By Steven A. Schroeder
November 1999
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Table of Contents
The Milbank Memorial Fund and the Association of American Medical Colleges (AAMC) established the Robert H. Ebert Lecture on Academic Medicine and the Public Interest as a memorial to an exemplary physician, scientist, dean, and foundation executive. Ebert Lecturers are persons whose careers and character demonstrate broad and effective concern for medicine and the health of the public. They are chosen by a committee appointed jointly by the AAMC and the Fund. The lecture is delivered in odd-numbered years at the spring meeting of the Council of Deans of the AAMC.
Robert Ebert (1914-1996) was an intensely private public man. He linked the laboratory bench and the clinic, care of individual patients with concern for the health of populations, and excellence in research with innovation in the organization and financing of health services. Ebert served his country and his profession as a clinician, investigator, department chairman, dean, foundation executive, and leader of many boards, committees, and commissions. The institutions he enriched during his career include Oxford University, the University of Chicago, Case Western Reserve University, Harvard University, The Population Council, and the Milbank Memorial Fund.
Paying tribute to Ebert in a talk that preceded the first lecture in 1997 and was subsequently published by the Fund, Eli Ginzberg concluded his remarks as follows:
Ebert valued peace over contention, consensus over authority. He had an instinctive sense of the way in which institutions become captives of their own history, and he spent considerable time and energy seeking solutions that produced change without upsetting large numbers of persons whose concerns could not, or should not, be ignored. He was a diplomat by instinct, who saw little point in wasting time and energy in conflict if compromise offered a satisfactory alternative.
But this man of peace was also a man of thought, who had a deep appreciation of how things were changing, especially in his area of expertise, and he considered it his duty to figure out what to do about the changes that were underway and how to respond to them constructively. Further, he concluded that it was also his duty to initiate and carry through actions to establish a new, improved match between opportunity and results. Ebert always wanted to improve life, not for those who had power and money, but for the average man and woman who had to work long and hard to make ends meet. He directed most of his life to figuring out how he could use his time and energy to improve the access of this population to medical care services; to do so at a price that society could afford to pay; and, in the process, to train the next generation of physicians, equipping them to minister more efficiently and effectively to the critical health needs of the American people. That was the challenge that Ebert set himself, surely from the time that he became dean of the Harvard Medical School, and that remained his goal for the remaining years of his life. In meeting this challenge, he displayed a dedication that must inspire those who now take up his responsibilities and follow his lead into the new century.
Ebert helped to guide the Milbank Memorial Fund for 30 years: as a member of its Technical Board, a director, and twice as president. Reflecting on his association with the Fund in 1995, he saw a "significant congruence between the evolution of my own thinking and the Fund's long-standing interest in public health and health policy."
The Board of Directors of the Fund adopted a resolution honoring Ebert that reads, in part, "We cherish Robert H. Ebert, the private as well as the public man. We affirm the moral and intellectual standards he set for himself, for his friends, and for the Fund. We will miss him."
Samuel L. Milbank
Chairman
Daniel M. Fox
President
Acknowledgments
Jordan J. Cohen, President of the Association of American Medical Colleges, collaborated with the Fund in creating the Robert H. Ebert Lecture on American Medicine and the Public Interest. The members of the committee who selected the second Lecturer were: John E. Chapman, Dean, Vanderbilt University School of Medicine; Kim Goldenberg, President, Wright State University; Richard D. Krugman, Dean, University of Colorado School of Medicine (Committee Chair); John M. Ludden, Senior Vice President for Medical Affairs, Harvard Pilgrim Health Care; Mark L. Rosenberg, Director, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; and John D. Stoeckle, Professor of Medicine, Emeritus, Harvard Medical School, and Physician, Massachusetts General Hospital.
Staff members of the Association of American Medical Colleges who helped to organize and administer the lecture and supervise its publication were: Albert Bradford, Deputy Editor, Academic Medicine; and Joseph A. Keyes, Jr., Senior Vice President and General Counsel.
