In a previous post, we shared highlights from an event about fixing health care featuring Dr. Michael Fine, a family medicine physician, former public health official, and the author of Health Care Revolt. The faculty of the Department of Public Health at California State University Los Angeles led the event as part of a department-wide book read. It was open to the community and you can watch it here.
Dr. Fine highlights the problems at the core of health care in America. He argues that fixing these problems will require a social movement (or revolt) on the scale of the civil rights and women’s suffrage movements. His ideas are timely because they also draw connections between fixing health care and strengthening democracy.
Such big ideas, however, necessitate equally big questions. If there is going to be a health care revolt, there would seem to be many impossible challenges that we must overcome. So together, we posed five big questions to Dr. Fine during his visit, and we summarize key parts of his answers here.
Question 1: How can we get physicians and other clinicians to participate in a health care revolt?
What I say to people is that physicians and other clinicians have been complicit in letting the health care system become problematic. We should have stood up and pushed back when we saw the problems developing. Twenty years ago, doctors regularly worked in their own private practices. Today they are more likely to be employees of companies. These companies treat providers as commodities, which is frustrating and stressful for them.
It’s time for us to stop that. Yes, we may pay physicians and other clinicians well. But we pay them, in a certain way, to keep quiet. The salaries that they make are partly reflective of their service. But to some degree, they are also leveraging something that Henry Ford called employment rent. You can pay people enough money and they’ll do what you want them to do, regardless of whether they think it’s right or not.
It’s time, however, for us to pay that back. I have a friend and colleague in Cleveland who proposed that physicians should start tithing. We should take 10% of our incomes and send it back to community organizing efforts, to help begin this revolt. That’s the kind of thing I think my colleagues could, and need to, start doing.
Question 2: Could COVID-19 be the event that sparks a revolt for fixing health care?
Unfortunately, the pandemic will not be the event to change the health care market into a health care system. We have not learned adequately from the pandemic. And because of such great political division, it is unrealistic to use this event to push towards a common goal. The COVID-19 pandemic is the first plague of the ten plagues we will have to go through before we are ready to make change. This does not mean that we cannot begin the work, so we are ready to make the change. We have closed our eyes and we need to work harder to open our eyes to achieve change.
Question 3: Given such divided politics, can we begin to fix the health care market without policy intervention?
Yes. Primary care is just 5% of the total health care budget. But it is the only medical service that actually reduces costs and improves health. So first, we need communities to establish primary care delivery systems (not markets). We can do this by activating communities, helping people understand that the market is taking $3000 per person per year from them to fund needless operating costs. This is money that could have gone towards people’s salaries, which would allow many of them to have a better standard of living.
We need everybody’s help in building the movement and gaining widespread support. Strictly focusing on legislation will not be successful due to the very long process and the insertion of lobbyists. But when thousands of people across the country are demanding specific desires, it’s different. Build the movement first, then the legislation.
Question 4: How does the revolt engage groups–BIPOC, undocumented, etc.–who often experience the worst of our “health care system”?
The change must begin in the communities. And more importantly, the revolt should not be done for or to the communities, but with the communities. To accomplish a revolt, it is important to be with people–be in churches and community groups–so people are involved in the process of understanding the costs and the benefits of having a true health care system. The communities should be involved from the beginning and should stand up and act up as a part of the revolt. Involving the community in the whole process is much more effective than just focusing on the vote. The vote will come, but first a movement is needed.
Question 5: If primary care is at the heart of reform, how do we make sure that we have enough people working in that field?
The easy way to change recruitment into primary care is to make sure that anybody who is going to do primary care gets trained for free. They shouldn’t have to pay or take out big loans. Instead, they should have the opportunity to do what I did. In exchange for getting their education for free, we would ask them to go back and serve for three to five years in the communities from which they came.
I ended up going to the mountains of East Tennessee for three years. I got a National Health Service Corps scholarship, which was widely available in those years. We should bring that to every community. The actual cost of doing that is kind of a rounding error. It’s what we call budget dust; it costs relatively little compared to the value that it generates.
One of the things that you learn after spending time in this “system” is that there is nobody in charge of figuring out how many physicians, nurses, and physician assistants we need and making sure they get trained. What actually happens is that medical schools, nursing schools, and PA schools just decide that they’re going to open up and we all hope for the best. That’s crazy!
The reason that there aren’t adequate primary care practices in every neighborhood and community is that nobody’s in charge of making that happen. We need a health care system that sorts out what we need to accomplish and then recruits the resources to get that stuff accomplished instead of just hoping for the best.
You can read the first part of this series here.
Sheila Seno
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