One Country--Insured--With Liberty And Justice For All

Presented by
Jordan J. Cohen, M.D., President
Association of American Medical Colleges
at Albany Medical College
May 27, 1999

---

The Class of 1999! Wow! What to say to the last class of medical students to graduate in the 20th century. I've got to do something more than deliver the standard commencement speech, full of platitudes about how hard you've worked, and how much you deserve the coveted M.D. degree you are about to receive. And certainly I've got to do more than just remind you to wear sunscreen. Well, never mind. Let me start again.

The Class of 1999! Wow! The last class of medical students to graduate in the 20th century. And what a century it's been for medicine. No century in the history of mankind can even come close to matching the medical advances - the veritable miracles - that this century has produced. Miraculous advances that have equipped you and your generation of physicians to do more to relieve human suffering and to promote human welfare than any other doctors before you could even hope to do. So, in looking to the future, you should be filled with high expectations, with boundless optimism as you contemplate a professional life in which the 20th century's cornucopia of medical science begins to yield truly unimaginable benefits for improving everyone's health.

Did he say, "everyone's health?" Yes, I did, because that, my friends, is the principal challenge we are facing at the beginning of the 21st century. And I'm convinced that America will never find the vision and political will to address what's becoming a crisis in health care without the leadership of you - the new generation of doctors. The real challenge you have as members of the medical profession is how to make the benefits of modern medicine accessible to all Americans.

If we had more time, I would be inclined to frame this question in its global context. As you well know, the disparities in access to modern health care across the globe are already monumental and the gaps between the haves and the have-nots are increasing day-by-day. And as medicine, along with most aspects of 21st century life, becomes more and more a global enterprise, those disparities in access are destined to become an urgent concern. Not just for the medical profession in its pursuit of human dignity and world health, but for the political establishment in its pursuit of social stability and world peace.

How much longer do you think people who are networked through the World Wide Web, and whose expectations are whetted by satellite television beamed from everywhere on the globe, are likely to suffer silently in the face of preventable epidemics and treatable diseases just because they happen to live in a less developed part of the world?

I would urge you, at a some later time, to reflect a bit more on what the globalization of expectations portends for the next century, but, for now, let me focus on the immediate challenge facing us in this country: how are we, here in the richest country on earth, going to ensure that the miracles of modern medical science are available to everyone who can benefit from them? In large measure, the answer to that question depends on our finding the political will to provide universal health insurance. As you undoubtedly know, the single greatest barrier to securing adequate, let alone superior, health care in this country is lack of health insurance. Not the only barrier, to be sure, but certainly the one most readily breached.

Consider the following facts:

• Uninsured women who develop breast cancer remain undiagnosed until their disease reaches a more severe stage than is the case for women with health insurance. As a result, uninsured women are nearly 50 percent more likely to die from breast cancer than they might otherwise have been.
  
• Similarly, a pregnant woman who lacks insurance faces a much less happy prospect than her insured counterpart. Uninsured women are 30 percent more likely than the privately insured to have their childbearing experience marred by an adverse event - more complicated deliveries, more prolonged hospital stays, newborns with greater need for neonatal intensive care, and even a higher likelihood of dying from childbirth.
  
• Uninsured people in general are more likely to be hospitalized with such serious conditions as pneumonia, malignant hypertension, bleeding ulcers, and uncontrolled diabetes. They also are more likely to require hospital care for diseases that could have been prevented entirely with immunizations or other routine care. As if that weren't bad enough, uninsured patients are also more likely to die while hospitalized than are insured patients with the same diagnoses.
  
• Matters are worse still for children who lack health insurance. Uninsured children are at least 70 percent more likely than insured children to go untreated when they contract a common condition like asthma. No more that 20% -- one in five -- uninsured kids have a regular source of care.