About the Author
Steven A. Schroeder is President and Chief Executive Officer, The Robert Wood Johnson Foundation. His lecture also appears in Academic Medicine 74.11 (November 1999): 1163-71. Dr. Schroeder acknowledges the invaluable assistance of his colleague Renie Schapiro in the preparation of this article.
Understanding Health Behavior and Speaking Out on the Uninsured
Ten years ago, together with two of my colleagues at the University of California–San Francisco, I published in the Journal of the American Medical Association an article titled "Academic Medicine as a Public Trust."1 In that article, we noted that society has entrusted academic medicine with several important missions to improve the health of the public and provided decades of generous public funding and independence to achieve those objectives. Two-thirds of this country's academic medical centers (defined as allopathic medical schools and their associated teaching hospitals and clinics) are public institutions, and all––public and private alike––receive significant public monies through government insurance programs, grants, and contracts. We argued that given the extent of this public support, the health needs of the population should be taken into account in academic medicine's institutional planning and policy development.
That article underscored some of the extraordinary accomplishments and contributions academic medicine had made, but also noted that it had been relatively unresponsive to a range of other important public health problems. The central issue, we said, is how well academic medicine is fulfilling its responsibilities to the public. We concluded that to the extent that it defines its mission narrowly, it may fail to live up to its social contract and thereby jeopardize its public source of financial support. We urged academic medicine to broaden its activities to be more responsive to the critical, changing needs of the general population.
Readers probably won't be surprised to learn that the response to that article from some of the leaders of academic medicine could be summed up as "Easier said than done." That's fair. In fact, today––ten years later––as I revisit academic medicine as a public trust, that response is probably even more on point.
Ten years ago managed care was an approaching threat to the prevailing economics of the academic medical center. Today it is an economic reality that is transforming the structure and substance of our academic medical centers. Fully 75 percent of people with private insurance are now in managed care plans.2 Teaching hospitals are losing patients to less expensive hospitals, and the changing mix of patients has huge implications for academic medical centers. Van Etten has reported, for example, that at Stanford's hospital, indemnity insurance declined from 15 percent of patients in 1990 to 1.5 percent in 1997, and each 1-percent drop subtracted $4 million from Stanford's bottom line.3 And a decade earlier, the indemnity insurance at Stanford had probably been closer to 40 percent.
We are also seeing that the effects of managed care penetration extend to the academic research enterprise. Moy and his colleagues at the Association of American Medical Colleges (AAMC) found that over the past decade there has been an inverse relationship between growth in awards from the National Institutes of Health (NIH) to medical schools and local managed care penetration.4 Although cause and effect are still murky, we have to ask whether managed care may be threatening the research base in medical school clinical departments. Recently Weissman and colleagues published a study showing that there is less unsponsored research in centers located in the most competitive managed care markets.5 And even the projected boost in NIH funding cannot fully compensate for declining institutional dollars, since attracting more research funds requires added investment for research infrastructure.
As academic medicine struggles to adapt to the new medical marketplace, the faculty grow uneasy and unhappy. There is pressure to speed up clinical encounters to bolster the bottom line, and a sense that academic values are being sacrificed at the altar of income-producing patient care. The reasonably stable and upward slope in income that academic physicians have traditionally enjoyed seems to have vanished. Layoffs are becoming commonplace and salaries are staying flat or even declining. Things feel out of control. There is some good news, including the proposed doubling of NIH research funds over the next five to ten years. But no question, these are tough times to be a medical school dean and tough times to take the high road.
Yet, a time of stress and fundamental change is precisely the time to reexamine mission, purpose, and focus. This is why I've chosen to return to this issue of academic medicine as a public trust, recognizing that with economic survival seemingly at stake, such introspection may seem indulgent. I would argue, however, that it is especially in this critical environment that we should pause and focus on academic medicine's core mission. This is precisely because, in responding to the exigencies of the marketplace, the risk is that we protect form over function. The danger is that we ultimately risk academic medicine's special standing as a public trust. Academic medicine is an enormous public resource. How can it live up to the unique opportunities and responsibilities it has been entrusted with to improve the health of the public?
