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PBS NewsHour

Reassessing the value of care for chronic health conditions


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JUDY WOODRUFF: Finally tonight, a conversation about changing the way we think about health care.

In an article in the latest issue of The New Yorker, Dr. Atul Gawande, a surgeon and author, makes the case for the value of what he calls incremental medicine to deal with chronic conditions. It’s the kind of medicine less heralded than that using heroic measures.

William Brangham spoke with Dr. Gawande recently and asked him how health care is changing.

DR. ATUL GAWANDE, The New Yorker: When you think about the future of health care and where we’re going at this moment of debate, there’s a transformation going on that involves a recognition that our focus in medicine has been on heroic interventions, like the kind that I do now as a surgeon.

But the biggest gains are coming right now from incremental medicine, from a commitment to the kind of steady, overtime management of complex problems like chronic illnesses that can add years to people’s lives. But that’s work done by some of the people with the least resources in our health care system.

WILLIAM BRANGHAM: So, who practices incremental medicine in our health care system today?

DR. ATUL GAWANDE: Well, good examples, just look at the list of who the lowest-paid people are.

Pediatricians are at the bottom. You would also look at internists. You would look at psychiatrists. You would look at family physicians, HIV specialists. People who take care of chronic illnesses by seeing people carefully over time, those are the people who get the least money.

The people who have the most are people like orthopedic surgeons, interventional cardiologists. And my point isn’t that — you know, that we’re — that there is something wrong with heroism.

My own son has a congenital heart condition, where his life was saved by a cardiac surgeon stepping in at 11 days of life to save his life. But he is now 21 years old because of constant monitoring and working with him with a primary care physician and people who controlled his blood pressure, recognized problems before they arose, dealt with learning issues that were related to his condition.

And that’s the only reason now that he’s getting to live a long and healthy life. That’s what we’re not rewarding. They don’t have the kind of resources and commitment that we are giving to people like me. I have millions of dollars of equipment available to me when I go to work every day in an operating room.

The clinicians who keep my son going are lucky if they can have a nurse.

WILLIAM BRANGHAM: So, if that care is so valuable, why are the incentives seemingly going in the opposite direction?

DR. ATUL GAWANDE: It’s mainly because our health system was built at a time when we couldn’t really do this kind of work.

Go back to the ’30s, ’40s, ’50s, and it was the discovery of heroic interventions, the ability to cure people with penicillin or do an operation to stop disease that was what saved the day. Primary care physicians couldn’t do all that much that really demonstrated a difference.

Now we have had the data to track people for a long time, the computational power that recognized, you know what, high blood pressure, which we didn’t even know was a huge problem, we discovered that it afflicts a third of all Americans, and it’s our biggest killer, that years down in the future, that that is our cause of everything from not only heart disease, but dementia and of kidney disease.

So, you know, the people who control and work with you to control your blood pressure, they’re not rewarded for doing that or to be innovative about doing that. So, the result is half of Americans have uncontrolled high blood pressure, despite seeing clinicians.

WILLIAM BRANGHAM: The Affordable Care Act tried to move the needle in this direction, to put more incentives towards the exact kind of care that you’re talking about. How successful has that been, that effort been?

DR. ATUL GAWANDE: Here’s what I would describe it as.

We now have 30 percent, for example, of Medicare patients who are seeing doctors who are rewarded for doing this kind of work, which is a dramatic change from six or seven years ago. So, the Affordable Care Act has pushed this direction down the road.

It has also offered protections that allow for preexisting conditions, as people know, that if you have preexisting conditions like my son does, that you’re provided coverage and you can maintain steady coverage. And that’s an important part of being able to stay in care and do better over the long run.

WILLIAM BRANGHAM: So, do you think — if the Republicans and president-elect Trump go forward and repeal this, do you think that some of these incentives will stay in it? Or what do you fear coming down the road?

