PROVIDENCE – Dr. Michael Fine often wears his heart on his sleeve. When he talks about health care in Rhode Island, he is not afraid to say truthfully what he thinks. For the past four years, serving as the director of the R.I. Department of Health, he has been on the front lines, leading the charge as an advocate for public health and primary care.

In the very first interview ConvergenceRI conducted with Fine, back in March of 2011, when he first became the director, when asked about the health care delivery system landscape, he corrected the reporter: it was not a system, he said, it was a market. There wasn’t a system of health care delivery, Fine continued, but a “system of wealth extraction.”

Much of Fine’s legacy will be defined by his committed response to the ongoing epidemic in accidental drug overdoses and the plague of addiction in Rhode Island. Through his actions, as many as 500 lives may have been saved in 2014, because of his advocacy for the use of naloxone by emergency responders and law enforcement, with more than 2,000 doses administered.

Fine had planned to give his second “Health of the State” report recently. For whatever reason, he was prevented from doing so.

Here is an exclusive interview by ConvergenceRI with Fine, sharing his views on Rhode Island’s health care landscape, past, present and future.

ConvergenceRI: In the first interview I ever did with you, in March of 2011, you described the health care delivery system in Rhode Island as being a process of wealth extraction, not a system of health.
FINE: It’s a market, not a system. And, it’s a market that works like markets ought to, which is as a method for creating profit for some by selling services to many.

ConvergenceRI: Has it changed at all for the better?
FINE: It has not.

ConvergenceRI: What needs to happen to change it?
FINE: I think we need to decide collectively that health care is a fundamental path, [that it] is a building block of democracy.

I don’t think of health care as a right; but I think it’s critical to democracy itself. Because, if people don’t have their health, then they cannot advocate for themselves effectively.

And, it’s people advocating for themselves in the public space that makes democracy work.

So, in order for us to focus on that, I think we have to make it nonprofit.

Health care should not be a source of profit.

It should be like public schools, as [an] instrument to democracy, one that is seen as a central service that we need to provide to everybody.

ConvergenceRI: What are the ways to change the attitudes of people to get them to realize this? Is there an aha moment?
FINE: I do not think people will have an “aha” moment by themselves. In some ways, the commitment to democracy ebbs and flows, and I think we’re in an ebb. We need to organize. This is not just about health care. When people are organized and participating in the public space, then all democratic institutions work better.

I think what we’re experiencing is a political problem. In order for democracy to work, people have to participate. And, I think, we’re in a point in our history where people aren’t participating.

People are letting others – and other products – get in the way of their connection to each other and their participation.

ConvergenceRI: I was struck yesterday, when this new working group to re-invent Medicaid was announced by the Governor, by the lack of basic understanding that Rhode Island can’t reinvent Medicaid; it’s a federal insurance program. There’s a basic disconnect there. And, the dysfunctions of the health care delivery market are being projected onto Medicaid, which, by in large, is very efficient, compared to the overall market.
FINE: Medicaid, like Medicare, is basically an insurance program. And if I have had one failure [while serving as director of the R.I. Department of Health], if I want to be self-critical, is that I haven’t made it clear enough to people that we don’t have a problem with insurance, the problem is insurance.

That thinking, that insurance, as a financial mechanism, can impact health, is a fundamental, categorical mistake.

The real challenge for us is to feel connected enough to each other in our relationships in order to build the delivery system that we need.

And, even the delivery system isn’t adequate to create health. Health is community, and what makes health is people acting in concert, being together; health care doesn’t create health. In some ways, I’ve always believed that medical care is at war with health.

Health happens when people function in relationships. And that’s the thing for us to understand.

When people start walking to each other’s houses, that’s where health starts to happen.

When people garden together, that’s where health starts to happen.

Giving your future over to something that someone sells you, instead of doing something together, with someone you love, that’s where health falls part.

ConvergenceRI: You’re saying that health is basically about neighborhoods and communities.
FINE: Yes, it’s all about neighborhoods and communities. And, everything that we do that makes a stronger neighborhood, a stronger community, is how we create health.

Anything we do that creates something for me, undermines health.