The enormous flow of public resources to academic medical centers in the post–World War II era–a reflection of society's commitment to academic medicine's mission––has created huge, complex institutions. They are without parallel anywhere in the world. Peter Drucker has called the academic medical center the most complex organization in human history.
The pervasive view has been that academic medical centers are precious resources for innovation, teaching, and the introduction of cutting-edge technology, and therefore deserve continued generous public subsidies. But there is another perspective as well, and I think it may be ascending. It goes like this: These institutions have enjoyed a tremendous run of prosperity, unlike anything in the United States or elsewhere, and such growth is simply not sustainable. Instead, it is high time to reassess what resources are needed to carry out academic medicine's basic missions. In a global world, all of our institutions are undergoing this critical examination. From the well-known "creative destruction" of worldwide capitalism, to higher education and even government, all sectors of American life are undergoing reconsideration.
I have to observe here that it is hard to recall a national meeting in my three decades in academic medicine in which we weren't told that disaster was just around the corner. I think that insistent cry has done us a disservice, making it hard to distinguish real crises from overblown, sometimes self-serving, alarms.
I won't try to convince you here that academic medicine faces an emergency that necessitates downsizing. That case has not yet been carefully made. But the idea merits further thought. The expansion of academic medicine has clearly served the public in many ways, but it is not clear that further expansion is essential to advancing its fundamental missions. Academic medicine has been entrusted with the three key missions of teaching, research, and patient care. Medical research is also conducted in other settings, including private industry and government. Patient care is not unique to teaching hospitals, although cutting-edge care and specialized care tend to be their province, and academic medical centers lead in quality in a number of areas. Of these three core missions, only medical education is uniquely entrusted to academic medicine. Yet, in the creation of the modern academic medical center, education has all too often been something of a footnote.
Medical schools have undergone tremendous growth over the past three decades, with faculty growth outstripping that of medical students and residents. Even when the number of trainees leveled off between the early 1990s and 1997, faculty size continued to grow.6,7 Yet, it is not clear that medical education has benefited from all this growth. Unfortunately, we lack good measures to gauge improvement in medical education, but we know that while the academic medical center complex was transforming itself with public dollars, the structure of the medical school curriculum was changing relatively little. Clearly, the emergence of the modern academic medical center was driven not by a focus on medical education, but by economic considerations.
So far, teaching hospitals have generally managed to maintain their economic footing, despite the encroachment of managed care. Although they have faced an adverse insurance mix and low payment rates, many have retained––and even improved––their profit margins. They accomplished this in part by reducing costs as they benefited from historically low inflation rates. What had previously seemed to be an inexorable spiral of out-of-control national medical costs came to a halt a few years back. Medical care expenditures have been essentially flat at 13.6 percent of GDP since 1992.
Academic medical centers have also responded to clinical competitive pressures in at least five ways. These include attempting to (1) reduce costs and (2) improve service in order to attract more patients and referrals. (In many––if not most––academic medical centers, customer service has been substandard. One of the most salutary aspects of the new market pressures will be to enhance customer service. Teaching hospitals and clinics must now realize that providing patient care is a privilege that must be earned, not an entitlement.) Academic medical centers have also sought to (3) expand feeder networks by purchasing or otherwise affiliating with community practitioners and hospitals; (4) merge with other clinical entities; and (5) as a strategy of last resort, shrink the number of clinical faculty positions, and/or reduce wages. But there is a limit to the efficiencies they can hope to achieve with these strategies.
There are signs that the national health care cost containment that we have recently enjoyed may be beginning to collapse. A study by the Health Care Financing Administration (HCFA) predicted a couple of years ago that medical spending would soon again grow faster than the rest of the economy.8 At the same time, the focus in Washington on balancing the budget, reducing taxes, and saving Medicare from bankruptcy is leading lawmakers to consider further cuts in Medicare graduate medical education and disproportionate-share hospital payments. This is obviously very worrisome for teaching hospitals; a recent article by Anderson and colleagues found that Medicare alone accounts for much of the surplus and cross-subsidy at these hospitals.9 These payments have kept teaching hospitals in the black, and their reductions in the 1997 Balanced Budget Act are now exacting a fiscal toll. In addition, it appears that much-heralded clinical integration strategies are not generating the increased flow of patients and income that was anticipated.
