Man With a Plan

On a cool evening in October 2013, the tables at La Casona—a Colombian restaurant in Central Falls, R.I.—were packed. But the crowd wasn’t there just for food. They were there for a forum on the town’s pressing health needs.

For the smallest and poorest city in America’s smallest state, the list was long: The teen pregnancy rate was four times the state average. Levels of diabetes, heart disease, obesity, and drug and alcohol abuse were worrisome. Half of Central Falls’ 19,000 residents lacked easy access to a car—so it was tough living healthy without a local supermarket or exercise options. Twenty percent never saw a doctor.

And yet, “there was a real sense of hope and commitment and energy in the room,” recalls Michael Fine ’75, a family physician who organized the meeting in his then-role as director of the Rhode Island Department of Health. “As I left the meeting with the mayor and the leader of the advocacy organization Progreso Latino, we said to each other, “This can happen. Central Falls can build a real health care system.”

Against all odds, it is doing exactly that. The Central Falls Neighborhood Health Station— the first health center in the U.S. that aims to provide almost all of the health care for almost all residents, in one place, regardless of income or health insurance status—is slated to open in late fall. “We’re doing something I don’t think has ever been done in the United States,” Fine said on a rainy September morning over breakfast at La Casona. “We’re actually building a health care system—integrating clinical care and population health to improve the well-being of an entire community. And we’re doing it in a way that’s fair and affordable and effective.”

Central Falls’ model could spark a nationwide health care revolution, he believes. “We have a health care market in America, not a health care system,” says Fine, who is now Central Falls’ chief health strategist. “It’s egregiously expensive—$3.2 trillion a year! But it doesn’t keep people healthy. That’s unjust, and it’s bad for democracy. There’s a better way.”

That’s Fine’s rallying cry. After nearly 40 years as a family doctor, public health official, and community organizer, this is his moment. Fine’s new book, Health Care Revolt: How to Organize, Build a Health Care System, and Resuscitate Democracy—All at the Same Time (PM Press), is a call to arms for health care reform. He’s organized the group Health Care Revolt RI, to replicate the Central Falls model across the state. And he’s looking ahead to a nationwide push he calls the Movement for Health Care in America. “It could take 20 to 40 years to change things,” he says. “We have to get started.”

A bearded and bespectacled 65-year old  who drives a tomato-red 1984 Alfa Romeo (bought on Craigslist for $4,100) that leaks when it rains, Fine seems to know everyone. Drivers honk and wave. “Oh, I know that guy!” he yells (the car’s top is down) as we careen through traffic on I-95. Whether it’s Rhode Islanders’ close-knit sociability or Fine’s friendliness is unclear. It’s probably both. At one point in his career as a family physician, he opened a branch of his practice in the basement of his family’s home in Scituate, R.I., so he could keep treating local residents. He kept a cherished quilt, sewn by a patient, on the wall.

Growing up in suburban North Jersey, Fine wasn’t thinking medicine. “I thought I’d write fiction, but realized after college I needed to support myself,” he says. (Fine’s first novel, Abundance, is due out in 2019.) He studied philosophy at Haverford and bumped up against health care’s harsh inequities as a VISTA volunteer in the South Bronx. After studying medicine at Case Western Reserve University in Cleveland, Ohio, he spent three years with the National Health Service Corps in the mountains of East Tennessee, in the fifth-poorest county in the U.S.

He and his wife, Carol Levitt, a fellow physician, opened a family practice in Rhode Island in the 1990s. (The couple have two children, Gabriel and Rosie, in their late 20s.) Fine clearly relishes one-to-one relationships with his patients—as well as opportunities to influence health care on a larger scale, harnessing data, coalitions, and government to make change. In 2010 he became medical program director for the Rhode Island Department of Corrections and ran the state health department from 2011-2015. He made headlines for attacking the epidemic of fatal drug overdoses with better data collection, and for petitioning the U.S. Department of Agriculture (unsuccessfully) to limit the use of food stamps to healthy items.

Fine thinks, talks, and writes—and seems to live and breathe—health care reform, serving on the boards of social justice and healthcare reform organizations including the Lown Institute and the George Wiley Center, and writing journal articles and books. His 2007 book Nature of Health: How America Lost, and Can Regain, a Basic Human Value is a study of health care services, human rights, society, technology, and industry. Fine founded HealthAccessRI in 2006, which gave uninsured people in Rhode Island access to primary care for an affordable monthly fee, and which helped spark the Direct Primary Care Movement. (Physicians who adopt the direct primary care model do not take insurance and instead charge patients a monthly fee.) He also helped launched the Scituate Health Alliance, a coalition that made Scituate, R.I., the first community in the U.S. to offer payment for primary medical and dental care to all town residents, and created a small-scale health station located in a shopping center that offers primary and dental care for all residents on a sliding fee scale.

