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Insurance – When Patients Fall Through the Cracks | Bestselling Author and Physician Dr. Ricardo Nuila
27 Plays2 months ago
In this episode, we sit down with Professor Dr. Ricardo Nuila, the best-selling author of The People's Hospital, which discusses Dr. Nuila’s experience as a physician at Houston’s Ben Taub Hospital, the difficulties of accessing healthcare in the US, and his vision for a more equitable health insurance model.
Dr. Nuila shares his journey from a three-generation medical family to working at Houston’s largest safety-net hospital, where patients can receive treatment regardless of their ability to pay. We explore why Texas presents unique challenges with its lack of Medicaid expansion, how local systems like Harris Health have stepped in to fill the gap, and what makes Ben Taub a trusted institution in the community. Through patient stories, from a restaurant manager overwhelmed by costs despite being insured, to a young college student blindsided by illness, Dr. Nuila illustrates the cracks in our system that affect both the uninsured and underinsured. We close with his perspective on what a sustainable two-tier model of public and private care could look like, and how storytelling through medicine and writing can help us reimagine a better future for healthcare.
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Transcript
Introduction and Dr. Nulia's Experiences
00:00:00
Speaker
Welcome to the Healthcare Theory Podcast. I'm your host, Nikhil Reddy, and every week we interview the entrepreneurs and thought leaders behind the future of healthcare care to see what's gone wrong with our system and how we can fix it.
00:00:15
Speaker
In this episode, we're speaking with Dr. Nulia, an associate professor of medicine at Baylor College and a practicing physician at Bentau Hospital in Houston. Dr. Nulia goes over how, coming up from a third-generation family, he's seen the trials and tribulations of an intensely bureaucratic health insurance system,
00:00:32
Speaker
But also through his experiences working at Bental, he's seen how he can transform insurance for the better.
Exploring 'The People's Hospital' and Insurance Challenges
00:00:38
Speaker
More recently, he's written a book called The People's Hospital, which is a bestselling book that goes over the difficulties of Texas's insurance system, why it's so hard for individuals to get access to health care, and where public safety net hospitals like Bental can really take place and deliver care at good cost.
00:00:55
Speaker
At the end of the episode, we also discussed what Dr. Nolia believes can be the future of the American health care system. So coming from a three generation medical family where your grandfather was physician in El Salvador and your father operated a private practice, I imagine your life was pretty much influenced by just seeing their daily lives and how they were kind of navigating the medical system as physicians.
00:01:16
Speaker
I even read that your dad kind of said he waged war with insurance companies and it was hugely difficult for him to balance the business side and the patient side. But I'd love to hear your story. What brought you into becoming a physician and what pulled you into practicing in a public hospital like Bentau?
00:01:31
Speaker
Yeah, that's a great question. And and it's hard to reflect back and and know exactly how much influence something like three, two generations of of your family have on you as doctors. You know, I do remember waking up on Saturdays and going to the hospital with my dad. And I remember being like, wow, I want to practice medicine. Cause it just sounded, it it just looked like he was helping people. it looked like he was respected.
00:02:00
Speaker
I could see that he was providing a good life for us with opportunities. it seemed so It seemed idyllic in many ways. and But then I also remember the business side, which was going to his office later on in my life and working with insurance charts and seeing these charts take over his office.
Dr. Nulia's Medical Journey and Commitment
00:02:23
Speaker
you know it would he used to have a ritual where he'd bring patients into his office and talk with them before anything medical would happen.
00:02:34
Speaker
and And those charts just overtook that over time where like he couldn't even he couldn't even have a place to sit. There was no place for patients to come and converse with him. So that i had mixed feelings going into medicine. I had this draw this this drive to be like, there's something good about medicine as a practice, as as helping people, but also as a career.
00:03:00
Speaker
There's something good about it. There's something in me about that. but i also had this strong sense of, I don't want to deal with the BS of like insurance companies, insurance companies to me were, were the bad guys. That's what how my dad's private practice had, had set me up for that.
00:03:19
Speaker
I don't want to deal with, I just want to deal with patients and with medicine. And, and I think that in many ways, keeping the keeping that in medical school. There's a lot of other reasons that came that went into me staying in medicine because i was also conflicted by writing. I wanted to write.
