By Ariel Lewiton
October 5th, 2017
For months, the fate of the United States’s healthcare system—one-sixth of the largest economy in the world—has seemed to be up for grabs. In May of this year, the Republican-controlled House passed a “repeal-and-replace” bill that died in the eleventh hour in the Republican-controlled Senate. Mitch McConnell announced that it was “time to move on,” and President Trump, known for graciousness neither in victory nor defeat, tweeted, “Let ObamaCare implode, then deal. Watch!” As of this writing, the Graham-Cassidy Act, which would dismantle Obamacare in favor of block grants for individual states, seems to have met an abortive end. Meanwhile, Bernie Sanders has announced a single-payer plan he calls Medicare for All; though it has no hope of passing the Republican-controlled Congress, its sixteen cosponsors include 2020 presidential hopefuls Elizabeth Warren, Kamala Harris, and Kirsten Gillibrand, signaling universal healthcare’s shift toward the center, at least among Democrats.
The only thing everyone seems to agree on is that the American healthcare system is in dire need of an overhaul. The Unites States spends over $3.2 trillion on healthcare annually, or $10,000 per person—more than twice the per-capita healthcare expenditure of other industrialized nations. Yet we lag behind those nations in important health indicators like life expectancy and infant mortality rates. That’s to say: we pay an exorbitant amount for healthcare that doesn’t even keep us healthy.
Dr. Michael Fine, a family physician, former director of the Rhode Island Department of Health, and current chief medical strategist for Central Falls, Rhode Island, believes that we’re missing a crucial point in our debates about healthcare. As he put it to me recently, “The problem with Obamacare, and even with the attempts to destroy it, is that they are all attempts to do a little social engineering by using the health insurance process. Obamacare was health insurance reform; it was not health care reform.
“We’ve done it backwards,” Fine says. “We’ve tried to figure out how we’d pay for it, but we haven’t figured out or articulated what it is.”
Instead of figuring out how to finance our ballooning, unsupportable healthcare industry, we should be questioning why American healthcare costs so much in the first place. In order to solve our healthcare crisis, Fine argues, we need to begin by developing a comprehensive understanding of what a rational, effective, and just healthcare system ought to look like.
Dr. Fine’s vision of health and healthcare is localized, community-based, and integrative: not just avoiding or managing illness, but supporting education, affordable housing, public transportation, and sustainable resources—elements that link to health in surprising ways. The cornerstone of Fine’s own healthcare strategy is the neighborhood health station, a facility that aims to provide almost all the care that patients need, in one place. Last fall, he and his team broke ground on the Central Falls Neighborhood Health Station, the first of its kind in the nation.
In a series of conversations in person and over the phone, I spoke with Dr. Fine about the current crisis of American healthcare, the inspiration behind his work, and what healthcare workers and ordinary citizens can do to create the healthcare system we need.
—Ariel Lewiton for Guernica
Guernica: Let’s get started by talking about what’s wrong with healthcare in the United States.
Dr. Fine: We’re spending an ungodly amount of money—international comparisons suggest that we’re wasting between a trillion and 1.5 trillion dollars a year on healthcare. Our per-person, per-year cost is a little over $10,000 now.
The overall infant mortality rate in the United States is three times higher than the best achievable infant mortality rate internationally. And infant mortality among black Americans is more than twice that of white Americans. Yet we spend around three times more than we need to spend, compared to the countries that have the best outcomes. The countries with the best health outcomes, the lowest infant mortality, and the best life expectancy usually spend about $4,000 or less per person per year. They do it by having a healthcare system. In the United States, we have a healthcare market, not a healthcare system.
Guernica: Where does our spending go?
Dr. Fine: It goes into profit for corporate entities, into salaries for healthcare executives, and income for high-earning specialist physicians. In 2003, the average American family was spending about 17 percent of its annual income on healthcare. In 2017, that’s risen to over 30 percent. The Congressional Budget Office projection is that by 2025, healthcare costs will be 50 percent of a family’s income, and somewhere between 2031 and 2038, it becomes 100 percent. I don’t get how that works.
Guernica: Obviously it can’t work. What does family healthcare spending mean in this context?
Dr. Fine: For most of us, healthcare spending is health insurance spending by either you or your employer. It means co-pays and deductibles. It’s coinsurance [a percentage of treatment costs not covered by insurance companies that individuals must pay on their own], because most people who are employed get 25 percent of the cost of their health insurance taken out of their paycheck, and a lot of treatments aren’t covered even after buying this expensive insurance.
