What the US health care system assumes about you | Mitchell Katz

Summary

The speaker, a director of a department, shares her experiences with the healthcare system's shortcomings for low-income patients. She highlights the barriers they face, such as lack of transportation, language, literacy, and stable housing, which hinder timely medical care. The narrative emphasizes the importance of a patient-centered approach, including providing housing, food security, and effective communication, to improve healthcare outcomes for the underserved. The speaker advocates for a healthcare system that meets patients' actual needs and provides compassionate, continuous care.

Takeaways

• 🚑 Healthcare systems often fail to accommodate the specific needs of low-income patients, leading to disparities in care quality.
• 🏥 The middle-class model of healthcare assumes access to resources like transportation and time off work, which low-income patients often lack.
• 🗣️ Language barriers and the need for translation services are critical issues that can impede patient care for non-English speakers.
• 📄 Literacy levels can affect patients' ability to understand and comply with medical instructions, a challenge often overlooked in healthcare settings.
• 🏠 Housing stability is a fundamental factor in health; without a stable home, managing chronic conditions like diabetes becomes extremely difficult.
• 🍲 Access to consistent nutrition is essential for health, especially for patients with conditions like diabetes that require dietary management.
• 📞 Communication infrastructure, such as having a working phone and a stable address, is assumed by healthcare systems but can be a significant barrier for low-income individuals.
• 💊 The assumption that patients prioritize healthcare over other immediate needs, like housing or food, is unrealistic for many low-income individuals.
• 👩‍⚕️ Primary care doctors play a crucial role in advocating for and coordinating the medical and non-medical needs of low-income patients.
• 🏢 The healthcare system can be improved by meeting patients where they are, providing services without obstacles, and focusing on what they actually need rather than assumptions.

Q & A

Why did the woman not attend the trauma clinic appointment?

The woman did not attend the trauma clinic appointment because her ride did not show up. She did not have the financial resources for an alternative like Uber or another friend to call upon for transportation.

What is one of the main challenges faced by trauma survivors in accessing healthcare according to the script?

One of the main challenges faced by trauma survivors is their resistance to dealing with difficult issues, which often leads to missed appointments. Additionally, practical barriers such as lack of transportation can also prevent them from seeking timely care.

How does the healthcare system in the United States often fail to meet the needs of low-income patients?

The healthcare system in the United States is often built on a middle-class model that assumes patients have resources such as transportation, time off work, language proficiency, literacy, stable housing, and a steady supply of food, which low-income patients often lack.

What example is given to illustrate the impact of work obligations on patients seeking healthcare?

A patient with partial blindness only sought care on a Thursday afternoon because he had to work to pay rent, highlighting how work obligations can delay patients from seeking necessary healthcare.

Why is translation services considered as important as a prescription pad for non-English-speaking patients?

Translation services are considered as important as a prescription pad for non-English-speaking patients because effective communication is vital for understanding medical instructions and ensuring proper treatment.

What is the significance of having a primary care doctor for low-income patients?

Having a primary care doctor is significant for low-income patients because they often lack other advocates who can help them navigate the healthcare system and access necessary medical and non-medical services.

How does the speaker suggest improving healthcare for homeless patients?

The speaker suggests that providing housing is the right prescription for homeless patients, as it not only decreases healthcare costs by reducing hospital visits but also restores their dignity.

What is the role of food pantries at primary care clinics in addressing healthcare needs?

Food pantries at primary care clinics play a role in addressing healthcare needs by ensuring that patients, especially diabetics, have a steady supply of food, which is crucial for managing their conditions and preventing complications.

Why is it important to provide healthcare materials at the level of fourth-grade reading?

Providing healthcare materials at the level of fourth-grade reading ensures that all patients, regardless of literacy levels, can understand their diagnoses and treatments, promoting informed decision-making and adherence to medical advice.

What is the impact of a stable relationship with a healthcare provider on low-income patients?

A stable relationship with a healthcare provider can provide low-income patients with a sense of continuity and care, which they may lack in other areas of their lives, and can be a significant factor in their overall well-being and adherence to treatment.

How does the speaker describe the current state of healthcare for low-income patients in the United States?

The speaker describes the current state of healthcare for low-income patients in the United States as inadequate and disconnected from their real needs, often failing to address the social determinants of health that significantly impact their ability to access and benefit from care.