00:03:42
Speaker
um i wanted to use my words that I wrote in some way in service of medicine. And I wasn't quite sure that clinical medicine was the avenue for that.
00:03:53
Speaker
But somehow it all came together at the teaching hospital, Bentob. And that's one of the reasons why i I just love that place so much and and and why the the book is is is in many ways a love letter because it felt like the people who practice there practiced because they love the medicine.
00:04:14
Speaker
because they could deal with patients and they and and they knew that some of the patients had come from the private hospitals ah across the the the Texas Medical Center. some of the Some famous institutions who had said, we can't treat you because you don't have insurance.
00:04:29
Speaker
It was the last stopgap but like of of healthcare care in the Texas Medical Center, one of the largest Texas Medical Center in the world. The people who couldn't get care these institutions came to Bentob.
Texas Healthcare Politics and Medicaid
00:04:41
Speaker
And so the people who practiced there were, we they loved medicine first, but they also felt like they could actually do something because there was a system, which I didn't know about at that moment.
00:04:53
Speaker
There was a system to support that healthcare. You know, there were, there were MRIs. It wasn't, it wasn't like this, medicine that you see in other parts of the world where you say this happens outside of ah of a country as wealthy as the United States. it was It still held on to standards and it still was very much geared toward patients too. So When I saw that, I felt like it all came together, like the stories of medicine. I felt like this inclination to to be a doctor.
00:05:31
Speaker
And it's also my aversion toward health insurance. It came together right there, too, because I was just like, oh, I don't like these patients don't have health insurance and they're still getting good care. I love this place.
00:05:42
Speaker
So that's kind of how it it it it it manifested for me. It's really interesting. A lot of the guests that we've had on, whether they're founder or researcher, they're kind of, they love the social impact and the mission-driven side of healthcare. care They want to help people, but they're all being kind of pushed away by how difficult it is, the insurance and the payer system how complex it is. So I can definitely really relate and understand where you're coming from. you want to help, but it's so hard to do so.
00:06:09
Speaker
And one thing I want to dive into is Texas has a really difficult healthcare, care health insurance and payer system, right? Like, Not only are there a lot of low-income neighborhoods, which maybe is not exclusive to Texas, but a lack of Medicaid expansion and some strict and confusing laws can make it very difficult for positions and are sorry patients.
00:06:26
Speaker
And can you dive a little into that? What makes Texas a little different from other states like California or the ones that have expanded Medicaid or even the ones that haven't? Yeah, that's a great question. And and really, at at the end of the day, it has to do with politics and philosophy and the the difference.
00:06:45
Speaker
and really what is like endemic to the United States, which is this idea of like, what is federalism versus states supported rights? And and what what, what,
Public Health Systems in Texas
00:06:57
Speaker
what are the state responsibilities versus the federal responsibilities? And I think Texas, as a lot of people might guess is on the side of strong states, you know, identity that not trying to abide by you know federal regulations, trying to do things by its own ways. And so what how that has manifested is that whenever there's been approaches to have, you know and this is, I'm talking broadly just to paint a big picture right now,
00:07:36
Speaker
whenever there's been like approaches to have like broad coverage, which might've included like the Affordable Care Act, Texas, because of its philosophy and its politics, which are a little bit more right, has pushed back. And, you know, Texas is one of the states that has not expanded Medicaid and, and, and, and probably will never do so.
00:07:58
Speaker
um You know, the Medicaid expansion, you know basically ah created so many – like people who were in the gaps or couldn't earn enough, yeah who but earned a certain amount, but they still you know lived in a situation where they couldn't afford health insurance. There were so many more people who were covered by the Medicaid expansion in different states.
00:08:24
Speaker
Texas, because it didn't accept the Medicaid expansion, you had to be exceedingly poor to qualify for any sort of government-sponsored health insurance.