These events, in combination with private payers' cutbacks, are placing severe financial pressures on academic medical centers. Indeed, we have recently been hearing that the glorious black ink has started to bleed red at many of the country's premier teaching hospitals.
So in this era of fiscal, organizational, and market pressures, how should academic medical centers position themselves to continue to thrive and to maintain and even enhance the esteem and public support they have enjoyed over the past 50 years? Obviously, continued attention to the organization and financing of the clinical enterprise, as well as enhancement of biomedical research capacity, are essential. But as David Blumenthal has put it, "Margin does not equal mission."10 I suggest that academic medicine should also attend to what I call "the two elephants in the living room"––or perhaps I should say "the waiting room." These are two relatively neglected issues, that is, issues that have enormous consequences for the health of the public. They represent an opportunity to capitalize on the unique power and prestige of academic medicine and live up to its public trust. First, academic medical centers must lead the nation in understanding and addressing preventable causes of morbidity and mortality. Second, they must take ownership of the growing problem of the uninsured.
Promoting Health
The new advances in molecular genetics and biology, together with the surge in federal research dollars, forecast an exciting era of unprecedented scientific breakthroughs in our understanding of human disease. This is, of course, good news for academic medicine and for the public. But our gains in terms of health status from such a fertile period will multiply if we define the research domain more broadly to include social and behavioral determinants of health. These are critical entry points for improving health status, yet they are poorly understood and studied. If we fail to include social and behavioral factors on the research agenda, we will fail to maximize the dividends from the generous public investment.
Let me digress only a little to describe a change taking place at The Robert Wood Johnson Foundation, where we, too, are taking a hard look at our mission. That mission, articulated 27 years ago, is "to improve health and health care for all Americans." The foundation's founders recognized that improving health care alone was not sufficient to improve the health status of Americans. Health care is only one of five determinants of health––the others being genetic predisposition, behavioral patterns, environmental exposures, and social circumstances. For example, inadequate health care is associated with only about 10 percent of premature mortality, while behaviors account for fully 50 percent.11 Yet health care tends to monopolize the interest of policymakers and researchers. McGinnis and Foege estimated that the national investment in prevention is less than 5 percent of total annual health care costs,12 and it is probably only about 7 percent of the NIH budget.13 The list of preventable causes of death in the United States demonstrates that the shift from infectious diseases to chronic illnesses mandates a shift in prevention from sanitation and immunization to strategies that improve personal health-related behaviors.
In reviewing our foundation's grant-making in its first 25 years, we saw that we, too, have paid a disproportionate amount of attention to health care. Recently, we reorganized into two groups, one focusing on health and the other on health care. The health group is expanding our investment in the social and behavioral causes of morbidity and mortality.
Let me dwell for a moment on what I consider to be the most important category of preventable diseases––those caused by harmful substances, including tobacco, alcohol, and illicit drugs. Table 1 takes a slightly different cut at disease burden, measuring it as years of potential lives lost.14 For each of the nine most common causes of loss of potential years of life, harmful substances are implicated in one-fifth to three-fourths of the deaths. In the case of cancer, the prime culprit is tobacco, though tobacco and alcohol act synergistically in many of the cancers of the gastrointestinal system. Tobacco is also the main culprit in chronic lung disease, and plays an important role in heart disease and stroke. Alcohol is a major factor in four of the conditions: accidents and trauma, suicide, homicide, and liver disease. Finally, illicit drugs used intravenously account now for more than 50 percent of the HIV cases in the United States.
