The People’s Hospital by Dr. Ricardo Nuila — Can Healthcare Be For Everyone?
“…There was no difference between men, in intelligence or race, so profound as the difference between the sick and the well.”
This quote by F. Scott Fitzgerald, starts the book The People’s Hospital by Dr. Ricardo Nuila. In a brief 300-or-so pages, Ricardo Nuila, a Houstonian doctor, navigates the complexity of the American healthcare system for those who are uninsured or underinsured, predominantly describing the lives and stories of five people who are unable to find or afford adequate insurances for their medical needs, leading all of them to eventually seek care at Ben Taub, the public hospital where Nuila works.
To clarify, safety-net hospitals are distinguishable from nonprofit hospitals. Nonprofits are tax-exempt because they are expected to perform a minimum amount of charity care, or free care to low-income populations. However, there is no mandated legal minimum of charity care required, so most nonprofits contribute minimal amounts of charity care, which severely disadvantages uninsured populations. Contrasting the functions of nonprofit hospitals and charity care, Ben Taub and the other 5% of safety-net hospitals in America are “not defined by [their] source of revenue, [but instead by their] mission: to treat all patients, whether they have private insurance or not” (88). Safety nets can be any hospital type, including nonprofit or even for-profit, though they are most often public. These hospitals also actively identify whether or not patients qualify for public insurance, and offer sliding-scale payment systems for people who do not qualify for insurance at all. This system is utilized at a number of safety nets, but Ben Taub has been uniquely successful because of its history.
In the early 1900s, Houston desperately needed a public hospital to address the urgency of unmet medical needs in the city, and Jefferson Davis Hospital was built. The hospital, like many other public hospitals, was notoriously underfunded and understaffed, but no one knew the extent of the poor and unsanitary conditions until Jan de Hartog’s The Hospital was published. The exposé fueled public outrage, and shortly after, a public health system (Harris County Health System) and a new hospital, Ben Taub, were set up. This time, Houstonians designated a specific portion of their taxes towards the financial success of the public hospital, and today, Ben Taub remains taxpayer-funded and an asset to the Texas Medical Center, a conglomeration of hospitals in Houston. Most other safety nets do not operate within a public system that financially supports them, but do receive federal and state funding (Ben Taub receives these, as well). Compared to other safety nets, taxpayer funding is a huge reason contributing to the success of the hospital.
In fact, Ben Taub has garnered an excellent reputation in the Medical Center, and has “extraordinary trauma, stroke, emergency and acute care services,” (6) as well as renowned specialty and outpatient services. Ben Taub is actually the “best hospital in the country for treating heart attacks” according to the American Heart Association, all while costs remain relatively low: while Ben Taub costs around $3,400 per patient admission, the rest of the country spends upwards of $10,000 per person. In an op-ed in the Houston Chronicle, Nuila affirmed that “Ben Taub helps us all — including the rich.” According to Nuila, his hospital has found a way to “treat patients as efficiently as French, German, and other healthcare systems regarded as the best in the world” while costs remain lower and care remains the same if not more efficient than the average care provided in the rest of American hospitals.
Nuila’s observations about Ben Taub, medicine, and systemic issues are guided by his childhood experiences. The son of a doctor from El Salvador who later immigrated to the United States, Nuila writes about how his father’s practices as an OB/GYN changed as he transitioned from El Salvador to the United States and adapted to the increasing prices and complexity of the American healthcare system. Over the years, Nuila’s father went from accepting everyone regardless of how they could pay in El Salvador, to having to “pause every time a patient without insurance asked him to be her doctor (43).” The American healthcare system forced Nuila’s father to start acting with insurance in mind; while growing up, Nuila recounts getting paid full-time to help his father sift through “files and insurance claims’’ (52) and feeling overwhelmed and frustrated by the amount of effort directed to the administrative side of his father’s practice. Therefore, when Nuila himself decided to attend medical school, he saw work at Ben Taub, where his father volunteered once a month, as a break from thinking about the complexities of insurance. Instead, like the rest of the doctors there, he could “[spend] hours discussing different types of problems encountered by their patients, [both] medical… and personal” (53). Without the worries of payment, Nuila could work “purely as a doctor” and not let the weight of insurance affect the way he offered care (53). Although both father and son eventually diverged into following different medical philosophies based on payment, they both agreed that “how or what a doctor is paid should not affect a patient’s experiences of medicine,” an issue that remains the case in modern-day medicine (53). Nuila’s frustrations over insurance’s dominance in healthcare craft his central argument around what we really should be prioritizing in medicine: the people.
