One of the most shameful things about modern America is that in our unbelievably rich land, the quality of health care available to many of our people is unbelievably poor, and the cost is unbelievably high.
--Sen. Edward M. Kennedy, 1978
Sen. Ted Kennedy's comments on the broken health care system in 1978 sadly are as true now as they were then. Kennedy believed that high quality health care is "a fundamental right, not a privilege." In the last months of his life, despite terminal illness, Kennedy continued working for the cause of his life: a national health insurance program covering all citizens.
Kennedy's dream seems remote still despite the pressing need. This summer, reasoned discussion of reform descended into shouts and threats fueled by right-wing rage and insurance industry money as millions of uninsured and underinsured people continued to suffer.
Journalist T. R. Reid recently told Real Change about how health care systems in the most developed nations provide health care for all citizens, while the U.S. relies on the most expensive yet least effective system ["Learning from our Neighbors," Aug. 26 - Sept. 1]. The author of the bestselling "The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care," Reid stressed: "A major reason why we have a lower life expectancy, a lower rate of recovery from major diseases, is we leave millions of people out of the system. It's not that we have bad care, it's that we don't give everybody access to it."
And many also are left out in Seattle. Dr. Audrey Young provides a timely, lively account of medical care in Seattle in her new book about her work at Harborview Medical Center, "The House of Hope and Fear: Life in a Big City Hospital" (Sasquatch Books, 2009).
Harborview opened as a charity hospital in 1931 and still serves the city's poorest, most vulnerable patients. As Dr. Young explains, Harborview's mission is to provide medical care to anyone who needs it, and its doctors, nurses and staff follow three rules instilled by legendary Emergency Department director Dr. Michael Copass:
One, work hard.
Two, be polite.
Three, treat the patient graciously, even if he is not the President of the United States.
Dr. Young's compassionate and poignant storytelling captures patients during the most trying moments of their lives as well as the trials of committed doctors and nurses at this overburdened public hospital. Her stories illuminate challenging medical cases while vividly showing the many stresses on our health care system.
Dr. Young also wrote the acclaimed book, "What My Patients Taught Me: A Medical Student's Journey" (Sasquatch 2004). She has worked as a staff physician at Harborview and as an assistant professor at the University of Washington School of Medicine, and she now practices at Kirkland's Evergreen Hospital.
In a recent conversation from her home in Seattle, Dr. Young reflected on her experience at Harborview and our health care delivery system.
How did you decide to write this book on Harborview Medical Center?
First, I wanted to write about people who had inspired me, who had been my mentors. I write about several, especially Dr. Michael Copass, who has been there for almost 40 years and has been a champion of the underdog. He has instilled a work ethic in thousands of doctors, nurses, paramedics and other medical staff that everyone ought to be treated equally, and if they're not, he's there to make sure it happens. Another is Dr. Patrick Fleet, who is known for taking some of the toughest cases: people fired by other doctors because they were too threatening or manipulative or even violent. It was amazing to watch Dr. Fleet care for these people and make sure they got very good health care.
Dr. Fleet proposed a vivid image for a new Harborview logo.
The logo now has the old 1931 art deco building with waves representing water at the bottom. [Dr. Fleet] thought that didn't represent Harborview at all. It's not about the architecture, it's about the guy lying in the gutter in Pioneer Square looking up the hill and seeing this citadel that's there whenever [he] needs it.
Harborview started as a charity hospital, and it's seen now as Seattle's medical safety net.
In the late 1800s, almost every hospital was considered a charity hospital where doctors cared about people and pushed forward the boundaries of medicine. About a half dozen hospitals [in the Seattle area] were dedicated to serving people who didn't have many resources. It's become a much more commercial environment in the last 30 years, and Harborview is the last remaining hospital with that mission.
Harborview seems the sole option for care for people who are indigent or lack insurance, and they get the most expensive medical care in an emergency department.
It's unfortunately true. There's a primary care system at Harborview, but it's crowded and the average wait for an appointment is about two months. So a lot of times the people end up walking into the emergency department because it's easier and faster and they get care when they need it.