00:08:37
Speaker
So, you know you know, this was like for single adults, you're we're talking like in in some of these years in like the 2010s, it was like something like $7,000, you know, that you would have to earn a year. lower If you earn more than that,
00:08:53
Speaker
you're considered able to buy health insurance. They've also not supported the, the, ah um, Oh gosh, I'm, I'm blanking right now, but Texas is also not, has not really supported the, the, this the the state sponsored, um, marketplace too. So what you end up, yeah what you end up having in Texas is that you have these locations like the big cities that have grown Houston, Dallas, San Antonio, El Paso.
00:09:32
Speaker
These are some huge cities that have exhibited enormous growth in the last 20 years. Some of the still the highest growing urban centers. I think Houston's going to pass Chicago as the third biggest city in the next like 10 years.
00:09:46
Speaker
And If you have that many people and so many people are left uncovered because of like these political philosophies, well, what happens is that emergency rooms are filled.
00:09:59
Speaker
And so what's developed since the 60s is that the cities themselves have provided ah public health insurance, health coverage is better said, for those for for that gap.
00:10:16
Speaker
And that has had, that has led to some interesting comparisons with the rest of the country, right? Because you have in like California, Illinois situations where the gut, where, where the state government is more in line with like sort of like, like they might have their own versions, but they're more in line with the idea of like federal coverage or some sort of coverage on a federal basis and, um, and expanding Medicaid. uh,
00:10:44
Speaker
ah But there's, they're working within the the space of Medicaid, right? Which is how, you know, Medicaid can be shaped and in the in different states in different ways, but there's also, that's one of the difficulties of
Local vs National Healthcare Systems
00:11:02
Speaker
it. It's this federal and state um program, joint program. So there there there are certain regulations and rules that have to be like abided by on both sides.
00:11:13
Speaker
In Texas, it's it's almost like these rules have been applied locally then, right? Because since Harris County is is the is the provider of healthcare through public property taxes in Houston, they devise this healthcare care system for Houstonians, not really with other people in mind, right? This is this is a local healthcare care system.
00:11:40
Speaker
And so I think that that's been a very interesting um and and many times very successful model, which is that there there to me, it does it does make sense that healthcare... care is a local issue.
00:11:57
Speaker
You know, I do think that there's something about like how the healthcare of one community in Texas is different than the, the healthcare care of a community in Maine.
00:12:07
Speaker
I can understand that, you know? So, so that's how these systems in like these public healthcare systems, which we don't have when in America, what we've had is public insurances.
00:12:20
Speaker
which are different than public healthcare systems. The public healthcare systems have the hospitals and clinics and they will employ different doctors, but they're they're automatically, they they because they're public, they can contain costs a little bit better because they are bounced to the public rather than insurances.
00:12:42
Speaker
which have had their own problems in in in containing costs and and and and have been capitalized upon by private hospitals and private practitioners. that make sense? yeah Sorry, go on.
00:12:54
Speaker
No, did that make sense? Sorry. Yeah, no, that made a lot of sense. Yeah, I was gonna say, I like the idea of how like healthcare is technically, it should be a local thing. If you think about like, when insurance was first, like a thing back like, like 1000s of years ago, it would be within like a communities like you have a community safety net, someone gets injured, you pull in money.
00:13:11
Speaker
I think about now, like people wonder, why can't we just have the European healthcare system and bring it here? It's because America is so diverse and complex and a different political philosophy, as you mentioned, yeah, other countries, but I want to get into like Ben Taub as a hospital. I mean, as you kind of mentioned, it's Houston has some of the best medical systems and hospitals in the country. But of course, that not all of them accept people that are uninsured. So you have Ben Taub, which is a public safety net hospital funded by the county, meaning that it's their mission from what I know to treat anyone who needs care, regardless of their ability to pay.
00:13:44
Speaker
But I would love for you to tend dive a bit deeper into that. Like what makes how does Bentau fit into Houston's medical landscape and what makes them unique? And who are the people this hospital mainly serves? It's great. It's a great question because you can I can answer that from different perspectives. I think that um from the perspective and I've heard this from colleagues who are like the top surgeons in a certain field.
00:14:09
Speaker
Bentob is a bit of a subsidy. It's a bit of like like a community subsidy because let's just say that because of an emergency lands on in front of you as a doctor, a person who who who does not have insurance but who needs your help, you know, you as that doctor,
00:14:29
Speaker
can say go to Bentop, go to the public hospital. You'll get pretty good care. And that is the reputation that it has in the city amongst doctors, that the care is really good.