DR. ATUL GAWANDE: My biggest fear — so, first of all, where we are right now, 27 percent of Americans under 65 have an existing health condition that, without the protections of the ACA, would mean they would — could be automatically excluded from insurance coverage.

Before the ACA, they wouldn’t have been able to get insurance coverage on the individual market, you know, if you’re a freelancer or if you had a small business or the like.

WILLIAM BRANGHAM: Because of preexisting conditions?

DR. ATUL GAWANDE: Now that — because of preexisting conditions. So, the first thing is that the ACA protections have to be preserved, or those people get pitched out.

But the big thing that’s happened is, in the time since the ACA has been going on, our medical science has been advancing. We have now genomic data. We have the power of big data about what your living patterns are, what’s happening in your body. Even your smartphone can collect data about your walking or your pulse or other things that could be incredibly meaningful in being able to predict whether you have disease coming in the future and help avert those problems.

That is the transformation that’s coming. But one of the consequences of if the ACA is repealed, is that all of us now are at risk of being a preexisting — of having a preexisting condition waiting to happen. Life, increasingly, is a preexisting condition waiting to happen, now that we have more and more of this data available.

WILLIAM BRANGHAM: All right, Dr. Atul Gawande of The New Yorker magazine, thank you so much.

DR. ATUL GAWANDE: Thank you.

The post Reassessing the value of care for chronic health conditions appeared first on PBS NewsHour.

Planning to cheer or jeer at inauguration? Here’s how to care for your voice

Supporters of Republican presidential nominee Donald Trump cheer during the election night event at the New York Hilton
         Midtown on November 8, 2016 in New York City. Photo by Chip Somodevilla/Getty Images

Supporters of Republican presidential nominee Donald Trump cheer during the election night event at the New York Hilton Midtown on November 8, 2016 in New York City. Photo by Chip Somodevilla/Getty Images

This Friday, an estimated 800,000 people will descend on Washington, D.C., for President-elect Donald Trump’s inauguration ceremony. A day later, protesters plan to join the fray at the Women’s March. One bridge will unite the supporters and naysayers alike: full-throated yelling.

When the dust settles, many may complain of hoarse voices, but why? Your vocal cords are mostly muscle. But unlike like your thighs or biceps after an overzealous gym session, your vocal cords don’t hurt when you strain them.

The explanation exposes how little is generally known about our resilient noisemakers and how those body parts age.

Your throat’s black box

“The larynx is a fascinating organ, and a black box to most — even most doctors,” University of Southern California laryngologist Michael Johns said. “The voice is obviously our primary mode of communication as people, and it’s one of those things that you kind of take for granted.”

There’s this myth among singers that if you drink hot lemon tea, that’s going to help because the vocal folds gets bathed in the tea. That’s completely false.

Situated in the upper throat, the larynx, or voice box, is a passageway that guides air between the mouth and lungs. But the larynx also houses a slitted piece of flabby muscle, known as the vocal cords or vocal folds, which is responsible for your voice. The two sides of your vocal cords bash rapidly together — 100 and 200 times per second in men and women, respectively — to create sounds required for human speech and singing.

“You figure over the course of a day of voice use, that’s millions and millions of collisions,” Johns said. The vocal cords are primarily muscle tissue, which power this repetitive exercise. This muscle is covered with sturdy, connective tissue and then a outer “skin” layer that makes mucus.

Vocal cords. Illustration by p6m5/via Adobe

Vocal cords illustration by p6m5/via Adobe

This snot is crucial for your voice. It lubricates the vocal folds and keeps them from stiffening or damage due to those rapid impacts. This moistness, in turn, influences the pace of the vocal cords’ vibrations — or mucosal wave.

“The vocal folds have a very specific viscosity, and you need that viscosity to create the mucosal wave,” said Susan Thibeault, an otolaryngologist and surgeon at the University of Wisconsin.

Mucus, or rather the lack of it, explains why talking becomes difficult in dry or cold weather.

