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.