RFK Jr. Promotes Public Health Malpractice

Jacqueline H. Wolf

During a CBS interview on April 10, Robert F. Kennedy Jr., the Secretary of Health and Human Services (HHS), posed a question. Should society pay for the health care of citizens who smoke or “eat doughnuts all day?” His question implied that, in addition to the other health services he seems determined to dismantle, Kennedy is also contemplating blocking people’s access to government health insurance—which includes Medicaid and Medicare—based on their behavior. Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank, applauded Kennedy—“People should bear the cost of their own unhealthy decisions, not just because it’s wrong to force other people to bear those costs, but because then they’re less likely to make unhealthy decisions.”

Is this how the Trump administration plans to cut Medicaid and Medicare? By refusing to pay for enrollees’ preventive services and medical treatments if they’ve eaten too many doughnuts?

Kennedy’s and Cannon’s statements demonstrate both their distorted view of the purpose of healthcare (they propose using it as a means of social control) and their ignorance of the factors that shape health behaviors. Here’s a quick lesson. The purpose of healthcare is to treat the sick. The purpose of public health is to prevent people from getting sick in the first place. The factors shaping the behaviors and decisions that may contribute to ill health are complex. Do we now have an HHS Secretary hell-bent on declaring who is unworthy of government health insurance, thereby committing public health malpractice?

How will the Trump administration identify Kennedy’s health-choice scofflaws anyway? Create a federal police squad to monitor the behavior of all Medicare and Medicaid enrollees? Require doctors to use breathalysers to detect Dunkin’ Donuts residue? Deputize American physicians and require them to report patients’ infractions to the health police?

While we’ll have to wait for answers to these questions (and as absurd as they are, they will have to be answered if RFK Jr.’s implied threat is to be implemented) there are other relevant questions that we do know the answers to. Can science and medicine connect “good” health choices to consistently favorable outcomes? Of course not. Do consistently healthy choices guarantee good outcomes? Of course not.

Take the case of Jim Fixx, author of the 1977 bestseller, The Complete Book of Running. In the 1970s, Fixx was the most prominent bestselling fitness author to argue that long-distance running was a surefire antidote to the effects of sedentary urban life. On one of his daily runs in 1984, Fixx died of a heart attack at 52.

Aside from both anecdotal and carefully culled evidence that the healthiest behaviors cannot guarantee a good outcome, there’s also the question of whether the health choices that RFK Jr. frowns upon are wholly voluntary. No one lives in a vacuum. Culture, political patterns, social policy, family traditions, and life’s daily difficulties constantly pull us all in one direction or another.

Let’s consider the effect of advertising on the public’s view of healthy behavior. Before Congress banned cigarette advertising from the airwaves in 1971, tobacco companies were the biggest advertisers on television and often used doctors to endorse their products. One ad featured a surgeon in a white coat offering a “doctor’s report”—“Not one single case of throat irritation due to smoking Camels!” The Camels’ ads that featured doctors always ended by noting, “More doctors smoke Camels than any other cigarette.” Philip Morris similarly employed doctors to peddle their poison. Before the U.S. Surgeon General issued his 1964 report linking tobacco to lung cancer, heart disease, and emphysema, three generations of Americans had learned from doctors that a highly addictive, life-threatening product was harmless.

And not only did Americans learn tobacco was harmless, they also learned that in many everyday circumstances, smoking was desirable. Marlboro, for example, ran print ads featuring a baby’s photo and the words, “Before you scold me, Mom…maybe you’d better light up a Marlboro.”

By the time the U.S. Surgeon General’s Report appeared, tens of millions of Americans had been hooked on tobacco for decades. But the report had an effect. Wealthier, more educated customers began to quit smoking. That’s why, in the 1970s and 1980s, cigarette manufacturers began to market heavily to working-class Americans. Today, consumers living in rural areas of the country have become a primary target for cigarette ads. And rural areas, unlike large American cities, have few-to-no tobacco cessation programs.

Social, cultural, historical, and political forces often shape health outcomes, far more than individual choice. Today, more than one-third of American adults and 20 percent of children and adolescents are obese. And the U.S. government helped create that public health crisis.

