A Texas doctor’s love letter to ‘the People’s Hospital’ (from 2023)

Ben Taub Hospital tour

0:00The fatal shooting of a teenager at a protest in Seattle has gone unsolved for six years. This is open in your face. How are there no answers? Our investigation has uncovered new evidence and witnesses who say they've never talked to police. Did police ever call you? Not once. Listen to We Keep Us Safe, a new true crime series on the Embedded Podcast from NPR. Hey there, it's August. Some of us are on vacation and maybe you are too. I'm spending a lot of the month planning for this fall and beyond.

0:32So today we are bringing back a favorite episode from 2023.

0:40Ben Taub Hospital is a publicly funded safety net hospital in Houston, Texas. The majority of patients don't have insurance of any kind. Dr. Ricardo Nuala has been working at Ben Taub since he was an intern, a medical student. He took me on a tour. I started here and, you know, literally I just did not want to leave here because I just really enjoyed my job here. He's just published a book called The People's Hospital. It's not just a love letter to the place, it's a pitch. And the pitch is, not only is this place way, way cheaper than what we're used to,

1:14in many ways it's better and it's a model, a real alternative to what we're used to. So when I ask him to pick one patient story from the book to tell, he picks a patient he calls Stephen, a restaurant manager, a Republican, a guy who did not expect to end up here. But he had a giant lump on the side of his throat and his insurance didn't cover much. He paid cash up front to get seen in a local ER. Finally, there was a doctor who had seen a CAT scan and said, you have tonsillar cancer, however, you don't have insurance.

1:47Tonsillar cancer, cancer of the tonsils. That landed hard. So did the however. He felt shitty that somebody could tell you cancer, but there's nothing that we're going to do about it because of your, of how much. Yeah, it's like it's too painful or too obvious to finish the sentence because of your insurance. Somebody tells Stephen to try the public hospital, then Todd, and he expects the worst. But that's not what he finds. He comes to love this place. This is like so Stephen, but he gives gift cards to the people greeting at the door

2:23because they're nice and they do their job well because they make his day. And it's not just that he likes the people at the door. He feels like he got really good health care and that he also thought that the price was extremely reasonable. Stephen lost his insurance when he got too sick to work and he doesn't qualify for Medicaid. He owns a house. He's got savings. Texas has really stringent Medicaid restrictions. So he's paying out of pocket. His final bill is pennies of what he thought he would pay.

2:53Stephen's dad had gotten radiation treatment for cancer and the sticker price was $700,000. Stephen had gotten radiation and chemo and surgery and he'd been hospitalized for a good while. And his bill was $32,378. Real money for sure, but he can pay it. And it's less than 5% of his dad's bill for much less extensive treatment. And the health care is really good. And so he's almost proud that he's had this experience.

3:26Stephen's become a convert. And as Ricardo Nuala walks me into a conference room, it's clear he hopes his book is going to create more conference. You start to see this model and it makes you think, can things be different in health care where I think that that's an option. But we as a country haven't thought about that seriously, you know. And if it seems politically unimaginable that we could have anything like this around the country, an effective, efficient, cheap, publicly funded health care system, well, the idea that Houston could have one, that was one's pretty unlikely too.

Why Ben Taub works

4:00In fact, the story of how Ben Taub got here, that may be the most surprising story in Ricardo Nuala's whole book. This is An Arm and a Leg, a show about why health care costs so freaking much and what we can maybe do about it. I'm Dan Weissman. I'm a reporter and I like a challenge. So our job on this show is to take one of the most enraging, terrifying, depressing parts of American life and bring you a show that's entertaining and empowering and useful. Ben Taub Hospital sits at the edge of the Texas Medical Center.

4:34That's a giant neighborhood full of hospitals and medical schools, including some of the best in the country, like the M.D. Anderson Cancer Center. In his book, Ricardo Nuala writes about how some patients at Ben Taub can see from their rooms the gleaming buildings of Ben Taub's neighbors. So when I visit, I make him show me the view. We look out from a stairwell at a glass tower, M.D. Anderson's Sheikh Zayed building. That's glamorous, right? You get a glimpse into the rest of the medical center here. And Ben Taub sticks out, I feel like, because it's it's brick versus glass.

