"Code Black"
Public Hospitals and Inequality in American Health Care
by Kang Kankyul
Research Proposal | UWS 4a Medical Ethics | Lisa Rourke | Spring 2020
This proposal as PDF | MLA format
The debate surrounding American healthcare is complex, but perhaps the most important issue to analyze is the methods of delivery for care and the quality of the that care. With the upcoming 2020 Presidential Elections and the current COVID-19 pandemic, questions and debate about healthcare accessibility and infrastructure abound. This essay will conduct a close reading of the 2013 documentary Code Black, which portrays the daily struggle faced by the doctors of L.A. County + U.S.C Hospital’s emergency room as they deal with their role as a safety net public hospital. Close readings will be conducted on the public health care model of care delivery, analyzing the role of public hospitals as safety net institutions, providing care for America’s uninsured population. The potential thesis of this paper is challenging the societal norm of the United States’ disjointed and fragmented healthcare network that puts other interests above the patient, arguing instead for a more unified, systematic, and patient-centered approach to medical treatment that could revolve around public hospitals. Adjustments to this thesis include trying to incorporate the anthropological analysis of why the United States is so resistant to universal healthcare and the direct human consequences of the broken system. Another societal norm that may serve as a better thesis is looking at why America believes that only those who can pay for healthcare deserve it.
Primary Literature Review
My research was initially broad with the majority of articles dealing with method of care delivery case studies. The two articles I will focus on in more detail for this review are about the role of public hospitals in U.S. healthcare and the struggle for uninsured patients to be seen at these supposedly “free” public institutions. These two sources provide a great deal of evidence to directly support my close reading of the documentary Code Black.
The first article is “The Role of U.S. Public Hospitals in Urban Health” by Ron J. Anderson, published in the Academic Medicine Journal. It defines public hospitals as “those owned by local governments or special authorities such as cities, counties, or special districts” (Anderson et al. 1162). Anderson adds to this definition by quoting from a report published by the Institute of Medicine, which explains that “by legal mandate or explicitly adopted mission, [public hospitals] maintain an ‘open door,’ offering patients access to services regardless of their ability to pay.” Another point this article addresses is the key difference between public hospitals and not-for-profit institutions. While both care for indigent and vulnerable populations, “the financial viability” of non-profit institutions their “forces them to focus on margin[s]” (Anderson et al. 1162). For me, this distinction helped to clear up a contradiction and question: if hospitals are non-profit, why are they not taking on more of a role in serving uninsured and indigent populations? The answer lies in the money. Nonprofit in the hospital world does not mean the hospital can operate as a free institution.
Interestingly, however, my second source, “Deadly Inequality in the Health Care ‘SafetyNet’: Uninsured Ethnic Minorities’ Struggle to Live with Life-Threatening Illnesses,” written by Gay Becker, an anthropologist, shows that even the supposedly free public hospitals are looking for ways to make patients pay for their care, including asking if the patient is currently employed and how much they are making (266). According to a patient quoted by Becker, “No, it [the public hospital] is not free. It is free if you don’t work, it is free if you are homeless, it is not free when you have a job, it is not free” (265). This statement by a patient named Mr. Swanson seemingly contradicts the information provided in Anderson about public health hospitals. Clearly even at these locations, care is not free.
Perhaps what I found most useful was that Becker’s article presents their arguments through a series of interviews with low-income, indigent patients. These interviews were part of a broader study being conducted, and close reading analysis was used to study each interview narrative (Becker 262). The interviews provide scathing evidence against public hospitals in particular, and America’s broken healthcare system as a whole. In addition to Mr. Swanson’s experiences, other patients recall public hospital emergency rooms refusing to give prescriptions longer than 30 to 60 days with the express purpose of steering these patients towards a more permanent primary care provider (Becker 265). While this may seem like a good idea, the patients pointed out repeatedly to the doctors that they could not afford to see the listed providers because they have no insurance, and the emergency room visit was their only way to receive necessary medicine (Becker 265). Becker’s article served many purposes, namely providing evidence about the negatives of public hospitals, but on a deeper level, it helped show that healthcare seems to have forgotten about the patient.