ConvergenceRI: Is there a way to drive home – such as with the work that Ana Novais and the health equity zone grants that have a community-based focus – the importance of investing in the front end of the health care system, and promoting health and healthy neighborhoods at the front end of the system, before people get sick?
FINE: I think that’s part of the picture. Everything we do when we talk about health care, every dollar we spend, needs to be spent on leveraging the strength of communities. I think that it’s one of the things that is hard for people to see is how the existence of a consumer society has undermined the existence of communities today.

The communities that we have are on their knees, suffering. That’s the trouble we’re having creating affordable health.

ConvergenceRI: Looking at Rhode Island communities, such as the efforts to establish a neighborhood health station in Central Falls, and the high school collaborative health clinic, do you see that as one of the more exciting things that are happening in terms of a community focus on health care?
FINE: I think it’s one of the most exciting that is happening in the United States. People all around the county are beginning to look at it, how a city is thinking about changing the dynamic in health care.

It’s about a city that says, let’s grab some of the health care dollars that are being spent, because much of what is being spent is wasted, and let’s use that to create a new community institution, a place where people can be together. And, some of that might be medical care, and some of that might be bicycle repair, and some of that might be [locally grown] food and farmers markets, and some of that might be a gym.

It’s about taking the money that we’re not spending on medical care that doesn’t matter, and instead, spending it on reasons for people to be together – that does matter.

And, if we can do it in Central Falls, then we can do it in Ashton [Cumberland], and in Conimicut.

If we can do it 75 or 100 times, think of what happens in Rhode Island.

ConvergenceRI: What do you see happening?
FINE: Two things happen at once, and they’re both amazing. One is the likely drop in the cost of health insurance by 15-30 percent. If we can do that, then health care spending becomes a business magnet. People come and locate businesses here, just because of our health care.

One advantage is that there’s certainly a correlation between health outcomes and incomes.

Another great advantage is that we build resilient communities, and it’s resilient communities that we really mean when we talk about health.

ConvergenceRI: In discussing resiliency, I’ve been impressed by the fact that the recovery community in Rhode Island has begun to emerge as a constituency of consequence. While they still have a long way to go, you really changed the public health priorities around prescription drug abuse, and helped to build a coalition.
FINE: I’m heartbroken every single day about the people we are losing. And, there are too many. We’ve lost nine this week. We’re in the middle of another explosion.

But, that said, when you compare us to other states in New England – there was a recent New York Times article that said Vermont had an increase of 60 percent [between 2013 and 2014], another community had an increase in deaths in the triple digits – the 232 deaths we had in Rhode Island, each one was a disaster, but at least we stayed stable.

That’s because everyone worked together, we kind of put our shoulders together and did everything we could to talk about it, and to try and make sure that those that were using, dependent or addicted had access to treatment.

We tried to make sure that families and friends understood the risk they were taking when [people] were using.

We still have big issues here in Rhode Island about use, and why so many Rhode Islanders are using. It may have something to do with the economy.

That’s why fixing the health care system, building a real health care system, and reducing the cost of health care by 15-30 percent is so important. That’s the keystone to rebuilding the economy, to getting all those middle-class jobs that the governor talks about.

We’ve got to fix health care first, and just the [annual rise in health care spending tied] to inflation isn’t enough.

If we put our brains and hearts and hands together, we can reduce the cost of health care by 15-30 percent. And, invest those savings to build new lives and a new future for people, so hopefully they quit using so much.

ConvergenceRI: Do you think there is a need to build a clinical center to treat chronic pain in Rhode Island, one that does not use prescription painkillers?
FINE: I’ve been advocating for that for three years. We need a multi-disciplinary, chronic pain treatment center in Rhode Island, one that doesn’t focus on narcotic and opioid medication.

We need a place where, if somebody is experiencing chronic pain, there is acupuncture and physical therapy, where there is counseling and where there are [support groups], because there is really good evidence that shows that chronic pain groups really help. There are probably other modalities [that should be involved].

But we need to bring every resource we have to bear to help people who are experiencing chronic pain.

[We need] to take care of chronic pain without opioids. Because, it turns out, when you really begin to understand the mechanics of how opioids [work], you [realize] that opioids used for more than a few days at a time actually make pain worse, not better. All they do is breed addiction, and [create a problem] for someone else.

ConvergenceRI: Is there a way to make that happen, to get all those modalities covered and reimbursed through insurance?
FINE: Trying to do it with insurance is the dumbest way to do it.