00:14:40
Speaker
The reason is because it's staffed Baylor College of Medicine. So these there's a lot of, there's a lot of um i think, reasons why this has grown historically. But one of the reasons is because Baylor College of Medicine staff a lot different hospitals.
00:14:59
Speaker
And so that an academic group practice of doctors with certain educational and clinical based standards And that takes those experiences from places like the VA, places like the, like Bentop and private hospitals, you're still in your same group with those doctors. You know, you, you, you know, the doctors that are from the VA, you know, that doctor everybody's there's different places who emphasize more evidence-based medicine. There's more, there's other places that emphasize more of the um of the, of of the newer technologies, but it's within the same group, those ideas are shared. And so there's a way,
00:15:39
Speaker
That's a way that like Bentob Hospital has kept its standards quite high for like what the medical care is like there. You know, so I think that the doctors and the history of it has had a lot to do with keeping the standards high in Bentob. But I also think that it is it's a manifestation of the growth of the community. Like I said, it's property tax based.
00:16:01
Speaker
And Houston has just grown. it has grown so much. And so it's tax, ah what it accrues from the taxes, it's allowed it to do more. So if somebody, what Bentob exists like in Houston right now is is that if you talk to many of the patients who are like workers who do who do not qual who do not get health insurance through their um through their employers, people who are working construction, small businesses, and they get sick,
00:16:32
Speaker
they know to go to Ben Taub hospital and the public system. They've talked to people and they say, this is, this is, this is, this is very good care, you know, and they trust it.
00:16:44
Speaker
And, and I think that's just been built out for decades of this kind of work that's done. And they,
Bentob Hospital's Role and Community Trust
00:16:51
Speaker
they might go to the hospital and they say, like, they have to fill, they have to provide information of, of, of, of what they earn and everything.
00:16:59
Speaker
And ah they can pay out of pocket ah if they earn too much. If they earn too little, there's financial assistance. And that level is set at a certain amount. It it had been 200% of the federal poverty level, which I think was was quite good. It had to be reduced to 150% at some time, at some point, but it's still not a bad threshold.
00:17:23
Speaker
And the prices are actually, that are given, are actually not that bad to begin with. You know, it's not what you're paying at private hospitals based on like if you're paying cash that that are that are they're trying to charge you for being an out of network person to an insurance. They're trying they're charging you prices of what the actual cost is.
00:17:46
Speaker
So that all comes together for a patient going in there to say this is actually not a bad deal at all. And what it does is that you have multiple type like type multiple people who are happy. The providers are happy because they're focusing on medicine.
00:18:01
Speaker
The patients are happy because, A, they trust and they're getting good care and they're actually not paying very much. you know so and and And the result is that the communities happen. And what's the proof that the community is happy?
00:18:14
Speaker
They had a um a referendum on the, uh, a voter referendum, uh, two years ago to ask, will you give $1.7 billion dollars more to this system? was the first referendum that's been asked since the and inception of this in 1965, 1.7 billion to build another hospital of, uh, like of, of, of the County and to expand Ben Taub and,
00:18:41
Speaker
overwhelmingly voters voted in favor of that to, to use more tax dollars, like what it, what amounted to like buying a cappuccino, an extra cappuccino a week in orders to provide for healthcare care for people who couldn't afford it.
00:18:58
Speaker
Houstonians voted in favor of that because the trust in the community. So that's, that's, that's what my, the premise of my book is, is that, you know, it is, it It like that if you have public health care, if it's done right, it is one of the solutions to our health care problems because there is there is just not that same impetus to overcharge and you can find the right providers to work in that system. They get market based level like payment and the patients can still have trust in in their providers.
00:19:36
Speaker
And one of the kind of the core things in your book, of course, is diving into that dynamic and exploring like how can a public health system be something that we can rely on as ah as a country and and like locality too.
00:19:47
Speaker
But one of the examples you had four different examples, all which are really like touching and really dived into the difficult, complex circumstances behind these people. They're not just numbers, but they're complex stories in itself.
