By Gregory Stevens
The Medical Care Blog
February 28, 2019
A book lying idle on the shelf is wasted ammunition.” – Henry Miller, The Books in My Life (1952)
The Medical Care Blog is home to many strong opinions. In the last year, contributors have written ferociously about the political determinants of health, highlighted the per-mile cost of President Trump’s wall in numbers of children who could gain health insurance, and referred (with rather appropriate snark) to our health care system as the “Ford Pinto of the world”. And last month, with Medicare-for-All breaking into the news cycle amid false claims of socialism, I tried to write with clarity about this important movement.
The common thread among these posts is the connection between politics, power, and medicine. This same thread runs throughout a provocative new book: Health Care Revolt: How to Organize, Build a Health Care System, and Resuscitate Democracy–All at the Same Time by Michael Fine (Oakland, CA: PM Press, 2018).* A family medicine physician, community organizer, and former state public health commissioner in Rhode Island, this is Dr. Fine’s third book on reforming the health care system. It’s also his best.
A Marketplace…Functioning As Intended
The U.S. health care system is not much of a “system”. It is a marketplace of private companies selling degrees of financial protection from the costs associated with receiving health care from mostly unrelated health care providers and hospitals. The government provides additional financial protection for people whom the private market has failed (i.e, Medicare, Medicaid and CHIP). It is not surprising that Medicare was the federal government’s first entry into health care; the private insurance industry saw them as bad risks, so when Medicare was under debate in the 1960s, only about half of older adults had any coverage. A similar argument about why Medicaid exists can be made for the poor (a population with high costs, but few resources).
Where Dr. Fine advances our thinking is by helping us acknowledge that the private market is, in fact, functioning perfectly at doing what it is supposed to do: maximizing profit. Few would be surprised to learn that health insurance and health care are two of the most lucrative industries in the U.S. A 2018 report from the White House Council of Economic Advisors, for example, notes that health insurance company stocks have increasingly outperformed the S&P 500 by a considerable margin. The report also notes that health insurers made about $100 in gross profit for every $400 in premiums (a 25% gross profit rate, which is high).
Referring to the health care system as a “wealth extraction system”, as Dr. Fine does, is not that far from the truth. What else could we call a $48,512 hospital bill for a cat bite? The challenge, however, is the risk that this wealth accumulation poses for policy-making for the public good. If more wealth is concentrated in the hands of a few individuals and health care conglomerates, this wealth can be used to tip the scales away from the best use of public funds. We all know the influence of wealth in politics, but the influence invades many levels of health care. For example, ProPublica has detailed how companies use their wealth to essentially bribe major insurance brokers.
The absence of power among those stripped of wealth is perhaps more disturbing. As Dr. Fine argues, health care is an essential service in a democracy because a healthy citizenry is necessary for the participation of individuals in the democratic process. Democracy suffers when people are too distracted by competing priorities, such as finding adequate food, to pay attention to politics. If people are too busy managing their uncontrolled diabetes and struggling with the costs of insulin, voting can become an afterthought, not a priority. And if people are simply too demoralized to vote by this struggle, the public process of democracy fails.
Elsewhere, the term financial toxicity is being used to describe the effect of medical debt on health. Perhaps we also need to talk about the toxicity of medical debt on democracy.
Dr. Fine invites us to revolt in several ways. All of them involves grassroots action, rarely looking to elected officials to be the principle drivers of change. This is empowering, because it enables us to recognize our own power. But it is also scary to recognize that changing the system falls on our shoulders. He gives examples of how to proceed, a few of which I highlight here:
• Fight for a strong, publicly-funded primary care systems, derived from the model that delivers the best primary care in the nation (our Federally Qualified Community Health Centers). This is a model that can be expanded to deliver care that meets the majority of needs in a population. While primary care is not the only solution, he offers a vision for how primary care can evolve into neighborhood health stations (as is being done in Rhode Island).
• Amplify the little embers and sparks of ingenuity that have allowed people to bring the focus of health care back to the community and not to profits. He gives examples of doctors and hospitals that have retooled to focus on the needs of the poor, and reminds us that some great ideas have been tried, found successful and then forgotten. He writes specifically about the creation of a community hospital in Hunterdon County, New Jersey.
• Be information advocates and community organizers. Health care profiteers and other naysayers will be continue to be extremely well-funded and ready to suppress new ideas. But individuals and (in particular) clinicians must share what they know, talk about how other health care systems work, remind all of us of why health care (and not the health care industry) is so important and valuable, and arm us with information we can use to participate in democracy.
Perhaps this is why I so appreciate Dr. Fine’s closing arguments about democracy and medicine:
“Democracy happens when we act up. That’s what democracy is, and a political revolution in health care is both democracy in action and exactly how we can bring democracy back to life.” (p. 120)
I’m not leaving this book on the shelf as wasted ammunition.
Note: Dr. Fine is a friend and colleague and we’ve written together on this blog before.*All profits from this book will be donated to the George Wiley Center, a 501(c)3 nonprofit community organizing institution located in Rhode Island.
Associate Professor at Keck School of Medicine, University of Southern California
Gregory D. Stevens, PhD, MHS is a health policy researcher, writer, teacher and advocate. He is an Associate Professor of Family Medicine and Preventive Medicine at the Keck School of Medicine of the University of Southern California. He received both his masters and PhD from the Johns Hopkins University Bloomberg School of Public Health with a focus on health care policy. He has focused his research on primary health care, children’s health, health disparities and vulnerable populations. He is an author of the book Vulnerable Populations in the United States and you can find his peer reviewed papers in Medical Care, Health Services Research, Journal of General Internal Medicine, and American Journal of Public Health, among other journals.