“The People’s Hospital:” Can Healthcare For All Work?

CHRISTIANE AMANPOUR, CHIEF INTERNATIONAL ANCHOR: So, as we mentioned earlier, there are numerous challenges facing the health care system in the United States, with millions of Americans uninsured and unable to pay for a doctor’s visit. Affordable health care is hard to come by Dr. Ricardo Nuilia works at a Texas hospital where cost is second to care. In his new book, he chronicles the lives of five patients who turned to his help after facing financial barriers. And he joins Hari Sreenivasan to discuss what America needs to do to fix its health care crisis.

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HARI SREENIVASAN, CORRESPONDENT: Christiane, thanks. Dr. Ricardo Nuila, thanks so much for joining us. First, to give our audience a little bit of a background, you’re writing this story about a safety net hospital in Houston, Ben Taub. What is a safety net hospital?

DR. RICARDO NUILA, AUTHOR, “THE PEOPLE’S HOSPITAL”: Safety net hospital is a hospital that provides health care even if people don’t have health insurance. The safety net hospital that I’m writing about is Ben Taub hospital. It’s part of a system, as health care system in Houston, Texas, that provides health care for people who can’t access health care or can’t afford health care, which is becoming more and more in our society. Again, the safety net hospital is part — in Houston is a public health care system. This is generated by property taxes to help assure that everybody has health coverage, health care in the city.

SREENIVASAN: So, give us an idea of the scale, the number or the percentage of people who are coming there for care who don’t have insurance?

DR. NUILA: Yes. I mean, and Houston is one of the highest uninsured rates in the country, more than 1 million people are uninsured. And Houston, Texas is one — is the highest uninsured state in the country, percentage wise. And that’s more than 5 million. In the United States, that’s 40 million people who are uninsured. And remember that we pegged health insurance to employment. So, as employment changes, people get laid off, we see more people at the safety net hospital.

SREENIVASAN: What’s the kind of experience that a young doctor can get at a safety net hospital that they might not be able to at — well, to put it crudely, a fancier one?

DR. NUILA: Yes. I think it’s that contact with people. I think it’s the ability to feel the responsibility. That’s what kept me in the safety net hospital is the feeling of responsibility. We’re in a crisis of burnout in our profession, and a lot of that has to do with the bureaucracy that comes with our health care system. But when that is spread away and you can just deal with what you are in — you’re trained to do, which is to sit and think through problems with people, I think that that’s one of the reasons why people come to the safety net hospital. They also come to see the different pathologies, the different illnesses that manifests in patients. And that’s why lot of students really want to come to safety net hospitals to learn how to train, it makes them better doctors.

SREENIVASAN: So, let’s talk about some of the things that you are more likely to see than perhaps other places. One of the patients that you describe is a woman named Ebony. And put this in the context of kind of maternal health challenges in the United States or even specifically to black women and what they face.

DR. NUILA: Right. Ebony had a problem, which is that she was bleeding during her pregnancy and that put her at high risk. She had moved from a State California where she had Medicaid or her health insurance provided by the state, but she moved to Texas where she was uninsured. And so, when the bleeding started, she was shuttled between emergency rooms until she found the safety net hospital. The placenta was blocking the birth canal, which meant that it could not be born without causing a catastrophic bleed. Doctors at that moment offered her a medical abortion. That would be the best way to ensure that Ebony’s life was saved.

SREENIVASAN: So, if she came to you with the same symptoms today in Texas, what would she be facing given how the political landscape has changed?

DR. NUILA: What she would be facing is the — you know, having to risk her own life for that — for the — for that birth, and not even the choice. That’s the thing. Ebony selected to proceed with the pregnancy. But this happens and many women don’t want to risk their lives, and that’s — in my mind, that’s their liberty. But in Texas now, it’s very confusing for doctors on what advice to give patients like these.

SREENIVASAN: Is it harder now in Texas for a doctor at a hospital or a doctor anywhere to have an honest conversation with a woman about her health care for fear of being sued by a third-party if the word abortion enters the conversation?

