Locally, doctors can make more in neighboring Massachusetts and Connecticut than they can in Rhode Island. And the state’s hospitals are overly dependent on Medicare and Medicaid, rather than the more lucrative reimbursement paid by private insurers. This adds up to a series of complicated challenges, if not a worsening crisis. State government has started making some efforts to respond, but these remain at an early stage. So what will it take to put healthcare in Rhode Island on a better footing? Does the state have too many hospitals? And is it possible to create a system more responsive to everyday people than insurance companies and healthcare executives? This week on Political Roundtable, I’m going in-depth with author, community activist and former state Health Director Dr. Michael Fine.
This transcript has been edited for clarity.
Ian Donnis: Welcome back to The Public’s Radio.
Dr. Michael Fine: Thanks, Ian. Nice to be here.
Donnis: One of your current roles is serving as president and board chair of a non profit called Primary Care for All Americans. What is the goal of this group and what is the plan for achieving it?
Dr. Fine: Well, the goal is to provide primary care to all Americans, to make sure every American in every person in every American neighborhood and community has primary care. And we’re going to achieve that two ways: with a local organizing strategy, organizing community by community, helping communities provide primary care for themselves; and then organizing at the state level, helping to educate people about the importance of primary care.
Donnis: As things now stand, doctors make more money by pursuing specialties rather than primary care. And Rhode Island is at a competitive disadvantage since doctors are paid more in Massachusetts and Connecticut. What would you like to change to make this better for Rhode Island?
Dr. Fine: I think the first thing we need to change is the number of doctors we’re training. Doctors, nurse practitioners, other clinicians, everybody. We are way, way, way, underpowered for the number of people we have. So we’ve got to figure out a way to improve that and we’ve got to find a way to make it so that primary care folks can go to medical and nursing school and PA school and do it for free, but then have an obligation to practice here so they stay here with us where we desperately need them.
We need our students from our communities to go to health professional school and then have incentives to come back and practice back in those communities.
Donnis: On a related point, you are part of a legislative panel studying whether to create a state medical school at URI. You’ve supported this idea for quite a while, and I was skeptical about whether it might be, whether the politics of moving forward might be insurmountable, but now it has some backing. Do you think this is an idea that could really happen?
Dr. Fine: Oh, I think it’s a great idea and an important idea, because we need people from our communities to be able to practice here. And the way to make that happen is to make sure that there’s a place for them to go. Brown’s a great place, but it doesn’t train that many real Rhode Islanders. Six to ten a year is what I hear out of a class of 150. We really need something like 50 to 100 people a year to replace the people who are retiring, as well as to take care of the fairly large number of people who don’t have primary care clinicians yet.
Donnis: Beyond raising the focus on primary care, what do you consider the most important changes for healthcare in Rhode Island?
Dr. Fine: Oh, you know, I think primary care has got to be our single focus, and our second focus has to be reducing the cost and organizing things so it’s simpler to use. For most people, it’s a complicated mess, and it’s not even clear who’s in charge at any moment. We’ve got to find a way to fix that and to reduce the cost so it’s affordable by everybody. Primary care in the United States now costs about $14,000 per person per year. It’s just not sustainable for regular folks. We’ve got to make it way cheaper.
Donnis: The idea of reducing costs sounds great. We know that Americans spend about more than four and a half trillion dollars on health care every year, but it seems like it’s such a complicated, interwoven knot of issues. How, what would, what would reducing costs for health care in Rhode Island look like?
Dr. Fine: Well, I hate to be obsessional, but it looks like providing primary care to everybody. You know, when you look at other countries, countries that provide the same quality or way better quality than we do, and do it at 60 percent less than we do. The way they do it is they make sure every single person has a robust primary care relationship, and that’s what we need to duplicate.
Donnis: A state health care system planning cabinet was created by Governor Dan McKee through an executive order, and it’s scheduled to produce a report later this year, and some bills aimed at improving health care were improved in the General Assembly this year. How do you evaluate the effectiveness of these steps at getting at some of the needs with health care in Rhode Island?
Dr. Fine: Well, you know, health care change is a long term process, so, we’ll see what comes up. I’ve seen people try to do different kinds of committees and, and commissions and so forth to, you know, put a cap on the cost or do this or that. Generally they’re an organization of stakeholders and the stakeholders are all pretty good at protecting their stake. The challenge is to listen to neighborhoods and communities and make sure neighborhoods and communities have what they need, and make sure that everybody’s got access to the care they need. That seems to me the need to come first. Committees and commissions are good things, but, you know, I’m not always convinced they can get it done.
Donnis: On a related note, the state official showing the most urgency on health care issues is Attorney General Peter Neronha. He and his office have no representation on Governor McKee’s health care planning cabinet. And we know there’s little love lost between the two men, does this show how politics and personalities get in the way of making progress on improving health care?
