Primary care for all Americans: What the U.S. health care system can learn from Scituate, Rhode Island


In the quaint New England town of Scituate, Rhode Island, with a population of 10,000, a health care revolution was brewing. Dr. Michael Fine, a passionate family physician, had moved to Scituate with his family in 1992 to serve a quiet, rural community with significant health care challenges. By 1999, though, Scituate’s residents had become very worried about the cost of health care. Two insurers packed up and left Rhode Island in a few weeks, and many people worried that the town would no longer be able to afford insurance for teachers and town employees.

By 2000, Dr. Fine had made a reputation for himself as a community organizer and an advocate for health care reform, so when the Scituate town council needed a physician to join an effort to find more affordable health insurance options for its 100 town employees, they turned to Dr. Fine. Fine had a vision for equitable and accessible care and wasn’t content with the traditional, reactive health care model. He saw the need for a proactive approach, one that focused on preventing illness and promoting wellness for the entire community, and he made the case that by investing in more access to primary care, the community would also save on other public expenses like ambulance services, police, and absenteeism of public employees.

In collaboration with town residents and two council members, Dr. Fine embarked on a revolutionary and audacious initiative: forming America’s first community health alliance. The plan was based on a concept called “population-based primary care,” and it was built on a backbone of advanced primary care paid for in a monthly per-member fee, a model now known as direct primary care (DPC). By leveraging medical savings accounts (MSAs) to cover ancillary and downstream services as needed, the health plan committee hoped to develop a comprehensive health plan that carved out predictable, prospective payments for primary care services, where most health care needs can be met.

It was not possible, however, to find an insurer able to provide high deductible insurance for town residents – and town employees were locked into traditional indemnity insurance by contract.

So the Scituate Health Alliance initially focused on providing primary medical care, then primary dental care, to every Scituate resident, understanding that primary care is the pathway to the best health outcomes at the lowest cost. The Alliance negotiated a per member per month payment relationship with a number of primary medical and then dental practices and combined it with funds raised from a community foundation, volunteer organizations, and a grant from the town council. This approach enabled the Alliance to support the primary care of any Scituate resident who lacked health insurance, making Scituate the first community in the U.S. that provides primary medical and dental care to its residents.

Now known as the Scituate Health Alliance, this process helped lead to the creation of the direct primary care movement and serves as a model of what communities can do to provide health care for themselves.

What can the broader U.S. health care system learn from Scituate? The central lesson is about the power of primary care, specifically advanced primary care, to improve lives and rein in out-of-control health care spending.

Primary care in distress, overwhelmed by too many patients and struggling to turn a thin profit, is only marginally more effective than no primary care at all. But with predictable, upfront cash flow and smaller patient panels, as seen in the DPC model, advanced primary care is liberated to unleash its full horsepower. In this setting, the most humanizing and impactful experience of health care blooms: the trusting, personal relationship between doctor and patient.

Only through this relationship can primary care serve as both partner and advocate, elevating patients’ health literacy, maximizing health promotion and prevention, and helping navigate patients through the complex and often dangerous health care ecosystem. Health care’s humble hero, the primary care physician, is a true difference-maker in society.

Dr. Fine knows this. He’s not only a family physician, he’s a public health expert, and in his 2018 book Health Care Revolt: How to Organize, Build a Health Care System, and Resuscitate Democracy―All at the Same Time, he meticulously describes the American health care problem: We don’t have a health care system, we have a largely unregulated, uncoordinated, for-profit marketplace that is making us sicker and poorer. While one may debate for hours the best way(s) to untangle this knot, there is ample evidence that primary care holds the power to increase life expectancy, improve quality of life, and reduce unnecessary health care spending.

It is with this in mind that Dr. Fine is on a new mission to rebuild American health care into a system that is “for people, not for profit,” starting with Primary Care for all Americans. In collaboration with other like-minded primary care champions, Dr. Fine is catalyzing a nationwide grassroots movement by doing what he does best – community organizing. Intended to galvanize and facilitate local and state advocacy along with national coordination, the vision for Primary Care for all Americans is one of universal primary care tailored to the unique needs of each community.

Scituate succeeded in building a better health care system because town residents were determined to make a change and they had Dr. Fine to advise them. Now, Dr. Fine wants to help the rest of America, too. The exact playbook used in Scituate might not apply to every community, but every community deserves better, more affordable health care, starting with primary care – for all Americans.

Sara Pastoor and Scott Conard are family physicians.






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