DR. NUILA: Undoubtedly. Now, I’m not an obstetrician. My dad is an obstetrician and my colleagues are obstetricians, and I’ve spoken with some of them about this. But one of the things that set safely net hospitals apart, one of the things that we strive for is those — that transparency and that conversation and that knowledge that we’re going to be trying to help the person make the best decision for their own lives, and that has changed now because of the abortion laws in Texas.

SREENIVASAN: I mean, you talk about one of the patients that you call Geronimo, and he had needs for a liver transplant, right?

DR. NUILA: Yes.

SREENIVASAN: And tell us a little bit about him. What happened?

DR. NUILA: Well, Geronimo was a gas station attendant who — he had liver disease that was — that had gotten to the point where he was very ill and he made too much — he qualified for Medicaid. But when he started to get his disability payments, it put him over the — he wasn’t poor enough for Medicaid. And so, it was taken away from him. That was right at the moment where he needed a liver transplant to survive. The safety net system does not have transplant capabilities. The infrastructure that’s needed to build transplant centers and to have the personnel so much high investment that, you know, a safety net a system really has to be utilitarian with these funds and say — and transplants, it’s just not something that it can afford. So, you know, one of our goals was to try to see if you could qualify for this insurance. Because in America, in order to get a transplant, you do need insurance, by and large.

SREENIVASAN: There’s also an entire demographic that you’ve probably seen more at this hospital in Houston and perhaps a lot of other hospitals, even safety net hospitals in other parts of the country, which are undocumented people.

DR. NUILA: Yes.

SREENIVASAN: And you wrote about Roxanna, undocumented women from El Salvador who had complications from a cancer related illness and she needed amputations. And it’s just startling that something like that could well slip through the existing cracks and get to you. Tell us a little bit about her.

DR. NUILA: Well, it’s an example of how broken our system is, that we don’t have these standards for dignity for patients. Roxanna came to the safety net hospital because she had suffered a great complication during a lifesaving surgery. Now, I want to make this clear, the lifesaving surgery that she had was a moonshine. It was an incredible manifestation of the American health care system. It showed our ambitions. It showed that we have surgeons capable of doing amazing things. We just can’t complete the job and give people chronic care. So, that when — in the hospital, when she changed from an emergency patient to a chronic care patient, she was discharged out into her apartment with gangrenous arms and legs, and there was no plan for how to deal with her. Thankfully, she lived in the city like Houston, where she could go to the public health care system that is funded by property taxes, from members of the community, and she could get those amputations and the care that she needed.

SREENIVASAN: So, you’re going to stay with conservative values and you’ve got a legal climate which creates other challenges for you, but you’re also saying that this hospital can be a model for the rest of the country to still have these conservative values and show compassionate care. Explain how.

DR. NUILA: What’s plagued us in America is trying to bring these two big concepts together. And they’re represented by different political sides. I think we want to get costs under control and we want to provide health care for everybody in this country. But because it’s so expensive, it’s very difficult to provide for everybody. What I found in the system where I work in is that these conservative values of cost cutting have come together with the more liberal values of providing to everybody, regardless of citizenship or insurance status. And I think that one of the reasons that that’s happened is because there’s been conversations in order to make this system work. And that’s what we really need to look for in designing a health care system, is that everybody needs to weigh in and we have to look at our similarities. Seven out of 10 Texans believe that the federal government has a role in providing basic health insurance to everybody in the country. I mean, think about that. That means that across the political spectrum there is agreement, we just have to focus on that agreement. And what I am really proud of is that I work in a system where we found those political ways through those political ideologies.

SREENIVASAN: One of the other things that’s interesting in the book is how Ben Taub, the hospital, is able to cost about half the national average per patient. But at the same time, you’re the fastest in the country for figuring out whether somebody is having a heart attack or not. So, how can you keep the costs where they are and still have a level of expertise that the rest of the country hasn’t got yet?

DR. NUILA: I think that is the philosophy of quality improvement and making sure that the health care goes to what’s needed, OK? There’s just not waste in the system like there is waste in the private health care system, since it’s evidence-based medicine and since we are not performing more health care than is necessary, then we can focus on emergencies like heart attacks, strokes, trauma and build — break protocols to identify those and to take care of those in a timely manner. You know, if you think on the other side, you know, those — the resources are used for other things that are not as essential and vital for those things. And I think that that’s one of the reasons why we can demonstrate quality while also cutting costs.

