Opinion: A chance to rebuild better, if health care, education institutions allow it

John A. Kitzhaber

Kitzhaber was governor of Oregon from 1995 to 2003 and from 2011 to 2015.

From the skybridge at OHSU, in a neighborhood where the median annual income is $42,000 and poverty is less than 15%—you can see neighborhoods six miles away with incomes half the size and the poverty rate twice as big. Between the skybridge and those neighborhoods, poverty and its associated health disparities increase over 2.8% per mile. This “social gradient” exists in cities across our nation and illustrates institutional racism hidden in plain sight.

The Black Lives Movement has powerfully highlighted one important manifestation of social injustice—the issue of police brutality and the need for more transparency and accountability in law enforcement. But the root causes of institutional racism run far deeper; they are embedded in the conditions of injustice that drive the widening disparities in health and income, and in the diminishing economic and educational opportunities that disproportionally afflict Black and Indigenous people and other communities of color.

Over the past six months we have seen the consequences of our historic failure to address those root causes. We have witnessed Black Americans dying from COVID-19 in dramatically disproportionate numbers—deaths attributable to structural social inequities that make Black people and other communities of color more likely to have diabetes, heart disease, and high blood pressure, inadequate housing and fewer economic opportunities. We have seen the difficulty non-medical essential workers have had obtaining adequate health protections, resulting in significantly higher infection rates. These are people who don’t have the luxury of working from home, people in low-wage positions, often with little or no sick leave or health insurance.

The pandemic did not create these inequities—it simply exposed them. They have been with us since before our nation’s founding, churning just below the surface, visible indirectly when we examine disparities in health and education outcomes, and income and wealth for chronically under-resourced communities, where people of color are disproportionally represented.

To get at the root causes of institutional racism will not be easy because it involves profoundly changing the pattern of our public expenditures. We must make a far greater investment in these communities themselves —particularly in very young children, their families and neighborhoods—and empowering those most impacted to play the central role in shaping the programs and investments that are needed.

The political challenge in making these investments is complicated because their impact will not become apparent over the course of a few years. To be effective, they must be sustained over several budget cycles. Yet, the political imperative to sustain existing institutions discourages investing in new initiatives, even those that could make those institutions more effective. Furthermore, in the current fiscal climate, investments of the magnitude necessary will require a significant reallocation of funds (and power) from the health care and education sectors and into the social service sector.

Taken together, education and health care comprise 72% of the general fund budget. If past is prologue, these politically powerful institutions will fight to protect their silos and entrenched business models, even though we know that sustained investments in at-risk children, their families and neighborhoods, would reduce the cost of health care and improve educational outcomes.

For example, the basic structure of our health care system has not materially changed in 70 years, beyond needing additional public subsidies to support it. Its fee-for-service business model drives the relentless increases in the cost of care, undermining our ability to invest in young children and in families and communities. Likewise, the siloed components of our education system—K-12, community colleges and higher education—compete with one another for resources, resulting in a huge cost for remedial education due to our failure to adequately invest upstream in very early childhood, affordable day care and preschool programs.

If there is an upside to the current crisis, the pandemic has disrupted both of these sectors, making possible policy solutions that were unthinkable a year ago. Both education and health care have been turned upside down over the past six months and the pieces are up in the air, creating an unprecedented opportunity to put them back together in a way that is more effective and more equitable—and recognizes that sustained “upstream” investments in young children, their families and communities are the foundation for both health and learning.

The current fiscal crisis has pushed us to an inflection point. We will have to choose between sustaining entrenched institutions or rebuilding those institutions to be more resilient and better reflect the needs and realities of 2020. If we hope to be effective in dismantling institutional racism, the energy of the movement must focus not only on law enforcement, but also on the investments needed to address the conditions of injustice that driving the disparities in our society.

Having spent most of my life in public service, I can tell you this won’t be easy—but it is necessary. Who will lead this brave and essential shift in our accounting for justice? Who in education? Who in health care? We must work at this together as though the success of our society depends on it … because it does.

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