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
Both conservative and liberal politicians have placed this issue near the top of the national agenda. But we have been there before and have always come away empty-handed. This time, we must not fail. A principal question for all the stakeholders participating in this debate is the dilemma of where to find the billions of dollars needed to solve the problem. Often overlooked in this discussion is the concept that we are already paying for the problem of the uninsured. When a patient without health insurance arrives at the emergency room in the middle of the night with a myocardial infarction, often an interventional cardiologist will perform an urgent angioplasty. Who pays the cost for this care? All of us do. Today, with our inequitable healthcare delivery system, we care for many of the poor and uninsured through cost-shifting. Hospitals and physician routinely charge insured patients more than needed, because they must adjust for the likelihood that a proportion of these fees will never be paid. So, in many ways, we are already paying for the uninsured. However, the problem is that the cost-shifting approach does not distribute the burdens equally. At urban hospitals in poor communities, a much higher percentage of care is not reimbursed. This is illogical and unfair. We must distribute these burdens more equitably. We also pay for