Friday, August 28, 2015

Scituate, Rhode Island, Can Save America


final great pumpkin Big Pumpkins People in Scituate, Rhode Island, have accomplished great things by staying focused. Joe Jutras of N. Scituate grew the heaviest pumpkin in world history (1689 lbs.) in 2007. Even more amazing, the Scituate Health Alliance is providing primary health care for all its citizens.

Scituate, Rhode Island, is a country place (yes, there is "country" here). It was all farms thirty years ago, and now is exurbs – a place for policemen and firemen, for teachers and nurses and plumbers and mechanics to live, tucked in among the trees where dairy farms used to be and landscapers and orchards are still, where once there were truck farms, and before that, sheep spreading over the hillsides. The Scituate reservoir supplies most of the state of Rhode Island with water – giving us beautiful lakes and forest-covered hills that make people think of Vermont and Wisconsin instead of the smokestacks and mills people sometimes associate with old New England.

Last night, my friends and colleagues in Scituate did something that gives me hope for the whole US of A and its jolting, stop-and-start, half-hearted attempt to create something that might pass for a health care system.

The people of Scituate, and of the Scituate Health Alliance, acting like the cranky Yankee Republicans they are, said "No," and by saying no, they did what no politician in America has yet done.  They laid the foundation for a rational health care system for their town, for their state, and for their nation.

You see, Scituate, Rhode Island, is already unique.  We are the first town in the country to provide health care to all our citizens. 

No, we don’t give away health insurance – that’s too darn expensive.  Instead, we make sure everyone who lives here has primary care (which only costs $25 a month).  By coupling together grants, and a little money from the town, and doing bake sales and walk-a-thons, something called the Scituate Health Alliance decided, ten years ago that we could fix the health care system ourselves – or, more accurately, build one from scratch— by providing primary care medical for everyone in town who doesn’t have insurance.  (We also do flu shots for anyone in town who wants one and organize prenatal classes for anyone who is pregnant.)

fine flu shot Scituate Health Alliance Author and family physician Dr. Michael Fine treats a citizen of Scituate to a free flu shot. Truth be told, we were hoping to build a primary care center for the town, to do everyone’s primary care for free, and to encourage everyone in town to get high-deductible insurance and a health savings account, but we couldn’t find the money to build the primary care center, and no insurance company wanted to provide us with high-deductible insurance that everyone could afford.  So we’ve contented ourselves with giving vouchers to people who lack health insurance, so they can have a family doctor, and  a family dentist, and see their family doctor and dentist without worrying about money. 

Scituate isn’t a poor place, so we provide health and dental care for only about 100 people, but now everyone in Scituate has something, and it’s the something that makes the biggest difference – primary health and dental care. Simple enough.  And effective.  A little health care system for Scituate, Rhode Island, we're already here, up and assembled, just waiting for the dust finally to settle in Washington, D.C.

But last night, we faced our Waterloo, and we stared it down.  Interesting, it’s a lot like the Waterloo called "Health Care Reform" that they face in Washington DC, only I don’t know what will happen there, in a process buried under committee meetings, with money changing hands and advertising back and forth and K Street lobbying.

In Scituate, the process is more straight-forward.  Somebody in Scituate was in an incredible amount of pain, needed a root canal, and couldn’t afford it. They heard about the Scituate Health Alliance and were asking us to help.  They needed $2000 worth of dental work, in fact, and they were having trouble paying their mortgage because somebody was out of work.  (Rhode Island has the third highest unemployment rate in the US – 12.8 percent – so we have lots of friends and neighbors out of work.)  Could we pay the bill?

scituate dedication Scituate Health Alliance The Scituate Health Alliance partnered with Scituate Ambulance and Rescue Corps ten years ago. Its board has met monthly ever since, providing primary medical and dental care to everyone by sticking with that limited but major goal. The Scituate Health Alliance Board is a pretty mixed group.  A small business owner  (an incredibly persistent, brave guy named John Marchant, who has held onto the vision of building a health care system for Scituate RI, for ten years, and has led the group through thick and thin).  An administrative assistant.  An EMT.  Two nurses.  A banker.   A researcher.  A family dentist.  A family doctor. We’ve been meeting every month for ten years, so we know each other pretty well.  Most of us have had tooth pain, and we all could remember how much it hurts.  We all wanted to help.

But then reason set in.  Yes, we had enough money in the bank to pay for this root canal.  Yes, the person was in terrible pain, and, yes, we wanted to help make the pain go away.  But if we paid for this root canal, then there would be another, and another after that.  A knee replacement.  A hip replacement for an old dairy farmer who could only barely get around.  A bone marrow transplant.  Somebody’s cosmetic surgery.  It’s hard to know what matters and what doesn’t when you are talking about the things people want and need, and incredibly hard to say "No" to one once you’ve said "Yes" to anything.  No, we just couldn’t afford to pay for everything that everyone in town needed or wanted but couldn’t afford.  We could afford primary health care.  And even primary dental care.  We’ve worked out some deals and some discounts, so we can pay for a little basic lab work and can get people discounts on almost anything else they might need.

