Address at National Priester Health Conference, Louisville, Ky.
April 25, 2006
"Higher Education and Health Care: The Challenges of Access and Equity"

We are at a critical juncture in the evolution of our nation's ability to provide adequate education and health care for its citizens. It is increasingly evident, as reflected in the persistent gaps between the performance of those who are affluent and those who are poor, that the United States is not living up to the promise of providing equal educational opportunity for all. It is imperative that we begin investing increasing amounts in the education of all Americans, from pre-kindergarten onward. Yet as we do so, we must not neglect investment in the health of the public. Only if we balance the goal of health care for all with educational opportunity for all will our nation's citizens emerge as a truly healthy and appropriately educated people. To plead for an investment in education without considering a concomitant investment in the provision of health care is both myopic and, in the long run, fiscally and morally irresponsible.

Most of our research universities conduct scientific examination of phenomena such as the effect of disparities in access to health care on health status, and also train the overwhelming majority of health care providers. But apart from relatively isolated teams of investigators conducting large-scale intervention studies in education and health, as well as far-reaching disease prevention programs in specified regions over extended periods, our universities generally have neither shouldered the burden to foster the policies nor initiated the comprehensive programs that will stimulate widespread and deep-seated amelioration of the prevalent inequities in education and health care. Our universities -- and especially those with academic health centers, should gear up to serve as laboratories for discovering possible solutions for our nation's health care ills and incubators in which new models of financing health care can be tested and developed.

All of us who are presidents of comprehensive research universities have a broad array of administrative responsibilities, and for the overwhelming majority of us that includes oversight of academic health centers. However, most of us find the demands of these jobs so consuming that we feel we're doing all we can just to keep our heads above water. Together with our academic health center administrators, we are so overwhelmed by the staggering day-to-day demands of our respective organizations that we feel powerless to deal with the enormity of factors causing these health deficiencies, to say nothing of stimulating efforts to remedy their staggering social and economic costs.

As if the issues before us are not already complex enough, there is also generally a gap between hospital-based care offered in academic health centers and community-based ambulatory care. Although it need not be the case, clinical faculty tend to labor in one or another of these vineyards. The gravity of this entire situation -- including dramatic increases in the cost of health care, is profoundly exacerbated by the politically popular anti-tax mantra, evident in the ubiquitous pledges taken by legislators swearing that they will never raise taxes. As our country gears up for the next Presidential election, political pronouncements from Democrats as well as Republicans vividly convey an even more dire prospect: often the person who can shout loudest the chant of cutting taxes -- a posture more Draconian than pledging not to raise taxes -- has the greatest likelihood of being elected.

In 1959, the English physicist and novelist C.P. Snow delivered the Rede Lecture at the University of Cambridge, and entitled it: "Between Two Cultures." In it, he lamented the chasm between the basic sciences and the humanities. He knew the divide well, because he traversed it all of his professional life -- doing science and writing novels. During my four decade career as a professor, then medical center administrator, then president in comprehensive research universities, I have observed another chasm: it's between academic health centers and the rest of the institutions in which they are housed.

Perhaps the most important factor contributing to the gap Snow described, but which has grown exponentially in the intervening decades, is the increasing atomization of knowledge and the concomitant proliferation of sub-disciplines and sub-specialties. A salient example of what is happening is the supremely ironic transmogrification of the general practice of medicine to a specialty -- family medicine. To compound the irony, many of its practitioners refer to themselves as sub-specialists within family medicine. An unintended, but nonetheless regrettable, consequence of this proliferation is that it serves to inhibit dialogue among medical specialists, as well as among faculty in medicine and other scientific fields, or between the sciences and the humanities.

Another of the factors contributing to this chasm is the lingering resentment of many faculty towards their medical school colleagues, whom they often have viewed as awash in money, and who could, if they were willing, transfer vast sums of wealth to their impecunious colleagues. Although this approach may accurately reflect the reality of an earlier era, it certainly is not the situation today. The continuous changes in health insurance and the increasing reliance on academic medical centers to care for those who are medically indigent, in addition to skyrocketing rates for medical malpractice insurance, the aggressive practice of defensive medicine laced with frequently unneeded tests to avoid lawsuits, and substantial elevation of the costs of ever more sophisticated technology, which both the lay public and medical professionals are increasingly eager to exploit, have combined to alter dramatically the financial situation of academic health centers over the past two decades. Thus it is imperative that we avoid pitting our academic health centers against the other entities of which our universities are comprised.

Yet another impediment to bridging the gap between these two cultures is that extremely few presidents of comprehensive research universities have been administrators in academic health centers. Consequently, most presidents choose to make ever-so-brief and episodic forays into the unfathomable abyss of IRBs, clinical trials, complex medical practice plans, shifting reimbursement policies, irascible patients, prima donna sub-specialists, soaring medical malpractice insurance premiums, heightened security of IT networks, complaints about technology and equipment that was regarded as state-of-the-art when it was purchased but now is uniformly derogated as hopelessly obsolescent, increasing governmental concern about biosecurity safeguards, histrionic protests against all animal research, as well as endlessly proliferating accreditation agencies, to say nothing of neighborhood opposition to expanding hospital and clinic facilities. If that weren't enough, one often witnesses disputes among schools comprising the academic center -- more often than not directed to the perceived if not real arrogance of the medical school faculty -- that generate liberal amounts of paranoia and ill will.

Once university presidents wind up in this morass, they typically perceive these dilemmas as irresolvable, and say to themselves: "Help! Let me out of here. I feel more comfortable solving the myriad problems of the other parts of the university. I'll let my Vice-President for Health Affairs deal with the complex and bewildering array of problems that fester in the academic health center. I'm going to keep an arm's length from this mess," and thus perpetuate the chasm between the two cultures.

Most presidents in this circumstance feel an admixture of anxiety and confusion, and many cunning vice-presidents of health affairs capitalize on their respective presidents' discomfort and naiveté by encouraging such administrative distance because it gives the academic health centers greater autonomy. Yet this situation often has disastrous albeit unintended consequences for the entire university in that academic health centers and their sister institutions in the same institution too often wind up competing philanthropy and legislative appropriations.

It is high time for university presidents to discover ways in which we might collaborate effectively with academic health center CEOs, as well as community and business leaders, to convince federal and local legislators of the enormity of our fiscal problems. But at the same time we must be resolute in refusing to abandon the medically uninsured as well as underinsured. It's my sincere hope that our academic health centers will take the lead in developing new models for health care that will elevate access to care while simultaneously reducing expenditures. It's abundantly evident that we need to work closely with the deans and faculty of medical schools, schools of public health, nursing schools, pharmacy schools, dental schools, and those of other health professions to develop more equitable models of health care. That includes enhancing access to education in the health professions. Only if we give passionate support to balancing access to medical care for all with educational opportunity for all, will our nation's citizenry finally emerge as a truly healthy people.