Setting aside specialized institutions like children, veteran, and mental health facilities, there are over 6,000 hospitals in the U.S.
Let’s start with the nonprofits. This type of hospital qualifies as a charity according to the IRS and is not required to pay property, state, federal, income, or sales tax. In exchange for this significant benefit, nonprofit hospitals are required to return any additional capital to their surrounding communities. One concern universally raised is how to measure what amount of giving back these hospitals actually provide given the high salaries often awarded to a heavy layer of administrators and chief medical personnel. As nonprofits are scooped up by a larger hospital chain, another question is how out of touch is the corporate headquarters given the often multi-state community to be served. Very little Congressional or IRS scrutiny has been dedicated to these two questions.
For-profit hospitals, on the other hand, are owned by various entities and are increasingly part of a large network. One of the primary goals of these facilities is to make a profit for their shareholders and others. One notable difference between nonprofit and for-profit hospitals is that for-profits expend far more resources on advertising and marketing. Critics contend that these expenditures divert net income away from improving medical care for patients, better wages for nurses, training for hospital staff, and upgrading equipment.
Less well defined is the safety-net hospital like the focus of this post – the Ben Taub Hospital. These hospitals can be rural or urban, public (like a county hospital), or nonprofit (like a university teaching hospital). Most have a stated mission or mandate of serving a low-income population, regardless of a patient’s insurance coverage, ability to pay, or immigration status. Safety-net hospitals typically depend on public funding and operate on thin margins and treat high numbers of the uninsured, Medicare, and Medicaid patients. There, often due to the lack of previous care, patients arrive with more complex medical and chronic conditions.
This brings us to an extraordinary book, The People’s Hospital: Hope and Peril in American Medicine, by Dr. Ricardo Nuila. In his words: “I work as an internal medicine doctor and hospitalist in my hometown of Houston, Texas. It’s hard to imagine practicing medicine anywhere else but at a safety-net hospital, where the primary focus is on a person’s healthcare problem.”
Nuila’s personal journey and his rejection of corporate medicine is what makes this book so interesting and shows what is possible. He gave up—more prestige, more money, more power—because he is a doctor first and foremost. He chose Ben Taub after working elsewhere because he found a receptive home for those qualities that originally drew him to the profession as a young man.
Nuila describes the theme of his book as: “I’ve pieced them [his patients] alongside some of my own personal stories in order to think about the basic foundations of our healthcare system in America and uncover for myself how Ben Taub illuminates what is missing in American medicine.”
The staff at Ben Taub primarily treat patients who lack consistent access to care. Nuila, like many of his colleagues, proves to be not just a good listener, but often takes the time to think outside the algorithm that has taken over medical diagnosis to an alarming extent.
While we learn so much about the modern-day Ben Taub in the book, Nuila also provides an important history of U.S. hospitals. As late as the twentieth century, most medical institutions were the opposite of safe, competent facilities. But a change occurred in the 1960s when public tax-investment programs such as Medicare and Medicaid brought improvement as well as public insurance for the elderly and the poor.
Following this new consciousness, in 1965 Houston voters approved the creation of a taxpayer-funded hospital district—Harris Health System. Harris County residents earning as much as 150% of the federal poverty level qualify for a Gold Card, which ensures access to near-comprehensive primary, specialty, and hospital care on a sliding-scale payment plan.
Unfortunately, this system of care is not only a rarity in Texas but in many states in the U.S. Through Nuila’s eyes and detailed narrative, we see issues that doctors, patients, hospital administrators, and the poor of Houston face as well as humane medical solutions. Ben Taub is a sanctuary but also a potential model for the nation to provide compassionate, affordable medical care – anywhere.
Because the heart of Nuila’s book is about good, affordable, and compassionate care, he mixes in what he identifies as key barriers. First is the rise of the medical-industrial-complex.
“Let’s call it Medicine Inc.,” he writes, “this amalgam of healthcare suppliers in America results in a level of sheer conscience-less competition.” Medicine Inc. is a growing patchwork of doctors, hospitals, pharma and benefit managers, and insurance companies that greatly influence state and federal policy makers. This powerful patchwork of financial interests work together to keep patient support and implementation of a functioning national health system out of the question.
Nuila also argues for putting the brakes on many treatments and medications. He asserts that much of what the typical physician does is unnecessary and potentially harmful. For example, some patients who are waiting for an expensive MRI learn that they didn’t need it after all. He devotes nearly a chapter to patients with kidney disease who choose at-home dialysis. This is often more convenient and cheaper, but if the physician owns part of the center performing dialysis, they are likely to recommend the pricier option, thus making more money. If we put this together with the rising cost of medicine, highly advertised drugs, increasing hospital costs, we have the world’s most expensive medicine. But the question remains—what are we getting out of this as patients?
Perhaps, the most long-lasting barrier to care of the poor and uninsured are the deeply rooted beliefs about the poor and working class. “Those people” is a frequent appellation. This prejudice, writes Nuila, is well hidden and is almost never (if ever) exposed in a book about U.S. healthcare. Many believe that healthcare should not be one of the government’s obligations to the people, that the poor bring on their own poor health, and then expect taxpayers to pick up the welfare tab.
In many countries, a person’s life is covered from birth to death through various programs. There, welfare has a different meaning – “wellbeing” – which is considered an essential human right. As a result, many standard burdens Americans must bear—medical debt, inadequate long-term care, and the absence of a life-long safety net of services—don’t exist there.
With the current lack of trust and confidence in government at possibly an all-time high, people who would have championed a national health program in the past are afraid to have the government get their hands on what’s left of the system. And many elected officials must be relieved since with a lack of public support, they don’t have to lose their corporate funding, take on powerful industries, or actually fix anything for their constituents.
On a positive note, what Nuila illustrates, without romanticizing the care provided, is what Ben Taub provides, and could be used as a new model of care. There are many more pluses than minuses in Nuila’s description of Ben Taub; too many to list here. Beyond the low-cost innovations that have created workable daily practices at the hospital, there is a genuine sense of community among the staff, between doctors and patients, and with patients’ families.
In the last pages of Nuila’s book, he describes attending the funeral of one of his patients, Geronimo, who died before he could receive a liver transplant. Addressing Geronimo’s mother and other mourners at the funeral, he said he was “sorry.”
Thinking back to that sad occasion, Nuila follows with a compelling list of what his “sorry” didn’t cover. “I’d have talked about where the responsibility for this death falls: on all of us. We accept these tragedies because we don’t demand anything different . . . I’d have said that Medicine Inc. isn’t working, not for medicine or for patients, and that in the name of profit it’s usurped this beautiful combination of art and science that doctors and nurses practice.
“We suffer from disaster syndrome, I would have said, because we can’t imagine anything better than what we have. I would have noted how joyless it can be to see a doctor today, the waiting, the middlemen, the upselling, the bills aimed at us from every direction. And then I would have shared my vision: more affordable healthcare for all.”
If you would like to hear Doctor Nuila interviewed as he talks about his book, the Ben Taub Hospital, and why he wrote it, you can find the link here:
Photo credits: Hospital – pramad-tiwari, I’m Sorry – steve dematteo, Don’t Give Up – rosie-kerr.