5:06But as Ricardo Nuala makes clear in his book, this unglamorous brick building gets the job done. In addition to Steven, there's Ebony, whose complicated pregnancy, there's a lot of vaginal bleeding, gets tracked more precisely than it would elsewhere. Like at other hospitals, nurses eyeball the pads that absorb that blood and note heavy, medium or light bleeding. At Ben Taub, they've adopted an innovative approach, weighing each pad to get an exact measurement. Another patient, Christian, has bounced around other systems without anybody accurately diagnosing the dire kidney problems that have kept him in pain for years.

5:43Because he didn't have good insurance, wasn't worth anybody's time. At Ben Taub, insurance isn't an obstacle. We organize things, which is basically, OK, we need to focus on your kidneys right now and we need to get you to see a geneticist. And both of those things happened. They not only diagnose Christian, they get him on a form of dialysis. He can manage himself at home. It's cheaper and delivers better quality of life for him. Everything at Ben Taub is cheaper. The system spends about a third as much per patient as the national average.

6:15In part, that may be because nobody earns million-dollar salaries here. But Ricardo Nuala makes the case over and over again that they take the time, because they have it, to make wise use of resources. They don't have as many MRI machines as other hospitals. But guess what? A lot of patients don't need MRIs. But Ben Taub can't meet every need. One patient, Geronimo, needs a liver transplant. And that requires resources the hospital just doesn't have. But Ricardo Nuala and his colleagues put a lot of time into wrenching Geronimo back onto Medicaid so he can get the transplant somewhere else.

6:50They wrote Ben a congressman to get it done. Geronimo tells his mom, It feels so important. Everyone treats me like I'm rich. That's what I think a lot of people really want is just the sense that the person who's responsible for your care is thinking through the problem with you and aware that you are not having a great day and wants to deal with that situation with you. And I just felt like this environment allowed me to, like, have those moments. So who pays for this environment?

7:21It may be cheaper, but it isn't free. Some patients are on Medicaid. Some are on Medicare. Some have private insurance. But the majority don't have any insurance at all. Some, like Stephen, pay cash. And a lot of the rest, about a third of Ben Taub's patients, are treated for free. The bulk of Ben Taub's funding comes from a special property tax in Harris County, where Houston's located. It funds a whole system called Harris Health, Ben Taub, a second hospital, and a bunch of clinics.

Jan de Hartog's campaign

7:50And, of course, none of this has always existed. In fact, it's only here, like this, because of a really wild story with two big characters, one of whom wasn't even from Houston. He was a writer I'd never heard of, a Dutch guy named Jan de Hartog. Jan de Hartog was one of the most amazing people that you could read about. He was a Nazi resistance fighter, Dutch ship captain. And while he was hiding out in Denmark during the war, in between saving a few Jewish babies and running war missions in his tugboat,

8:26he wrote a romantic dramedy that later became a Broadway hit and then got adapted into a Broadway musical called I Do, I Do, which Broadway musical nerds in the house starred Mary Martin and Robert Preston, you know, the music man, and had a song your mom might still remember. My cup rides over with a light. Yeah, so, interesting guy. And in the early 1960s, he came to Houston to teach playwriting at a local university.

9:01It was a big time for him. He'd just gotten married for the third time, but this one was for keeps, and become a Quaker. And when he and his wife, Marjorie, come to Houston, they find that there is all these whisperings about this charity hospital in town in Houston, about how awful the conditions are. Whisperings were that children in the maternity ward would cry all night for a lack of milk. And so, as part of his faith, he decides that he needs to volunteer there. When DeHartog writes about the hospital later,

9:31he describes the experience of walking in for the first time as literally mind-boggling. He's like, I know what a hospital smells like. Disinfectant. Maybe some fresh laundry. And I know what a slaughterhouse smells like. Blood. Shit. The smell here is slaughterhouse. And as he looks around, the sights are something else, too. The conditions are atrocious. He sees a cockroach crawling into the tracheostomy of, like, a patient. He sees, like, people sitting in their own filth.

