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  • Viewpoints

    Crossing the Inequality Chasm

    Editor’s Note: The following column is adapted from Dr. Kirch’s address at Learn Serve Lead 2015: The AAMC Annual Meeting.

    Dr. Darrell G. Kirch, MD
    In a 2001 landmark report, Crossing the Quality Chasm, the Institute of Medicine recognized equity as a central pillar of quality care. Nearly 15 years later, we continue to examine the ways in which racial, social, and economic inequality affect society and health. These issues have figured prominently in recent public discourse, as protests erupted in cities such as Ferguson, Mo., and Baltimore, and deep frustration too often turned into violence. Health disparities related to race are deep and profound, and I encourage everyone to read the inspiring address on the topic that AAMC Chair Peter Slavin, MD, gave at the 2015 Learn Serve Lead meeting. As we discuss inequality across our country, all of us in health care need to ask ourselves: Where do we stand on crossing the “inequality” chasm?

    Faculty, students, and staff at academic medical centers see firsthand the countless ways in which inequality affects health. Our teaching hospitals represent only 5 percent of all U.S. hospitals, but provide nearly 40 percent of all charity care—often the only care available for the poor, the uninsured, and the undocumented in our communities. The Affordable Care Act has helped make health insurance available to millions of previously uninsured or underinsured Americans. But insurance does not guarantee access, and access does not guarantee proper care. People might have insurance, but they may not have the physician they need nearby, they may not have transportation, or they may not know how to navigate a complex health system.

    Health care access issues will intensify as the physician shortage becomes more severe, and vulnerable populations will be hit hardest. Nowhere are access issues more visible today than among our nation’s veterans. The Department of Veterans Affairs (VA) has long been a leader in patient care, and the VA Office of Health Equity works to ensure equitable care for veterans. This is vital because our veterans and active-duty military face complex health challenges, including traumatic brain injury, limb loss, and post-traumatic stress disorder. But physician staffing challenges in recent years have made it difficult for many veterans to access the care they need.

    Other vulnerable populations also face difficulty accessing necessary care. For example, more than half of U.S. counties currently have no mental health professionals at all. While many patients with mental illness lead stable and productive lives, others are falling through our social safety nets. And because of our country’s inability to provide adequate support for this population, many people with serious mental disorders end up in the criminal justice system. Nearly 20 percent of inmates nationwide suffer from mental illness. If you wanted to visit the institution caring for the largest number of mentally ill people in America today, you would need to visit Cook County Jail in Chicago.

    Unfortunately, health issues within our prisons go beyond mental illness. Correctional populations are among the sickest in our country, and, in many cases, inmates come from underserved communities with significant health disparities. Most will return to those communities when they are released, continuing a cycle of disease and disparity. Despite these issues, incarceration rates continue to rise. Between 1980 and 2008, the number of people incarcerated in America more than quadrupled, from approximately 500,000 to 2.3 million. More strikingly, one in six black men has been incarcerated since 2001. This trend is impacting the health of individuals, families, and communities across our country.

    We continue to face many obstacles to achieving health equity. However, there is one area of historic disparity where our country made real progress this year. The Supreme Court’s decision to extend marriage equality to all 50 states was a step toward greater health equity for the LGBT community. With marriage rights comes access to spousal insurance, Social Security survivor benefits, and hospital visitation rights. While the LGBT community still faces conscious and unconscious bias within our health care system, I hope the Supreme Court’s decision will be a turning point toward greater health equity.

    “By looking at each of our individual roles in academic medicine through a health equity lens, every one of us can help reduce disparities, contribute to community health, and support our colleagues in doing the same.”

    The progress made by the LGBT community this year gives me hope that we can continue to reduce the disparities that all vulnerable populations face. With every opportunity I have to visit one of our medical schools or teaching hospitals, I see the work that faculty, students, and staff are doing to address these challenges. Our students run free clinics and patient outreach programs in our poorest communities. Our faculty and researchers study genetic and environmental influences on mental health and educate new physicians about the unique health needs of LGBT patients. And through our unparalleled 70-year partnership with the VA, academic medicine is giving hope to those injured and traumatized by war.

    The AAMC supports this work by facilitating collaboration and disseminating exemplary research, innovative care solutions, and best practices for teaching the social determinants of health. We also strive to advance solutions at the national level. We advocate for National Institutes of Health funding because research translates into medical practices that reduce health disparities. We advocate for increased funding for residency positions because failure to address the physician shortage will affect vulnerable populations first. And we file briefs in every Supreme Court case that threatens to undermine holistic admissions because to succeed in reducing health disparities, we need a health care workforce that truly reflects the diversity of our communities.

    All of us in health care are called to reduce inequity because of our commitment to social justice and our mission to provide quality care. By looking at each of our individual roles in academic medicine through a health equity lens, every one of us can help reduce disparities, contribute to community health, and support our colleagues in doing the same. Over the coming year, political battles and partisan spin will escalate. More than ever, we will need to ignore the noise and focus on bridging the inequality chasm. The health of too many people hangs in the balance.

    This commentary originally appeared in the December 2015 issue of the AAMC Reporter.