00:19:58
Speaker
And one story I want to get into today a little bit was Steven, who's a restaurant manager who you spoke about. He signed up for his company's cheapest cheapest health plan and faced insurmountable, really difficult costs after a cancer diagnosis.
00:20:11
Speaker
He, from what I knew, tried to do everything right, pay out of pocket, but over what was overwhelmed with these massive costs. But we'd love if you can dive in a bit into Stephen's story. Like what hurdles did he encounter but before finding help? And what struck you most about his experience?
00:20:25
Speaker
i think I think what struck me most about Stephen's experience is that is how relatable it was for people who are um working and have insurance and think that they're insured, but they don't realize that there is ice beneath their ground. And that's the truth of how American healthcare is organized is that we all have ice beneath our feet and like in the right diagnosis, the right problems, we can fall through that ice.
00:20:53
Speaker
And I mean, the different ones of us have different thicknesses underneath our our feet, but Steven earned like $80,000 a year as a restaurant manager had in, he was insured as so far as, as he thought, but really he's one of the people who was underinsured because there's so many different plans.
00:21:13
Speaker
There's so many different types of, of plans that employers can negotiate, that that that some of them are meaningless. you know Some of them don't really cover that that really catastrophic or problematic diagnosis like a cancer diagnosis, his his neck cancer diagnosis.
00:21:31
Speaker
He went to an emergency room and somebody said, this was in the time of COVID, said, you know you're going to have to pay $600 to be in this emergency room.
00:21:41
Speaker
Yeah. just upfront. And so, and, and it wasn't until he, um he, he saw a doctor who, who saw his scans and the doctor was like, we'd love to you know, yes, you have cancer, but we're going to have, we're like, but, but unfortunately you don't have insurance.
00:22:00
Speaker
And, and I think that that's the, that, that experience is one that a lot of Americans have that they don't realize what they're paying for in insurance is actually,
00:22:13
Speaker
meaningless in many situations. you know um It might have covered some things for Stephen, but it did not cover him when he needed it most, when he when he was diagnosed with cancer.
00:22:25
Speaker
A social worker told him, go to Ben Taub Hospital. Now, Stephen happened to be ultra conservative, did not think much of anything public or anything governmental.
00:22:37
Speaker
And he had to go to what he thought was going to be the worst hospital. He associated Ben Taub as like only the homeless and only ah people who take drugs go to that hospital.
00:22:51
Speaker
And I think his story is really interesting is because like, that's not the only people who go, the people who go to the public hospital in Houston are the ones who fall through the cracks.
00:23:02
Speaker
And there are large gaping cracks in the Texas system and in the federal system. And what he found was that he, he ultimately, loved the care that he got to the point where even now where he, he, he still insists to go back to to, to, to, to Ben top. He, he thought that he got some of the best care that he could have gotten.
00:23:24
Speaker
and and a lot of it had to do with the focus on him as a person on, on, uh, not really the impediments that things like insurance bring, you know?
00:23:36
Speaker
Uh, and so it's It's an example that I see a lot that, you know, good care is really, truly available. How to get it to people involves, to me, a lot of, you know, just realizing what are our goals here and what are people going to be happy working as. And I think in the in at Ben Taub, it's like there's there's a certain amount of people who are just really happy working in medicine.
00:24:04
Speaker
There's a certain, we don't need to have profit in every single sphere of of life. maybe Maybe we should dedicate a certain part of it. I'm not saying get rid of the whole profit system, of course. I'm just saying that like, that there might be an avenue if we open it up to like accepting not profit, that could be a help for the for profit people that acts as a subsidy in the city.
00:24:29
Speaker
You know, like I said, the person who does not have to weigh the idea of turning somebody down, that's a subsidy for you because that you get to say, Hey, I have somebody who can take care of You you can go over there and I don't have to like, ah maybe that person would, uh, would take the patient on a voluntary basis. Then they would be cost sunk, you know?
00:24:53
Speaker
But it's it's it's I think I think that it it took me years to realize that. But working at Bentob made me realize that the public way of health care can be done well in the United States. We just have to think about ways of implementing it.
00:25:08
Speaker
And before we get into like how we can do this better and dive and actually create a good public health system. i mean, there was a few other examples in your book, of course, one stuck out to me a lot as being a younger person is Christian.
