WHY DO SOME PEOPLE benefit from health care in America while others are excluded?
That’s the question that hospitalist Ricardo Nuila, MD, poses in his new book, “The People’s Hospital: Hope and Peril in American Medicine.” In the book, he answers that question by detailing the rise of what he calls “Medicine Inc.,” his term for corporate medicine and the hugely profitable private health insurance industry. According to Dr. Nuila, Medicine Inc. creates health-care haves and have-nots based solely on patients’ ability to pay.
He also lays out a model for a publicly-funded alternative that everyone can access, the type of care available at Ben Taub Hospital in Houston. That’s where Dr. Nuila trained as a resident and where he’s worked as a hospitalist for a dozen years.
The country’s largest safety-net hospital, Ben Taub is part of Harris Health, a system in Harris County (where Houston is located) funded through property taxes. Ben Taub—as well as another Harris Health hospital and a network of outpatient clinics—delivers care to any county resident, including those who are un- or under-insured or undocumented.
“Doctors increasingly acknowledge that something is astray in health care.”
Ricardo Nuila, MD
Ben Taub Hospital
The book is also a love letter to Dr. Nuila’s hospitalist practice, even with its limitations. While his number of daily patients is capped at 15, his hospital has to allocate resources to benefit the most patients.
Some very costly services, like transplants, aren’t available, and if Dr. Nuila wants to prescribe an expensive antibiotic, an infectious diseases doctor must first approve the order. And Dr. Nuila’s patients may wait for services—like MRIs—that doctors elsewhere can access immediately. In exchange, Dr. Nuila delivers comprehensive, evidence-based care for less than half of what’s spent on patients as a national average. Throughout the book are stories of several of his patients, many of whom present with advanced disease.
The son of an ob-gyn who emigrated from El Salvador to practice in Houston, Dr. Nuila also directs the Humanities Expression and Art Lab (HEAL) at Baylor College of Medicine, which develops educational materials to integrate the humanities into medical education. He spoke with Today’s Hospitalist.
What feedback about the book are you getting from physicians?
My initial impression has been very positive. When I was writing it, I was prepared for doctors who work in private health care to have a lot to say about how there shouldn’t be anything between themselves and their patients. I also had that expectation when I published [in March 2023] an opinion piece in the New York Times that called for a national referendum on government-sponsored universal health care.
But I didn’t receive any negative feedback from physicians on that at all. I feel that doctors increasingly acknowledge that something is astray in health care and that burnout is real—and part of that is the mechanism of health insurance and the implications for health care access. I think doctors now are more willing and thoughtful about looking at other options.
Many of your patients are turned away from other facilities before they arrive at Ben Taub. Why don’t they come to the public hospital first?
It shows just how deep preconceptions about health care are in America. The assumption is that the public health care system can’t do what the private system can or that patients won’t get the same level of care.
I also think the Houston public health system has been operating in the shadows, and they didn’t want to gain the attention of people like politicians who may have a different ideology. For decades, the thinking has been, “Let’s not broadcast that we are providing evidence-based health care for undocumented immigrants.” But that’s definitely changing. In fact, public officials are considering how to amplify the public health system and rebuild and expand the hospitals, including Ben Taub.
You make it clear that caring for patients who won’t be treated elsewhere has a lot of meaning for you. Does that tamp down burnout?
The burnout we experience is related to the kind of difficulty our patients have getting health care. We see a lot of people with no preventive care, so they arrive with end-stage organ failure or metastatic cancer. That’s something we have to commonly absorb, so it’s a different level of burnout.
You write that, during the pandemic, your boss and mentor at the hospital committed suicide. Were you and your colleagues able to come together and support each other?
A lot of people did come together. For a while, we were checking in with one another, but we haven’t been doing that as of late. One of the values in telling that story is to alert people that this is a real risk in our community. We’re at such high risk that maybe we need ongoing programs and activities to combat it.
You’re advocating for fundamental change in how health care is paid. Have political or physician advocates reached out to you?
I’ve heard from people in other safety-net hospitals, such as Parkland Memorial Hospital in Dallas, and I’m getting invitations from around the country to talk about health policy—from the Stanford Big Ideas in Medicine meeting in September, for instance.
I’m also being invited to discuss the book at NYU Langone in New York and with people who work with the Los Angeles County health system. So the book is receiving interest from those who live these ideas daily.
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
A few years ago, Today’s Hospitalist covered how hospitalists are taking the lead on health care initiatives across the country. Read Good medicine? Health systems address patients’ social determinants of health.
Published in the May/June 2023 issue of Today’s Hospitalist