This forgetting about the patient is a central theme of the documentary Code Black. The featured doctors express their frustration that they are unable to do more to help their patients (McGarry). A significant part of the documentary is spent chronicling an experiment conducted by these physicians to create a more “patient centered” approach to their ER, mimicking the legendary “C-Booth,” the nickname given to a section of the old L.A. County hospital’s emergency room where all the patients were treated in a central island. While the documentary explicitly uses the term “patient centered,” many if not all my sources implicitly seem to be addressing this topic. One of the studies I read, “Does Providing Care for Uninsured Patients Decrease Emergency Room Visits and Hospitalizations?” by Ted MacKinney points out that giving patients early access to a strong network of care, including primary care and specialist care, seems to reduce emergency room usage. This touches also on the theme of “non-emergent use of the emergency room” seen through my lens text, and in Becker’s article. Within public hospitals, the emergency room is at the front line of the health care crisis. This theme of patient-centered care is something that I want to try and incorporate, maybe directly, maybe indirectly as part of my thesis.
Research Methods
The research for this topic will be conducted primarily using Brandeis Library’s online search tool OneSearch. Before conducting research, it was helpful to create a list of keywords to use. Keywords can be anything that might relate to my topic. Because my primary source was a documentary, I tried to take note of words or phrases that were repeated, especially in the captions. Some words and phrases include: “public health,” “county hospital,” “uninsured,” “safety-net hospital,” and “access to care.” Using these phrases, I had OneSearch look for scholarly articles that either mentioned or discussed some of these terms. In addition to keyword-based searches, I also used a technique I call “back searching,” which uses the reference page, often of a Wikipedia article, to find more sources. I was fairly surprised that many Wikipedia articles use scholarly journal articles as sources. One page I found particularly helpful was Wikipedia’s article on Public Hospitals. I found at least four sources from this page alone. After locating the sources, I would enter its DOI number into OneSearch which would tell me if my Brandeis credentials gave me access to the material. Amazingly, all my sources could be accessed through OneSearch.
I noticed immediately that my articles could grouped in a couple of different ways: by discipline and by type. Discipline-wise I found that many of my sources were written by public policy experts who specialized in healthcare policy. Type-wise I noted that the majority of my articles were case studies, both observational and experimental in nature. In statistical terms, experiments involve some sort of treatment being applied to a group usually with data being collected, while observational studies collect and analyze sets of data. A couple of articles studied the different patient outcomes for patients being treated for a specific disease such as Hepatitis C at a public versus private hospital. Other articles analyzed the data of a situation, for example looking at the utilization of public healthcare by specific socioeconomic groups. In terms of entities, most of my articles were published in journals. However, I was also able to find a couple of government-published reports and guides as well, namely through the United States Department of Health and Human Services (HHS).
My sources were dense with information, but broadly, I was able to understand the role and definitions of public hospitals, specifically learning more about the idea of safety-net institutions and from a policy standpoint what that means. My sources helped me to see and develop questions about specific societal norms. Some social norm questions I would like to keep in mind as I outline the paper are: (1) Who should have access to healthcare? Only those who pay? (2) What kind of care should people have access to? Good care? Mediocre care? (3) What is it that society expects doctors to do? What is the reality of what doctors do? Going forward, I want to narrow these questions and find the best evidence that helps me to craft an argument answering or addressing these questions.
Significance/Motive
I wanted to address this topic partially to inform people better about the real issues facing America’s healthcare system. Politicians on both sides of the political spectrum acknowledge our system is broken, but I feel people are quick to jump to radical solutions without first considering the full issue. I was also drawn to the topic of public hospitals because as I mull whether I want to pursue a healthcare career, I wanted to be informed where my potential skills as a healthcare provider are much needed. It is clear that the populations who frequent public hospitals need care, and there are simply not enough people willing to work at these institutions. On a more personal level, I also wanted to write about this topic because my family has not been able to get healthcare since returning from Korea. Only after I enrolled in university, was I finally given healthcare. We are grateful that as a backup, we can always return to Korea for more long-term care, but it concerns us what happens if there is an accident or a sudden need for emergency care.