Outlines

00:00

🚑 Challenges in Accessing Trauma Care

The author shares a story of a woman, a victim of violence, who missed her trauma care appointment due to a lack of transportation. Despite efforts to get her the care she needed, the author explains how trauma survivors often struggle with attending appointments due to their difficult life circumstances. The healthcare system, built on a middle-class model, fails to accommodate the unique needs of low-income and traumatized individuals. This incident highlights the challenges of ensuring care for vulnerable populations.

05:01

🚶‍♀️ The Struggles of Low-Income Patients

This section dives into the challenges that low-income patients face, such as missing appointments or delaying care due to work obligations and limited resources. Two examples are given: a patient with partial blindness who delayed seeking care for days and a trucker who worked through a severe infection. The narrative illustrates how the healthcare system's assumptions — like being able to take time off work — do not align with the realities of low-income lives, often jeopardizing their health.

10:04

🌍 Language and Literacy Barriers in Healthcare

The author recounts several cases where language and literacy barriers complicated care for patients. One patient from West Africa spoke a rare dialect, and the only available translator was limited in availability. Another patient, who was illiterate, struggled to navigate the healthcare system. These examples emphasize how the U.S. healthcare system assumes patients are literate and fluent in English, often leaving those who aren’t without proper care or instructions. This lack of accommodation can result in misunderstandings and delays in treatment.

15:04

📞 Barriers to Communication and Housing

In this section, the author describes how having an accurate address, a working phone, and access to basic needs like food and shelter are vital for healthcare. Patients often move frequently or have disconnected phones, which hinders communication. In one case, a patient missed vital follow-up for an abnormal mammogram because letters were sent to an outdated address. The healthcare system overlooks the basic survival needs of homeless and food-insecure patients, making it nearly impossible for them to manage their health.

💊 Life on the Street and Prioritizing Health

The author explores how the healthcare system assumes people prioritize their health, but low-income patients often face impossible choices. Patients may have to choose between taking medication or maintaining basic needs, like housing. The author reflects on how these choices make it difficult for low-income individuals to keep appointments or focus on their health. The narrative explains that these circumstances lead to delays in care or missed medical visits, not because patients don’t care, but because other life challenges take precedence.

🏠 Housing: The Prescription for the Homeless

The author argues that housing is essential to improving health outcomes for homeless individuals. Drawing from personal experience in Los Angeles, the author shares how housing 4,700 chronically homeless individuals resulted in fewer hospital visits and lower overall healthcare costs. Providing stable housing addresses many barriers to health and restores dignity to those in need. The healthcare system should focus on providing services tailored to the real needs of vulnerable populations, such as housing for the homeless.

🍽 Addressing Food Insecurity in Healthcare

The narrative highlights how food insecurity impacts healthcare, especially for diabetics. Low-income patients may lack access to steady supplies of food, which can lead to life-threatening situations like hypoglycemia. Solutions like food pantries at primary care clinics and enrolling patients in food assistance programs (like food stamps) are discussed. The author stresses that addressing basic needs like food is essential for effective healthcare delivery, especially for low-income individuals.

🗣 The Importance of Communication in Healthcare

The author emphasizes that effective communication is crucial for delivering quality healthcare, especially for non-English-speaking patients. Translation services are as vital as medication for these patients. Additionally, providing materials at a fourth-grade reading level can ensure that patients understand their diagnoses and treatment plans. The author advocates for making healthcare more accessible by improving communication and understanding between patients and doctors.

👨‍⚕️ The Role of Primary Care in Low-Income Health

The author stresses the importance of primary care for low-income patients, who often need continuous support. Primary care doctors can provide essential advocacy and help patients navigate both medical and non-medical services. Many low-income patients lack other forms of support and benefit greatly from the consistency and care offered by primary doctors. These long-term relationships can be life-changing for patients, providing them with a stable and supportive connection.

❤️ The Power of Compassion in Healthcare

The author shares a touching story of a long-term patient who, despite a difficult life of gang involvement, drug addiction, and imprisonment, rarely missed his clinic visits. His strong relationship with the clinic staff, particularly with a registration clerk, illustrates the importance of care and continuity in healthcare. The author believes that when healthcare systems commit to serving low-income patients with the same level of dedication that patients show in seeking care, the system will be truly responsive to their needs.

Keywords

💡Trauma survivors

Trauma survivors are individuals who have experienced significant emotional shock or physical harm due to a traumatic event. In the video, the speaker discusses the challenges faced by trauma survivors in accessing healthcare, highlighting how they often resist dealing with their issues and miss appointments. The example of the woman who didn't make it to the trauma clinic due to her ride not showing underscores the practical barriers that can prevent trauma survivors from receiving necessary care.