“Warmer air holds more water than colder air. Same thing goes for dry climates versus humid climates,” Johns said. “When there’s less hydration, there’s less lubrication, and when there’s less lubrication, just like oil in your car engine, there’s going to be more wear and tear on the parts.”

The vocal cords during phonation -- the rapid, periodic opening and closing that creates different sounds and pitches.
         Muscle (red), connective tissue (yellow) and mucus-making "skin" layer (brown) are indicated. Image by Reinhard/via

The vocal cords during phonation — the rapid, periodic opening and closing that creates different sounds and pitches. Muscle (red), connective tissue (yellow) and mucus-making “skin” layer (brown) are indicated. Image by Reinhard/via wikimedia

Intense voice usage, such as singing for hours and screaming at a concert, can also dry out and damage the mucous membrane. This skin layer cracks, or pieces of it slough off faster than they can be replaced. You might expect for these events to hurt, but they don’t.

“One thing that’s missing in the voice is a natural feedback for warning signs,” Johns said. “So when you get hoarse or maybe [when] you’ve had laryngitis, it doesn’t hurt.”

That’s because, unlike other muscles, your vocal folds don’t contain pain nerves. From an evolutionary perspective, this dearth makes sense, Johns said. The mammalian larynx and vocal folds originally evolved to protect the airway from choking (or aspirating) on things like water or food. It’s only later that the human brain evolved the coordination with our tongue, palate and lips to create speech. If there were a lot of pain receptors in the larynx, then you’d be more prone to think something is wrong and aspirate.

Lasers are better than acid

Thibeault said if a person continues to misuse or overuse their voice, then the stress can also aggravate the inner connective tissue, called the lamina propria. The lamina propria is where people develop little masses called cysts, polyps or nodules. Cysts and polyps resemble swollen bumps on the vocal cords, while nodules are like calluses. For most folks, these lesions are benign, but for singers, the injuries can be career threatening.

Such was the case for British singer and songwriter Adele. In 2011, a polyp — a kind of swollen blister — burst inside the British singer’s vocal cords and caused a hemorrhage. She suspended her tour and sought out Steven Zeitels, a laryngeal surgeon at Massachusetts General Hospital in Boston, who is known for treating the vocal injuries of superstars. Julie Andrews, Sam Smith, Steven Tyler and Keith Urban have passed through Zeitels’ clinic because of a breakthrough he made around the turn of the century.

Adele performs on stage at the The 28th Annual MTV Video Music Awards at Nokia Theatre L.A. LIVE on August 28, 2011 in
         Los Angeles, California. Photo by Kevin Mazur/via Getty Images

Adele performs at the the 28th Annual MTV Video Music Awards in Los Angeles. Photo by Kevin Mazur/via Getty Images

“Through much of the 20th century, people were brought to the operating room for little lesions, masses and polyps, and things were removed with little hand instruments,” Zeitels said. “What’s happened in the last four decades, and even more so in the last decade, is highly sophisticated laser technology.”

He said a century ago doctors had their patients swallow nitric acid to burn away cysts, polyps or nodules. Needless to say, that wasn’t great because it often burned the vocal cord tissue too.

Normal female vocal cords recorded with a stroboscope, which slows down the apparent motion. Female vocal cords open
         and close (phonate) 200 times per second, on average, while male cords move slower 100 times per second. Slower vibration
         equals lower pitch and deeper voices. Professional singers' vocal cords move faster than normal. Zeitels said Steven Tyler's
         vocal cords, for instance, vibrate at 170 times per second. Image by James Thomas/Creative Commons

Normal female vocal cords recorded with a stroboscope, which slows down the apparent motion. Female vocal cords open and close (phonate) 200 times per second, on average, while male cords move slower 100 times per second. Slower vibration equals lower pitch and deeper voices. Professional singers’ vocal cords move faster than normal. Zeitels said Steven Tyler’s vocal cords, for instance, vibrate at 170 times per second. Image by James Thomas/YouTube/Creative Commons

Surgery replaced this acid wash, but a windpipe is a small workspace. If a doctor struggled to patch an incision, then it may bleed and scar. Large scars reduce the vocal cord’s flexibility and change a person’s pitch, which would be detrimental for singers.