00:25:20
Speaker
Yeah. Younger college student who didn't think he was healthy, didn't think he'd need any health care at all. And of course, like couldn't get an accurate diagnosis or treatment. He tried to pursue medical health. And as you mentioned, Steven, of course, he had insurance, wasn't able to really get the best care until coming to Ventalb. So I think the dynamic is not as simple as insured versus uninsured.
00:25:40
Speaker
Insured people get good healthcare, uninsured don't. It's not that easy. And as a physician where these stories are not just stories, but real everyday people to you, mean, what have you realized to be the biggest problems that patients at Ventalb and who come to Ventalb are facing? Like, why do these people who aren't really outside the system still fall through the cracks? Like, what have you noticed through your career, just seeing all these different, I mean, that's,
Advocating for Public Health Coverage
00:26:02
Speaker
that's a great question. And I, and I think it's just this, i think to a certain extent that there's this faith that if you have some level of insurance, it'll end up being fine. And, and, and what I've learned through my patients experiences is that like,
00:26:24
Speaker
a lot of those plans are made so that you just pay for them and not use them. You know, a lot of them are trash plans and, and to, and like, I think of Christian a lot, you know, ah because I feel like Christian being 25, I mean, I do remember what it's like to be 25. I know like that there's times where you're like, this doesn't make any sense. How am I sick right now?
00:26:51
Speaker
People do get sick. But, you know, i think that it just – When you're coming, when you're 25 and you, and you you, like Christian, you get a first job, you don't think you're going to get sick. And so you might just look at these plans of insurance and just be like, just deduct the lease for my paycheck. Right.
00:27:14
Speaker
But my question is like, wouldn't why? Why wouldn't all of us just not want to have to pay health insurance for that? And at that at at that age, you know, what if we had a system like the Ben Taub system, which is a public health care system where you come out of 25 and you don't have to pay for health insurance at all.
00:27:34
Speaker
You don't have to deduct it from your because you can rely on a public system. If something happens to you for catastrophic issues or if you get a bad cancer diagnosis, you go through the public system. And that's something that you if you decide that you want to have a ah high insurance when you're 25, maybe because you have um health scares in your family. Maybe it's because you like you're just you're you you just are a warrior like this, which is for some people it's understandable.
00:28:04
Speaker
Maybe you purchase another another health care. That's fine. But. But there seems to be in America this this sort of idea that we all have to like have health insurance. And at the end of the day, it's just not helping all of us, even even though we pay for it.
00:28:20
Speaker
especially people who are young, especially people who are just coming into into their careers, especially people like like like Christian, who, man, had all of his whole life to look forward to, got sick, and is just like, this this insurance just doesn't work at all for me. you know i think of, I just think it'd be if I was that age, I would just be like, you know what?
00:28:47
Speaker
I'm, I'm going to take the risk. I will like, I will, I I'm okay with the public health system as long as it's okay, you know, and I would rather not pay for health insurance, especially if I can't trust if it's going to be there for me.
00:29:01
Speaker
And it's, yeah. And I'm sure we could keep going on and on about like how many problems are on our healthcare system. I think one thing you talked about was like medicine Inc and like how there's different systems and,
00:29:13
Speaker
players all following their profit motive, which creates like a really intertwined and misaligned set of incentives, which makes it difficult. And we can probably spend like hours talking about different issues, but I want to get into like kind of what you believe a public health system should look like. I know you've spoken on some of the strengths you believe are going on with Bantel, but if you could kind of design the hospital of the future based off what you've learned and would add or change, like what would you exactly look for and want to build within these public health systems and public hospitals that allow them to not only like innovate and great create good care, but also just be able to serve everyone and have good access.
00:29:48
Speaker
Well, I like the model that that, you know, I'm speaking from my own experience in this model and I can tell you what are the good things, which are, I think that, like I said, that, there's an academic group of doctors who staff it, who are also as a group aware of how medicine is practiced elsewhere, you know, that they raise the standards of that public health, ah health system, that it's not purely just run by government, but it is actually integrated into some sort of like academic, uh, model.