These data highlight what I consider to be the most important challenge today facing the health of the public: determining how to promote healthy personal behavior. There is a great deal to be done. Despite widespread knowledge about the dangers of tobacco, the prevalence of its use among adults has been stuck at about 25 percent, and its use among young people has climbed. We recently learned the astounding news that most smokers––even heavy smokers––do not even believe that they are at higher risk than non-smokers for heart disease or cancer.15
Although tobacco use is the single most important behavioral risk factor, exercise and diet come close behind. One of the consequences of our industrialized society is that people have become less physically active, in both work and leisure activities. By itself, this information would not necessarily be of interest to health professionals, but it turns out that physical activity is a powerful factor in preventing or postponing chronic illnesses, as well as improving function in those who are ill.
Six common chronic diseases––cardiovascular illness, hypertension, non–insulin-dependent diabetes mellitus, osteoporosis, obesity, and depression/anxiety––illustrate this point. For each of these conditions, prevalence is higher in persons with low activity levels, and increased physical activity is itself a treatment of proven efficacy. Similar potential benefits could result from modifying dietary behavior.
What can academic medicine do to promote healthier habits that involve personal choices about tobacco, alcohol, illicit drugs, diet, physical activity, and sex?
In my view, two streams of effort are needed. The first is to increase the science base of prevention. Though impressive gains have been made in our knowledge about the determinants of human behavior, there is still much more to be learned. For example, why do some young people become quickly addicted to tobacco and others not? Why does the withdrawal syndrome of smokers attempting to quit vary so much––sometimes lasting a few weeks and other times several months––and why do women tend to experience the latter? These are the kind of important and challenging questions that belong on academic medicine's agenda, but are currently marginalized issues––at best.
The second challenge is to become more effective at translating into action what we already know. Here we can learn much from the commercial worlds of marketing and communication, as well as from successful citizen action campaigns. Only by improving both our science base of health behavior and our understanding of social marketing can we achieve meaningful improvements in health.
Unfortunately, compared with the seductiveness and reductionistic purity of basic science, too often behavioral research comes off second best in the contest for resources and for the best minds. But perhaps that is beginning to change. Both the NIH and the Institute of Medicine have lately become more interested in behavioral research. As I mentioned earlier, our foundation is also increasing its support in these areas. And at academic medical centers we are beginning to see collaborative efforts among experts across the biological and social sciences.
Academic medicine has led the nation––indeed, the world––in biomedical research and cutting-edge, high-quality care. The nation continues to look to our academic medical centers for that leadership. Now as we increasingly recognize the dominance of social and behavioral factors in health status, academic medicine has a key leadership role to play in that arena as well. Otherwise, even if we triple the amount of money we spend on basic biomedical research, we will find ourselves disappointed by how hard it is to improve the nation's health.
There is a rebuttal to my plea for a broadened research agenda. It goes something like this. There is already considerable public support for biomedical research. And we can expect that the remarkable new discoveries already in the pipeline will only whet the public appetite and stimulate further investment. So why rock this boat? Why mess with a good thing? I understand this point, but am concerned that it may not be the most prudent long-range strategy, especially if scientific breakthroughs are not matched by commensurate gains in health status.16
There is also the view that the research mission of academic medicine should be construed more narrowly, leaving broad social research to schools of public health. This argument has been made most powerfully by Seldin.17 While I agree that it resonates strongly with the traditional medical academic power base, it lacks the spirit of adventure that underlies the scientific inquiry to follow where need and opportunity beckon. It also risks failing to keep the implicit social contract that academic medicine merits public support in order to improve the health of the public. It is not obvious to me why the study of human behavior should be any less thrilling than the study of human genes, though I admit that behavioral variables are less easy to isolate and manipulate. Thus, notwithstanding these two arguments, I hope that those of you who are leaders in academic medicine will opt for a broad construction of the research mission.
What specifically can you do? First, make clear in your own house that both biomedical and social/behavioral research are essential to your goal of improving the public's health. This means giving more attention, recognition, support, and––yes––respect to intellectual disciplines that buttress social/behavioral research: epidemiology, preventive medicine, and the behavioral and social sciences. It means encouraging and supporting students who want to enter these fields. It means building on the nascent efforts to link researchers across the sciences who are toiling in the same field but isolated from each other by the silos of disciplinary research.