So, to be uninsured in America is, by that fact alone, to be denied anything like the full benefits of 20th century medicine. And today, over 43 million of our countrymen and women have no health insurance. That's nearly 18 percent of our non-elderly population. What's more, we are moving in the wrong direction. The number of uninsured has grown by nearly ten million over the past decade alone, a period during which our economy has enjoyed unprecedented success, with our unemployment rate shrinking to its lowest level in three decades. Imagine how many more people will fall into the ranks of the uninsured when the next economic downturn comes, as it inevitably will.

Indeed, a recent study commissioned by the Robert Wood Johnson Foundation projected that the number of uninsured could, if the economy sours, reach levels as high as 67 million by as soon as the year 2010. In other words, it's well within the range of possibility that by the time you -- the class of 1999 - are in the beginning phases of your medical practices, the number of people in this country without health insurance will be half again what it is now…and the numbers already are staggering.

Why in the world do people choose to go without health insurance? For the most part, of course, the answer is: they don't choose to be uninsured. Oh, a small percentage does make that choice - largely healthy young adults who apparently believe they are indestructible and invulnerable to illness. But, there can be little doubt that the vast majority of the uninsured would much prefer the peace of mind and security afforded by having health insurance. They simply can't afford the premiums.

By far the largest group of people who go without health insurance are the working poor. Eight out of ten uninsured individuals either hold full-time jobs or are the dependents of people who do. The reasons they have no health insurance are clear. In many cases, employers simply do not to offer health insurance as a benefit of employment. This is particularly true of small businesses, which compose the fastest-growing employment sector of the American economy. Even large employers, as a group, are cutting back on their contributions to health insurance, forcing many low-wage workers to forego insurance in favor of food and shelter for their families.

The same applies to many people who are self-employed, work part-time, or do contract work. Welfare reform is yet another reason. Moving off of the welfare roles into a low paying job frequently means losing state or federal health care benefits. The cost of having a job, in other words, is the loss of health insurance. Some tradeoff: the pride of working for a living, in return for a life full of fear that a sudden illness or injury could wipe you out.

A resident at Johns Hopkins recently told me the story of a neighbor of his who approached him at home because he needed medical advice. The man was a tree trimmer, and a 600-pound trunk had fallen on his hand earlier in the day. The resulting hematoma was so large that the resident couldn't tell whether the hand was broken or not, but the injury was clearly severe. With no insurance, the man was panicked about having to go to the hospital for treatment because he knew he couldn't pay the medical bills. He was hoping the resident would tell him he could forego treatment without the risk of permanently losing function in his hand.

Such anecdotes -- and much worse -- are now so common they are beginning to lose their poignancy, as if they were part of the irreducible background noise. Yet each such anecdote bears witness to a glaring failure of our democracy. Here in the wealthiest nation in the world, millions of people are deprived of proper medical care, are suffering avoidable illness, and are dying unnecessarily, all because we as a nation cannot agree on how we can pay for some form of universal coverage. But, we and our elected representatives never will agree, unless we muster the political will to resolve the question.

Following the collapse of the Clinton health plan, Congress has shown no willingness to address this issue in a comprehensive fashion. Perhaps even more troubling, the national media has chosen to give it scant attention, as well. In a recent Washington Post editorial, David Broder pointed out that Monica Lewinsky's "Saturday Night Live" appearance garnered more press coverage than did a recent report from the National Coalition on Health Care - a report documenting that a staggering 1.7 million Americans were added to the rolls of the uninsured in the most recent year for which data were available.

Why this apparent blind spot for an issue as glaringly obvious as the uninsured? Maybe it's because people without health insurance are generally people without much money. In our society, people without much money are people without much power. And people without power have a hard time getting anyone, especially elected officials, to listen to them. What they need are advocates.

Advocates who do have power, who can force their case onto the public agenda, who are credible, who are insistent, who speak with authority, who can stand on a solid foundation of principles forged over centuries, principles validating a primary commitment to serving the interests of other people.