Over the course of the book, Nuila follows and interweaves the stories of five patients who all eventually land at Ben Taub for treatment. All five are underinsured or uninsured for various reasons. One person, Geronimo, is in desperate need of a life-saving liver transplant but cannot afford any kind of insurance to cover costs. Another patient is Roxana, a woman at a for-profit hospital whose brain tumors have spread to the point where, post-surgery, complications leave her with dead limbs resembling “charred wood” on her body (27). Without insurance, she is asked to “let all the dead parts ‘auto-amputate’’” (28). Eventually, unable to afford insurance, public or private, and out of all options financially, those doctors send Roxana to hospice, even though she is not dying. Only when the hospice nurse finds an infected wound does she recommend Roxana forgo hospice for urgently needed treatment, which is when she comes to Ben Taub. While we follow the paths of these five individuals as they navigate the stressors of American healthcare, Nuila points out some of the highly complex circumstances regarding coverage. For example, in Texas, disability assistance alone counts as income and disqualifies you for public coverage, and more than one person in the book works less or refuses supplemental government-provided assistance like disability or unemployment in order to remain on Medicaid. One patient, Aquieria, meets a life partner and “[wants] more than just what a person living on welfare can earn,” so she “couldn’t afford to stay on Medicaid” (192). After being disqualified from Medicaid coverage for her AIDS medication, she becomes severely ill. Roxana, mentioned earlier, does not qualify for Medicare, as one needs to be disabled for at least two years before they can apply. Christian, an uninsured young man with unrelenting and undiagnosed pain, believes doctors outside the United States will finally investigate his issues, and if he had a Mexican residence, he would have been able to access the Mexican public hospitals and clinics that could have treated him. “‘I’m really sorry you’re from the United States,’ a doctor in Mexico says to Christian.”
All five underinsured or uninsured patients, whether or not they originally intended to come to Ben Taub, are treated the same as insured patients, who can also be patients at the hospital. As Nuila himself notes, one of his medical colleagues had her baby at Ben Taub. Most safety-net hospitals serve predominantly people in rural or impoverished areas, but Ben Taub is different in that its services are accessible in the heart of Houston alongside a number of other medical facilities. The fact that these safety-net services can and do work well for everyone, even people who are privately insured, amplifies Nuila’s main message: “Medicine, Inc.” as he calls it, where “the primary goal of healthcare is to generate income” does not have to be the case. In an op-ed from the Texas Observer, Nuila states that “we need a public healthcare system that competes with [Medicine, Inc.],” and Ben Taub is an exceptional example of an American hospital that is a model for the possibility of equity in American healthcare (38), where those who are insured and uninsured can walk into the same hospital and be treated like people.
Nuila goes further, asking us whether or not private systems are even worth justifying. Both major American political parties, whether realizing it or not, justify the existence of a private insurance system. Democrats argue that we add different public insurance components to cover various vulnerable minority populations; for the poor, we have Medicaid, and for seniors, Medicare. However, with the creation of public insurance in components, we continue to justify the very existence of private insurance and therefore health inequity. Nuila hypothesizes, “what if we removed the middleman of insurance?” (39). With Ben Taub as the central focus to advocate for this concept, this idea of deprioritizing insurance no longer appears so revolutionary. In a nation where no one would have to navigate administrative burden and the frustration of income inequality to obtain insurance just to seek proper care, people seeking healthcare would be viewed as people first, not profit. The goal of healthcare “wouldn’t be to earn money, but to help solve people’s medical problems” (39).
