Like him or not, Bruce Springsteen’s albums have served as the soundtrack to our lives, writing songs that are a reflection of ourselves, challenging our assumptions, and helping us make sense of our messy, chaotic lives. People from all walks of life and from all over the world have found meaning in his music. So, it was no surprise that several months prior to the 2024 presidential election, while on his world tour, Springsteen dusted off a song he hadn’t played since 2014: “Long Walk Home.”

He introduced the song to European and Canadian audiences saying the song was about a “prayer for his country.” The prayer reflects Springsteen’s response to political events – the song was recorded in 2007 during his dissatisfaction with the George W. Bush administration – and the “long walk home” was a symbol for a hoped-for return to the ideals that Springsteen saw his country representing, when he was young. The most poignant lines in the song are:

You know that flag, flyin’ over the courthouse
Means certain things are set in stone
Who we are, what we’ll do and what we won’t

Springsteen typically concluded Long Walk Home with the hopeful remark, “See you on the high ground.” That was before the results of the election were known. Now, with Donald Trump as our next president, one thing seems certain. Nothing will be set in stone, and there will be no permanence for the next four years, at least not in health care, assuming Trump’s second term in office is like his first term, which was characterized by significant turbulence for government health care programs.

Not all of the health care trends predicted during Trump’s next term will be directly attributable to him, but they will occur on his watch alongside his broader agenda of deporting undocumented immigrants, imposing huge tariffs, replacing civil service employees with party partisans, and punishing his enemies.

I’ve looked back on the past (as Springsteen often has) and considered the present. I’d like to offer 20 key predictions of the future of health care, deriving many from the pundits and powerful in our field. I’m making these forecasts randomly, and they clearly have overlapping themes and (dire) consequences.

1. Pseudoscience and antiscience aggression – ignoring the practice of evidence-based medicine in favor of unproven, fad treatments

2. Public health setbacks – ranging from removing fluoride from the water supply to restricting reproductive health access to easing vaccine mandates (the specter of polio making a return is truly scary)

3. Weaken Medicaid and the Affordable Care Act – creating more uninsured Americans based on “concepts of a plan”

4. Political creep – putting politicians and other unqualified loyalists into crucial health policy positions

5. Brain drain – removing talented health experts from government

6. Rearrange key agencies – dismantling many offices and transferring staff

7. Focus on deregulation – reversing or modifying existing policies

8. Spread misinformation – confusing the public with untrue and untested medical theories

9. International implosion – withdrawing support for the World Health Organization and Paris Agreement on Climate Change

10. Silence critics – muzzling those who would speak up for medicine, science, health, and data

11. Protect corporate interests – strengthening the for-profit health care sector via market competition

12. Big pharma gains – failing to reign in high drug costs

13. Gonzo health journalism – increasing misinformation, misinterpretation, and crazy-making hysteria spread by disreputable media sources

14. Economic spiral – continuing to spend more per capita than any other country on health care

15. Moral failure – obfuscating honest, transparent, and ethical decision-making

16. Death to DEI – furthering the marginalization of minorities resulting in greater health disparities

17. Innovation inertia – granting fewer government contracts to advance biotechnology and biomanufacturing, stifling creative entrepreneurs from coming forward with good ideas

18. Loss of academic freedom – fearing retribution, being cancelled, or suffering professional repercussions for speaking “woke”

19. Health care leadership – selecting toxic agency leaders and policy advisors who are not subject to Senate confirmation

20. Decentralized control – potentially creating a more fragmented health care system

One of Bruce Springsteen’s more personal and optimistic songs, Better Days, was recorded on a solo effort in 1992. Springsteen wrote: “With a young son and about to get married (for the last time) I was feelin’ like a happy guy who had his rough days rather than vice versa.” Also in 1992, in an interview with the New York Times, Springsteen commented, “I’ve always believed that people listen to your music not to find out about you but to find out about themselves.”

Personally, I’ll be immersed in Springsteen’s music over the next four years, seeking the strength and resilience to persevere—and I’ll pray for a better health care system.

Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. He is the author of several books on narrative medicine, including Medicine on Fire: A Narrative Travelogue and Story Treasures: Medical Essays and Insights in the Narrative Tradition.