00:30:19
Speaker
But also i think that, um, I think that ah that ah that a that a ah great public hospital should have some sort some level of subsidization from the community. you know I think that there's – like I said, it's – what you talked about with the first insurance is there's something about like being beholden to an institution and knowing that it's going to help you.
00:30:45
Speaker
that good public hospitals give to each community. Like in, at Ben Taub for years, it had been like, oh, if I'm in a big accident, which there are plenty of, of and even more so motor vehicle accidents, you know, in the in the city, like those people are going to do as well as anybody else in the country.
00:31:07
Speaker
That's the mentality in Houston. Now that's gone to like strokes and heart and heart attacks. it's it's It's this designated place. So it's like every single person in the city feels like this is what the ideal hospital is, what I'm saying. You know, it's like is it feels like, you know what, that's exactly where I want to go if something catastrophic happens and I don't have to worry about payment for it.
00:31:35
Speaker
because it's subsidized in some way by the community. I think we we can address the problems of like different size communities, because I know Houston's a huge and and growing, but but we can have we we can think about the VA a model and how it has been organized in different parts of the country where they have referral systems to larger you know like um urban centers.
00:31:58
Speaker
you know you have You don't have to have enormous hospitals in very small rural towns, you do, you should have maybe like rural, rural, like ah centers that can refer out to different community hospitals, you know, and, and maybe the subsidization of those, of, of like the patient care at those hospitals can follow those patients to different locations as we're being kind of like, we're, we're ah as, as patients are being referred to higher centers for higher levels of care and things like that.
00:32:30
Speaker
But I think you have to have some level of, this is what I believe in. Like you you have to have, you have to understand that the goal is not profit.
00:32:40
Speaker
The goal is to provide something to the community. ah The goal that, That also the that that the community is invested in it. And that's why the subsidization is is important there.
00:32:56
Speaker
And there's probably going to have to be some other level of um of responsibility sharing. Now, that's a real difficult. so what I mean by that is, is like, is there going to be dual subsidization from the federal government, from the state government? That's like.
00:33:10
Speaker
In a way, that's kind of like America's like big question always. Always it comes down to is this state or federal? I don't know what the answer to that. What I can tell you is is that I feel like Houston has done it purely from the basis of property taxes right there.
00:33:26
Speaker
I don't know if that's a real working model for all of the different parts of the United States, but I do think that... We should agree that if this is our goal, then maybe the federal governments or state governments help subsidize these public hospitals and this referral clinic is within so that there's public health care.
00:33:43
Speaker
And that, to me, would free up the market for people to actually buy. They wouldn't that would set the standard, the baseline. This is what healthcare costs.
Proposing Universal Coverage
00:33:54
Speaker
This is what it is. And then from there, people can buy private insurance if they want to, to go to private health, ah to ah to go to private hospitals and and see private ah practitioners. And so you kind of think like a, basically like a universal like coverage floor would make the most sense, right? Like everyone has like some sort of basis for healthcare.
00:34:12
Speaker
Yeah, my i that's what I think. And I think that my experience is from the not like the universal like care is is is existent at the at the like infrastructure level of buy of like actually like the hospitals are owned by the public and the clinics are owned by the public rather than it being like and insurance.
00:34:34
Speaker
Cause I'm just wary of the history here. Like I, I do really, the you know, reading about that, the medic, the moment that Medicare as a public insurance was started, it just, that was the moment that like doctors started taking advantage of it and, and like driving up prices, you know? And so, and I think that part of me is like really wary of that. I think that if you're able to own the the The structures of like where this health care takes place, you're able to control the costs a little bit more.
00:35:07
Speaker
But ah but I do believe in ah in a definitely ah like in my book, I call it like really like a two tier system. Right. Which is like we have a basic system that is really good for. And I do believe that that that two tier system exists in Houston in the form of like the Harris Health System where I work.
00:35:24
Speaker
ah That there's very good care at the basic level and ah that's subsidized by government, in this case local. Second, but, and that and that people go to the private hospitals through their own like you purchasing of ah privately, however they want to.
00:35:41
Speaker
And I think like it's it's really interesting if you can have like a floor like that. it's Whether it's through the infrastructure or insurance, it probably makes more sense to the infrastructure, as you mentioned. It's not completely radical of an idea, right?