10:03He and Marjorie do not quit. They stick around. And then they recruit a dozen Quakers and a few society ladies to come volunteer with them and get the Red Cross to train them. And it's nuts. This is a rich city. The zoo is air-conditioned. Not this hospital, though. And he starts to catch on. Why it's so horrible. Number one is racism. The hospital serves mostly black and brown patients. When Jan and Marjorie start volunteering, the other volunteers are all society ladies. And the whole program is set up so they don't touch patients.

10:36DeHartog later says he asks why. And the volunteer coordinator says, Southern ladies can't have physical contact with black people. But she doesn't say black people. She uses the N-word. When he asks staff why public officials don't do something about the rotten conditions, they say, what politician is going to stick up for black people? The N-word comes up again. And DeHartog does not make this particular connection, but it seems pretty on the nose. The hospital itself is named after Jefferson Davis,

11:07who led the Confederacy in the Civil War. But there's also a political mechanism for institutionalizing this neglect without ever having to acknowledge the role of racism. And that's this. No one particular political entity, no one particular political leader is responsible for the public hospital financially. The city of Houston and Harris County are each supposed to kick in half. So it doesn't belong to either of them. Here's DeHartog describing that city-county dynamic in a lecture he gave many years later.

11:38And they were continuously at each other's throats. The one said you don't pay enough. The other said, but you don't. And it went back and forth. The top official for Harris County actually has the title county judge. At that time, this was a guy named Bill Elliott. And you can hear in this clip from a local newscast, he wasn't exactly reaching for the bill. Here he is explaining why some problem with the hospital is actually the city's fault. And it's absolutely ridiculous to say that this is a responsibility and this is the fault of Harris County. And the city?

12:08At least one council member is calling for a budget cut, which really pisses DeHartog off. And DeHartog actually loves the city of Houston. It's an exciting place. It's booming. It's growing super fast. And it's not just an oil town. Houston at that time was the home of NASA. All right, Houston. Go ahead, Houston. Future manned spaceflight missions to the moon, and perhaps the planets, will be commanded from this control room of the Mission Control Center at NASA's Manned Spacecraft Center,

12:4022 miles southeast of Houston, Texas. It had built the Astrodome. It was the city of the future. The Astrodome. You know, a sports stadium with air conditioning. A fully enclosed building, large enough for any sport, convention, show, or conclave, with constant temperature and humidity, independent of outside weather. CBS News does a report about the booming city, NASA, the oil wealth, the Astrodome. And DeHartog is a main character, talking about how much he loves the town. It is a city of unlimited opportunities.

13:13It's an immensely exciting town, and you feel that anything is possible. The CBS report wraps up with Walter Cronkite talking about how everybody in town is absolutely nuts about football. Their brand of football is like their brand of city and brand of life. Play wide open. Take a chance. Try anything once. Above all, do it with zest and do it big. Oh, and there's this other thing Houston is really becoming known for. Cutting edge medicine. For 20 years at this point, the city had been building the Texas Medical Center,

13:45that giant campus where more than a dozen hospitals and med schools now operate right on top of each other. Houston is a really deeply medical city, and at that time, they're all working on extraordinary things. In 1964, while Jan DeHartog is witnessing the suffering at the charity hospital, Dr. Michael DeBakey is performing the world's first coronary artery bypass at a private hospital in town. But the Houston medical establishment, they're not allies here. Jefferson Davis Hospital on the outskirts of town was about to be replaced by a new building

14:15in the Texas Medical Center, but the medical society, the local doctors association, had not wanted the charity hospital as a neighbor. They'd actually put up a ballot initiative to keep the new building at the old site. You, the taxpayer, will pay the extra cost. That's why your doctor recommends you vote for the new hospital to remain at its present site. It hadn't worked, but along with the budget cuts, officials were now talking about delaying the charity hospital's move to the new building. DeHartog and his friends smelled a rat. They were thinking the powers that be

