Document 10yJM7qvRpyab5Q6BvrQDZ3am

HEALTH PAC Health ' Policy Advisory Center Cant No. 28 February 1971 BULLETINe Health gether to distribute as a methodology guide for our readers. Since we have received many Research requests for bits and pieces of information about specific institutions, as well as broader Guide Guide requests for a way to figure out the total health picture in a community, we hope that this guide will not only be of general inter- est, but also of specific use to readers. INDEX This guide is made up of three interwoven PAGE components. First, it is a schematic guide I. Health Delivery Institutions . 2 to the health system - the components of the A. Classifications system, their interrelationships, key issues, B. Groupings and Associaitons etc. Second, it is an annotated bibliography, C. Researching Health Institutions listing both primary sources of information II. Health Education Institutions.. 5 A. Universities B. Medical and Dental Schools and a selected set of articles and books about the health system. Finally, it is a re- search guide, in that it suggests ways of find- C. Nursing Schools III. Doctors and Institutions. 6 A. Doctors in General B. Individual Doctors C. Doctors'Associations ing out about various institutions, programs, and issues the publications, organizations, libraries, etc. to turn to. A few words are in order about the func- tions and techniques of research, and their relation to organizing around the health sys- IV. Health Financing Institutions. 7 tem. No guide like this one can actually tell A. General Information you how to find out the most important issues B. Blue Cross or the most important power relationships in C. Commercial Insurance a particular setting. The way power works in D. Independent Private Insurance a given institution rarely corresponds to a E. Government Financing formal organizational chart. Those who hold F. Philanthropy power will rarely tell you they hold it; even V. Governmental Agencies 9 A. Federal Government more rarely will they reveal their vulner- ability. Understanding an institution is like B. State Government the work of a spy. You must talk to people C. Local Government who work in the place, use the place, or D. Quasi Governmental - Agencies know about the place doctors, medical VI. Health Products Industry 11 students, patients, community groups, news- A. General Information 0... papermen, etc. The kind of formal informa- tion you can get through the sources and B. Sectors of Industry procedures discussed in this guide help in VII. Health Workers .12.12 knowing what and whom to ask and in inter- A. Information Sources preting the answers, but that is all. Similarly, B. Worker Organizations ' the way in which power comes down on peo- VIIII. Libraries, General Reading 13 ple, the way in which they feel it, be they A. Libraries workers or consumers, cannot be read in a B. General Reading C. Organizations book. Finally, power that isn't used may be power unrevealed. The questions you ask, the agitating you do, and the organizing that comes from it evoke responses, and it is This issue of the HEALTH - PAC BULLETIN those responses, more than anything else, marks a departure from previous BULLE- TINS. In the several years that HEALTH- PAC has been involved in research and an- that are the real source of understanding how and why an institution works, how de- cisions are made and in whose interests, etc. alysis of the health system, a method of re- search has evolved. It includes the short- Research itself can be a powerful organiz- ing tool. Interviews can be part of the pro- cuts to getting information; those issues and questions that reveal institutional powers and priorities; and a familiarity with basic publications and documents of the health system. This month we pulled this information to- cess of helping people understand their own grievances and their own situation with re- spect to an institution. A workshop of people who collectively research a subject or an institution may be the nucleus of an action and / or an action group. Research even by a small group can help identify points of lever- age and points of weakness in an institution. The goal of research is often interchangeable with at least short - run organizing goals. One may find that attempts to get information (e.g., about how a hospital is planning to set up a certain program) are met with con- tinued rebuffs. The demand for information itself then may become an organizing and agitating goal, one easily coupled to a more strategic demand for an on going - release of information to the people affected by it and for an on going - role of those people in mak- ing