In Rhode Island, we spend a little over $12 billion a year on healthcare. Just little Rhode Island. The average healthcare inflation in the United States, including Rhode Island, has been a little over 6 percent a year for as long as everybody can remember, about three times the cost of general inflation. That means the increase in cost in Rhode Island—and remember, we’re not buying anything new, this is just the cost of healthcare inflation—is $720 million a year. That’s equivalent to the salary of about thirteen thousand teachers. It’s enough to build twenty-four units of affordable housing.
If we’re going to improve infant mortality rates and health in general, we need to spend money on education. We need to spend money on safe and healthy housing so that people have safe and secure places to live. We need to spend money on public transportation, community development, public safety, and the environment. These turn out to be the things that matter most for health. The paradox is that the more we spend on medical service expenditures that we don’t need, the less we spend on those things. In a certain way, healthcare is at war with health.
Guernica: You’ve argued that we are not using the right metrics for measuring health, or that we misunderstand what it means to be healthy in this country. How do you define health?
Dr. Fine: You have to think about what the human project is. Health doesn’t exist as a construct on its own. Health is about relationships. And democracy is a critical piece because it creates peace and stability, which allows relationships to be nurtured and mature.
You have to draw an intellectual distinction between personal and public health. It’s an important distinction because personal health is self-defined: most of us don’t want to be in pain, and we want live until seventy or eighty. None of us really thinks that you’re not healthy if you don’t live until 110. Everyone wants an equal shot of getting to eighty, I think, or at least almost everybody does.
Public health is totally different. Public health is a set of measures like life expectancy and infant mortality, concepts like years of potential life lost and reasons for that loss. From a public health perspective, you put these indicators together to give you a measure of how a population in a place is doing. That allows us to compare the ecology and the social organization of different places. In places where they’ve got it figured out, people live a long time, and their kids grow, and you’d think we’d want to emulate the social organization in those places.
Guernica: What’s an example of a place that’s doing it right?
Dr. Fine: Finland has one of the lowest infant mortality rates and long life expectancies, and the Finns pay about $4,000 a year for healthcare. When you look around the world, many countries that do this well have done what the Finns have done. The Finns build one community health center for every ten to twenty thousand people, and that community health center is responsible for taking care of everybody in that place.
In the 1960s, ’70s, and ’80s, Finland had the highest rate of heart disease mortality in the world. They flipped it around by doing a bunch of guerrilla public healthcare; they had people who would go into barrooms and convince men in their forties and fifties to go out cross-country skiing and bicycle riding. They got farmers to change what they put in sausages. So instead of using beef fat or pork fat, they started using mushrooms that they were growing. That made the whole country healthier. You can do this. The Finns proved it.
Guernica: You drew inspiration from the Finnish model when you began addressing the healthcare crisis in your own city of Central Falls, Rhode Island. Talk about the work you’re doing there.
Dr. Fine: Central Falls is a city of twenty thousand. It’s a small place, only 1.2 square miles. It’s the poorest city in Rhode Island: about 50 percent of people live below 200 percent of the federal poverty threshold. Fifty percent of people don’t have cars and most people are immigrants from Colombia, Cape Verde, Guatemala, Honduras, El Salvador, the Dominican Republic, Liberia, and Nigeria. It’s got an old Polish and Syrian-Christian population. So it’s a really diverse and interesting place.
We’re doing something that I don’t think has ever been done in the United States: we’re actually building a healthcare system. We’re building a single clinical enterprise that is ready to take care of the entire population of the city. It’s classic primary care plus mental and behavioral health, substance use disorder treatment, physical therapy, dentistry, home health, emergency medial services, lab, and X-ray.
Guernica: I’ve heard of community health centers, but you refer to this entity as a neighborhood health station. What is the difference?
Dr. Fine: A community health center is charged with caring for the underserved. The community health center movement in the United States was started in the 1960s by Dr. Jack Geiger. Dr. Geiger was deeply involved in the civil rights movement, so for him this was a way to use healthcare as a social justice intervention, to give people whose lives had been disrupted by racism a shot at equal treatment. There are now 1,375 community health centers in nine thousand locations that care for 25 million Americans—almost 10 percent of the population, focusing on the underserved, those people who live at 200 percent of poverty or less.