14:47are actually going to sell the new building in the medical center to some other hospital that wants in. I mean, this was a public conversation. There had been offers to buy it, and they wanted to wait for the highest bidder. He writes a series of op-eds for the Houston Chronicle that start to get press, not just in Houston, but around the country and, in fact, around the world. DeHartog describes the awful things he's seen, and he appeals to Houstonians' sense of pride

15:18in their, you know, bustling, futuristic city. A city he loves, too. Here's how his first op-ed ends. I cannot believe that it is the will of the citizens of Houston that our growing medical center, rightly becoming famous all over the world, shall be allowed to harbor the cancerous sore of man's inhumanity to man. It would turn the entire center, planned as Houston's glory,

15:50into Houston's shame. Just that first op-ed made a lot of noise. The bomb exploded,

15:58and the national magazines and newspapers and TV zeroed in on the hospital to find out what was going on. And immediately, the hospital does get to move into its new home in the medical center. But the funding issue is not solved. So DeHartog keeps on pushing. He writes a book called The Hospital. He goes to churches around town, synagogues, everywhere he can, recruiting hundreds of volunteers. But there's no political progress, and conditions at the hospital actually get worse.

16:28Key nurses get burned out and quit. Things go to hell. In a harrowing diary entry, DeHartog writes about full bedpans left on tables next to trays of food, about a patient crying out for help and hearing back, shut up. Never before had I realized to this extent the depth of our damnation. And at that deepest moment of desperation,

16:58when we knew nothing could be done, nothing would change, for the simple reason that those who had the fate of the hospital in their hands were not there. Mayor Welsh didn't work there. Commissioner Bill Elliott, judge, the county judge, did not work there. But then there's a turn. Somebody shows up. That's right after this. This episode of An Arm and a Leg is produced in partnership with KFF Health News. That's a nonprofit newsroom

17:29covering health issues in America. The folks at KFF Health News are amazing journalists. Their work wins all kinds of awards every year. The midterm elections are drawing near, meaning fact-based reporting is more important than ever. I'm Libby Denkman, host of SoundSide, where we bring you news and conversation rooted in the Pacific Northwest. We delve beyond the headlines to bring you different perspectives on stories that impact your life right here in Washington State.

17:59And we're easy to find Monday through Thursday at noon and 8 p.m. on KUOW 94.9 FM. Or you can listen anytime on the KUOW app or wherever you get your podcasts.

18:11So Jan de Hartog's slugging away. He gives a talk at a Baptist church. He reads that diary entry, the one with the bedpans and the absence of Judge Elliott

Judge Elliott volunteers

18:19and other leaders. And at first he thinks, eh, it didn't go over so big here. Nobody even raises their hand to volunteer. And then it happens. When we were about to leave, a man turned up with a baby on his hip who said, do you train people at night? And the guy seems to be like looking around, trying to make sure nobody's listening. And de Hartog tells the guy, yeah, we could do that. He said, I mean, at dead of night without anybody seeing.

18:49And de Hartog's like, yeah, sure, I guess. Why though? He said, well, I'm Judge Elliott. Judge Elliott, the county judge, probably the most powerful politician in town. That's who wants to volunteer in secret without anybody seeing. He says to de Hartog, I cannot do it as a judge, but I must do it as a man.

19:15And that was the moment that the whole damn thing changed. Because Judge Bill Elliott followed through. He trains himself in a clandestine manner to be unorderly at night. And he verifies everything that de Hartog has said. De Hartog actually oversees the judge's final practical exam, where Bill Elliott tends to an African-American man named Willie Small. So the judge, with his thermometer, went and put his hand on Willie's shoulder and said, Mr. Small, sir,

19:46I'd like to take your temperature. To hear that, to hear a Southern judge say, Mr. Small, sir. It was a symbolic moment. The judge had to touch, had to defer to, a Black man. So not only had the judge now seen everything, he took responsibility for what he'd seen. There's a proposal for a county-wide property tax to fund what's called a hospital district. Now there's a referendum, and Elliott backs it

20:16all the way. And we all waited with bated breath for the outcome, and it was no. Yeah, the referendum fails. And as de Hartog tells it, once it does, a real backlash starts to build. It gets personal. Those who had resented our presence from the very beginning became vocal. Margie and I were called communists. De Hartog just would not flinch. He and his wife's lives were threatened.