So Zeitels and other laryngeal surgeons spent decades finding a new way. His team now uses microsurgery to slice away the little masses, but the real kicker comes with their lasers. The heat from those light beams seal the wound before its busted blood vessels can leak everywhere and cause a scar. Zeitels’ laser technique prevents those scars from forming.

“It was a perfect technique to solve the bleeding problems that both Sam Smith and Adele were having,” Zeitels said.

Call your grandma. It’s time you had a talk.

Vocal cord injuries are not an infliction of the young or old, Zeitels said, but rather they happen among those who are fundamentally committed to using their voice. This habit is prevalent in modern society. Most jobs at the beginning of the 20th century involved manual labor and little voice usage, he said. But these days, the trend has flipped, and most gigs involve regular talking. Voice recognition technology — think Amazon’s Alexa — is rapidly improving, which may further shift the balance toward vocal communication.

So what can people do to protect their voices? Well, you can skip the hot tea.

“There’s this myth among singers that if you drink hot lemon tea, that’s going to help because the vocal folds gets bathed in the tea,” Thibeault said “That’s completely false, because the tea doesn’t even come close to touching your vocal folds.”

The larnyx is protected from liquids by the epiglottis, a flap of cartilage the end of the tongue that covers the voicebox every time you swallow. “You don’t want things to touch your vocal folds, because that causes you to cough — that’s the sense of food going down the wrong pipe,” Thibeault said.

The warmth likely creates a placebo effect, whereby the drinker assumes something is happening, she said, even though the temperature changes in the throat are minimal. At best, the tea can hydrated a chapped mouth or boost your body’s water levels overall. The latter might aid hydration of your vocal cords, but the change isn’t immediate, Thibeault said.

No, the only remedy for a hoarse voice is taking a break. Because the vocal folds lack pain receptors, the only way to sense their weariness is when your voice feels hoarse. Avoiding strain — excessive screaming — in the first place is key, Johns said. But once the vocal cords are hoarse, then the sole mode of recovery is rest or frequent breaks. This rule applies to the average Jane yelling on a sidewalk and the rock superstar.

Protesters calling for massive economic and political changes to curb the effects of global warming hold a sit in around
         the Wall Street Bull statue on Broadway on September 22, 2014 in New York City. Photo by Andrew Burton/Getty Images

Protesters calling for massive economic and political changes to curb the effects of global warming hold a sit in around the Wall Street Bull statue on Broadway in 2014 in New York City. Photo by Andrew Burton/Getty Images

“If I went out and ran a marathon I’d injure myself, right?,” Johns said. “But if I trained, and I gave myself periods of rest during my training, then I would be able to grow my vocal stamina.”

This stamina helps, but even professional singers can push too far. Adele, for instance, said if she ever tried a 200-date tour again, then her injury would return. Yet with the proper rest and training, singers can maintain their regular voice for decades. Opera singer Luciano Pavarotti performed well into his 70s.

But if you can’t work on your voice for hours everyday, then it’ll likely change as you age. Yes, your voice keeps evolving even after puberty. Male voices get higher pitched, as their vocal folds lose muscle mass and stiffen with old age. Meanwhile, female voices get lower from their 20s through their 70s, thanks to hormones.

The same thing happens when women have their periods. Testosterone levels increase, and a woman’s pitch tends to drop.

“Many women report change in the voice through menopause,” Johns said, which is most likely due to testosterone. Throughout most of a woman’s adult life, her ovaries secrete estrogen and progesterone, which dictate her sexual features and menstrual cycle. But a woman’s ovaries produce small levels of testosterone too.