With a neighborhood health station, it’s 90 percent of the healthcare services people need, in a single building, using a single medical record, so that 90 percent of the population uses that one clinical entity. We’re bringing primary care to all people, combining primary care and public health for the first time. The neighborhood health station provides services for pregnant women, but also works on improving infant mortality, reducing adolescent pregnancy, extending life expectancy, reducing the number of people who are smoking, reducing the number of deaths from opiate overdoses. The neighborhood health station becomes the agent of public health in every local community. And the vision is, if you can build one of these for every ten thousand people, then you have a real healthcare system.
Guernica: Do you accept health insurance? Do some people pay out of pocket? Is there a sliding scale for people who can’t afford the treatment they need?
Dr. Fine: The money comes from both federal grants (about 10 percent) and from health insurance. Community health centers are paid fairly for this work, which makes it all possible. By law, CHCs care for everyone regardless of ability to pay or immigration status. They all use a sliding scale. Some people pay nothing—they’re charged a minimal amount, but aren’t turned away if they can’t pay it.
Guernica: What is the advantage of bringing all of these services together under one roof?
Dr. Fine: By bringing everyone together in one place and using the single electronic medical record, we can find out lots of things about this population, and begin to improve the health of the population.
Every Friday at 1:15 p.m., twenty-five people get together: People from the state’s largest homelessness organization come. The city housing authority comes. Folks from two different mental health agencies come, as well as someone from the substance abuse recovery agency. The home nursing agency comes. People who do community-based social work and counseling come. We have a couple of clinicians, physicians, nurses, nurse case managers, people who know how to prevent utility cutoffs for people who are sick and can’t pay their bills. People from emergency medical services come. This is all totally voluntary.
Guernica: What do you do once you’ve assembled the twenty-five people?
Dr. Fine: We sit around a table, put our heads together, and think about how we’re going to take care of the people in the city who are most at risk. At each meeting, we discuss twenty-five to forty people. Sometimes we hear about somebody from a doctor, but often we’re hearing about people from the housing authority, or recovery coaches, or the police.
Guernica: Are you able to preserve patient confidentiality? Do your patients sign HIPPA agreements or something similar?
Dr. Fine: Everyone who participates [in these meetings] signs a business associate agreement, which prevents them from sharing any information they may receive. In addition, whenever there’s a non-clinician in the room, we refer to people only by their initials and dates of birth. The data isn’t merged—only the clinical side shares a data system. And HIPPA was never meant to keep clinicians from talking to one another. It was meant to protect people’s privacy in the era of electronic data.
I talk about the neighborhood health station as a single clinical entity that involves multiple disciplines. But that’s different from the multidisciplinary team, which is wider in the community. That includes housing, police, EMS, more extended mental and behavioral health. When people are at greater risk, those people are often already known to most of the caretakers in the community. We can protect people’s privacy while taking advantage of folks who are already involved with them, and their collective knowledge and experience.
In addition, everyone who takes an ambulance ride signs a consent form that includes consent to have their case discussed with the multidisciplinary team. Obviously they can refrain if they don’t want to. And we don’t take that to be that significant, because it’s not full consent when you have an emergency. But on the flip side, when we looked closely at the data about EMS transports, we discovered that most of the time, 70 to 80 percent of the time, people use the ambulance not because they have an emergency but because they don’t have other access to healthcare. By working on this issue, we’ve been able to reduce the number of EMS transports by 15 percent, which saves the city somewhere between $2 to $4 million in a year.
Guernica: What would be an example of a non-emergency reason to call an ambulance?
Dr. Fine: Somebody with back pain, a headache, emotional distress or anxiety. Twelve or thirteen percent are alcohol intoxication. In May, we saw a jump in the number of EMS transports for alcohol intoxication. Now, the literature on alcohol intoxication and alcoholism from Europe suggests that if you shrink the open hours of stores and bars that sell alcohol, you reduce the number of people who get intoxicated. The state legislature decides open hours; local communities can’t. We learned that the people who wanted to sell alcohol had gone to the state legislature and lobbied their way into influence. On May 1, “summer hours” begin, which lets liquor stores stay open later. So we had caused this outbreak of alcohol intoxication with a public policy that was influenced by people with something to sell.
