1988–1990: A Look Back

Twenty-five years ago at the time of this writing, the first National Conference on Health Care for the Poor and Underserved was held at Meharry (in 1988). That year too, President Reagan invited me to serve on the Council of Graduate Medical Education, and two years later, I was elected Chair. During my tenure as Chair, the Council developed a landmark report on the human capital needs to adequately attend to the health of the U.S. population, pointing out the impending shortage of providers, especially in primary care and for underserved communities.

In a health care system that rewards procedures in volumes of care rather than quality and value, the poor and underserved are often the victims of poor quality of care. The recently-implemented Patient Protection and Affordable Care (ACA) incentivizes quality of care by rewarding value of outcomes rather than volume of interaction. However, poor communities have a history of difficulty attracting doctors because they have very few resources to incentivize them, and because of their challenging and unsafe living conditions. Yet at the time of that 1988 conference Meharry Medical College’s students and residents were becoming increasingly comfortable with caring for the poor and the underserved, and around three-quarters of them ended up going on to practice in underserved communities, taking up careers consistent with Meharry’s mission. Meharry had for many years been providing care to the poor and underserved populations in North Nashville, though at great financial loss to the hospital’s bottom line.^* The 1988 Conference on Health Care for the Poor and Underserved was an indication of Meharry’s commitment to this work, and it was thus appropriate for Meharry to serve as host. Out of this conference came the idea of a journal dealing with the needs of the poor and the underserved and strategies for meeting those needs. Thus, the Journal of Health Care for the Poor and Underserved was born (its first issue appearing in 1990).

David Satcher, MD, PhD

In 1985, Secretary Margaret Heckler of the Department of Health and Human Services reported on excess deaths in the Black population, adding impetus to this area of research and priority policy focus. But in 1988, no African American had ever held the position of Assistant Secretary for Health or Surgeon General or Director of the Centers for Disease Control and Prevention. Furthermore, in 1988 the nation had not yet made a commitment to the elimination of disparities in health. Even later, for the first decade of the Centers for Disease Control and Prevention’s (CDC’s) Healthy People program (1991–2000), there were no goals and objectives in this area. The establishment of the Healthy People program did, however, bring much-needed focus to the challenge and needs of the underserved, among whom African Americans were over-represented.^*

Tipper Gore, whose husband was a U.S. Senator from Tennessee at the time (four years later to be elected the nation’s Vice President), provided the dinner keynote at the 1988 Meharry conference on health care for the poor and underserved. She addressed the topic of the mental health needs of children. Her remarks that evening highlighted the fact that the poor and underserved were a population that cut across racial and ethnic lines who were not only greatly underserved but also disproportionately affected by mental illness. There was perhaps no better example of the effects of mental health disparities than the fact that people suffering from mental illness can experience a life expectancy of up to 25 years less than the rest of the population. While Mrs. Gore would go on to become Second Lady of the United States and a mental health advisor to the Clinton Administration, in 1988, there had never been a single Surgeon General’s Report on Mental Health (the first would come 10 years later).

In his 1992 presidential campaign, Governor Bill Clinton of Arkansas took on health reform as a major component of his platform, and read the report of the Council of Graduate Medical Education that...