 mortality rate similar to that of other developed countries.

But The Lancet’s meticulously-researched report, written by over a dozen distinguished authors, goes far beyond condemning the record of Trump alone. It argues that the nearly half million dead in the US from COVID-19 should be added to the toll of the “missing Americans” whose deaths were attributable to the rise of social inequality over the course of the past four decades. The Lancet report presents both the pandemic and the Trump administration as the outcome of deeper and more profound tendencies in American society.

“An emboldened plutocracy, under the guise of deregulation and austerity, has augmented its wealth and power by re-regulating markets to their advantage and adjusting government budgets for their own gain,” wrote The Lancet. “Under this type of governance, wealthy firms and families receive generous government transfers” while “job opportunities have disappeared.”

The Lancet concludes, “The disturbing truth is that many of President Trump’s policies do not represent a radical break with the past but have merely accelerated the decades-long trend of lagging life expectancy that reflects deep and longstanding flaws in US economic, health, and social policy. These flaws are not only evident in faltering longevity … but also in the widening gaps in mortality across social class.”

The massive loss of life in the COVID-19 pandemic—centered in the American working class—only accelerated the decline of life expectancy in the United States, and more importantly, the stratification of life expectancy along class lines.

“At the time of Trump’s inauguration in January 2017, the health of the US population was already on a downward trajectory,” writes The Lancet. “Average life expectancy in the US had declined from 78.9 years to 78.7 years between 2014 and 2018, a period that included the first 3-year decline in longevity since World War 1 and the 1918 flu pandemic.”

The report noted that “since the 1980s, the disparity between social and economic classes has widened as high-paid manufacturing jobs disappeared. ... Despite a booming stock market … many people living in the USA were forced into precarious jobs that offered low pay and insufficient benefits. This widening income inequality has widened inequalities in health.”

The Lancet report offers a historical analysis of this process, in which both parties of American capitalism played a leading role. “Faced with economic stagnation and mounting inflation, President Jimmy Carter (in office from 1977–81) pushed to reduce government deficits through spending cuts.”

Democratic President Bill Clinton “embraced key aspects of the neoliberal, pro-corporate agenda.” Clinton deregulated “banks and telecommunications firms; imposing time limits and other restrictions on welfare benefits and nutrition assistance.” Under Clinton, “Stock prices rose rapidly,” while “income and wealth inequalities widened.”

The health care programs of Barack Obama “reinforced decades of market-oriented reforms that made profitability the fundamental measure of performance, drove the commodification of care, and increasingly vested control in investor-owned conglomerates.

“Declining US longevity between 2014 and 2017, and the minimal uptick in longevity in 2018, attracted substantial media attention. However, a focus on these recent trends risks obscuring how far the USA lags behind other high-income nations and how long these cross-national gaps have been in the making. Life expectancy in the USA was average among high-income nations in 1980, by 1995, it was 2.2 years shorter than the average of other G7 countries, and by 2018, the gap had widened to 3.4 years.”

The report comes to a shocking conclusion about the number of Americans who have died prematurely as a result of America’s soaring social inequality. “The extent of difference can also be quantified as the number of missing Americans—i.e., the number of US residents who would still be alive if age-specific mortality rates in the USA had remained equal to the average of the other six G7 nations. By this measure, in 2018 alone, 461,000 Americans went missing, an annual figure that has been increasing since 1980.

“Lagging life expectancy in the USA has coincided with growing income-based and education-based mortality gaps among adults. These inequalities in mortality mirror widening economic inequality, with rising incomes for the wealthiest decile of the population (and huge gains for the very rich), but stagnant real incomes for the bottom 50%. By 2014, the life expectancy of the wealthiest 1% of men was 15 years longer than that of the poorest 1%.

“Between 2000 and 2014, adult life expectancy increased by over 2 years for people in the top half of the income distribution, while the lower half of the income distribution had little or no improvement.”

The Lancet concludes, “The Trump administration represents the culmination of more than three decades of neoliberal policies seeking to privatise many public services and deregulate corporations to maximise profits.

“Trump’s election was enabled by the failures of his predecessors. A four-decade long drift toward neoliberal policies bolstered corporate prerogatives. … The rich got much richer while their taxes were halved. Workers’ earnings stagnated, welfare programmes shrank, prison populations greatly increased, and millions were priced out of health care even as government payments enriched medical investors.”

“The suffering and dislocation inflicted by COVID-19 has exposed the frailty of the US social and medical order,” notes the report.

“Americans’ health was deteriorating even as our economy was booming,” says Dr. Steffie Woolhandler, one of the committee’s co-chairs. “This unprecedented decoupling of health from national wealth signals that our society is sick. While the wealthy have thrived, most Americans have lost ground, both economically and medically.”

In its political conclusions, the report aims to convince the incoming Biden administration to carry out a fundamental break with the policies of its predecessors. But the very record presented in the report—of decade after decade in which the Democrats were the spearhead of a drive to redistribute wealth upward—makes clear that this is impossible. Biden was, after all, vice president under Obama, helping to organize the 2008 bank bailout.

The Lancet report, like a skilled physician, expertly lists the symptoms of America’s social disease. But if American society is sick, as Dr. Steffie Woolhandler insists it is, the appropriate medicine is not the Biden administration, any more than it was the Clinton or Obama administration. The disease they have identified is terminal. The solution is to be found in a fundamentally new and different political movement—one based on the struggle of the working class for socialism.