During menopause, estrogen and progesterone levels drop, but testosterone remains steady. The relative imbalance, Johns said, likely thickens the vocal cord muscles and lowers a woman’s pitch. The same thing happens when women have their periods. Testosterone levels increase, and a woman’s pitch tends to drop.

“Once women reach about 80, the effects of volume and muscle loss in the vocal folds kind of takes over and pitch rises,” Johns said.

Singing and vocal activities can battle age-related voice problems, but regular conversation can help too.

“As we get older, people can be more isolated, and maybe using their voice less because they may not be working as much,” Johns said. “It’s a use it or lose it type situation.”

Or, to put it simply, he said: Call your grandparents.

The post Planning to cheer or jeer at inauguration? Here’s how to care for your voice appeared first on PBS NewsHour.

Poll: Americans of all stripes say fix health care

File photo by Getty Images

File photo by Getty Images

WASHINGTON — Sylvia Douglas twice voted for President Barack Obama and last year cast a ballot for Democrat Hillary Clinton. But when it comes to “Obamacare,” she now sounds like President-elect Donald Trump. This makes her chuckle amid the serious choices she faces every month between groceries, electricity and paying a health insurance bill that has jumped by nearly $400.

“It’s a universal thing, nobody likes it,” Douglas, a licensed practical nurse in Huntsville, Alabama, said of Obama’s signature law. “They need to fix it with whatever works, but not make more of a mess like they have now.”

That Americans agree on much of anything is remarkable after a presidential race that ripped open the nation’s economic, political and cultural divisions. But on the brink of the Trump presidency, a new poll finds ample accord across those divisions on the need to do something about health care in the United States.

More than 4-in-10 Republicans, Democrats and independents say health care is a top issue facing the country, The Associated Press-NORC Center for Public Affairs Research poll showed. That’s more than any other issue named in the survey, conducted Dec. 14-19.

But there seems to be little agreement on what to do about it.

Democrats say they want to fix problems in the current program — among them, rising costs and dwindling competition — but not dismantle it. They warn that the GOP is threatening the coverage gained by 20 million people under the 2010 overhaul.

Republicans want to repeal Obama’s signature law but fear the political damage of stranding millions of Americans who secured coverage. Congress’ nonpartisan budget analyst lent weight to that concern Tuesday, estimating that a bill passed in 2016 to only repeal — not replace — the law would result in 18 million more uninsured people and a spike in premiums.

Trump says he has a plan, but so far he’s given no details. He told The Washington Post last weekend that his approach would provide “insurance for everybody.”

Congressional Republicans say the revamp will offer “universal access” to coverage, not quite the same thing.

The desire to fix Obamacare stretches across party lines, but some are skeptical it can be done.

“It can’t be made to work,” said James Gemind, a 55-year-old restaurant worker from Orlando, Florida. “That’s why both sides have been unanimous in their agreement that it has to be repealed or replaced. Part of it is funding; it just does not exist to insure everybody.”

Health care aside, in the poll there was more modest agreement on other national priorities.

About a third of Republicans and a quarter of Democrats put unemployment among their top issues. About a fifth named the economy in general as a top priority regardless of party, according to the poll. Most Americans said the government should put a substantial amount of effort toward addressing the public’s priorities, but few expect much will be accomplished in the next year, the survey said.

Overall, domestic issues including health care, education, the environment and racism were cited by 86 percent of Americans.

But Democrats were more likely to mention the environment, racism and poverty, while Republicans were more likely to cite immigration, terrorism, government spending and taxes.

Immigration was named by 40 percent of GOP respondents, compared to 15 percent of Democrats. Trump during the campaign connected immigration to national security and vowed to build a wall along the southern U.S. border and make Mexico pay for it — an idea Mexican leaders have not accepted. Trump now says Mexico will pay for it “eventually.”

In a turn-around from a year ago, most Republicans now say the country is on the right course, while Democrats have become more pessimistic.

But it’s health care reform that survives this era of division, in part because it touches on peoples’ day-to-day quality of life, and in the most personal ways.