20:47Also, someone threw a bag of excrement at their door. Eventually, de Hartog says the Red Cross, which was training and supervising volunteers at the hospital, came to him and Marjorie and said, it might be better for us if you left town for a while. So they did, for more than 20 years. They went on all kinds of adventures. Meanwhile, Bill Elliott kept pushing, kept pulling in allies, including eventually the medical society. He rallies them to get behind it. He gets the question on the ballot again later that same year and it passes

21:17in November 1965. It's a big moment. What's also interesting is that it's forgotten. Something that I've gleaned from all this is that people will forget and you have to remind them. And while we're reminding ourselves, it's worth noting, in 1965, the whole country is making some big commitments to health care for a lot of people. President Lyndon Johnson signs Medicare and Medicaid into law in July of that year. It's probably also worth noting that Medicare and Medicaid helped make Ben Taub possible. About a third of the hospital's patients are on one or the other.

21:48It's a minority of patients, but it's many millions of dollars of funding. The 1960s were a notoriously divisive time. So is this. And Ricardo Nahuila does not ignore today's political polarization or how that polarization makes it hard to imagine a national conversation about creating a different health care system or the role that doctors have historically played in resisting

Doctors and family politics

22:09that conversation. It's part of his story, his family story. And in a book about a place where a lot of sad things do happen, this may be the toughest one. Well, I was born into a family of doctors and my dad, in many ways, was a hero to me. And I saw how much pride he took in his work of being a doctor. But over time, as insurance companies got tougher to deal with, the business side of running a medical practice looked a lot less appealing. He had to hire more and more staff. He hired his mother, my grandmother,

22:41who is the type of person not to back down from Chicago, you know. And so her job was to be on the insurance companies to make sure that they wouldn't screw him out of money. And his dad turned away patients who didn't have insurance and growled and grumbled about insurance companies and about patients who didn't have money to pay. When Ricardo finished college and got into medical school, he put off starting for two years. What he was seeing as his dad's life in the business of healthcare was not appealing. The grind wears on him,

23:13you know, the fighting with the insurance companies. I mean, in the book, your dad is a bit of a stand-in for doctoring his profession and the way in which doctors get alienated from medicine. Yeah, he is a stand-in a bit for doctors and it's going to be, I think the doctors have a lot to say about how healthcare goes in America. And unfortunately, the history shows that they haven't been a great piece of that, at least as far as universal healthcare is concerned. This becomes part of Ricardo's story with his dad. Dad invites him

23:43to form a family practice. Ricardo chooses Ben Taub. And over the years, it becomes clear. They're on opposite sides of a political divide. There are painful conversations and then they go months without speaking. That's how deep politics run, you know? It's really difficult. When you overlay like politics onto a family dynamic, it just felt like he was like totally on board with this idea that healthcare is something that is earned and if you can't afford it,

24:13you don't deserve it is what I heard from what he was saying. Is your dad an ideal reader of the book? Is your dad kind of the person you want to make that case to? That's really interesting. I would say this, that I did not write this to preach to the choir for sure. But he's not sure his dad would actually pick up a book like this. It's just because I know my dad. My dad's the type of person who reads John Grisham on a beach, you know? So I'm not 100% sure if he would pick up this book, you know? Unless, say, his son wrote it. Ricardo does expect his dad to read The People's Hospital. And even if his dad doesn't agree with everything

24:44his son has written, Ricardo thinks he'll be proud. I can tell you now as a father, it's not clear that your kids are going to come out okay, you know what I mean? And so he has reason to be proud just because I'm a living and breathing person right now, you know? And I'm working as a doctor, so I feel good for him. I really do. I mean, it's not easy being a parent. And I think that he's probably very happy that I wrote about medicine because he loves medicine. The last chapter of The People's Hospital is called Faith. And in it, Ricardo Nuala describes a daily ritual he says keeps him grounded.