💡Safety net systems

Safety net systems refer to healthcare services and providers that offer care to underserved populations, particularly those without health insurance or with limited access to care. The speaker mentions running safety net systems in various cities, emphasizing the inadequacy of these systems in meeting the complex needs of low-income patients and the persistent healthcare disparities.

💡Healthcare disparities

Healthcare disparities refer to the unequal access to or quality of healthcare services among different population groups. The video script discusses how despite the expansion of health insurance under the ACA, disparities along economic lines persist, with low-income patients facing unique challenges in receiving adequate care.

💡Middle-class model

The middle-class model of healthcare is an approach that assumes patients have certain resources and lifestyles typical of middle-class individuals, such as the ability to take time off work for medical appointments. The speaker critiques this model for not accommodating the realities of low-income patients, who may have to prioritize work or lack the means to travel for care.

💡Literacy

In the context of healthcare, literacy refers to a patient's ability to read, understand, and act on health information. The script illustrates the importance of literacy by sharing a story of a patient who was illiterate and needed assistance with signing a form, highlighting how literacy can impact a patient's ability to navigate the healthcare system.

💡Homelessness

Homelessness is the lack of a fixed, regular, and adequate nighttime residence. The video addresses the specific healthcare challenges faced by homeless individuals, such as storing medications, accessing clean water for hygiene, and finding a safe place to rest. The speaker argues that providing health insurance alone is not sufficient to bridge the gap in care for homeless patients.

💡Primary care

Primary care is the first level of contact for patients with the healthcare system, typically provided by general practitioners or family doctors. The speaker advocates for the importance of primary care in coordinating and advocating for the comprehensive needs of low-income patients, emphasizing the role of primary care doctors in providing continuity and care.

💡Supplemental nutrition program

The supplemental nutrition program, also known as food stamps, is a government assistance program that provides eligible individuals with financial resources to purchase food. The video mentions efforts to enroll patients in this program to address food insecurity, which is a significant barrier to health for many low-income individuals.

💡Translation services

Translation services are critical for non-English-speaking patients to ensure effective communication with healthcare providers. The script highlights the importance of translation by sharing an example of a patient who spoke a rare dialect, emphasizing that without adequate translation, patients cannot fully understand or comply with medical advice.

💡Housing

Housing is presented in the video as a fundamental social determinant of health. The speaker shares data from Los Angeles, where housing chronically homeless individuals with medical, mental, and addiction issues led to decreased healthcare costs and improved quality of life, underscoring the importance of addressing housing as a healthcare intervention.

💡Disenfranchised

Disenfranchised individuals are those who are deprived of rights or privileges, often due to social, economic, or legal barriers. In the context of the video, the speaker describes low-income patients as disenfranchised from community supports, highlighting the importance of primary care in providing not just medical care but also continuity and a sense of belonging.

Highlights

Healthcare in the United States often fails to meet the needs of low-income patients, as it is built on a middle-class model.

Transportation barriers frequently prevent low-income patients from accessing healthcare, as seen with a patient who missed her appointment because her ride didn’t show.

Many low-income patients delay seeking care due to work obligations, jeopardizing their health in critical situations.

Language barriers complicate healthcare for non-English-speaking patients, with limited access to translators, making effective communication difficult.

Healthcare systems assume patients are literate, but many low-income individuals struggle with illiteracy, affecting their ability to navigate complex medical paperwork.

Patients without stable housing face challenges such as storing medications properly, which complicates chronic disease management, especially for diabetics.

Healthcare systems assume patients can prioritize their health, but many low-income individuals have to choose between healthcare and basic survival needs like housing or food.

Social and economic barriers, including transportation and work obligations, often prevent low-income patients from keeping medical appointments.

Healthcare systems often fail to provide essential services tailored to low-income patients, such as housing for the homeless to improve health outcomes.

Low-income patients face food insecurity, especially diabetics, which can lead to life-threatening complications like hypoglycemia when they lack food.

A more responsive healthcare system would focus on meeting patients where they are, rather than imposing middle-class assumptions on low-income individuals.

Housing for chronically homeless individuals significantly reduced healthcare costs by decreasing emergency room visits and hospitalizations.

Primary care doctors provide vital continuity and support for low-income patients, often becoming their only stable and healthy relationship.

Non-medical staff, like registration clerks, can form meaningful relationships with patients, providing emotional support and continuity of care.

A healthcare system committed to low-income patients must fulfill their needs holistically, rather than just checking medical boxes.

Transcripts

A few years ago,

I was taking care of a woman who was a victim of violence.

I wanted her to be seen in a clinic that specialized in trauma survivors.