Dr. Fine: Politics and personalities have been getting in the way in Rhode Island for as long as I can remember. That said, you have to remember we start from a position of strength. Remember, we are one of the best rated states in the nation for our health care. I think Wallet Hub rated us second in the nation. Which is great. The problem is when you compare us to other countries, it’s sort of like we’re the best, we’ve got the best deck chair on the Titanic. We do way better than other states, but nowhere near as good as we can do. And for Rhode Island, from an economic perspective, particularly reducing the cost of care is critical, because when you reduce the cost of care, you make our businesses more competitive.
Donnis: We’re talking here with Dr. Michael Fine. What would you say about healthcare if you were running for president?
Dr. Fine: Oh, I’d say that we need to do two things. One is I think we need, a, you know, maybe, maybe you want to call it a moonshot, maybe you want to call it a Marshall Plan, maybe you want to call it a New Deal for Healthcare and focus on quadrupling the number of people we’re training. We need, we desperately need more doctors and nurses and so forth. Desperately, desperately, desperately. We’ve not paid attention to this. So, if I were running for president, I’d say, we’re gonna, we’re gonna make sure everybody’s got a primary care doctor, and we’re gonna make sure everybody who wants to go to medical and nursing school can go there, and do what we need to support them. That’s thing one. And then I’d be looking at something like a public option for generic medications. Generic medications are cheaper than water, but there’s no good business model for making them. So somehow we have to get government involved, to making them so that they are as cheap as they can be. And so that prescription pharmaceuticals don’t, overpriced pharmaceuticals don’t suck up all our public funds.
Donnis: There’s ongoing uncertainty about two safety net hospitals near Providence, Roger Williams Medical Center and Our Lady of Fatima in North Providence. Attorney General Neronha has imposed some accountability on the owner of these hospitals, Prospect Medical Holdings, which is trying to sell them.
But you’ve written on, on a website for a Newport publication that you think the hospitals are going to close. Why do you believe that?
Dr. Fine: You know, if you look at the trajectory of healthcare in the United States and in Rhode Island, we have changed what we have to do in the hospital. Hospitals aren’t as important in the way they used to be, and we just don’t need as many of them. It’s really hard for politicians to think about closing hospitals, because hospitals bring jobs, and politicians never like to lose jobs, but the truth is, we have way more hospitals than we need, The flip side is the only way to shrink hospitals so that you don’t get sort of a run on emergency rooms is to really expand access to primary care. If you expand access to primary care first, then people get the services they need in their own communities, and then you can shrink hospitals and save money.
Donnis: You wear a lot of hats and one of them is as chief health strategist for the city of Central Falls. What difference has your approach made in Central Falls as far as health care and health care outcomes for people there?
Dr. Fine: I’d like to think that what we did in Central Falls was particularly useful during the pandemic when we called attention to what was going on and You know, in Central Falls, we had the, Central Falls was the most COVID infected place in the state, in the nation and for periods of time in the world. We called attention to that and got a whole great group of people organized, to something, into something called Beat COVID-19, which really helped protect the underserved, so that, you know, though Central Falls was incredibly infected, our, our crude death rate from COVID was about average for the state. That was a great advance. And then the other thing I think we’ve been able to do is really pay attention to the people who are underserved and don’t have access to primary care, and have been able to bring that access up and, and, and provide more access. And then at the same time, we run an amazing process called the Central Falls Multidisciplinary Team, which brings together all the people who are involved with human services once a month. We look at the folks who are most at risk, and we make sure they get the services they need. That kind of work has in the past, helped us reduce unnecessary use of EMS, unnecessary emergency room use. All of which are important things to do when you’re looking at the health of the population of a city.
Donnis: In about 30 seconds, how would you describe your main takeaways from the pandemic in terms of how it got very politically polarized?
Dr. Fine: My main takeaway is that it got politically polarized and that political polarization was dangerous to our health. We lost 900,000 people we didn’t need to lose in the United States just because of that political polarization. My second main takeaway is communities need to protect themselves. They need to remember the cavalry isn’t coming. That at the end of the day, the state and the federal government are helpful, but communities have to organize themselves to take care of themselves if they’re going to do that effectively.
Donnis: We’ve got to leave it there. Author, community organizer, former state health director, and chief health strategist for the city of Central Falls, Dr. Michael Fine, thank you so much for joining us.
Dr. Fine: Thanks, Ian.
—
It was more than 50 years ago when Mick Jagger and Keith Richards were arrested in Warwick while on the way to a performance in Boston. Mugshots of the two Rolling Stones remain a reminder of the time in 1972 when the late ProJo photographer Andy Dickerman stood up to the brash British invaders during a scuffle at T.F. Green Airport. Years later, Mick and Keith are still rocking. You can read more about that in my TGIF column, posting around 4 this afternoon at thepublicsradio.org/TGIF and on what used to be known as Twitter @IanDon. That’s it for our show. Political Roundtable is a production of The Public’s Radio. Our producer is James Baumgartner. I’m Ian Donnis, and I’ll see you on the radio.
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