Douglas’ husband is disabled and she recently was diagnosed with a condition that required abdominal imaging. Blue Cross Blue Shield of Alabama is now the only provider in her state exchange — a fact she blames for the boost in her monthly premium, from around $600 to nearly $1000. Additionally, she learned, her deductible had zoomed to $4,000 a month. That torpedoed work she’d done to build a future.

“I was going to buy a new home, I was getting my credit straight, but now that is down the drain,” Douglas said. “Obamacare helped the less-fortunate, and that’s what I liked about it. I had no idea it would tear out the middle class like this.”


The AP-NORC poll of 1,017 adults was conducted Dec. 14-19, 2016, using a sample drawn from NORC’s probability-based AmeriSpeak panel, which is designed to be representative of the U.S. population. The margin of sampling error for all respondents is plus or minus 3.7 percentage points. Interviews were conducted online and using landlines and cellphones.

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A way to save money when half of all health costs is spent on a fraction of patients

File photo by Jack Wild via Getty Images

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JUDY WOODRUFF: But first: how some lesser-known changes to health care might fare, given president-elect Trump’s vow to repeal the Affordable Care Act.

One of those involve so-called “super utilizers” — high-cost patients who frequently turn to emergency rooms for problems better handled by primary care doctors and social workers.

Special correspondent Sarah Varney reports.

This story was produced in collaboration with our partner Kaiser Health News.

SARAH VARNEY: Protective gown. Rubber gloves. Face mask. Dayna Gurley is getting dressed for work. She’s a social worker charged not with treating infectious diseases, but with figuring out why her clients all but live in Houston’s hospitals.

DAYNA GURLEY, Social Worker: What’s been going on?

SARAH VARNEY: This patient, who asked not to be identified, has chronic massive ulcers, AIDS, hears voices, and, at times, spends three weeks out of the month at multiple hospitals around Houston.

Gurley is part of a promising effort in the U.S. health care system: Honing in on so-called “super-utilizers,” patients with complex problems who frequent emergency rooms and cost public and private insurers dearly.

Super-utilizers make up just 5 percent of the U.S. population, but they account for 50 percent of health care spending. As health care costs continue to rise, providers are trying to find these patients and get to the root of their problems.

An effort to do just that started in New Jersey’s poorest city: Camden. Family physician Dr. Jeffrey Brenner was inspired by how police departments were using crime data to detect hot spots. To find Camden’s health care hot spots, Brenner dug into ambulance records and E.R. data to show how high-cost patients were shuttling between city hospitals.

DR. JEFFREY BRENNER, Camden Coalition of Healthcare Providers: In America, we’re medicalizing social problems, and we’re criminalizing social problems, and we’re wasting huge amounts of public resources.

SARAH VARNEY: To steer super-utilizers away from expensive emergency care, Brenner’s team, including social workers Latonya Oliver and Bill Nice, seek patients out in local neighborhoods.

BILL NICE: There’s been a few patients that I have had like that…

SARAH VARNEY: They work intensively with people like Peter Bowser.

Bowser was once homeless, and went to the E.R. 28 times in one year.

PETER BOWSER: Because I was telling people when I was staying in the shelter, I said, ‘When I get my place,’ I said, ‘I’m going to maintain it.’

SARAH VARNEY: But after they helped get a permanent roof over his head, Bowser’s trips to the E.R. all but stopped.

BILL NICE: And I think you would prefer to spend your time here than the hospital any day of the week…

SARAH VARNEY: This high-touch, data-driven approach has yielded big savings. E.R. visits for the first group of patients dropped by 40 percent, cutting monthly hospital bills from $1.2 million to $500,000.

The Affordable Care Act has boosted efforts like this around the country by funding so-called Accountable Care Organizations — teams of health care professionals who team up to improve care, lower costs and reap the savings.

And it was Brenner’s pioneering work in Camden that inspired others, including the program in Houston — a sprawling city desperate to aid its sickest and most isolated patients.