I made the appointment myself because, being the director of the department,

I knew if I did it,

she would get an appointment right away.

The clinic was about an hour and a half away from where she lived.

But she took down the address and agreed to go.

Unfortunately, she didn't make it to the clinic.

When I spoke to the psychiatrist, he explained to me

that trauma survivors are often resistant

to dealing with the difficult issues that they face

and often miss appointments.

For this reason,

they don't generally allow the doctors to make appointments for the patients.

They had made a special exception for me.

When I spoke to my patient,

she had a much simpler and less Freudian explanation

of why she didn't go to that appointment:

her ride didn't show.

Now, some of you may be thinking,

"Didn't she have some other way of getting to that clinic appointment?"

Couldn't she have taken an Uber or called another friend?

If you're thinking that,

it's probably because you have resources.

But she didn't have enough money for an Uber,

and she didn't have another friend to call.

But she did have me,

and I was able to get her another appointment,

which she kept without difficulty.

She wasn't resistant,

it's just that her ride didn't show.

I wish I could say that this was an isolated incident,

but I know from running the safety net systems

in San Francisco, Los Angeles, and now New York City,

that health care is built on a middle-class model

that often doesn't meet the needs of low-income patients.

That's one of the reasons why it's been so difficult

for us to close the disparity in health care

that exists along economic lines,

despite the expansion of health insurance

under the ACA, or Obamacare.

Health care in the United States

assumes that, besides getting across the large land expanse of Los Angeles,

it also assumes that you can take off from work

in the middle of the day to get care.

One of the patients who came to my East Los Angeles clinic

on a Thursday afternoon

presented with partial blindness in both eyes.

Very concerned, I said to him,

"When did this develop?"

He said, "Sunday."

I said, "Sunday?

Did you think of coming sooner to clinic?"

And he said, "Well, I have to work in order to pay the rent."

A second patient to that same clinic,

a trucker,

drove three days with a raging infection,

only coming to see me after he had delivered his merchandise.

Both patients' care was jeopardized by their delays in seeking care.

Health care in the United States assumes that you speak English

or can bring someone with you who can.

In San Francisco, I took care of a patient on the inpatient service

who was from West Africa and spoke a dialect so unusual

that we could only find one translator on the telephonic line

who could understand him.

And that translator only worked one afternoon a week.

Unfortunately, my patient needed translation services every day.

Health care in the United States assumes that you are literate.

I learned that a patient of mine who spoke English without accent

was illiterate,

when he asked me to please sign a social security disability form for him

right away.

The form needed to go to the office that same day,

and I wasn't in clinic,

so trying to help him out,

knowing that he was the sole caretaker of his son,

I said, "Well, bring the form to my administrative office.

I'll sign it and I'll fax it in for you."

He took the two buses to my office,

dropped off the form,

went back home to take care of his son ...

I got to the office, and what did I find next to the big "X" on the form?

The word "applicant."

He needed to sign the form.

And so now I had to have him take the two buses back to the office

and sign the form so that we could then fax it in for him.

It completely changed how I took care of him.

I made sure that I always went over instructions verbally with him.

It also made me think about all of the patients

who receive reams and reams of paper

spit out by our modern electronic health record systems,

explaining their diagnoses and their treatments,

and wondering how many people actually can understand

what's on those pieces of paper.

Health care in the United States assumes that you have a working telephone

and an accurate address.

The proliferation of inexpensive cell phones

has actually helped quite a lot.

But still, my patients run out of minutes,

and their phones get disconnected.

Low-income people often have to move around a lot by necessity.

I remember reviewing a chart of a woman with an abnormality on her mammogram.

That chart assiduously documents that three letters were sent to her home,

asking her to please come in for follow-up.

Of course, if the address isn't accurate,

it doesn't much matter how many letters you send to that same address.

Health care in the United States assumes that you have a steady supply of food.

This is particularly an issue for diabetics.

We give them medications that lower their blood sugar.

On days when they don't have enough food,

it puts them at risk for a life-threatening side effect

of hypoglycemia, or low blood sugar.

Health care in the United States assumes that you have a home

with a refrigerator for your insulin,

a bathroom where you can wash up,

a bed where you can sleep

without worrying about violence while you're resting.

But what if you don't have that?

What if you live on the street,

you live under the freeway,

you live in a congregant shelter,

where every morning you have to leave at 7 or 8am?

Where do you store your medicines?

Where do you use the bathroom?

How do you put your legs up if you have congestive heart failure?

Is it any wonder that providing people with health insurance who are homeless

does not erase the huge disparity

between the homeless and the housed?

