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A Word From the President: The Supreme Court Bends Toward Health Equity

AAMC Reporter: July/August 2015

On Thursday, June 25, I was traveling to a national health conference, knowing that the Supreme Court would issue its decision in King v. Burwell that morning or one of the next several mornings. I expected much of the discussion at the conference to be about the decision. Since March 2010, when the AAMC was one of the first national health care organizations to endorse the final version of the Affordable Care Act (ACA), we have worked to support and strengthen the law, including filing an amicus brief in support of preserving the law’s insurance subsidies.

Despite our hard work and the work of many others, there was considerable uncertainty and anxiety about how the court would rule. In the weeks leading up to the decision, the AAMC focused on what could be done to mitigate the destabilizing effects on national health care if the court reached an adverse decision. Shortly before the meeting began, I heard the good news: The subsidies had been upheld, and millions of Americans, many of whom had been uninsured or underinsured before the ACA, would retain access to health care. I found myself feeling both relieved and re-energized by the good news.

In the weeks since the court’s decision, my thoughts have turned to the work we still need to do to improve the law and the state of health care in this country. Although the ACA has brought the rate of uninsured Americans to an historic low, 11 percent of our citizens remain uninsured and, therefore, deeply vulnerable in the event of illness or accident. As the institutions that provide 37 percent of hospital charity care to uninsured patients, AAMC-member teaching hospitals are particularly concerned about those who still lack health insurance. We believe attention should now turn to solving these gaps in coverage at a systemic level.

We can begin by working for Medicaid expansion in the states. Twenty-one states have not expanded Medicaid under the ACA, although the law clearly intends and provides for expansion. Expanding Medicaid would provide insurance access to an additional 4.4 million Americans, many among the most vulnerable in those states. We also can improve access by working with the federal and state governments to strengthen the insurance marketplace and support programs to get more Americans enrolled. 

Even Americans with insurance continue to face issues relating to access, and this problem will become more critical over the next decade. By 2025, we anticipate a shortage of between 46,000 and 90,000 physicians, largely the result of our growing and aging population. The impact of this shortage will be felt nationwide—in months-long wait lists for appointments and in emergency rooms full of patients who could not get in to see their regular doctors. Legislation currently before Congress would address the shortage by increasing the number of residency positions by 15,000 over five years. While this increase would not solve the shortage entirely, if combined with ongoing efforts to improve care models and mobilize other health professions, it would be a significant step toward alleviating the problem if combined with ongoing efforts to improve care models and mobilize other health professions.

As we continue to address gaps in insurance coverage and access, we also must ensure continued investment in the prevention and treatment of illness. To this end, the AAMC is working with congressional leaders and the Obama administration to promote federal budget policies that would provide predictable, sustainable increases in funding for medical research through the National Institutes of Health (NIH). We also are working with our congressional allies on legislative approaches to supplement the annual spending bills, such as the 21st Century Cures Act recently passed by the House of Representatives. This bill would reauthorize the NIH for three years at an increase of $1.5 billion per year and create an NIH Innovation Fund supported by $1.75 billion a year in mandatory funding for five years. As shown on a daily basis in our AAMC-member medical schools, hospitals, and clinics, “research means hope” for patients suffering from chronic or life-threatening illnesses. Just as we work to ensure that patients will have access to doctors when they need them, we must do all we can to sustain the research that will help them live longer, healthier lives.

King v. Burwell was not the only landmark decision at the end of this Supreme Court term. The next day, the court released another major opinion—the 5-4 ruling in Obergefell v. Hodges, which extended marriage equality to all 50 states. Unequal treatment of LGBT individuals contributes to health disparities. Prior to marriage equality, same-sex couples faced exclusions related to hospital access, medical decision-making authority, and access to spousal health insurance. The decision in Obergefell v. Hodges righted these wrongs.  

But we cannot rely on the courts to solve every instance of inequality in our country. Speaking of the history of legal discrimination against the LGBT community, Justice Anthony Kennedy wrote, “The nature of injustice is that we may not always see it in our own times.” Many inequities continue to exist today and too often go unnoticed in the midst of the other problems we are trying to solve. Communities across our country struggle with systemic poverty, social exclusion, racism, and bias, all of which are predictors for health inequity. 

As leaders in academic medicine, we have an obligation to work tirelessly to improve access to health care, ensure funding for medical research, and eliminate health care disparities. Justice Kennedy’s words on injustice remind me of a quote by Martin Luther King Jr.: “The arc of the moral universe is long, but it bends toward justice.” Following the two landmark decisions at the end of this Supreme Court term, I would add that it also bends toward health equity.

Darrell G. Kirch, MD

Darrell G. Kirch, MD