SREENIVASAN: Give me an idea of sort of what’s the cost difference here on what either you’re spending per patient or how do you quantify the level of efficiency that the safety net hospital has?

DR. NUILA: Yes, that’s a great question. And so, there’s ways to look at how much Medicare is paying per patient per year. For instance, this year it was $15,000 per patient per year that Medicare is paying. Private insurance pays less, but only because Medicare is for patients that are 65 and older, who usually utilize health services more. So, if you take apples and apples, private insurance is actually paying more. But at that our health system, you can look and see what the overall budget is and how many people are in the system and it’s — more or less, it’s less, it’s 30 percent of the total costs. And one of the things that I do in my book is follow a patient and the medical bill that he occurs in our public health care system where there is that profit motive. One of the patients who had treatment for (INAUDIBLE) cancer that involve x-ray therapy, surgeries, admissions, his total bill was, what he calls it, less than a pickup truck, $40,000, which is for people who have been in the health care system, they know how little that is compared to the equivalent in the private system where there’s a profit motive.

SREENIVASAN: You know, I also wonder if there is a hesitation on the parts of now doctors, especially in a state like Texas, to come out and speak like you are. You’re talking about the difficult climate about having reproductive health conversations with women. You’re talking about sort of compassionate care for undocumented. You’re talking about universalized health care. And I wonder if there is a concern that even having these conversations, being out front, puts a bull’s eye on your back.

DR. NUILA: I feel hopeful in my system because, for instance, I feel that the local government is supportive of this safety net health care system. But you’re right that it — there is — it’s — because it is a public health care system, it is subject to the politics of what’s going on locally. I think that, you know, we’re also arriving at a crux right here, which is that position burnout is occurring and it’s a big problem for the United States. If you think about how much society pours into doctors studying what they do and performing all the acts, what they do, and that my colleagues, many of them are leaving the profession early, it just means that we’re going to have less doctors with more health care that’s needed for this country. So, we’ve hit a point where we need to think about it. We’re spending so much money on health care. It’s a problem that we’ve just kicked the can down the road since 1910s. And now, what it’s — what’s happened is that the profession itself is people are leaving it and not wanting to go into it. And so, that’s one of the reasons why I think some people like me are speaking up about it because we’re genuinely concerned about that experience the patients have with the health care system and also, that our colleagues are leaving the profession early.

SREENIVASAN: Now, you are from El Salvador, you came from a family that’s three generations of doctors. You also write about your grandmother who came to you for advice, a medical advice. Tell us what happened.

DR. NUILA: Yes. My grandmother from El Salvador came and — when I was a younger doctor, she had this problem where she couldn’t swallow very well. And I just went through what the algorithm on how to deal with that, you know. And when the algorithm — she got a test and it was a normal test, I just chalked it up to, OK, your symptom — I don’t know what your symptom is due to. And later, I found out that she got another test when she went back to El Salvador that showed that she had esophageal cancer. And it just showed me that I had been subject to something that I call algorithm mania, which is that the over reliance on algorithms. I had stopped thinking about the symptom, stop thinking about the person of my grandmother, the moment that that test came back. And what I wish that I had done was followed that symptom and said, OK, this test was negative. What — do you still have symptoms? What else can we do to figure this out? What ended up happening was is that it led to a spiral, really, where she ended up getting an unnecessary surgery in El Salvador and she — I think she suffered greatly from that. I think she could have been diagnosed in a more precise manner. And I still — it still weighs on me today.

SREENIVASAN: What do you want people to take away from this book?

DR. NUILA: I want them to take away that there — we can come together to solve this health care crisis. This health care crisis manifests in so many ways that we don’t think about, that’s hidden from us and it affects real people’s lives. And — but we can solve this problem if we just think about what we aim for, which is we need to decrease costs and we need to give health care access to everybody. There’s strength in numbers. And if we can bind together and think about building a health care system rather than just patching one up, which is what we’ve done since the early 1900s, then I think that we can actually solve this problem.

SREENIVASAN: The book is called “The People’s Hospital,” doctor and author Ricardo Nuila, thanks so much for joining us.

DR. NUILA: Thank you so much for having me.