Review: The People's Hospital

 I found The People's Hospital through An Arm and A Leg podcast. The podcast is incredibly informative about how massively painful the US healthcare "system" is, and how beaten down most people are --- even the heroes of the podcast are people who cannot conceive of the idea that the US healthcare system could be any better, or that there are alternative healthcare systems that provide much better value for money, much better overall health outcomes, and that other countries do it much better.

The book is written by Ricardo Nulla, faculty member at Ben Trau hospital in Houston. Nulla clearly loves the hospital, and explains the challenges of serving the uninsured and under-insured in Texas:

The rate of mothers’ dying shortly after childbirth was also rising. In Texas, it had nearly doubled from 2011 to 2012, for reasons public health experts and statisticians couldn’t explain. The spike in maternal deaths loomed so large that Texas lawmakers added it to an emergency legislative agenda. The numbers looked bad. Only during war or catastrophes had there ever been such a spike. Was there a connection between the uninsured rate and the rate of maternal death? Nobody knew. What experts did know was that African American mothers bore the highest risk. So much of our healthcare system is mired in discrepancies. While the rate of new mothers dying in Texas was increasing, Ebonie’s home state of California was bucking that trend. When the Affordable Care Act was signed into law, California expanded Medicaid to cover more than twelve million Californians, making it the largest public insurer of the poor and near-poor in the country. Right in the middle of a pregnancy, Ebonie had left the country’s safest state for expectant mothers—where the mortality rate looked more like that of France or Germany—for one of its most dangerous. Her new home state, Texas, had the same maternal mortality rate as Mongolia. (kindle loc 520)

I was at a kids' soccer game, and one of the other parents came from Canada. He told me that his dad liked the US system better, because it made him feel like a customer. Nulla, of course, would disagree, as would I. I personally think that it's much harder to trust a US medical doctor whenever he recommends something, because the likelihood that he's increasing his revenue through an unnecessary procedure is much higher than the doctors in a system where his income isn't tied to "fee for service":

 “Medical-industrial complex” paints the picture of a firing squad, except the squad is disorganized, each of the gunmen—the insurance companies, doctors, hospitals, and Big Pharma—aiming not only for us but also for the other gunmen. The promise of profit means each of these players is clawing and charging the others: insurance denies claims, hospitals inflate bills for insurance, Big Pharma ups drug prices to scrounge from insurance’s profits. Let’s call it “Medicine Inc.,” then, this amalgam of healthcare suppliers in America, for its level of sheer conscience-less competition. It’s not a perfect term, and it’s not meant to disparage business or capitalism. Perhaps Medicine Inc. wouldn’t be so bad if we were the customers, but we aren’t. We might pay for our care, as a customer would, through insurance premiums and co-pays, but our bodies are the merchandise. (kindle loc 551)

The book follows 3 sample patients, all of whom have been failed by the healthcare system because they didn't have insurance, or bought less insurance that they thought they heard. For instance, I had no idea that the Bronze level of Obamacare didn't cover transplants!  Ben Traub doesn't do transplants either, since it's incredibly expensive, and Ben Traub is actually covered by local property taxes in Houston. Nulla argues:

Healthcare was simply too expensive. Health insurance was too expensive. The reason universal coverage in America is still being debated isn’t because most Americans oppose it in principle (though a few do). It’s because Americans fear the costs. We are already paying so much for our own care; how much can we pay for someone else’s care, too? Some people think that to solve the problem of healthcare in America, we will have to spend an inordinate amount in overhauling what we have. But in fact, healthcare in America already has too much money. The excessive profits made by middlemen and corporations keep prices high. We don’t need to spend more, we need to spend better. To cover more people, we have to decrease healthcare costs across all of America. Perhaps in this regard, Ben Taub presents a model. It offers universal coverage to residents of Harris County and yet it manages to keep costs so low that it was listed by the New York Times as the second-least-expensive hospital in the United States. (Kindle loc 3339)

Ben Traub's costs indeed rival those of what a good universal healthcare system would cover in the rest of the developed world. It's doctors do not operate on the "fee for service" model, and can therefore consider the patients' interest before the doctors':

In 2016, a group of researchers decided to survey the healthcare team members of a for-profit hospital in the United States to figure out if they could identify a “customer.” Doctors, nurses, administrators, patients, patient family members, and anyone working at a hospital—including support staff and therapists—were asked, “Who is and is not a customer for the hospital, and what leads to customer satisfaction?” The results, which appeared in the Journal of Healthcare Management, showed that neither patients nor doctors saw patients as a hospital’s customers. Nearly everyone in the study thought that the hospital’s customer was the doctor... One of my colleagues who splits time between Ben Taub and private hospitals explained it to me like this: “The private system is set up to be overused.” Working at nonprofit and for-profit hospitals introduced temptations he hadn’t experienced at Ben Taub. He could call a colleague in during a surgery when he didn’t really need an extra set of hands (and, likewise, expect to be called by that colleague). He felt incentivized to act lazily at times, letting other doctors perform the medicine he could handle well himself. (kindle loc 3399-3417)

You might think that doctors prefer the American system because it lets them charge more, make bank, and drive expensive Ferraris. Instead, Nulla argues that it actually leads to burnout:

 more than half of American doctors reported bureaucratic tasks as the top burnout factor. Only Portuguese doctors complained so much about bureaucracy. The survey showed similar levels of doctor burnout in all countries, including in France, Germany, and Spain, but for different reasons. American doctors craved more control and autonomy than their counterparts. Notably, UK doctors reported the lowest burnout and depression rate in this survey. These doctors, who, by and large, worked for the National Health Service, complained of government regulations more than doctors from other countries, but they didn’t identify these regulations as factors for causing burnout as much as US doctors did bureaucracy....Opening more medical schools and allowing more foreign medical graduates to work in the United States only places a Band-Aid on a larger problem: most doctors simply don’t like practicing the American style of medicine anymore. In a 2018 opinion piece published by Stat, a Harvard plastic surgeon and a military psychiatrist argued that the problem went beyond tired and downcast workers. “We believe that burnout is itself a symptom of something larger: our broken health care system,” they wrote. “The increasingly complex web of providers’ highly conflicted allegiances—to patients, to self, and to employers—and its attendant moral injury may be driving the healthcare ecosystem to a tipping point.” (kindle loc 3845-3859)

 Yet of course, the American Medical Association advocates against universal healthcare systems and obviously also fights to keep the number of doctors low to keep doctor pay high.

The book's not a depressing read --- Nulla's case studies are instructive and tell you how to work the system. It's got plenty of insights though I wish Nulla had personal experience in other developed country hospitals to see if those are better. It doesn't advocate anything --- Nulla, like many Americans has a "learned helplessness" about the system, but he goes a long way towards explaining why doctors themselves would fare better in a system like Ben Traub. My guess is it'll take more American suffering before Americans decide to vote for change. Needless to say I recommend this book and encourage everyone to read it.