While the more than 100 hospitals here typically know their own super-utilizers, they had no way of knowing the top users across the entire city. Tackling that problem took unprecedented planning among typically disjointed city and county agencies, hospitals and nonprofits.

DAYNA GURLEY: And you know that guy that you helped me get appointments for the other day? He apparently had warrants out for his arrest.


SARAH VARNEY: Now, many of the hospitals here, including the county hospital, Ben Taub, pool their data and send it to Kallol Mahata, a former oil industry I.T. engineer with the Patient Care Intervention Center, who combines it into one database.

KALLOL MAHATA: And we saw that breakdown by EMS.

SARAH VARNEY: Mahata and Dr. David Buck, the group’s founder, help to identify patients at the top of the list — the outliers of the outliers. Some of the data comes from the Houston Fire Department’s 911 calls. Then, teams are dispatched to parks and neighborhoods to find the patients.

Firefighters and paramedics like Thomas Pierrel often know these residents from those emergency calls. But, this time, their mission is different.

THOMAS PIERREL: We make appointments. We find specialists. We try to maximize the resources that you have.

SARAH VARNEY: The results of these intensive interventions can be stunning. Timmy Williams was dying when Dayna Gurley found him.

WOMAN: Has your blood pressure been that high in the past three or four weeks?

TIMMY WILLIAMS, Houston Resident: Mm-hmm.

WOMAN: It has been?

TIMMY WILLIAMS: Yes, it be high. It be up there.

SARAH VARNEY: He was holed up at home and reeling from untreated HIV that had progressed to AIDS. He couldn’t take care of his young son, and cycled through Houston’s hospitals.

DAYNA GURLEY: When we first met Timmy, he was very hard to engage. We knew that he probably wasn’t taking any of his medication, and he was very skinny.

SARAH VARNEY: Gurley arranged for a home aide to care for Williams seven days a week, got his apartment cleaned and the lights turned back on. Now Williams’ HIV is undetectable and his health, and life, have been steadied.

Although these efforts involve many staff members, in the two years since the Patient Care Intervention Center has been up and running, costs for those in the program have gone down 83 percent and hospital visits by 70 percent.

DAYNA GURLEY: I really want to get to know them and spend time with them…

SARAH VARNEY: But it can be difficult to keep these programs moving. Often, those savings go straight to insurance companies and government payers. And Dr. Buck and Dayna Gurley were once banned from a Houston hospital that was afraid of losing money if their high-cost patients stopped showing up.

DR. DAVID BUCK, Patient Care Intervention Center: Nobody wants to take ownership of any of it. The people just want ownership of what they have authority over. And that’s really the issue.

SARAH VARNEY: Back in Camden, even Dr. Brenner is less optimistic than he once was. His office now overflows with pillows and kitchenware for clients they’re trying to place in housing, and he thinks homelessness and entrenched financial interests in health care are the biggest barriers.

DR. JEFFREY BRENNER: I think this is going to take a lot longer than I ever imagined. I think we’re in a 20-year arc of recalibrating and rethinking what is health and what is health care, what is the purpose of our health care system, what are we trying to accomplish?

SARAH VARNEY: But Brenner still believes these intensive efforts are the best way to help patients like Timmy Williams. He’s now healthy enough to make his way around the city on his own. He says Gurley did more than rescue him from his darkest days.

TIMMY WILLIAMS: I had to put it in my head that no one is going to do it for me. I have to do it for myself. I have got to step out and do it myself.

Read this here.

STUDENT: This whole thing?


SARAH VARNEY: At home now with his son, his illness no longer gets in the way of being the father he wants to be. But efforts like these could be undercut if president-elect Donald Trump and the Republican Congress follow through on their vow to repeal the Affordable Care Act. And it’s unclear what would come next.

For the PBS NewsHour and Kaiser Health News, I’m Sarah Varney in Houston, Texas.

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