But if we paid for this root canal, and then we paid for the next one, we’d be out of money in a few months, and then the 100 people who are getting primary care from the Scituate Health Alliance, and the 10,000 people we hope we can provide primary care for someday, when we find the money to build the Primary Care Center for the town -- all of those people will get nothing. Instead of the something we all have now, we will have no Scituate Health Allaince.  No one will have anything unless we were able to balance what most people really need against what a few other people feel like they need and want – and what many people really do need, but what we all just can’t afford.

scituate foliage City data The "Ice Pond" behind Cork Brook, in Scituate, Rhode Island, Fall 2008

So it was hard, but we looked at each other around the kitchen table in the Scituate Ambulance Corps, on old Route  6, which is where we meet one Tuesday night a month, and we said, reluctantly, "No."  No root canal.  No paying for what isn’t primary care.  No major surgeries, or cancer treatment, or bone marrow transplants.  We had some other ideas, about how the person who needed the root canal might be able to get it done, but we decided to focus on what we could accomplish and succeed at, and not go down the path of trying to do everything for everyone.

And so, in its way, the Scituate Health Alliance laid the groundwork for health care reform in the United States.  We recognized, painfully, that we can’t do everything for everyone.  We understood that we can do a lot for most people, and we can do that by working together, thinking together, understanding what really matters and  what people really need, and sometimes, by saying no to what we just don’t have the resources for.

That’s what Congress needs to do.  We need to give primary health and dental care to all Americans.  We probably don’t need to --- or just can’t-- give insurance that pays for everything anybody wants or thinks they need, to all Americans.  Sometimes, we need to just say "No."
That’s how the little country town of Scituate, Rhode Island, saved America.  We showed that health care isn’t some big complex behemoth, only understood by the sanctified few.  We showed that a couple of  dedicated people, in a community of people who know and care about each other, can make sense of this expensive, dangerous mess.

Now all we need is for Congress of the United States of America to follow Scituate’s lead.


Nice start - want to know what happens next?

While I applaud the town of Scituate for DOING SOMETHING - you are reinventing the wheel. A decade or so ago, Oregon did on a state level exactly what you are doing in your town. The Oregon Health Plan was developed by going out to citizens all over the state and letting them choose what would be on the list of accepted conditions under the state health plan, and what would not. As you have found, some of the choices were difficult! - and it took awhile to agree but they did it!  The Plan was funded and implemented - and immediately became too much of a good thing.  Sick people from other states with lousy health care moved to Oregon and were a major factor in over-burdening the system. This is why we MUST have on a national level what you have created in your town. Funds to support the program, costs, risks and benefits must be distributed equally across the country or it will not work.  Why is U.S. the only developed country in the world too dumb to get that?

Rationing care rationally

What a great effort.  Perhaps this account will help spread your story and inspire other communities to create something similar.  To hear the health care industry and some elected officials tell it, you’d think that we don’t have rationing in our current system.  But to my way of thinking, failing to cover pre-existing conditions or having to shoulder $2500 deductibles are merely forms of rationing.  Having a procedure be affordable only to the economically secure seems another form of rationing.  The question we seem to be faced with is how do we ration care responsibly and reasonably so that it serves the common good.  Personally I’d rather live with a system that rations care on criteria other than profit.

One Thing More

Scituate must also have the primary care nurses and the Dr. Michael Fines. Nothing being done now and in the next ten years will address the deficits of primary care. Family physicians, pediatricians, nurse practitioners, and physician assistant primary care levels are insufficient and stagnant.

It is the family practice forms of NPs and PAs that contribute where needed just like family physicians, but unlike permanent primary care family physicians the flexible primary care non-physicians are departing family practice for better opportunities.

Internal medicine primary care physicians are departing primary care at a rate that will take them from 110,000 to 50,000 over the next generation of physicians. This is because internal medicine only contributes 1000 graduates to primary care a year. The loss of the largest source of primary care leaves a huge gap in adult, older, and oldest population primary care. Instead of the 400,000 that we will need for a primary care physician number in 2040 and beyond, we will have 90,000 FM plus 50,000 PD plus 50,000 IM (maybe) and about 50,000 physicians worth of NP and PA primary care. This is 240,000 and not the 400,000 primary care physicians. It is also not the predominantly family practice mode that distributes where needed with 50 - 60% found in zip codes with 65% of the population and 70% of the elderly. Scituate can provide the facility and can keep the local people local in health care to support the facility and the type of care, but it will need the nurses and doctors to provide the care. Scituate cannot win in a bidding war with other more economically powerful states and cities that will take the few primary care practitioners remaining.

We must work together as a nation to support medical student choice of family medicine in the way Scituate took on basic health access. The federal efforts are far too little and far too late (loan repayment, special programs). Once medical students pass the opportunity to choose family medicine, the United States loses 25 years of most needed health access contributions for old, older, oldest, rural, underserved, lower income, and middle income Americans.

Our new school has clearly admitted 30% rural origin, 30% first generation to college, older, lower and middle income origin, life and health experienced, people oriented, and service oriented types most associated with choice of family medicine but without some reassurance that their choice of a permanent primary care career will be supported by the nation and communities like Scituate, they will have 15 - 20% choice of family medicine instead of 35 - 40%. But I will share the story of Scituate with them and with others as a message of what can happen.

Robert C. Bowman, M.D.   Professor of Family Medicine
A T Still School of Osteopathic Medicine Arizona