Monday, September 03, 2018

Michael Fine's Health Care Revolt

Michael Fine, M.D., HealthCare Revolt: How to Organize, Build a Health Care System, and Resuscitate Democracy – All at the Same Time (Oakland, CA: PM Press, 2018).

Dr. Michael Fine is a man on fire. He’s on fire with anger about a healthcare marketplace that serves well to maximize the profits of investors and CEOs, but violates the values of many of those working in it. He’s on fire with enthusiasm about the potential of public health and prevention and about the value of integrated primary care. He’s on fire with determination to work to change our scattered health care marketplace into an actual health care system that could monitor and manage every citizen’s health. And he has concrete suggestions and a vision of how to work toward that end.

And, from what’s recounted here, Dr. Fine has an admirable practical record of implementing health care change on a local level in Rhode Island and in the Scituate area. In Scituate, he organized the non-profit Scituate Health Alliance and worked with residents and local officials to provide primary medical and dental care to all town residents. He envisions small local health care systems like his serving as a model that will show the feasibility of a better health system to both conservatives and liberals and eventually enable scaling up to a better national system. (This is quite reminiscent to me of how the great Nye Bevan, in the middle of the last century, successfully used the model of the Tredegar Medical Aid Society  and similar organizations to plan the NHS at its inception.)
What I liked best about the book is that Dr. Fine has an accurate gut understanding of just how much money we do spend on healthcare and of how harmful it is that we have let the “healthcare” sector balloon to such a large part of our economy. He realizes too how much of this - including many foolish things - is supported by public tax monies. And he really gets that this comes at a huge cost to the other things we could be spending that money on – and spending it on other things instead that are just as important to health would enhance people’s health, not diminish it. As he said in a related interview: “[To improve health,] we need to spend money on education … housing … community development … the environment. These …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.”

I love Dr. Fine’s suggestion that one of the things we need to do to move toward healthcare improvement is to constantly highlight these costs and the damage done. Once we get to where everyone really understands this, we will have moved a big step forward. Working hard to publicize and delegitimize the cruelly extractive techniques of health care profiteers is worthwhile.

There’s all the difference in the world between making a living, including an excellent living, from people’s medical needs and making a killing from them – and in recent years the balance has shifted where we can fairly say that pharmaceutical companies, large hospital organizations, and many other medical sector big players are doing the latter.  I also like how he points out that “with …few exceptions, no health care market actor has a public portfolio (p. 84).” He’s right, and the corrupt marketplace – what Dr. Fine terms a “wealth extraction system” – has not gotten us to a good place for the public – at all.

So, in some ways, this book is inspiring – but in other ways, it is quite irritating. Dr. Fine is so wrapped up in his own perspective that he often is blind to and discounts the value of those parts of medicine that have not been his personal focus. Although I certainly agree with him that there are too many specialists and too much medical overuse, Dr. Fine seems insultingly unappreciative of valuable, needed services that specialists also offer, suggesting that one of the main ways generalists help their patients is by keeping them out of the clutches of specialists who may injure them. He seems, too, to class highly-paid specialists with high earners like CEOs where in my opinion this is ridiculous (specialists are after all basically pieceworkers and are not really similar to administrators, investors, and pharmaceutical executives – even if you think – and I do - they could rightly earn a bit less). Similarly, although I agree with him that the incorporation of a profiteering infrastructure into Obamacare and its lack of universality diminished its value, it’s unseeing to contend that it helped only a few people and that hardly counted. Dr. Fine grudgingly concedes that he likes that Obamacare funded more preventive services, ignoring the far more important benefits it provided to some of those MOST in need of medical care, those with clinical problems and issues. Dr. Fine should talk to some of the people who literally moved to Medicaid expansion states to save their lives first, before minimizing Obamacare’s benefits.

And, Dr. Fine doesn’t seem to have a grip on how unappealing many of us would find the world he dreams of. “Let’s close all center cities to private cars during normal working hours; let’s find ways to provide incentives for people who are not disabled to use the stairs rather than elevators (p. 71).”  He also suggests heavily taxing industrial food products, as well as the production of wheat, corn and sugar (p.70), oddly suggesting that we don’t need any of these crops any more for human consumption (which is news to me). Many readers, unlike Dr Fine, would have less than zero enthusiasm for living under such a heavy-handed, dictatorial regime and would (I believe fairly) consider some of their freedom lost.

As I read this book, I couldn’t help but compare it to a book by another strong advocate of more primary care, Richard Young’s American Health$care: How the healthcare industry’s scare tactics have screwed up our economy – and our future. Dr. Young is the single other person I can recall being as angry and as perceptive as Dr. Fine about the damage done from monies that could and should be spent on other things for more benefit – including health benefit – but which instead are being sucked away by what he calls the “government-medical-industrial coalition.”

Both really believe in primary care. But Dr. Young also realizes, as Dr. Fine does not, that “prevention” – just as truly as medical care for the sick - has many limits and can itself be a waste of money and inordinately expensive. (His discussion of what costs vs. benefits would be of an imaginary Texas tetanus initiative is sound.) And to Dr. Young, the primary purpose of medical care is care for the SICK.  (No matter how much prevention we have, at some point sickness or injury will happen to all - and this is the crux of medicine.) I recommend reading these two books together, to understand how two capable, decent, intelligent, and sincere doctors can have so much agreement on some things and such intense lack of agreement on others.

I know one thing – if I had to choose one as my primary care doctor, I’d be very comfortable choosing Dr. Young and would absolutely avoid Dr. Fine. Clearly, Dr. Fine would have his own agenda for me (he sees primary care doctors as mostly health nags), but Dr. Young, by contrast, would be responsive to what matters to me and my agenda, so we would be able to work together to manage any ailments in a “minimally disruptive” way that would be actually helpful. And although I personally agree with Dr. Fine’s desire to have more publicly-run, genuinely non-profit healthcare such as community health centers (and ultimately nationalized health care) and to legally rein in health profiteers, there are some definite “stoppers” for me in buying off on his whole vision and signing up to his plan.

Fine’s insensitivity and rigidity in some areas and his impersonality is the reason that if I’m going to introduce a friend to the concept of health care revolt I’ll give them instead Victor Montori’s book: Why We Revolt: A patient revolution for careful and kind care. Dr. Montori’s down-to-earth compassion for the ill inspires more trust, and, like Dr. Fine, Dr Montori too insists on the role of patient as citizen in reforming health care to a system more consonant with patient and physician values, but in a more persuasive way that is more convincing in making me like his healthcare vision.

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