decisions based on that information. I. Health that the institution is exempt from most taxes, from federal labor laws, and from various Delivery Institutions Hospitals, clinics, nursing homes, community mental health centers, extended care facil- ities, etc. other provisions affecting the usual private business. These institutions are generally governed by a self perpetuating - and unac- countable board of private citizens. Tradi- tionally such hospitals were heavily sup- ported by philanthropy, but philanthropy rarely accounts for more than 2-3% of their A. Classifications: There are several ways of classifying health delivery institutions which are relevant to understanding and in- terpreting statistics and other information about them. The most common classifications are by ownership and by function. 1. Ownership income at present. Included in this category are institutions controlled by religious groups (e.g., Catholic hospitals). C. Private, proprietary: i.e., profit - mak- ing, privately controlled. These are essen- tially businesses; seeking to provide health care at a profit. Many so called - " doctors ' hospitals " are in this category. In the last . Public: includes city and county few years, chains of such proprietary hos- general hospitals, state and mental hospitals, pitals and / or nursing homes have been Public Health Service and Veterans Admin- formed (e.g., Medicenters of American; Ex- istration Hospitals, etc. These are publicly owned and are financed almost entirely by tax money (directly - e.g., a city budget ap- propriates money for the hospital; or indi- rectly p- ropriates e.g., through Medicare or Medicaid paying for individual patients). These insti- tutions may be entirely and directly oper- ated by the governmental entity, or the gov- ernment may contract with a private hos- pital or medical school to provide certain services at the institutions, under an " affili- ation " agreement (see Robb Burlage: New York City's Municipal Hospitals: A Policy tendicare); in a number of cases they sell stock to the public (see Health - PAC BULLE- TIN, November, 1969; Barrons, February 10 and 24, 1969; Modern Hospital, March, 1969; American Health Empire, Ch. 7). In both pri- vate control cases voluntary - and proprie- tary - the institution's income comes largely from charges to patients (which may be paid by commercial insurance companies, Med- icaid, Medicare, Blue Cross, or others). 2. Function a. Acute care hospitals: this is the or- Report, available from Health - PAC, for a de- dinary general hospital, normally complete tailed study of the nature and impact of such with emergency room, outpatient depart- agreements). In a small but growing num- ments, maternity, pediatric, medicine, sur- ber of cases, municipal governments are gery departments, etc. turning the operation of the public hospitals over to an " authority ", similar to the re- gional authorities that run transit systems. (See Health - PAC BULLETIN, Winter, 1969) Both of the latter two institutional arrange- b. Chronic (or " long term ") hospitals: may include mental hospitals, TB hospitals, etc. These provide substantial medical care for patients staying longer than thirty days. ments are really mechanisms for turning C. Extended care facilities: in between control of supposedly - public institutions over a hospital and a nursing home in terms of to the private sector in health. medical facilities and intensity of medical b. Private, voluntary: i.e., " profit non -, " privately controlled. Note: All that " non- profit " means is that there are no share- care offered; generally for moderately ex- tended convalescences. d. Nursing homes: more or less cus- holders to whom profits are distributed, in- ( todial. They provide food, unskilled care, come may exceed expenditures, but the ex- etc. but only minimal medical services. cess is plowed back into the institution), and There is a growing category of " skilled ~~ Published by the Health Policy Advisory Center, Inc., 17 Murray Street, New York, N. Y. 10007. Telephone: 212 () 267-8890. The Health - PAC BULLETIN is published monthly, except during the months of July and August when it is published bi monthly - . Yearly subscriptions: $ 5 students, 7 $ others. Application to mail at second class postage is pending at New York, N. Y. Subscriptions, changes - of - address, and other correspondence should be mailed to the above address. Staff: Constance Bloomfield, Robb Burlage, Vicki Cooper, Barbara Ehrenreich. John Ehrenreich. Oliver Fein, M.D., Marsha Handelman, Ken Kimerling, Ronda Kotelchuck, Howard Levy, M.D., Susan Reverby and Michael Smukler. 1971. 