ConvergenceRI: How would you do it?
FINE: We could build it. The [John E.] Donley [Rehabilitation] Center [an outpatient facility under the purview of the R.I. Department of Labor and Training] actually has most of the resources that are necessary. We would need to find a way to open the Donley Center to anyone who is suffering from chronic pain.

We could build [such a chronic pain center] at the Eleanor Slater Hospital. That’s a public facility with many resources.

Four years of experience tells me that drugs are the problem, not the solution. We don’t need to spend more time trying to figure out how to get different things covered, instead of just coming to the plate and providing the services we need.

Other countries do chronic pain centers in this way, with great frequency. We don’t even have one in the state. And, we have among the worst problems of addiction of any state in the country.

ConvergenceRI: What’s taken so long?
FINE: I don’t know. This is not rocket science. It’s not rocket science to build a neighborhood health station for every community in Rhode Island. That’s what most other countries do.

It’s not rocket science to build a network of chronic pain treatment centers. That’s what other countries do.

We walk around and say, “Gee, we spend twice as much as the average of the other industrialized countries in the world, and we’re ranked 37th to 39th in outcomes and quality.”

Why is that? Well, let’s look at the other ways in which we’re different.

In other countries, 50 percent of their spending is on primary care. Here’s it’s 5 percent. In Rhode Island, the health insurance commissioner has tried to push it up from 5 percent to 10 percent. I’m not sure we’re even at 10 percent, despite years of working at it. There are things that are counted as primary care spending that I’m not sure that I would count.

The push to invest more in primary care, the push to increase the spend, is a good thing. But, I think we need to be realistic about what our goals are. Ten percent is a drop in the bucket. We need to be at 50 percent.

ConvergenceRI: Wouldn’t that mean changing the hospital systems as we know them?
FINE: The one thing we need to do is to make sure that every Rhode Islander has access to great primary care in every neighborhood and every community.

As we do that, we ought to be able to shrink the hospital system. We can shrink the hospital system by one or two hospitals today. And, if we don’t do it, all we’re doing is perpetuating a costly infrastructure that doesn’t work.

When you build out the full delivery system of one neighborhood health station for every community of 12,000 people, it is very likely that we can reduce the total number of hospital beds by 40 to 45 percent. That means dropping [the number of hospital beds in Rhode Island] by about 900 beds.

That may sound revolutionary. But, if you think about what neighborhood health stations are, they are basically community hospitals without walls. What we’re doing is getting rid of an old technology that is expensive and doesn’t work well and replacing it with a cutting edge technology that brings every Rhode Islander into world class care – as they need it, where they need it, when they need it, in a way that builds community instead of building profit for others.

ConvergenceRI: What was the best part of the last four years, serving as director of the Department of Health?
FINE: For four years, I have been able to call it as I saw it. It’s one thing that I was really lucky about; I didn’t have to play games with what I saw.

I was also really lucky to work with a great bunch of colleagues.

We spend a lot of time making sure that we understood the science. We committed ourselves as a department to stand on the science. And, then to make the calls from [that position.]

It’s been a wonderful opportunity. I’ve had really great support from people across the state, and even sometimes from across the nation. It’s been a huge opportunity and it has been nothing but fun.

ConvergenceRI: What do you plan to do now?
FINE: I’m hoping to write books, because I think what we confront in public health is [related] to the outcomes of problems in our social and political organization.

That we haven’t imagined what it is like to really live a life together. My strong belief at this point is that I want to start working with that, tapping into the imagination that all of us have, to help us remember or imagine what it’s like to be connected to each other.

Too much time is spent at home watching television – or on mobile devices – instead of spending time together, instead of participating in the democratic process.

ConvergenceRI: How does a community become engaged in the digital world we live in? To share and to collaborate?
FINE: It’s a perception, not reality, that there’s not enough to go around. It’s a perception created by people with something to sell, in the drive of what they believe is personal profit.

Personal profit is a kind of oxymoron. If you get richer than anyone else, then who are you going to talk to?

Richness isn’t how much money you have in the bank. Richness is the connectedness you have to the people around you, whom you love, and who love you.

As the Beatles [expressed it] so well, “And, in the end, the love you take is equal to the love you make.”