And you can help reset national policy so that some of our best researchers have the resources to explore the complexities of the social and behavioral determinants of health. You can best make the case to the NIH and other funding sources that we can get the most from public investment if we employ a broader definition of medical research.
The Medically Uninsured
The second "elephant" that I think has been overlooked too long is the worsening problem of the uninsured in this country. Many of you in academic medicine already have front-row seats to this problem by virtue of the disproportionate amount of uncompensated care that academic medical centers provide. Although academic medical centers include only 4 percent of the hospitals in the country, these hospitals provide at least a third of the uncompensated care.
The lower payment rates and cutbacks are making it increasingly difficult for academic medicine to absorb the costs of uncompensated care. Not surprisingly, less uncompensated care is being provided in areas with high managed care penetration.18 Contrary to what some argue, the uninsured are not managing to get adequate care. There is no doubt that, compared with the insured, the uninsured have less access to care, use less care, and cannot obtain some specific services. In addition, the uninsured are twice as likely to end up hospitalized with serious conditions such as asthma, diabetes, and stroke that could have been averted or treated if they had access to ambulatory care.19,20
Nevertheless, this bad situation is steadily getting worse. For the last decade, the number of uninsured has increased at the rate of about one million people a year, a rate greater than overall population growth. In 1991, an estimated 34.6 million people in the United States lacked health insurance. Today that number has risen to about 43.4 million, plus an additional five million undocumented aliens. And the number of medically underinsured is rising even faster than the number of uninsured.
It may be tempting to assume that the uninsured are people who irresponsibly choose to spend their discretionary income on personal indulgences rather than insurance. And there are certainly some uninsured in that category––especially the young, who feel invulnerable. But the largest segment of the uninsured are the working poor whose employers either don't offer health benefits or whose co-payments are increasingly difficult to handle on their salaries.
The working poor includes many of the six million former welfare recipients who have moved into low-paying jobs without health benefits over the last five years. Typically they can continue to get Medicaid coverage for only a limited time after they begin working. Then, the price of working is the loss of coverage.
In addition, over the past decade employers who offer insurance have required employees to pick up larger shares of the costs of their health benefits. In 1987, 44 percent of workers with employee-only coverage were fully financed by their employers. By 1996 that number dropped to 32 percent. A similar drop occurred among employees with family coverage––37 percent were fully covered in 1987 compared with 26 percent in 1996.21
With a health care system that relies on employer-based coverage, it is especially disturbing that record employment rates and a robust economy have not improved the situation. It is a blot on that system that at least 75 percent of the uninsured in this country are employed or are in families where at least one person is working. And we can anticipate further deterioration in employer-based coverage.
On the employee side, the trends toward more part-time and temporary work and increasing numbers of self-employed workers increase the numbers who are out of reach of employer-based coverage. In addition, premiums are rising for those eligible for health insurance, and we have seen the "take up" rate––the percentage of employees who took the insurance that was offered––decline from 88 percent in 1987 to 80 percent in 1996.22 On the employer side, the fastest-growing sector of American employers is small business, which is least likely to offer affordable coverage to its employees.
Incremental change has been the quintessential American way to patch these holes. So it is important to note that the number of uninsured has increased even as we have seen legislation such as the Kennedy-Kassebaum Bill and COBRA, aimed at expanding coverage. It is still too early to measure the effect of the $24 billion appropriated by Congress in 1997 to expand coverage for children from low-income families. But delays in execution seem to be occurring in virtually every state, as state bureaucracies wrestle with cumbersome eligibility and enrollment procedures. And veteran policy-watchers offer ominous warnings about the unintended consequences of well-meaning incremental changes that might reduce insurance coverage for employed families. There is also the tendency for modest incremental legislation to achieve only cosmetic results, substituting political theater for substantive reform while creating the illusion of progress.