I'm not calling for the advocacy of a specific plan to achieve universal or near-universal coverage. There are many possibilities to choose from. Examples include expanding Medicare to cover not just the elderly but the working poor as well; or employer mandates to guarantee that all employees receive basic health care benefits; or tax credits for those who purchase health insurance in the private market; or tax penalties for those who don't; or government vouchers issued to those whose income falls below 200% of the poverty line. Or any one of the other examples of what we might elect to do.

The challenge for the moment is not to decide which one to choose among the many possibilities for achieving universal coverage. I concede that choice to the political process, which is democracy's tried and true method for surfacing debate and arriving at compromise when competing ideas are on the table. The challenge for the moment is simply to get the issue back to the top of the national agenda. For that we need an army of advocates to speak out on behalf of the uninsured, advocates whose political voice can make a difference.

Where are we to find such advocates for the uninsured? Advocates willing to use their power to force this issue to the top of the country's political agenda; advocates steeped in a tradition of service to others; advocates who can talk credibly about the unacceptably high price we pay for ignoring this responsibility of a civilized society; advocates who can speak authoritatively about the avoidable burdens of illness and disability borne by the uninsured, and paid for, ultimately, by all of us.

I believe we are to find those advocates right here, in the class of 1999. Your class, chosen as it was to usher in the new millenium, strikes me as precisely the right class to usher in a renewed commitment to the precept that basic health care is a fundamental right of everyone. You, along with your colleagues who are graduating this month from medical schools across the country, must take up this cause. As individuals, I urge you to speak out against the injustice of the status quo. As members of professional societies, I urge you to craft public policy statements demanding attention to the unfulfilled promise of universal coverage.

As prominent citizens, I urge you to badger your government representatives to embrace their public responsibility to bring this country's health care system into alignment with every other Western democracy. As stewards of the medical profession - a profession grounded in patient advocacy --, I urge you to express your moral outrage at our country's failure to protect the interests of all patients. And as practitioners, I urge you, in the interim, to devote a sizable portion of your professional activities to caring for those without the ability to pay, and in that way, at least help to minimize the unfair burden borne by the uninsured.

Soon, you will all rise to take an ancient oath, the oath of Hippocrates, that will bind you to a timeless tradition. That tradition speaks to the sanctity of the doctor/patient relationship, to the centrality of your patient's best interests, and to your duties as a trustworthy and honorable professional. The values embodied in the Hippocratic oath are fundamental to the preservation of medical professionalism, and have served society and the profession extraordinarily well for centuries as guideposts for meeting the professions' altruistic goals. Those core values command and deserve your utmost allegiance.

But they are not enough. They are insufficient, in my view, to serve equally well as guideposts for reaching the added goal facing our profession at the dawn of the next millenium. That goal is to ensure that everyone can benefit from the promises offered by medical science. So, if I may be so bold, I would propose to our friend Hippocrates that he permit us to take an additional oath today -- a pledge of allegiance to yet another value in the canon by which we define the medical profession in the United States.

And that oath is this: to be one nation - insured -- with liberty and justice - and quality health care -- for all. A pledge I sincerely hope all of you will hold close to your heart, and keep firmly in mind as you become the newest and most promising members of our country's premiere profession.

Before I close, I want to bring you salutations from yet another time honored guru of medicine. More contemporary certainly than Hippocrates but, in his way, no less profound. I am referring to the well known, Dr. Seuss. Here is what that good doctor has to say in his last text book, Oh, the Places You'll Go:

"Congratulations! Today is your day. You're off to Great Places! You're off and away!

You have brains in your head. You have feet in your shoes. You can steer yourself any direction you choose.

You're on your own. And you know what you know. And YOU are the guy who'll decide where to go."

And as you go, remember: one nation, insured, with liberty and justice for all. And good luck.

AAMC Home | Government Affairs | Newsroom | Publications | Meetings | Students and Applicants | About the AAMC | Search
Questions and Comments | © 1995-2001 AAMC Terms and Conditions | Privacy Statement

Revised: 07 December 1999