It's not a great system for them or for anybody who's helping to pay for that, because it's really expensive care. We can serve people better by having more primary care and outpatient care available. The Pioneer Square clinic, a satellite of Harborview, operates in that mode. You can walk in any time and chances are that the person you usually see will be there. It would be wonderful if we could expand that.
Your husband had an expensive emergency visit at Harborview.
It was eye opening. He had a stomach bug [with] vomiting and cramps. The total bill just for getting IV fluids and some anti-nausea medication -- it was about a two-hour visit -- was about $3,500. We were incredibly grateful to have insurance. For [my husband] it was great. He didn't have to miss work. He got better right away. He didn't have to suffer through it.
I understand that you're expecting and see a physician for your condition. How do you feel as a patient who needs medical care?
When you're pregnant, you see the doctor all the time. I really appreciate having one doctor. I see my OB and nurse practitioner and like them both. There's something comforting about knowing there's going to be a familiar face there.
Was there anything surprising about being a patient?
I would say the bills -- seeing what things cost and what we pay and what insurance pays. And how many different people send you a bill for what seems to be one service or one trip to the doctor.
In your book, a patient you call Kermit threatens to kill you.
He did that with everyone. It took me a few visits to realize he was all words, but it was scary at first. With experience I became better at handling those situations and knowing there are plenty of people to back me up. By the time patients got to me they were relatively stable. The medics and the nurses face more of the physical danger than many of the docs.
You write that a big part of solving medical care issues is addressing poverty. You praise the "wet house," or the housing for poor, chronic inebriates, and explain how just having a home helps reduce the need for medical care.
Absolutely. What we do as physicians is so at the end of the line that it patches things more than fixes structural problems for people. Good schools, housing, access to nutritional food are all things that affect people's health.
The wet house is an innovative project conceived by the Downtown Emergency Service Center. The idea is that you take people where they are, not make assumptions, and just provide what they need -- in this case shelter. The health of these mostly men, some women, improved. Some people were very ill. One I described in the book died of liver failure. He probably didn't live much longer because of housing, but he died in a warm place in his own bed, and that's a lot more humane than being on the streets.
There's a lot of controversy [about the wet house] but preliminary data this past spring showed that this actually saved taxpayers about $4 million a year just by putting these people in a house, and not doing anything else. It saved money in terms of jail costs, detox costs, attorney and court costs, but primarily health care.
What kind of health care program would you like to see?
Ideally, I think a system similar to France, [with] several large health care payers or insurers who compete for patients. The idea of co-ops makes sense. The way co-ops are conceived currently takes a lot of teeth out of them, because they have trouble competing with larger companies with a larger patient base. But retaining some competition is good for the patient.
I would like to see everybody covered somehow. It's the right thing to do. It's not okay that some people don't get health care because it's so exorbitantly expensive.
Like T. R. Reid in "The Healing of America," you note that the U.S. spends much more per patient on health care than other developed nations, yet our system is much less effective. You and Reid also indicate that, rather than selling health care as a commodity for profit, we need to make it available to all.
Yes, we do have the most expensive health care in the world, but with basic markers such as child mortality, mortality at birth, and life expectancy, we rank low among the industrialized nations. Some advance the idea that the gap between the richest rich and the poorest poor in a country correlates with health markers. In places where people are more equal, people tend to be healthier. In the United States, the richest rich and the poorest poor are so far apart [and that] contributes to our health.
How does writing inform your work as a doctor?
There is a lot of overlap between taking care of a patient and being a writer, because every time you encounter patients, they're telling their story, trying to make sense of that story and make it into something cohesive that can be acted on. Journalists do a similar thing in putting together a story that has meaning beyond a collection of facts.
I believe that diagnoses get made from the story more than [from] expensive testing. And not just in a cost saving way, but taking care of a patient, figuring out what's going on, and relating their medical care to their circumstances.
What would you like people to take away from your book about Harborview?
I hope it's read by people who don't necessarily think we need health care reform, because a lot of stories in the book describe what doesn't work well with our system. I hope it makes people think a bit.
You stress the need for a place like Harborview that serves everybody regardless of status.
And hopefully it just won't be Harborview in the future, [and] that will be taken on more broadly by the medical community. I hope the idea that care for the poor is somebody else's job can be overcome in our lifetime. n