Ben Taub is not a perfect solution, and Nuila acknowledges that, but if America’s healthcare system changes systematically, the hospital can serve as a great starting model to maximize equity and efficiency on a larger scale. There are notoriously long wait times at Ben Taub’s emergency ward (Nuila writes that the wait time “is as legendary as the trauma care it provides’’), but this is because ER systems across the country, including the one at Ben Taub (which alone does “the work of three or four trauma centers”), are overstressed (99). However, this stress is largely because “the ER has become the first stop for all medical ailments, large and small” for the uninsured, as ERs cannot turn anyone away until they are stabilized. If we ensure that people, regardless of their insurance status, have access to and knowledge of primary care providers, we can reduce this barrier to care, and therefore see an inclination towards ERs prioritizing actual emergencies.
In the latter half of the book, we are introduced to Geronimo, a 36-year-old man with liver failure who has recently lost Medicaid coverage because his disability income alone places him above the cutoff for coverage. Out of options, he finds himself at Ben Taub. However, he cannot receive a liver transplant at the hospital because “[liver] surgeries are simply too expensive for any safety-net system, including ours,” writes Nuila (323). While this story provides another limitation to the capabilities of safety nets, the hospital’s staff at Ben Taub write to and collaborate tirelessly with Geronimo’s Congressman to requalify him for Medicaid. While hospital staff work through all of the administrative burden, Geronimo’s condition deteriorates rapidly and he passes away while awaiting assistance. Given the circumstances, Ben Taub had assisted him to the best of its abilities, but if Geronimo had never been revoked of his Medicaid coverage to begin with, he would have been alive today. At Geronimo’s funeral, Nuila thinks, “‘I’m sorry we’re in the richest and most innovative country in the world, and we couldn’t find a way to help your thirty-six-year-old son over a hundred and seventy-nine bucks’” (326). Geronimo’s story exemplifies a clear call to action: the systemic issues in healthcare need to be urgently addressed in order to turn into a compassionate and equitable system.
Even though Ben Taub has limitations, the hospital provides care in a large number of medical specialties and has innovative cost management techniques built into the system that are intentionally designed to reduce costs, including open wards (versus private rooms) that maintain efficacy and safety and the minimization of unnecessary testing, both of which have been shown to reduce costs and waste while ensuring better patient outcomes. When we apply some of the strategies Ben Taub uses to manage costs to other hospitals, we will see an overall decrease in costs and waste in every hospital in the nation. The truth is that Ben Taub represents the maximization of our use of money in healthcare, where “every penny from our pockets [is] well spent” (333). Nuila writes, “the responsibility falls… on all of us. We accept these tragedies because we don’t demand anything different” (326), but we can. We cannot keep reinforcing that some are more deserving of healthcare than others. We can demand a healthcare system that models after Ben Taub, that prioritizes lives over profit.
Throughout the course of this book, Nuila has thoroughly convinced me that America is settling for the healthcare system that we have today, and that we can and should be advocating for better, as everyone in this country deserves access to care. Ben Taub is an already-existing model for equitable care, as Nuila is proud to tell us stories of recovery and hope from his hospital. It is up to us if we want to implement some of these same techniques and structural changes into the rest of the country’s healthcare system.
The book closes with Roxana, the patient who has to amputate her limbs because of her cancer and surgical complications. Roxana meets Dr. Nuila one last time, at her last rehabilitation appointment. After fighting for coverage and obtaining the necessary surgeries to amputate her limbs as a result of her brain tumor, Roxana has been working hard for her new life. After feeding herself, dressing herself (putting on makeup and jewelry!), and arranging her own transportation to the center, she greets “Doctorcito” Nuila at the door. “Do you like my Mercedes?,” she jokingly gestures to her blue powered wheelchair (331). Roxana’s recovery exemplifies the possibility of what can happen when we care for our poorest as we would care for any insured individual, something that was only able to happen so easily in a safety-net like Ben Taub. To Nuila, stories like Roxana’s highlight the sanctity and power of authentically practicing medicine, and to me, are a glimpse of the possibility of what equitable healthcare can collectively transform the nation’s health to. Not only does Roxana benefit, but the rest of “the city [gets] the best out of one of their own” (333). If everyone, regardless of their insurance status, was given the same opportunity and medical assistance as Roxana was given at Ben Taub, imagine the health of the society we would be living in.