In the early 1970s, the Nixon administration responded to rising food prices by subsidizing the large-scale production of corn, soy, and wheat. And food prices did fall. But then farmers were left with unsold crops, especially of corn. The solution? Use corn to produce high-fructose corn syrup for the manufacture of soda, sugary “juice” like Hawaiian Punch and Minute Maid Lemonade, breakfast foods like Pop Tarts, and snacks like Ritz crackers. Even seemingly healthy sides like applesauce now contain corn syrup.

The Nixon administration was also looking for ways to revitalize urban neighborhoods, focusing on black entrepreneurship, just as fast-food corporations were looking for new markets after saturating suburbia and highway rest stops. Equal opportunity loans through the Small Business Administration thus made it easier for aspiring minority business owners to open fast-food restaurants than to open grocery stores. That’s why, today, most low-income neighborhoods have at least one fast-food restaurant within walking distance but no grocery store with a produce section.

Federal policy has likewise spurred the epidemic of childhood obesity. In the 1980s, Reagan-era budget cuts left public school systems looking for ways to supplement their shrinking coffers. One solution was to give fast food chains entree into school cafeterias. By 2006, 23.5% of public schools in the federally funded National School Lunch Program were selling fast food, sodas, and processed snacks. Schools then used their share of the profits to finance physical education, music, and art classes—classes that would have been eliminated otherwise.

And this is where Kennedy’s absurd musing about “eating doughnuts all day” comes into play. As only one example of the social determinants of health, poorer neighborhoods have a far higher percentage of fast-food outlets than wealthier neighborhoods and a far lower percentage of healthy food options. To tell people that they must take individual responsibility for their health status is absurd. So much affects health that is beyond individual control.

A decade ago, a physician penned an opinion piece in the Journal of the American Medical Association describing several complex cases. The cases weren’t complex because of patients’ medical conditions. To the contrary, the conditions were straightforward—kidney failure, pancreatitis, that sort of thing—and their treatments long established. The cases were bewilderingly complicated because of patients’ social situations: underemployment, lack of health insurance, homelessness, social isolation, and inability to travel to and from doctors’ appointments.

The author’s point was this—there is no one-size-fits-all treatment for any illness or condition. Patients, as part of a complex society, are subject to no end of forces.

No physician can successfully treat a patient who has Type 2 diabetes, for example, unless the physician understands the patient’s context. What eating traditions does the patient have? How and where does the patient’s family purchase food? How do they cook the food? How do they consume it? Does the patient have a willingness or time to exercise? Can the patient afford a gym membership? If not, is the patient’s neighborhood safe to walk in? Does the patient have access to a grocery store that sells fresh produce? Or do they live in a food desert—an area with no full-service grocery store, a common phenomenon in low-income communities? How has the marketing of soft drinks and processed foods affected the patient’s food choices? Does a patient rely on fast food because they have no time for food preparation?

So there you have it, Secretary Kennedy. Factors contributing to patients’ choices are infinite. Factors contributing to patients’ health status are infinite. Rarely can a physician point to a purely voluntary choice as the cause, or even a cause, of a patient’s illness.

A sound health care system addresses the unique needs of all patients and facilitates their access to care. Kennedy proposes the opposite—blocking care for anyone he deems unworthy. Judging patients’ choices and making threats based on patients’ behaviors undermine the core mission of public health that Secretary Kennedy should be defending and maintaining.

Jacqueline H. Wolf is professor emeritus of social medicine, Ohio University.

Sources

Lauren Weber, “RFK Jr.: If you eat doughnuts or smoke, should society pay for your health care?” The Washington Post, April 10, 2025, find article online here, accessed April 15, 2025.

Darcy C. Plymire, “Running, heart disease, and the ironic death of Jim Fixx,” Research Quarterly for Exercise and Sport 73(1) (March 2002): 38-46.

Allan M. Brandt, The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America (New York: Basic Books, 2007).

Chin Jou, Supersizing Urban America: How Inner Cities Got Fast Food with Government Help (Chicago and London: University of Chicago Press, 2017).

World Health Organization, World report on social determinants of health equity, 2025, available HERE.

Komal Kothari, “The Case for Social Medicine,” JAMA 311(24) (June 25, 2014): 2483-84.

Allison E. Karpyn, Danielle Riser, Tara Tracy, Rui Wang, and Ye Shen, “The changing landscape of food deserts,” United Nations Standing Committee on Nutrition 44 (Summer 2019): 46-53.