Reflections on the IHI National Forum (Part III): The Moral Test of Health Care

This post originally appeared on the Doctors for America Progress Notes blog.

“The moral test of government is how that government treats those who are in the dawn of life, the children; those who are at the twilight of life, the elderly; and those in the shadows of life, the sick, the needy, and the handicapped.” — Hubert Humphery, at the dedication of the Department for Health and Human Services Building

For the final keynotes of the IHI National Forum, we were treated to a speech by Dr. Don Berwick, former head of the Centers for Medicaid and Medicare and founder of IHI. Unfortunately, I was unable to attend due to my flight schedule, but I read the text of his speech afterwards and was struck, as he had been, by Hubert Humphrey’s quote above. That quote spoke to his desire to put patients first, especially his most disadvantaged patients who were not among the rich, white men that dominated decisions on Capitol Hill and elsewhere.

In health care, we have started to recognize that the disadvantaged are among those with the worst health outcomes, that perhaps we do need to devote more resources to “underserved medicine” from case workers or community health workers on the ground to a new generation of medical school graduates that are educated in health disparities and interested in doing all they can to combat it. There are programs that are even starting at the college level, connecting college volunteers with low-income patients to help with their psychosocial needs inside and outside of health care.

In our work to improve our healthcare system, I believe that we need to take this a step further. **We need to recognize that the success of our health care system also rests on the extent to which it addresses the needs of the disadvantaged.**As was reported in the BMJ Journal of Quality and Safety earlier this month, one of the many reasons why the United States is spending so much on health care and getting so poor results may be that we spend so little, comparatively on social services to help the disadvantaged. When the researchers included expenditures on social services, they found that the United States spent disproportionately less on social services (dropping from #1 in health care expenditures to #10 in combined health care and social services expenditures), and that higher life expectancy and lower infant mortality correlated most strongly with the countries that spent more on social services as compared to health services.

In the public health world, this should not come as a surprise. Last year, the head of the CDC published a pyramid for health impact that notes that direct patient counseling and education requires the most individual effort and resources while having the least population impact. On the other hand, socioeconomic factors and programs that address those factors have the greatest potential for having the largest impact while being relatively uncostly. As health care providers, we tend to work on the top of the pyramid. Even in the quality world, we agonize about ways to integrate behavioral health into the patient-centered medical home in order to address the need for individual patient counseling and education.

We need to move down the pyramid. We need to recognize that as health care providers who care about truly improving the health of our nation, we need to be helping those who can least help themselves. And that means recognizing and addressing head-on the social disparities and the lack of support in this country for the disadvantaged. To quote another principle put forward by Dr. Don Berwick: “there is no more time left for timidity…the time has come to do everything.”