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New Conversations: Justice, Disparities, and Meeting the Needs of Our Most Vulnerable Populations

Sklar, David P. MD

doi: 10.1097/ACM.0000000000001947
From the Editor

Editor-in-chief, Academic Medicine

Editor’s Note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members.

This is a difficult time in health care. In Washington, health care legislation has advanced that would result in tens of millions of Americans becoming uninsured.1 Proposals to reduce Medicaid funding could affect access to health care among our most vulnerable populations, and the effects of these proposals upon insurance premiums and coverage options for those who purchase insurance through the exchanges are uncertain. All of this has occurred without the support of major health care organizations or consumer groups. How could such momentous changes affecting those most in need of health care access occur without including the opinions and expertise of the health care community or the patients that would be most affected by the changes? Can we find ways to have our voices heard?

On a global level, vulnerable populations are facing other challenges related to health care. The problems of the health care of refugees, victims of natural disasters, and those exposed to emerging infections have garnered well-deserved attention. The poorest and most vulnerable populations of underdeveloped nations are particularly affected. But there are also ongoing problems of aging populations, chronic disease, health care workforce supply, and funding of health care that are creating problems for the health care of vulnerable populations in even the most developed nations. What can we learn from the experiences around the world to inform our conversations about ensuring that vulnerable populations have access to health care?

Mechanic and Tanner2 have described vulnerability as an interaction between the capacities of individuals, the stresses that they are exposed to, and their various support networks, which can facilitate or hinder the ability of the individual to cope with various health challenges. They identify as sources of vulnerability poverty, race, social isolation, physical and cognitive impairments, and limitations related to physical location. They suggest that moral values and politics interact in the way in which social policy priorities are developed, which may be an apt assessment of the drivers of current national health policy discussions. They end by noting that “attention to vulnerable groups not only assists their life chances but contributes more generally to the safety and quality of life of the entire community.”2

We have decided that the current context of health policy in the United States and around the world demands a New Conversation about our responsibility to our most vulnerable populations and what we can do at our academic health centers (AHCs) and through our education programs to address their needs. While we recognize that there are journals that have always focused on health disparities, immigrant health, and racial and ethnic minority health issues, our hope is to augment those efforts with the voices of our health professions leadership in education, research, administration, and clinical care in this journal.

We recognize that a focus on vulnerable and underserved populations will inevitably lead to discussions of social justice and health equity, and we acknowledge that many institutions have a long history of commitment to the needs of the poor and vulnerable that evolved from moral or religious perspectives. We would like to hear how these principles have been sustained, how they have evolved over time, and what the institutions intend to do to address current and future challenges. Others have recognized the need to understand and manage the health care needs of those whose vulnerabilities have led to high health care costs that affect the financial viability of institutions and health systems. We would like to hear how AHCs are improving population health management, especially through programs aimed at vulnerable populations.

The truth of the matter is that no one is invulnerable. All people have vulnerabilities as a result of genetic, environmental, age, race, education, psychological, or other factors. The difference is that some people have resources they can use to address situations in which the vulnerabilities have manifested themselves in illness. Others rely upon the support of public programs like Medicare or Medicaid, or the local support of emergency departments and hospitals that provide unreimbursed care. Development of systems that identify vulnerable patients and provide organized programs of disease prevention and management would also be of interest in this New Conversation.

I ask that you submit contributions on this third New Conversations topic—guided by the questions, examples, and goals stated in this editorial—to be considered for publication in the journal. Please submit contributions through the journal’s online submission system, Editorial Manager (, using the article type “New Conversations.” Submissions should be scholarly contributions that follow the journal’s regular submission criteria for Commentaries, Perspectives, Research Reports, Articles, or Innovation Reports. (For more information about those criteria, please see the journal’s Complete Instructions for Authors at Submissions will be peer reviewed.

We will carry on the conversation outside the pages of the journal as well. Our blog AM Rounds ( will feature a series of discussions related to the New Conversations contributions that are published in the journal. I also encourage you to discuss New Conversations on Twitter using the hashtag #AcMedConversations by offering your opinions, posing questions, and responding to the opinions and questions posed by your colleagues. We will be using the journal’s Twitter handle, @AcadMedJournal, to do the same.

I will consider New Conversations submissions at any time, starting immediately—there is no deadline for submitting a contribution. Although we may not publish New Conversations contributions in every issue of the journal, we hope to have many of them to share in the pages of the journal and beyond as this third New Conversation unfolds over the course of 2018.

In the end our approach to ensuring that vulnerable populations have access to health care will still come down to the commitment of our health professionals to provide compassionate, high-quality care to every person they encounter regardless of their various vulnerabilities. How we educate our students, residents, and faculty about their responsibilities, and how we recognize and support their activities to meet the needs of vulnerable populations, will be more important than ever. We would like to hear about programs and ideas that provide the guidance and experience that help imbue in our students, residents, and faculty a lifetime commitment to the needs of vulnerable populations.

David P. Sklar, MD

Editor-in-chief, Academic Medicine

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1. Congressional Budget Office. H.R. 1628, American Health Care Act of 2017: Cost estimate. Published May 24, 2017. Accessed July 12, 2017.
2. Mechanic D, Tanner J. Vulnerable people, groups, and populations: Societal view. Health Aff (Millwood). 2007;26:1220–1230.
© 2017 by the Association of American Medical Colleges