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A few years ago,

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I was taking care of a woman[br]who was a victim of violence.

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I wanted her to be seen in a clinic[br]that specialized in trauma survivors.

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I made the appointment myself because,[br]being the director of the department,

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I knew if I did it,

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she would get an appointment right away.

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The clinic was about an hour and a half[br]away from where she lived,

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but she took down the address[br]and agreed to go.

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Unfortunately, she didn't[br]make it to the clinic.

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When I spoke to the psychiatrist,

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he explained to me

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that trauma survivors are often resistant

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to dealing with the difficult[br]issues that they face,

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and often miss appointments.

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For this reason,

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they don't generally allow the doctors[br]to make appointments for the patients.

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They had made a special exception for me.

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When I spoke to my patient,

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she had a much simpler[br]and less Freudian explanation

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of why she didn't go to that appointment:

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her ride didn't show.

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Now, some of you may be thinking,

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"Didn't she have some other way[br]of getting to that clinic appointment?"

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Couldn't she have taken an Uber

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or called another friend?

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If you're thinking that,

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it's probably because you have resources.

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But she didn't have[br]enough money for an Uber,

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she didn't have another friend to call.

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But she did have me, and I was able[br]to get her another appointment,

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which she kept without difficulty.

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She wasn't resistant,[br]it's just her ride didn't show.

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I wish I could say that this[br]was an isolated incident,

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but I know from running[br]the safety net systems

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in San Francisco, Los Angeles,[br]and now New York City,

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that health care is built[br]on a middle class model

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that often doesn't meet the needs[br]of low-income patients.

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That's one of the reasons why[br]it's been so difficult

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for us to close[br]the disparity in health care

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that exists along economy lines

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despite the expansion of health insurance

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under the ACA, or ObamaCare.

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Health care in the United States

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assumes that, besides getting across[br]the large land expanse of Los Angeles,

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it also assumes that you[br]can take off from work

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in the middle of the day to get care.

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One of the patients who came[br]to my East Los Angeles clinic

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on a Thursday afternoon

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presented with partial blindness

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in both eyes.

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Very concerned, I said to him,

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"When did this develop?"

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He said, "Sunday."

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I said, "Sunday?

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Did you think of coming sooner to clinic?"

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And he said, "Well, I have to work[br]in order to pay the rent."

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A second patient to that same clinic,

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a trucker,

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drove three days with a raging infection,

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only coming to see me[br]after he had delivered his merchandise.

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Both patients' care was jeopardized[br]by their delays in seeking care.

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Health care in the United States[br]assumes that you speak English

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or can bring someone with you who can.

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In San Francisco, I took care of a patient[br]on the inpatient service

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who was from West Africa

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and spoke a dialect so unusual

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that we could only find one translator[br]on the telephonic line

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who could understand him,

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and that translator only worked[br]one afternoon a week.

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Unfortunately, my patient[br]needed translation services every day.

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Health care in the United States[br]assumes that you are literate.

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I learned that a patient of mine[br]who spoke English without accent

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was illiterate

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when he asked me to please sign[br]a social security disability form

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for him right away.

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The form need to go[br]to the office that same day,

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and I wasn't in clinic,

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so trying to help him out,

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knowing that he was[br]the sole caretaker of his son,

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I said, "Well, bring the form[br]to my administrative office.

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I'll sign it and I'll fax it in for you."

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He took the two buses to my office,

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dropped off the form,

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went back home to take care of his son,

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I got to the office, and what did I find[br]next to the big "X" on the form?

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The word "applicant."

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He needed to sign the form.

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And so now I had to have him[br]take the two buses back to the office

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and sign the form so that[br]we could then fax it in for him.

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It completely changed[br]how I took care of him.

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I made sure that I always went over[br]instructions verbally with him.

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It also made me think about[br]all of the patients

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who receive reams and reams of paper

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spit out by our modern[br]electronic health record systems

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explaining their diagnoses[br]and their treatments,

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and wondering how many people actually

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can understand what's on[br]those pieces of paper.

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Health care in the United States assumes[br]that you have a working telephone

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and an accurate address.

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The proliferation[br]of inexpensive cell phones

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has actually helped quite a lot,

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but still my patients run out of minutes

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and their phones get disconnected.

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Low income people often have[br]to move around a lot by necessity.

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I remember reviewing a chart of a woman[br]with an abnormality on her mammogram.

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That chart assiduously documents[br]that three letters were sent to her home

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asking her to please come in for followup.

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Of course, if the address isn't accurate,

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it doesn't much matter how many letters[br]you send to that same address.

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Health care in the United States assumes[br]that you have a steady supply of food.

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This is particularly[br]an issue for diabetics.

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We give them medications[br]that lower their blood sugar.

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On days when they don't have enough food,

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it puts them at risk[br]for a life-threatening side effect

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of hypoglycemia, or low blood sugar.

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Health care in the United States assumes[br]that you have a home

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with a refrigerator for your insulin,

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a bathroom where you can wash up,

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a bed where you can sleep[br]without worrying about violence

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while you are resting.

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But what if you don't have that?

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What if you live on the streets,

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you live under the freeway,

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you live in a congregant shelter

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where every morning[br]you have to leave at 7 or 8 am?

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Where do you store your medicines?

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Where do you use the bathroom?

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How do you put your legs up[br]if you have congestive heart failure?

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Is it any wonder that providing people[br]with health insurance who are homeless

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does not erase the huge disparity

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between the homeless and the housed?