He wanted to do more.

"We keep working on health care backwards,” he says, “trying to figure out how to pay for it without first articulating what it is. Real health is about being able to participate in family life and work and community; it’s about good relationships, promoting healthy choices, and the right to have what you and your family need for your well-being.” Obamacare, he says, missed the boat despite extending insurance to millions. “It will likely help with preventive health in the short term, but is driving up costs in the long term.” As the cost of healthcare skyrocketed and Americans’ personal health stagnated or grew worse, Fine grew impatient. And he got to work.

Packed with compelling numbers and shocking stories from inside the nation’s chaotic and overpriced medical “non-system,” Fine’s latest book, Health Care Revolt, argues that more than our health is at stake when profit is in the driver’s seat. Democracy and other pillars of American life— schools, public services, economic well-being, and strong families—take a hit, too.

"The United States spends twice as much on medical services as the average of other industrialized nations,” Fine notes. “It’s now $3.2 trillion—about $11,000 per person. But our population health ranks 43rd to 55th in the world. Our infant mortality is three times higher than the best achievable rates in the world. For African Americans, it’s three to four times higher than that. Our life expectancy is five years less than nations with the most effective health care systems. For African American men, mortality rates are on par with poor nations. We’re paying two to four times what nations with the best outcomes pay for healthcare, yet we have huge disparities by race, location, and income.”

Thanks to advanced medical research and dedicated practitioners, America has the tools to deliver great health care. “We know how to prevent most heart disease, stroke, and diabetes,” Fine says. “We can nearly eliminate colon cancer and cervical cancer, end unplanned teen pregnancy, and reduce infant mortality by half. But we don’t have a systematic approach to bringing preventive services to all Americans.”

Instead, we have a kleptocracy, he says. Hospitals pay administrators 25 percent of their revenue—most from public Medicaid and Medicare funds—and “try their level best to hospitalize more people and do more tests and procedures, regardless of the actual health impact.” A network of disconnected electronic medical records has cost the country at least $19 billion in public money—but is often too complex and disjointed to work well. Pharmaceutical companies boost the prices of once-affordable drugs—such as 17-hydroxyprogesterone, an effective preterm labor preventive once priced at $5 per dose. Fine writes that at the time he headed the Rhode Island Health Department, the price spiked to $1,500 per dose and then came down to $690 as a concession. Cheaper options were nixed by lawyers. “So Rhode Island just handed over public money to a private enterprise that was smarter than us,” he writes.

One-third to one-half of health care spending is wasted, Fine says. Worse: Less than five percent goes to primary care—where most prevention and early intervention for big killers like heart disease, diabetes, and obesity happen. “The per-person cost of health insurance is about $11,000,” Fine says. “Of that, just $400 to $500 goes to primary care. And 20 to 40 percent of that goes to staff time billing insurance companies. We could fix most of what ails health care if we just paid primary-care practices a certain amount per month and spread them across the nation so everyone had easy access.” Universal access to primary care could save 140,000 lives just by reducing infant mortality and deaths from heart disease and stroke, he estimates.

Obamacare hasn’t helped much, despite enrolling millions in insurance plans. “The Affordable Care Act allowed already-rich insurance companies, pharmaceutical companies, hospital executives, and others to get richer, while insurance premiums climbed,” he says. Trumpcare would be no better. “I’m no communist,” Fine says. “The market is a great way to sell tomatoes and cars and TVs. But it’s not buying us health. It’s promoting deep political and economic divisions, contributing to poverty, and taking public money we desperately need for other things. A real health system promotes prevention, community, and democracy.”

Fine envisions health care stations that serve the primary-care needs of 10,000 people, linked with clinics staffed by specialists and with hospitals. “Practitioners will likely know you and your family and your neighbors,” Fine says. “With services in one center, it’ll be easier to get what you need— like walking downstairs to start physical therapy when you have back pain, instead of filling an opioid prescription and calling PT later.” Funding for primary care would come from public money; private insurance would still be available, to pay for care at private practices and private hospitals, but would likely shrink to just 10 percent of health spending. “We’d save $1 trillion a year over what we have now,” Fine says. “That could all go to great schools, public transportation, safe affordable housing, and other public services.”

Not surprisingly, doctors and public health experts familiar with Fine’s work and ideas say his assessment of the health care mess is on target and his solution could work—but it’ll meet skepticism and opposition.