2 nursing homes " which, under Medicare regu- lations, provide slightly more care. Length of stays are indefinite. e. Various special categories: clinics, community mental health centers (see Am- erican Health Empire, Ch. 6), specialty hos- pitals (e.g., Memorial Hospital in New York City is a cancer hospital), etc. 3. Other categorizations: In statistics, hospitals are often divided by size (number of beds), location (urban vs. rural, or part of country), relation to medical schools, whether they have programs for interns and residents (i.e., are a " teaching hospital "), special facilities or services, etc. These factors clearly affect interpretation of sta- tistics (e.g., two hospitals differ in per diem costs or average cost per day.) This could reflect different degrees of efficiency- possibly politically interesting - or it could merely reflect differences in kind of patient population, differing roles of outpatient de- partments, location, age of plant, etc.). B. Groupings and Associations of Health Delivery Institutions 1. Medical centers: a somewhat vague term, implying a grouping of several institu- tions usually geographically contiguous, un- der a more or less common administration. The complex may include acute care institu- tions, chronic care institutions, and various special facilities (e.g., an outpatient psychi- atric clinic). It may or may not include a medical school, but always includes " teaching hospital " (i.e., a hospital with training programs for interns and residents). 2. Empires: a medical school or medical center may control, through formal or in- formal mechanisms, a number of other health care institutions. Control may be formal through contracts to provide staffing, grants to operate a community mental health center, etc. or it may be informal through overlapping staffs, faculty appointments for certain staff members, teaching arrange- ments, etc. One of the most fully developed - examples is the empire centering on Einstein Medical College and Montefiore Hospital in the Bronx (see Health - PAC BULLETIN, De- cember, 1968 and April, 1969; on empires in general, American Health Empire, Ch. 1-6). 3. Associations: The American Hospital Association (AHA, 840 North Lake Shore Drive, Chicago, Illinois 60611) represents hospital interests through activities such as lobbying and provides various services to hospitals by collecting data, etc. Hospitals, a bimonthly magazine, is the AHA journal. There are also state hospital associations in most states (e.g., New York State Hospital Association) and often city or country asso- ciations (e.g., Hospital Association of Greater New York). There are also associations of special groups of hospitals (e.g., Catholic Hospital Association, 1438 S. Grand Boule- vard, St. Louis, Missouri 63104; which also puts out a journal, Hospital Progress.) Lo- cally, there may also be other special asso- ciations. For example, in New York City, the League of Voluntary Hospitals and Nursing Homes, originally formed to enable the hos pitals to bargain jointly with the hospital workers union, now plays the role of a gen- eral association of voluntary hospitals for its thirty - odd members. The Association of Pri- vate Hospitals of New York acts similarly for the proprietaries. 4. Other representatives of hospitals: As will be discussed below, such organizations as Blue Cross, local health facilities planning agencies (Health and Hospitals Planning Council in New York City), Comprehensive Health Planning Agencies in some places, and local joint fund raising organizations (United Hospital Fund and Federation of Jewish Philanthropies in New York) act in some respects as associations of local hos- pitals in lobbying, planning, etc. This re- flects the fact that in most cases these agen- cies are wholly or largely controlled by the hospitals. (see American Health Empire Ch. 10 and 14; Health - PAC BULLETIN, July / August and September 1969). C. Researching Health Delivery Institutions 1. Health delivery institutions in general a. Hospitals Guide Issue: the August ! issue of Hospitals, available separately from AHA, (see I.B.3) at $ 4.50, contains the most complete collection of statistics on beds, costs, personnel, services provided, utilization, etc. for US hospitals, broken down by year, state, type and size of hos- pital, etc. b. Local Blue Cross, hospital associa- tions, fund raising - groups, state and local departments of health all gather statistics, prepare reports on various subjects (e.g., New York State Department of Health report on wages in hospitals; New York Health and Hospital Planning Council report on capital needs of local hospitals). C. Group health organizations such as Kaiser