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The Moral Test of Health Care

By Emily Lu
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“The moral test of government is how it treats those who are in the dawn of life, the children; those who are at the twilight of life, the aged; and those in the shadows of life, the sick, the needy, and the handicapped.”

We all know that health care in America is too expensive and yet ineffective, falling consistently at the bottom of the rankings of industrialized nations when it comes to outcomes like life expectancy and infant mortality and so forth. As others on this blog have written, there are many reasons why the healthcare system is the way it is – and many ways in which we can fix it.

Last week, I went a conference run by the Institute for Healthcare Improvement National Forum where the theme was just that: picturing what a better healthcare system would be and talking to health care quality leaders around the country about what they were doing to turn their system into the ideal healthcare system that they envisioned. There were many great stories told that day, including many touching stories about the importance of listening to patients and putting patients first in redesigning healthcare systems. In all of these stories, we always came back to how groups were measuring and tracking their improvements, what balancing measures were in place, what they used to determine whether their project was successful and addressing real patient needs.

There are many ways to define how a health care measure improves, from patients seen to HbA1C’s within the target range, but the criteria that stuck out to me was from a quote from the ending keynote given by Dr. Don Berwick. He spoke about how inspired he had been by a quote by Senator Humphrey he saw while he was at DC that defined the success of government based on how it addressed the needs of the very young, the very old, and the very needy – in other words, on how it addressed the needs of the disadvantaged who generally do not have a voice for themselves to be among the rich, white men that are the ones that make 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 just last week, 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 does 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, while socioeconomic factors and programs that address those factors have the greatest potential for having a population-wide impact. 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.”

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