Ricardo Nuila

The People’s Hospital is an in-depth look at how a hospital in America operates without asking its patients to be insured or documented, nor pay the full cost of healthcare. For America, this is shocking and outside the norm. If you live in Australia, the UK or other countries with universal healthcare, this could be preaching to the converted. Still, it’s a chilling look at how healthcare operates when left to the market to decide prices and decide who ‘deserves’ healthcare and why.

Dr Ricardo Nuila is an internal/general medicine doctor at Ben Taub Hospital in Houston, Texas. It’s a big hospital with a major trauma centre so it’s well known for treating victims of shootings and other violence. It’s also what’s known as a safety-net hospital, meaning that you are treated regardless of whether you have insurance, Medicare or Medicaid. (Medicare in the U.S. is very different to Australian Medicare, as it only covers selected disability and the elderly while Medicaid is for the poor but much more stringent and difficult to access than the Australian concessional health care card). Patients who are undocumented immigrants are also treated. It’s seen as a last resort for some Texans but for others it’s the only way that their healthcare needs will be treated.

The book covers several different patients and their interactions with the U.S. healthcare system and ultimately Ben Taub. There’s the young man who earns ‘too much’ on welfare to be eligible for Medicaid and a life saving liver transplant. There’s the woman with dry gangrene across all four limbs, sent home from a for-profit/not-for-profit hospital as her immediate needs were ‘treated’. A man who chose not to purchase employer-based health insurance is turned away from potentially curable cancer treatment because he doesn’t have insurance. When he is later treated at Ben Taub, he pays for his healthcare – a sum of tens of thousands of dollars. He believes it’s a fair price. To me, an Australian working in public healthcare his story was amazing – how dare he be denied care? (And also, as a public patient his costs for hospital stays, radiation and chemotherapy would all have been covered. There may have been some small payments for medications, but the costs would never have reached thousands). The American healthcare system is complex and confusing, covered at multiple levels – federal, state and even local. Whether you’re eligible for Medicaid depends on where you live and the politics of that state – do they expand Medicare as suggested in the Affordable Care Act? It was interesting to read that the ACA hasn’t been a panacea for healthcare coverage and has made it more difficult for some. (Interestingly, Medicare for All, Bernie Sanders’ suggestion doesn’t get much page time here. Perhaps because it’s clear that all people need healthcare).

I could go on and on about the problems I see in American healthcare as it stands, but Nuila does a better job of showing the problems to the reader and explaining the gaps and the growth of Medicine, Inc – the growth of profits and payments by doctors, insurers, hospitals and others because they can. I do wonder if this will seem as shocking to American readers as it seems that many (including some of the people in the book) just accept it for what it is. What you can afford/insurance will cover over patient centred care? That seems to be the way. If you’re familiar with health economics, a lot of this book will cover what you know in a more personal way. If not, the book raises important questions on equity, justice and fairness – who should get healthcare and why? Is it if you contribute to society, and how is that defined? Is healthcare a right? Or a want?

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