It begins to feel like bailing water from a leaky ship. The economic growth and incremental steps are not enough to offset the erosion of employer-based coverage. The number of uninsured will continue to rise. A little over a year ago, the foundation commissioned the Institute for the Future to project health and health care in the year 2010. One of their most striking projections, from my perspective, was that even in the most optimistic of their three scenarios––which was not the one they expected actually to materialize––some 30 million Americans would still lack health insurance. The most pessimistic put that number at 67 million.
Those with medical insurance find themselves in a land of plenty. They have access to the most sophisticated medical care in the world, much of it provided at academic medical centers. From imaging technologies to treatment technologies such as angioplasty, coronary artery bypass surgery, and hip replacement, the United States outstrips other industrialized countries in both accessibility and volume. Yet we also stand apart in having so much of our population dependent on charity care.
With all the other problems that academic medical centers have to worry about, why should they take this one on? There is, of course, an economic argument to be made. It would help hospitals' coffers if they received some reimbursement for those who now do not pay. But I believe that it is more than that. I want to argue that there is also a moral issue here: a question of moral leadership.
The problem of the uninsured is a moral failing of this country, and to the extent we don't actively work to remedy it we, in effect, accept it. Some have argued that is precisely what we should do: accept it. According to this view, the medically uninsured, like the poor, will in fact always be with us, and instead of worrying about expanding health insurance coverage we need to focus more on strengthening the medical safety net.23 This viewpoint explicitly accepts health care rationing of all but the most basic services, such as life-threatening emergencies. It is troubling on two grounds. First, it is morally offensive that the world's richest nation would be willing to relegate so many of its citizens to hand-me-down medical care. Second, in today's market-driven medical economy, there is good reason to doubt whether the safety-net institutions will remain sufficiently robust to provide needed services.
Academic medicine can, by word and deed, declare otherwise: that the uninsured figure is not acceptable, that the number of uninsured in this country is a dangerous side effect of our American health care system, and that it must be treated. Academic medicine has been entrusted with the health of the public, yet more than 16 percent of that public––and growing––lies largely outside its reach. This is such a powerful reality of health care today that I don't see how academic medicine can both ignore the problem and do justice to its public trust role.
The uninsured in this country have lacked a true champion in the public policy arena. Academic medicine could be that champion by elevating the issue onto the national agenda by singling it out as an urgent matter for American medicine and health policy. The public looks to academic medicine to identify and take on medicine's toughest challenges––and pays well for that! This is an issue in keeping with that public trust.
Think about how academic medicine has rallied to further another mission: biomedical research. Many of you in academic medicine lobbied intensively, formed coalitions with other like-minded groups, and can now take at least partial credit for the NIH's recent huge budget increases. If one-third––even one-sixth––of that effort was channeled into bringing about some resolution of the uninsured problem, what a difference that could make! When academic medicine puts its power and prestige behind an issue, it can bring the public along. The tide can turn.
Forty-four states have academic medical centers, and in a number of states they span several congressional districts. That is a lot of political leverage with our national political leaders. You can also help make it a priority for the AAMC and your professional societies. You need not box yourself into a divisive political strategy by advocating any specific plan, but you can relentlessly insist that we as a nation tackle this shameful problem.
It is not only national policy that you are influencing when you embrace this issue. You are also making a very important statement at home. You have been entrusted with preparing future physicians––teaching them not only the science of medicine, but also the values of the caregiver. By your example, these medical students and trainees will appreciate that medicine's responsibility is to all Americans. I think that is a most important message.
I have talked about the public trust and urged you to focus on your core mission even in––indeed, especially in––these economically challenging times. I have mentioned two issues––the social and behavioral determinants of health, and the problem of the uninsured––that need your leadership and would do honor to the trust that the public has invested in you. I hope in another ten years I can again revisit this issue and celebrate your success.
Notes
1 Schroeder SA, Zones JS, Showstack JA. Academic medicine as a public trust. JAMA. 1989;262:803-12.
2 Iglehart JK. The American health care system: expenditures. N Engl J Med. 1999;340:70-6.
3 Van Etten P. Marketwatch: Camelot or common sense? The logic behind the UCSF/Stanford Merger. Health Aff. 1999;18:143-9.