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Annotated Bibliography
Anderson, Ron J., et al. “The Role of U.S. Public Hospitals in Urban Health.” Academic Medicine, vol. 79, no. 12, Dec. 2004, pp. 1162–1168.
This source is an article, originally published in a journal. It provides background information regarding public hospitals, including definitions, historical background/timeline, and the state of urban public hospitals today. The author argues that public hospitals exist to serve a community-oriented role and their future survival depends on that role being expanded and strengthened. I intend to use this as a grounding source, providing me with the information needed to understand the topic and provide definitions to the reader. Additionally, its arguments also help provide ideas for my thesis.
Becker, Gay. “Deadly Inequality in the Health Care ‘Safety Net’: Uninsured Ethnic Minorities' Struggle to Live with Life-Threatening Illnesses.” Medical Anthropology Quarterly, vol. 18, no. 2, 2004, pp. 258–275.
This is an anthropological article that reports on the results of an anthropological study conducted through interviews with indigent, low income patients. As implied by the title, the authors work to show the struggle to receive care even at free public hospitals by those these institutions are mandated to serve. It details the hurdles, both financial and societal faced by the patients using public hospitals. This resource was invaluable because it is written from more of a humanities perspective, providing direct human interaction and statements to analyze. This article was key in trying to understand and express some of the societal norms being reflected. It can also serve as a potential counterargument and/or criticism that my essay should work to address.
Ko, Michelle, et al. “Residential Segregation and the Survival of U.S. Urban Public Hospitals.” Medical Care Research and Review, vol. 71, no. 3, June 2014, pp. 243–60. DOI.org (Crossref), doi:10.1177/1077558713515079.
This source is case study article, originally published in a journal. It provides a specific hypothesis and analysis of data regarding the closure public health hospitals and the relation to residential and racial segregation. The author presents the various associations discovered in the course of their statistical analysis, the most interesting being that high levels of segregation does not significantly lead to hospital closures. I intend to use this as a supporting source, providing me with the information I may use in supporting my close reading. I want to be careful not to use more than needed from this paper, however. My goal is not to summarize and republish someone’s research results in the context of their discussion. The information must fit my discussion.
MacKinney, Ted, et al. “Does Providing Care for Uninsured Patients Decrease Emergency Room Visits and Hospitalizations?” Journal of Primary Care & Community Health, vol. 4, no. 2, Sage Publications, Thousand Oaks CA, 2013, pp. 135–42. ProQuest, doi: dx.doi.org/10.1177/2150131913478981.
This source is another case study article, originally published by the Department of Health and Human Services (HHS). The authors attempted to conduct a statistical experiment, the applied treatment being giving certain uninsured patients immediate access to primary and certain critical specialized cares and giving others delayed access. The goal was to see if doing so reduces emergency room visits in the immediate care group. The results, however, were somewhat inconclusive according to the author’s analysis for statistical reasons, mainly due to the presence of bias. The authors found that both the immediate and delayed groups had less ER visits. The authors hoped to see that immediate and early treatments would have a more visible effect. I chose this article because my primary lens is set in an emergency room and focuses a lot on the “non emergent use of emergency rooms.” I am interested in seeing and potentially arguing for more alternative methods of care to keep patients out of the ER who don’t need to be there.
Walker, Michelle. “Cost Comparison of Treating Uninsured Patients at a Hospital-Based Free Clinic, Emergency Room, and Inpatient Hospitalizations: A Retrospective Chart Review.” Clinical Scholars Review, vol. 6, no. 1, 2013, pp. 47–52. DOI.org (Crossref), doi:10.1891/1939-2095.6.1.47.
This source is a cost analysis study that looks at the cost of treating patients at free clinics. It argues that providing primary and preventative care to the uninsured is perhaps the best long-term and cost-effective solution to the healthcare. The authors provide numerical data to back up their claims showing that the average cost of free clinics sits around $75. I wanted to use this article because it provides some information regarding perhaps the most central hurdle to healthcare access: cost. Specifically, it can help provide facts and data to answer questions like who should pay for people’s health care?