A few years ago,

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,

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 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 economy 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 need 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 followup.

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 are resting.

But what if you don't have that?

What if you live on the streets,

you live under the freeway,

you live in a congregant shelter

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

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?