In the coming weeks, Kaiser Permanente will turn its attention to the extreme economic and social challenges the people in this country face. Two high-profile events, the Community Benefit Summit and the National Diversity Conference, give us an opportunity to discuss the challenges facing the country and how we must lead the nation as the model to provide the best care. The conversation leads us to ask:

Who is “them”?

Who is “us”?

Not your grandfather’s class struggle

Over the last 150 years, many people who advocated a more egalitarian society looked at things in terms of class struggle. This ideology tends to divide the world between “them” and “us” or the “haves” and the “have nots,” that is, those who are economically secure and those who are not. Proponents of this way of looking at the world often look at political economy—how social and public policy, as implemented by those in the power, affect economics.

Prior to World War II, class had pretty clear meaning. There were the rich, and then there was pretty much everyone else. Things got a bit more complicated from 1945 to 1975, when the middle class in the U.S. emerged. It took that long for tens of millions to finally attain “the American Dream.”

In this period, strong unions, an economy based on manufacturing and building infrastructure, strong government regulation of services, and new social programs like the GI Bill, Medicare and the Civil Rights Acts lifted all boats.

The U.S. middle class came to be defined as not only white collar professionals but also included “workers,” meaning, primarily, industrial workers who made a rapid climb from poverty to property ownership. These folks believed their kids would have a better life than they did. In fact, income grew (actually doubled) for all categories of wage earners from 1945 to 1975. By 1975, home ownership, social mobility and a better future were the accepted definition and experience of a big middle class, regardless of what one did for a living.

Back to the future

Today, we are back to pre-1945 reality. Ninety percent of the people in the country are again struggling to be “middle class,” as income has been distributed more and more unequally over the last 35 years. Chronic unemployment, the loss of most high-paying industrial jobs, the elimination of pensions, and the skyrocketing cost of health care have eroded income growth across all “classes” except the very rich (top 10 percent). The median income in 2009 was  $49,777[l1] , according to the U.S. Census Bureau. However, for a family of four to “feel” they are middle class—that is that they have a little extra left over after paying for the essentials—requires much more income in most major metropolitan areas.  Nearly all of the 90 percent who aren’t “very rich” have significant debt and little to no savings. Most households require multiple family members to work extraordinarily long hours to make ends meet. Polls indicate that more than 60 percent of people believe the country is headed in the wrong direction and people generally do not believe that their kids will be better off than they are.

We’re at a crossroads

We will participate in the conferences on Community Benefit and diversity in the context of national health care reform and the greatest and longest economic crisis this nation has faced since the 1930s. This means that we must understand the meaning of “them,” because “them” is just about everyone.

Medicare cuts will be deep over the next three years as we approach the 2014 benchmarks of the new legislation. It will be a requirement that health care be available for the uninsured as well as for those who may be forced into exchanges or Medicaid—a very diverse and insecure group of tens of millions. The question is: Who will be ready to serve these tens of millions who will need, deserve and be eligible for high quality health care?

Will the newly insured receive lower quality care because insurers and providers decline to participate in the exchanges? Will low Medicaid reimbursement rates create a two- or three-tier system of care? Will part of that lower quality include lack of cultural competency, lack of multi-language capacity, and lack of understanding of health disparity based on race and ethnicity? Not if Kaiser Permanente can offer high quality care to  this new group of potential members.

Kaiser Permanente was originally created to care for largely “working-class” people.

Working class in the U.S. is pretty hard to define. Today, what it really means is that we have an overwhelming majority of people in this country that we used to call “them.” The fact is they are “us,” meaning that today vulnerability and insecurity abound, while health care dollars are shrinking.

National Diversity and Community Benefit are two important places for all of us to discuss a way forward.

The watchwords of Diversity and Community Benefit can be summarized by one word: inclusion.

What does inclusion really mean today? Can we achieve more of the best inclusion possible in today’s economic reality? These are the questions we will be discussing.

I believe we can achieve new heights of inclusion by renewing our commitment to do so.

Our mission demands it.