"It’s going to take persistence like his to make the idea of a neighborhood health station more widespread,” says David Sundwall, MD, a primary care physician and former executive director of the Utah Department of Health who writes frequently about public health issues such as access to care. Sundwall has also served as administrator of the federal agency that oversees the nation’s community health centers and helps run a community health clinic primarily for immigrants in Utah. “I share his values and commitment to public health,” he says. “I’m just skeptical from wrestling with the issues for a long time. Reforms like this have been suggested for decades, but it’s like swimming upstream against the entrenched medical-industrial establishment. It’s the strategy of organized medicine to call ideas like this socialism. I’m a Republican, but I think it’s shameful whenever an attempt to come up with a more rational system is made, the immediate cry is socialized medicine and that turns people off.”

When Fine discussed his book in late September in Washington, D.C., at the Robert Graham Center for Policy Studies in Family Medicine & Primary Care, the research arm of the American Academy of Family Physicians, an audience member raised an important issue, recalls Graham Center Director Andrew Bazemore, MD. “The concern was that it may sound too much like Bernie Sanders’ approach and that’s may not work well in some communities, especially conservative communities where rugged individualism is highly valued,” says Bazemore.

"I think it’s hard to know until you try it,” he continues. “I think his book is provocative and aspirational—we have nibbled around the edges of real health reform for too long in America. Michael has worked at the highest levels of state government and at a local, neighborhood level and really found that working from the ground up is more likely to have the most immediate impact—and perhaps cascade into broader reform.”

Dodging construction workers in hard hats, Fine toured the Central Falls Neighborhood Health Station with a visitor in early September. The grand opening of the $16-million, 47,000-square-foot brick-and-glass building is slated to open in December. Asked what it was like to see his vision becoming a reality, he was uncharacteristically silent. “I don’t know how to express how I feel, I’m so awed and so grateful,” he said.

The health station continues the work of the local Blackstone Valley Community Health Care, Inc, a community health center, which serves 50-60 percent of local residents. What’s new here—and new to the U.S.: The center will take one-stop health care to a new level, with family doctors, pediatricians, OB/GYNs, mental-health counselors, urgent care, physical and occupational therapy, basic xray and lab work, translators (many in the city speak Spanish, Portuguese, or Cape Verdean Creole), and social-service workers all under one roof. Fine hopes community groups will use it for activities like healthy cooking classes and health education, too. And he hopes to use the station as a way to reach out to residents who aren’t receiving regular health care, identifying problems through a deep dive into city data and then drawing people in.

"Other health centers wait for people to come through the door. We intend to reach out to everyone in Central Falls and bring prevention to those we don’t know yet,” he says. “We’re combining clinical care and public health, creating better health in a way that’s fair and affordable and effective.”

Much has already been put into place. “After the meeting in 2013, a health clinic was set up in the local high school that offered contraception. Rates of unplanned teen pregnancy fell,” Fine says. “Residents have better access to exercise facilities— including a free bus to use a local YMCA for free in the mornings and a new, state-of-the art fitness park in a city park. We’re working to connect with people who use 911 to get the ongoing healthcare they need. That’s reduced non-emergency calls. When EMS calls for intoxication rose in the summer, we realized it was connected to liquor stores in Central Falls opening at 7 a.m. for summer hours. We worked with state legislators to push the opening time later here. It helped.”

Every Friday, Fine convenes a multidisciplinary meeting of local physicians, social workers, diabetes educators, and social-service providers to discuss the needs of Central Falls residents who are falling through the safety net. “It’s everyone’s favorite meeting of the week,” he says. “It’s always inspiring.” At a meeting in early September, the group brainstormed often-simple solutions that could make a big difference as people struggle to hold their lives together—helping a woman with a disabled spouse get a hospital bed and lift at home, helping a young adult get a photo ID so she could access medical services on her own, negotiating the payment of overdue rent for a single mother whose young children have chronic health conditions. “You guys do the most amazing work there is,” Fine said as the meeting ended.

Outside, it was gray and rainy. Inside, there was hope. Central Falls is making national headlines for its resilience—battling back from bankruptcy and twice electing an enthusiastic, young Latino mayor to replace a city boss jailed in a 2012 corruption scandal. Now, it may make headlines as a model for better health care. “Central Falls is making a comeback, and health is part of the picture,” said Mayor James Diossa, who leads neighborhood walks and started a series of popular and very aerobic Salsa Nights that bring 1,000 residents out to dance on a local bridge. “It’s inspiring to look at the data so far,” Diossa said. “And inspiring to think about all the groups in the city that are working together on this. We can be the healthiest city in Rhode Island. That could start something big.”