Now we’re in the process of working with the city government and the city’s general assembly delegation to shrink those hours again, at least for Central Falls. But that kind of feedback loop—where you see something happening, you get to its social cause, and you begin to address that social cause politically—is a huge opportunity to think about health and democracy together, and begin to understand the extent to which they’re more intertwined than most of us realize.
Guernica: You’re a family physician, and you’ve called primary care “the only medical service that is affordable and effective.” Can you explain what you mean?
Dr. Fine: Our data shows a clear association between lower-cost and improved health outcomes in places where there are more primary care clinicians per ten thousand people. That data is replicable all across the country and validated by international comparisons. Why should that be? To a certain extent, it’s because of prevention. If you have a primary care clinician, that person will harass you if you’re smoking until you stop, remind you to exercise, tell you to eat right, check your cholesterol, and remind you again to exercise and diet, and then if you can’t do that, may put you on some medicine, but only once nothing else works. If you get pregnant, your primary care doctor gets your prenatal care started when you’re six or seven weeks pregnant, because that’s when we get the best health outcomes. If you’re a sexually active teenager, your primary care person makes sure you’re practicing safe sex and have birth control so you don’t get pregnant in high school, because that has all sorts of its own bad health impacts and costs associated with it. With all of these factors, you’re likely to live longer.
Guernica: So that’s prevention. What’s the other part?
Dr. Fine: The other part is protection. If you’re part of a good primary care practice or community health center and you get sick, you can call up and get someone who knows you to take a look at you right away. They’re going to take care of you, unless they find something [beyond what they can treat onsite], and then they know how to steer you to specialists who are reputable, honest, and aren’t going to subject you to tests or treatments you don’t need.
If you don’t have that person and you get sick, you’re probably going to go to the emergency room. And there, if you have a headache, they’re going to do a CAT scan, an MRI, get you a neurology consult, maybe do a lumbar puncture. They might find a thing that looks a little funny, and that encourages them to do more testing. You’re in the hospital while they’re doing that testing, and hospitals are this soup of bad bacteria, so that increases the chance that you’re going to get an infection that you didn’t come in with, which is a common occurrence. You’re going to be exposed to the things that the healthcare market throws at you in the interest of profit, many of which are quite dangerous.
When you begin to know and understand the epidemiology, a primary care clinician has a huge impact on protecting you from the malfeasance of the medical market, which exists only to sell stuff and which is actually reasonably dangerous. The per-person per-year cost of primary healthcare in the US is $500. We can provide primary care to all Americans and still save $250 billion a year, because of the savings that providing primary care to all will generate.
Guernica: Yet I’ve heard that fewer and fewer medical students are going into primary care. Is that true?
Dr. Fine: Fewer medical students are interested by far. Primary care physicians don’t earn as much as specialists—though compared to average Americans, we should all be ashamed. Some of it is because of the student loan problem. When you come out of medical school with $250,000 worth of debt, it’s a little harder to convince yourself to make a little less money.
Another big reason is because of the industrialization of primary care that’s happened as a result of the dynamics of the health insurance market. Insurance companies now force us to see four patients an hour. Connecting to human beings and trying to build four relationships an hour, and take care of the thing that bothers them, and get their medicines refilled, is really tough. Primary care physicians don’t even get to look at the patient in front of them anymore; they look at the electronic medical records on the computer. It has become a dehumanizing industrialized experience, and that probably dissuades a lot of people from going into primary care as well.
But it’s more than just primary care people who are industrialized and feeling alienated; that sense has now spread across the whole health worker community. Nurses feel this way. Specialists feel this way. PTs feel this way. Everybody’s had their professional integrity undermined by the market. And now the hope is that this group of people will revolt. In fact I don’t think there’s another way out. When healthcare workers revolt, they can actually lead to change. But they’ve got to stand up and do it.
Guernica: Do you see that happening?
Dr. Fine: Well, not as quickly as I’d like it to. But I think those of us who’ve been around a long time need to start standing up and giving people the courage to do it. If people who’ve been doing this for twenty, thirty, forty years don’t stand up, how are people who just got out of residency and have $250,000 worth of debt going to have the courage to do it? This is the responsibility of my generation and hopefully some of us are doing it now and will keep doing it.