Dr. Nulia's Writing Journey and Conclusion
00:35:52
Speaker
We've seen this in other health systems, like even in the UK, but bringing that to America would obviously save many, many lives.
00:35:59
Speaker
And quickly, kind of for the last question, want to type into your kind of experience as a writer and author. um What kind of messages have you wanted people to take away? I mean, what kind of drove drove you to be like a writer and author on the side on top of being a physician? And what kind of messages have you hoped for like listeners and readers to take away from your work?
00:36:17
Speaker
Because it seems like it's always, you're always trying to inspire people kind of frame these ideas for everyday people. But I'd love to hear from you. Like, where do you think that's provided value for you and others? Well, I mean, I'll tell you what, like it was a big conflict for me to decide whether to be a writer or or a doctor because um I felt naturally like pulled into medicine through my family upbringing.
00:36:41
Speaker
But I just felt so enriched by so many books. I felt like it changed me as a person, made me see the world through different eyes is what I felt like reading great books.
00:36:53
Speaker
And, and so I wanted to contribute to that always. I just didn't know how to, and, and somehow, and, you know, medicine coming together with writing at, um, at this hospital helped me because I was like, well, and I can, I feel like I can engage different stories, different lives, uh, and write about them in in in, in, in, you know, by, by having observed them like this.
00:37:19
Speaker
And, and I, so and i And I do believe that I i approached this book thinking not – this was not approached via like idea first. This was approached by people first.
00:37:32
Speaker
Like the very beginning was just like who are the people who are compelling to me and why are they compelling to me? Why are their stories so compelling to me? And in it I think that this made it like why it was one of the reasons why it took very long for me to write this book. But it wasn't like I had a thesis at first and like, now let me look at the patients who fit this thesis.
00:37:51
Speaker
It was the opposite. It was just like, who are the people that I connect with? why Why do these people make me like inspire me or make me think about these things? And what are the lessons that I can derive from them?
00:38:01
Speaker
You know? And so I kind of look at like writing as as that, more more interested in like how human beings are and what is interesting about them rather than like – like certain ideas.
00:38:16
Speaker
I think that there's like idea based writers and, and more kind of like people based writers and that, and, and, or, you know, and people based writers do characters and scenes a little bit differently. And I'm been more of like the, the person and character based writer. So it was really what drove me is like, is like, is like these people. I mean, I can tell you like with Geronimo and with, with some of the,
00:38:42
Speaker
Like the the patients, I was just like, I mean, my heart was pounding on the wards. I was worried about them. I was meeting their mom and I was just like, this is actually happening. This really, really happens to this really good person right here.
00:38:55
Speaker
and And that's what I wanted to really reflect in the book. and and And what took a long time was like, well, how do I structure this so that it makes sense for somebody why this feels unjust, you know?
00:39:08
Speaker
But it's really that feeling that drives me. And in your book, you really make it easy to empathize with people like Steven, Christian, Hironi Mo. like You dive deep into their stories and you can see the decisions they have to make. And it's not, there is no right decision often. And it's super hard. It's difficult. And also you provide a great framework for the future. So, I mean, if anyone wants to read the book, it's going to be linked in the description. It's available on a lot of major platforms. But I mean, I've really appreciated your time, Dr. Taddy, for coming on, and sharing your story, but also just diving into like Bental as a hospital within the health system, what our health care system could look like in the future.
00:39:43
Speaker
I really appreciate your time today and you taking the time to dive into all of this. Well, thanks for inviting me and thanks for all you do. This is really important that um that topics like these get out and and that people are aware of that there's interest in this and that and there's different viewpoints and we have to like take many viewpoints and think about them ourselves. So this is really great work you're doing and I'm really honored to have been on this on this podcast.
00:40:12
Speaker
Thanks for listening to The Healthcare Theory. Every Tuesday, expect a new episode on the platform of your choice. You can find us on Spotify, Apple Music, YouTube, any streaming platform you can imagine.
00:40:24
Speaker
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00:40:39
Speaker
Again, i appreciate you tuning in and I hope to see you again soon.