Health care in the United States assumes that you prioritize your health care.

But what about all of you?

Let me assume for a moment that you're all taking a medication.

Maybe it's for high blood pressure.

Maybe it's for diabetes or depression.

What if tonight you had a choice:

you could have your medication but live on the street,

or you could be housed in your home but not have your medication.

Which would you choose?

I know which one I would choose.

This is just a graphic example of the kinds of choices

that low-income patients have to make every day.

So when my doctors shake their heads and say,

"I don't know why that patient didn't keep his follow-up appointments,"

"I don't know why she didn't go for that exam that I ordered,"

I think, well, maybe her ride didn't show,

or maybe he had to work.

But also, maybe there was something more important that day

than their high blood pressure or a screening colonoscopy.

Maybe that patient was dealing with an abusive spouse

or a daughter who is pregnant and drug-addicted

or a son who was kicked out of school.

Or even maybe they were riding their bicycle through an intersection

and got hit by a truck,

and now they're using a wheelchair and have very limited mobility.

Obviously, these things also happen to middle-class people.

But when they do,

we have resources that enable us to deal with these problems.

We also have the belief that we will live out our normal lifespans.

That's not true for low-income people.

They've seen their friends and relatives die young

of accidents,

of violence,

of cancers that should have been diagnosed at an earlier stage.

It can lead to a sense of hopelessness,

that it doesn't really matter what you do.

I know I've painted a bleak picture of the care of low-income patients.

But I want you to know how rewarding I find it

to work in a safety net system,

and my deep belief is that we can make the system responsive

to the needs of low-income patients.

The starting point has to be to meet patients where they are,

provide services without obstacles

and provide patients what they need --

not what we think they need.

It's impossible for me to take good care of a patient

who is homeless and living on the street.

The right prescription for a homeless patient is housing.

In Los Angeles,

we housed 4,700 chronically homeless persons

suffering from medical illness, mental illness, addiction.

When we housed them, we found that overall health care costs,

including the housing,

decreased.

That's because they had many fewer hospital visits,

both in the emergency room and on the inpatient service.

And we gave them back their dignity.

No extra charge for that.

For people who do not have a steady supply of food,

especially those who are diabetic,

safety net systems are experimenting with a variety of solutions,

including food pantries at primary care clinics

and distributing maps of community food banks and soup kitchens.

And in New York City,

we've hired a bunch of enrollers

to get our patients into the supplemental nutrition program

known as "food stamps" to most people.

When patients and doctors don't understand each other,

mistakes will occur.

For non-English-speaking patients,

translation is as important as a prescription pad.

Perhaps more important.

And, you know, it doesn't cost anything more

to put all of the materials at the level of fourth-grade reading,

so that everybody can understand what's being said.

But more than anything else, I think low-income patients

benefit from having a primary care doctor.

Mind you, I think middle-class people also benefit

from having somebody to quarterback their care.

But when they don't, they have others who can advocate for them,

who can get them that disability placard

or make sure the disability application is completed.

But low-income people really need a team of people who can help them

to access the medical and non-medical services that they need.

Also, many low-income people are disenfranchised

from other community supports,

and they really benefit from the care and continuity provided by primary care.

A primary care doctor I particularly admire

once told me how she believed that her relationship with a patient

over a decade

was the only healthy relationship that that patient had in her life.

The good news is, you don't actually have to be a doctor

to provide that special sauce of care and continuity.

This was really brought home to me when one of my own long-term patients

died at an outside hospital.

I had to tell the other doctors and nurses in my clinic

that he had passed.

But I didn't know that in another part of our clinic,

on a different floor,

there was a registration clerk

who had developed a very special relationship with my patient

every time he came in for an appointment.

When she learned three weeks later that he had died,

she came and found me in my examining room,

tears streaming down her cheeks,

talking about my patient and the memories that she had of him,

the kinds of discussions that they had had about their lives together.

My patient had a hard life.

He was by his own admission a gangbanger.

He had spent a substantial amount of time in prison.

He suffered from a very serious illness.

He was a drug addict.

But despite all that, he rarely missed a visit,

and I like to believe that was because he knew at our clinic that he was loved.

When our health care systems have the same commitment to low-income patients

that that man had to us,

two things will happen.

First, the system will be responsive to the needs of low-income people.

It will speak their language, it will meet their schedules,

it will fulfill their needs.

Second, we will be providing the kind of care

that we went into this profession to do --

not just checking the boxes,

but really taking care of those we serve.

Thank you.

(Applause)