By Paul Lazar, MD
“There was this immense mess,” Russell Baker wrote in 1970.1 Although he was certainly referring to the civil discord that followed the Cambodian incursion and the Kent State massacre, he might have been describing the present state of US health care. It is a task undertaken with more attention to factual detail but essentially the same findings by Michael Fine in the first part of his book, Health Care Revolt. His articulation of the “cheat to win” tactics of drug and insurance companies and the diseased political and judicial system that allows them is written in clear and accessible language that could be used in conversations with patients and families when they come in with asthma attacks or wildly uncontrolled diabetes because the generic insulins or inhaled long-acting beta agonist/inhaled corticosteroid we prescribed somehow cost too much.
Health Care Revolt is a book about what is wrong with the delivery of health care in the United States, and what we ought to do about it. It is not the first such work, and regrettably, will not be the last. It is somewhat unusual in linking the problems and proposed solutions to the impending demise of our democracy, but that shouldn’t stop anyone from reading it.
Michael Fine, MD is a family physician who served as director of the Rhode Island Department of Health. His career includes participating in the development of several community-level organized health systems in collaboration with community organizations and elected officials. He participated in policy discussions at the time the Affordable Care Act was coming together, and like many of us, was greatly disappointed that the “public option” did not become part of the law.
As such, he is well able to describe, in terms accessible to lay people as well as clinicians, both the frustrating mess that is the US health care system, and the reasons why it fails to deliver outcomes that could justify even a fraction of its outsized cost. The first half of the book expertly delivers and explains the diagnosis, and gives the prognosis of inevitable collapse.
The second half discusses the treatment options. Fine gives a strong argument why the Affordable Care Act, while including some positive steps, is far from adequate. His prescription includes two main elements: community organizing and a physician-led revolt (or many small revolts). This is the weaker portion of the book. He gives some good examples of how community organizing created some excellent local health care systems, and how physicians collaborated with community organizers, but the limited history of physician-led union organizing or strikes (in which he suggests we should participate early and often) is not discussed in any detail. Some in the family medicine advocacy community may find the references to Saul Alinsky and revolt disquieting. I have to admit that I myself have become a rank incrementalist.
Those heavily involved in advocacy already likely know most of the facts discussed in the first part of the book—and many of them would scoff at the second—so I can’t strongly recommend this book to those who have a lot of familiarity with literature in health policy. But, for those who work with our young doctors, it should have a special place on your shelf, where you can reach for it when they come into your office fuming about a third visit with a patient who has twice been prescribed, but never received, an inhaled corticosteroid or a generic insulin. I don’t have a lot of confidence that our young doctors are going to find time between repaying their loans and updating their Facebook statuses to do much organizing. But, perhaps, with a little context, which Fine provides, and a little encouragement, they could carry out one of his small revolts. It could happen, and maybe it would help.
1. Baker, R. Observer: everything should be just fine. New York Times 1970; June 30, 1970: Col. 3-6.
Michael Fine, MD, is a writer, community organizer, and family physician. He is the chief health strategist for the City of Central Falls, RI, and Senior Clinical and Population Health Services Officer for Blackstone Valley Community Health Care, Inc., and recipient of many awards and prizes for his pioneering work bringing together public health and primary medical care. He was director of the Rhode Island Department of Health, 2011–2015.