We’ve got a little organizing experiment happening in Rhode Island called Healthcare Revolt that’s trying to bring healthcare professionals together to stand up and fight for the stuff that matters. There’s the Lown Institute in Boston that’s trying to do this across the country, called the Right Care Alliance. Not only do we have people’s professional integrity and meaning at stake, not only do we have the health of Americans at stake, but democracy itself is at stake. If people revolt and start building little healthcare systems, neighborhood health stations, one in every community, that’s the recharge that we’re looking for.
Guernica: What can ordinary citizens, non-healthcare workers, do to improve healthcare in their community? What kind of useful pressure can we put on our elected officials or candidates for office? Are there other concrete actions we can take to help improve the health of our communities as well as our own access to good healthcare?
Dr. Fine: What I say to everyone who has been denied healthcare, or lost their financial security, or can’t afford health insurance, is this: Listen up. Someone is stealing a trillion dollars a year from the American people, and all of us are letting them get away with it. You want affordable healthcare? Use the Community Health Center in your own community. Get on its board. Tell your friends, so we engage them as well. You want someone who will stand up to the hospital executives and the pharma people and the insurance industry? Then you better run for office if you can, because the people there are already bought and paid for by the healthcare profiteers. If you can’t run, you better use your vote and vote for people who can stand up. Start writing letters.
It took fifty years to make this mess. It isn’t going to get fixed overnight. Too many people will go broke, and too many will die because of it, but many more will be hurt if we don’t start demanding a CHC or NHS in every community, publicly supplied generic medication, a cap on what we pay executives and doctors at hospitals and through Medicare and Medicaid, to close hospitals we don’t need. Communities can start closing the many unnecessary and incredibly expensive hospitals that are sucking down money we need for primary care, and that contribute nothing to the public health.
Guernica: Part of this revolt seems to require that healthcare workers make a conscious choice to leave for-profit hospitals and private practices. Does staffing a NHS require persuasion, education, grassroots organizing?
Dr. Fine: Our guys mostly work for community health centers. Many healthcare workers did healthcare because they love communities and the people who live in them. People want to work like this. We still have challenges: EMRs
[electronic medical records]
, productivity measures and standards, and way too much bureaucracy in healthcare, driven by way too many healthcare profiteers. But this work is what many healthcare workers long to do. As we build it, they are coming. If there were more neighborhood health stations, there would be more people flocking to do this work. It takes relatively little or no persuasion: pay people a living wage, treat them like human beings, respect their knowledge and skill, and they keep coming. If you talk to people who are in healthcare, they’ll tell you over and over all the dumb things they get asked to do that have much more to do with keeping the billing system going than taking care of people. There are a hundred different ways we can revolt, and hopefully we’ll keep discovering new ones until we humanize this process. Until we have the ability to sit down and listen to patients. Because that’s what this is about.
Guernica: When talking about the factors that go into evaluating health in general, you’ve mentioned access to education, safe and affordable housing, public transportation, and sustainable resources. You’ve described current healthcare in the United States as less a system than a market that is enabled by lobbyists and politician, and plundered by profiteers including hospital executives and Big Pharma. To put this bluntly: Is market-driven capitalism antithetical to health as you’ve defined it?
Dr. Fine: Unregulated crony capitalism that creates substantial and growing income inequality, that exists to extract wealth? That has nothing to do with the maintenance or improvement of the public’s health. That capitalism is not consistent with health; it’s in conflict.
But I can imagine a capitalism that’s more regulated and restrained. Where healthcare is regarded as essential, along with safe and healthy housing, transportation, decent free education through college and graduate school. Where we fund community development as part of the infrastructure of democracy. That’s a capitalism that we have never seen before in the United States, but it’s one I can imagine, and that does not seem to be inconsistent with health. It’s the environment in which I think our democracy and politics make health happen.
Guernica: Some people might hear the examples you’ve just given and call that “socialism.”
Dr. Fine: I don’t think markets are intrinsically evil, but the challenge is when someone takes the market posture as a fundamental belief about society as a whole. That posture has brought us to where we are, and is unsustainable over time.
We must treat healthcare as an essential service, much like police and fire departments, like water treatment and sanitation. We know pretty well what everybody needs and it’s a whole lot cheaper and more effective if everybody has it.
Ariel Lewiton Ariel Lewiton is the Director of Marketing and Publicity for Sarabande Books. Her essays and stories have appeared in Vice, The Los Angeles Review of Books, The Paris Review Daily, Ninth Letter, and elsewhere. She lives in New York.