If we consider the scalability of a model like Ben Taub, we quickly recognize that the successes the hospital has found are not confined to the limits of the Houston Medical Center. In fact, we can replicate and adapt some of Ben Taub’s practices to hospitals all across the country. Some of the work the hospital has done to minimize costs, like reducing unnecessary medical testing and personalizing care, have been cost-effective and backed by successful health outcomes; these cost reductions are essential to the functioning of safety nets, which traditionally face intense budgetary constraints. Hospitals nationwide face notoriously high spending costs, but reforming some practices can make the adaptation of safety-net-style systems more realistic on a nationwide scale. Additionally, Ben Taub’s unique funding model, supported by the county’s additional tax designation to public hospitals, has allowed the hospital to thrive as a public resource. When we consider the possibility of implementing similar taxation systems nationwide in order to facilitate the creation of essential public safety nets, we can realistically envision a more equitable and redistributive healthcare system.
Nuila has written a compelling — and radical — book about how we should re-examine the current state and purpose of healthcare in America, except the concept is not radical; Ben Taub already exists. Through reading stories of patients from his time at the safety-net hospital, Nuila asks Americans to shift away from the current profit-driven system and observe a system that prioritizes care over profit to create an equitable healthcare system that sees positive patient results, lowers costs, and creates a healthier America. Even though Nuila only shares the stories to emphasize a people-centered approach in care, stories in this book represent the possibility for America to push for the same kind of system at Ben Taub to every other hospital in the nation.
All of the stories Nuila shares position him to be the poster child for a larger, more compelling push for reform in American healthcare and encourage us to think about the reality of scalability. The idea of advocating for a system of people-centered care can seem daunting, but if Ben Taub is thriving in the most conservative state in the nation, why can’t we have this kind of system everywhere else? Nuila’s boss and one of the administrative leaders at Ben Taub is a staunch conservative, yet Ben Taub is a shining model of care that centers around local government to him. It can also be easy to wonder why such a seemingly impressive idea has not taken off, but we will never be able to redesign the healthcare system for the better until we deemphasize profitability in healthcare. Healthcare would be a less glamorous industry, doctors would make less money, and hospitals would be less flashy, so it can be a hard argument to make, but people would finally be at the center of healthcare. Ben Taub’s success does not have to be American healthcare’s sole victory; by reevaluating our priorities and advocating fervently for guided change in healthcare, we could apply Ben Taub’s model nationwide to ensure that everyone in America can receive quality care.
Works Cited
Ben Taub Hospital | Harris Health. Ben Taub Hospital. (n.d.). https://www.harrishealth.org/locations-hh/Pages/ben-taub.aspx
Kendall, David et al. Revitalizing Safety Net Hospitals: Protecting Low-Income Americans from Losing Access to Care. Third Way. (2023, November 14). https://www.thirdway.org/report/revitalizing-safety-net-hospitals-protecting-low-income-americans-from-losing-access-to-care
Nuila, R. (2023, October 22). How Ben Taub Hospital Helps Us All — Including the Rich (Opinion). Houston Chronicle. https://www.houstonchronicle.com/opinion/outlook/article/harris-health-bond-ben-taub-18436337.php
Nuila, R. (2024). The People’s Hospital: Hope and Peril in American Medicine. Scribner.
Olsen, L. (2023a, September 27). Ricardo Nuila: The People’s Doctor. The Texas Observer. https://www.texasobserver.org/ricardo-nuila-peoples-hospital-ben-taub/
