Health Care Disparities, the Uninsured, and the Role of Cardiologists in the National Debate

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Health Care Disparities, the Uninsured, and the Role of Cardiologists in the National Debate Presidential Address to the Opening Plenary: American College of Cardiology Scientific Sessions

Steven E. Nissen MD MACC

We live in the wealthiest nation in the history of the world and practice our profession in an era of unprecedented technological capability. In cardiovascular medicine, we can diagnose and treat heart disease with innovative approaches unimaginable to the previous generation of physicians. However, as a wealthy nation with a technologically advanced health care system, history will judge us not by our scientific progress, but by how we treat the weakest and most vulnerable amongst us. By this critical measure of success, the fair and equitable distribution of healthcare, we have been a miserable failure. For the poor and uninsured, our technological sophistication is irrelevant. If you can’t afford $50 a month in blood pressure medications, it doesn’t matter that we can ablate your atrial arrhythmias using advanced magnetically-guided robotic catheter placement. Yet, that is exactly where we stand at the beginning of the 21st century. Every day in America, patients needlessly suffer poor outcomes, because we lack the political will to demand a more equitable distribution of healthcare resources.

The problem is not a lack of financial expenditures. As a nation, our healthcare costs are staggering and far exceed any of our peer countries. In 2006, we spent an estimated 2.1 trillion dollars on healthcare, a figure that now represents 16 percent of our gross national product. This is expected to grow over the next decade to $4.1 trillion dollars, nearly 20% of GNP. Per capita, we spend at least 50% more than most Western European countries, and double the expenditures of some. Yet, despite this enormous expenditure, our infant mortality rate is 39% higher than Belgium and 56% higher than Germany. In terms of life expectancy, we now rank 46th among countries of the world, just barely ahead of Albania, living, on average, about 5 years less than our counterparts in the leading countries.

With incredible technological advances and a huge national budget for healthcare, why have we failed so miserably to lead the world in public health outcomes? The answer is absolutely clear. We fail, because we provide healthcare unevenly, offering extraordinary benefits to the most economically privileged and inadequate access to healthcare for the weakest and poorest amongst us. It is only fitting that we discuss this subject in New Orleans, a city that has suffered so much during the past 18 months. But we should not forget that healthcare disparities in New Orleans were enormous long before Katrina destroyed the medical infrastructure. In the lower Ninth Ward, a cardiologist who is a prominent member of the College, treated a population in which 50% of his patients were unable to pay for their care. Throughout our nation, there are hundreds of communities like New Orleans, where this pattern of uneven distribution of healthcare results in poor outcomes. In America, we have two health care systems, one for the advantaged and a second, substandard system for the disadvantaged, a group that includes a disproportionate representation of people of color, immigrants (both legal and illegal), women and children, the mentally handicapped, and the working poor. Although I do not have access to statistics, it would be interesting to compare the health of the 250 million Americans who actually have health insurance to other Western nations with universal coverage. I would not be surprised if we rank amongst the best in outcomes using this metric. For the privately insured, we offer outstanding healthcare. Most of the uninsured are hard-working citizens, many of whom toil at the jobs most Americans consider undesirable. Approximately 80% of the uninsured are members of a family with a fulltime worker. These are...
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