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  • 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,