4 Moy E, Mazzaschi AJ, Levin RJ, Blake DA, Griner PF. Relationship between National Institutes of Health research awards to US medical schools and managed care market penetration. JAMA. 1997;278:217-21.
5 Weissman JS, Saglam D, Campbell EG, Causino N, Blumenthal D. Market forces and unsponsored research in academic health centers. JAMA. 1999;281:1093-8.
6 Dunn MR, Miller RS, Richter TH. Graduate medical education, 1997-1998. JAMA. 1998;280:809-12.
7 Barzansky B, Jonas HS, Etzel SI. Educational programs in US medical schools, 1997-1998. JAMA. 1998;280:803-8.
8 Smith S, Freeland M, Heffler S, McKusick D., and the Health expenditures projection team. The next ten years of health spending: What does the future hold? Health Aff. 1998;17:128-40.
9 Anderson GF, Greenberg G, Lisk CK. Academic health centers: Exploring a financial paradox. Health Aff. 1999;18:156-67.
10 Cunningham R. Research squeeze at AHCs, but high-tech care pads margins; Boston woes due to Medicare or rival med centers? Med Health Perspect. 1999; April.
11 Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. Washington, DC: US Department of Health, Education, and Welfare; 1979:9; publication PHS 79-55071.
12 McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270:2207-12.
13 NIH Funding: A question of behavior. Facts of Life. Washington, DC: Center for the Advancement of Health. 1999;2:1.
14 Schroeder SA. The importance of relating medicine and public health. Am J Med Sci. 1992;303:355-359.
15 Ayanian JZ, Cleary PD. Perceived risks of heart disease and cancer among cigarette smokers. JAMA. 1999;281:1019-21.
16 Schroeder, SA. Improving the Health of the American Public Requires a Broad Research Agenda. Acad Med. 1999;74:530-31.
17 Seldin DW. The boundaries of medicine. Trans Assoc Am Physicians. 1981;94:lxxv-xxxvi.
18 Cunningham PJ, Grossman JM, St. Peter RF, Lesser CS. Managed care and physicians' provision of charity care. JAMA. 1999;281:1987-92.
19 Billings J, Zeitel L, Lukomnik J, Carey TS, Blank AE, Newman L. Impact of socioeconomic status on hospital use in New York City. Health Aff. 1993;12 (spring):162-73.
20 Bindman AB, Grumbach K, Osmond D, et al. Preventable hospitalizations and access to health care. JAMA. 1995;174:305-11.
21 Fronstin P. Features of employment-based health plans. Employee Benefit Research Institute Issue Brief no. 201. Washington, DC: 1998; September.
22 Kuttner R. The American health care system: Employer-sponsored health coverage. N Engl J Med. 1999;340:248-52.
23 Schroeder SA. The medically uninsured-will they always be with us? N Engl J Med. 1996;334:1130-33.
Appendix
At the conclusion of the 1999 Ebert Lecture, the 69 medical deans in attendance were asked to respond anonymously to eight questions related to the presentation. The responses as tallied by Henry Hsiao, professor of engineering at the University of North Carolina, were as follows:
Academic Medical Center Size
1. How likely is it that the average size of academic medical centers will increase in the next 10 years?
2. How likely is it that your AMC will increase in size in the next 10 years?
Research on Health Issues
1. Concerning research on the behavioral aspects of health (e.g., why do people start to smoke or use drugs, why do some become addicted and others not, etc?), how appropriate is the size of the investment in this field at your AMC?
2. Ten years from now, will there be more, less, or about the same proportion of research in this field at your AMC?
3. What proportion of the NIH budget should go toward behavioral research?
The Medically Uninsured
1. How much of a problem are medically uninsured patients for the population that your AMC serves?
2. How active is your institution in lobbying for national resolution of the problem of the medically uninsured?
3. Given that there are about 43 million people who lack medical insurance today, how many will there be in the year 2010?
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