25:15It starts with passing a plaque on his way in. So, of course, I have him show it to me. I park, like, right over there. I come in here and I just look at this every time. And describe what we're seeing here. Well, we're seeing a plaque that talks about when this hospital was founded and the people who constructed the building and there's also the, I forgot, this is bad of me, but I forgot the name. The snake around the snake? Yeah, I forget the name of it. I'm in big trouble now because I'm on the, Caduceus. Caduceus? It's the Caduceus, yeah. So it's a reminder,

25:46you know, that we have this structure in place. And that people decided to put this building here? Yeah, exactly. It's a community effort. Ricardo Nahuila writes he sees that community as he walks from that plaque to his desk, all the co-workers in every kind of job doing their best. And this is the faith that he says gets affirmed. I'm reading from the book here. He writes, if someone is suffering and there's capacity within the community to help in a way that doesn't harm anyone else, then we not only owe it to that person, we owe it to ourselves to help.

26:19Whatever your politics are, I think that's pretty great.

26:23Ricardo Nahuila practices at Ben Taub Hospital. He's associate professor of medicine, medical ethics, and health policy at Baylor College of Medicine. His book is called The People's Hospital.

Recent funding and updates

26:40Quick update. A few months after we published this episode in 2023, Ben Taub Hospital's parent organization, Harris Health, held a new referendum. They asked voters to fund a tax increase to fund $2.5 billion in construction and repairs, including an expansion for Ben Taub Hospital. And this time, the vote was not even close. More than 70% of voters said yes. Now, $2.5 billion in construction does not happen overnight,

27:11but it's happening. A second county hospital, named for Lyndon Johnson, broke ground on an upgraded level one trauma center in 2024. And this spring, the Ben Taub expansion cleared a hurdle, getting the county boards okay to take over nine acres of parkland. So in a few years, The People's Hospital will be able to serve more people. We'll be back with a new episode in a few weeks. Till then, take care of yourself. This episode of An Arm and a Leg

27:42was produced by me, Dan Weissman, with help from Emily P. Zecreta and edited by Afie Yellowduke. And Ellen Weiss edited this revision. The recording of Jan de Hartog's lecture is courtesy of the Baylor College of Medicine Archives. The audio of Bill Elliott is from the KHOU-TV newscast, thanks to the Texas Archive of the Moving Image. Big thanks to the archivists who helped us find some of the tape for this episode. That includes Emily Vinson at the University of Houston Library, Matt Richardson and Sandra Yates at the Texas Medical Center Archives, and David Olmos at the Baylor College

28:13of Medicine Archives. Adam Raimunda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Claire Davenport is our engagement producer. Amanda Boyd is our operations manager. Bea Bosco is our consulting director of operations. An Arm and a Leg is produced in partnership with KFF Health News. That's a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism. Zach Dyer is senior audio producer

28:44at KFF Health News. He's an editorial liaison to this show. And Arm and a Leg is distributed by KUOW, Seattle's NPR news station. Thanks to the Institute for Nonprofit News, they serve as our fiscal sponsor which allows us to accept tax-exempt donations. You can learn more about INN at INN.org. And finally, thank you to everybody who supports this show financially. You can join in anytime at armandthelegshow.com slash support. Thanks for listening. I'm Chris Morgan,

29:24host of The Wild. Over the last 35 years, I've worked in the wildest places on Earth, tracking tigers in Siberia, filming orangutans in Borneo, following humpback whales, migrating jaguars, iridescent hummingbirds, and learning from the people devoted to protecting them. These stories changed how I see the world. I think they'll do the same for you. The Wild with Chris Morgan, available wherever you get your podcasts.