Health Care Revolt: Building Small Health Care Systems in Every Community

Start small to go big

America's most essential public services—from education to fire protection—weren't created through sweeping federal legislation or corporate initiatives. They began as community solutions, developed by neighbors solving local problems with practical approaches. While politicians and pundits insist that transforming healthcare requires massive top-down reform, Dr. Michael Fine reveals a compelling alternative path through his work in Scituate, Rhode Island. His experience demonstrates that lasting change often grows from the ground up, with communities designing healthcare systems that serve their specific needs—creating successful local models that can ultimately scale into national solutions. In a nation where grand healthcare reform efforts have repeatedly fallen short, Fine's "start small to go big" approach offers a historically proven blueprint for meaningful change.

For those following Health Rosetta, a Public Benefit Corporation and the Nautilus Health Institute (501c3) we helped fund and catalyze, you can see why we're so aligned with Dr. Fine. I think you will be too. The following is an excerpt from Dr. Fine's book Health Care Revolt:

Building Small Health Care Systems in Every Community

The health care reform efforts of 1993 and 2009-2010 were run by large national organizations that used orthodox processes to change the way the federal government deals with health care. politics, it is said, is the art of the possible, and the result that was finally achieved in 2010 (which more or less got the reform that was designed in 1993 by a bipartisan group of senators) is likely all that is possible using the legislative processes of the federal government. And that wasn't good enough.

Public education, the police, fire protection, public water systems, public sanitation, and even the U.S. mail all started the same way. They started with local efforts—with communities designing solutions for themselves.

So perhaps we need to think about building the Movement for Health Care in America differently. Large national organizations failed us. So we'll start the Movement for Health Care in America by building small local associations, and then bring those small organizations into large coalitions. Let's look for a moment at other models of systems that bring services to all Americans. Public education, the police, fire protection, public water systems, public sanitation, and even the U.S. mail all started the same way. They started with local efforts—with communities designing solutions for themselves. Some communities built local schools. Others created police departments. Still others created different versions of fire protection. Each used a different way of organizing the services and created different ways of spreading the cost. Some worked by subscription initially—you got fire protection in some places only if you paid for it. Others designed fire protection for every household and paid for it out of tax dollars.

The same approach was true of city water, and even roads. In some places city water was a private enterprise, and you got it only if you paid to hook up to it. In other places, the first good roads were built privately and you paid a toll to use them. Some communities did this better than other communities. Not all communities got involved. But eventually people recognized that public education, public water and sewage, roads, the police, and fire protection were public services, and most communities came on board, funded all these services centrally, and supplied them to every household. Eventually, state and federal regulation, and then state and federal (mostly federal) funding, made sure all the approaches were safe and effective. Then state and federal funding was used to tie local approaches together into a single system that offered very similar services to all Americans and to enable communities that hadn't yet developed those services for their citizens to do so.

Health care is no different. Health care—at least primary health care—is an essential service. Shame on us that it has taken us all so long to figure this out.

To create the Movement for Health Care in America, we can all start where we live.

I live in Scituate, Rhode Island, a little exurban town of ten thousand, about fifteen miles from the city, which for us is Providence, Rhode Island. Twenty years ago, I started talking and listening and finding people who thought there was something we could do together. I gave them the numbers and then got out of the way while people worked together. We spend almost $100 million a year on health care for the people who live in Scituate. No one knew that. Almost all of that money leaves town. No one knew that either. People who live in Scituate have about seventy five babies a year. Those babies are delivered by sixty different doctors. Their mothers travel hither and yon all over the state when they are pregnant. No one knew that either. But everyone in Scituate knows those facts now.

Fifteen years ago, Scituate became the first community in the U.S. to guarantee all its residents access to primary medical and dental care. We got a little foundation money to get that started, and now the very Republican town government contributes every year to make sure every person in Scituate has health care. We are one of the best-vaccinated places in the county. People get flu shots when they go to vote and when they walk around the streets doing their Christmas shopping in December. Our kids get sports physicals in the fall at the school. We just built a Neighborhood Health Station at the little shopping plaza in the middle of town, a primary care center that aims to care for everyone in town, like the primary care centers described in Chapter 5. It has primary care doctors and dentists and will eventually be open from 8:00 a.m. to 8:00 p.m. weekdays and from 9:00 a.m. to 5:00 p.m. on weekends. We still have challenges—our town financial meeting has dwindled to the point that only about a hundred people out of six thousand voters come every year. There are three different volunteer ambulance corps that waste time and money competing with one another to serve the community—so there is room for our cooperation and democracy to improve. But working together we have accomplished a lot over twenty years. Other communities can and will do the same. It will look a little different in each place. In some places it will be stronger and in others weaker, but that diversity is good for us all, because that is how we learn.