Permanente - and the Health Insurance Plan (HIP) of Greater New York provide de- tails about their programs, as well as reprints of articles written about them. Increasingly, prepaid group practices are being set up as experimental programs in medical schools; e.g., Harvard, Johns Hopkins, Washington University University ((St. St. Louis), Yale University, Georgetown, etc. On a national level, pre- paid group practices have united in a organi- zation called the Group Health Association of America (1321 14th Street, N.W., Wash- ington, D.C. 20005), which publishes a monthly newsletter about changes in group practice organizations. d. Council of Teaching Hospitals (COTH, One Dupont Circle, Washington D.C. 20036), is a national organization that publishes periodic surveys of information 3 about teaching hospitals (i.e., those that Financing and Utilization (revisions) (Vol. train interns and residents). They have par- 1 and 1A of the Health Economics Series) ticularly concentrated on surveys of data on have useful breakdowns of statistics (e.g., salaries, organizations, and activities of in- utilization by sex, age and race). Others in terns and residents. this series are more specialized - e.g., Ma- e. Other publications: several peri- ternal Care: Utilization and Financing. These statistics are all somewhat dated, but still ~ odicals carry articles about hospitals, nurs- useful. ing homes, and their problems; new develop- ments; new laws affecting institutions, etc. 2. Individual hospitals (1) Hospitals (biweekly), 840 N. Lake Shore Drive, Chicago Illinois 60611. The journal of the AHA. Contains monthly statis- tics on the nation's hospitals and articles on hospital topics. The Guide Issue comes with a subscription. (2) Hospital Topics (monthly), 2737 W. Peterson Avenue, Chicago, Illinois 60645. (3) Hospital Progress, 1438 S. Grand a. Service and financial statistics and other information (1) The Hospitals Guide Issue (see I.C.l.a) is indispensable. It gives annual ex- penses, annual payroll, annual income, num- ber of beds, number of admissions, number of workers, number of outpatient visits, etc. as well as information on control, type of hospital, accreditations, teaching program, Boulevard, St. Louis, Missouri 63104. The etc. for every hospital in the US. journal of the Catholic Hospital Association. (2) Local planning agencies and the (4) Modern Hospital (monthly), 1050 Merchandise Mart, Chicago, Illinois 60654. (5) Modern Nursing Home (monthly), same address as Modern Hospital. (6) Nursing Homes, 4015 West 56th Street, Minneapolis, Minnesota 55435. (7) American Medical News (weekly), 535 N. Dearborn Street, Chicago, Illinois 60610. Nominally independent, but actually like may have similar compilations on local hospitals, which provide information beyond the Guide Issue. e.g., in New York City the Health and Hospitals'Planning Council puts out an annual Hospitals and Related Facil- ities in Southern New York (from HHPC, 3 E. 54th Street, New York, New York 10022). Agencies such as Blue Cross certainly collect similar information; the problem is in getting it out of them. the AMA weekly newspaper. (3) The hospital itself may have an (8) Hospital Tribune (twice weekly), 120 E. 56th Street, New York, New York 10022. annual report (large hospitals invariably it's do useful for fund raising). If they do, Medical Tribune is a slightly varied edition you can probably get it from their public of the same thing. Of these first six periodicals listed, Modern Hospital and Modern Nursing Home information office. Local libraries specializ- ing in health may have it (see VIII. A. on libraries). These frequently have finan- are the most interesting on issues of rele- cial information, information on expansion vance to health activists - hospital response plans, etc. to unions and to criticism of rising costs, new ways of using hospital facilities and workers, etc. They are also good on news about hos- pitals (strikes, conflicts with Blue Cross, (4) Non profit - institutions must file a report in lieu of a tax return with IRS (Form 990A). These are public documents - copies available by mail, for a fee, from IRS. In etc.) and on political developments affecting New York the state requires a similar docu- or potentially affecting hospitals and nursing homes. Hospitals and Hospital Topics are okay on news, and Hospitals'statistics are ment, filed with the Department of Social Services. These give financial and service data, sources of funds, etc. useful, but the articles tend to be more tech- nical (e.g., advances in how to run a hospital laundry). American Medical News and Hos- pital Tribune carry a lot of political news relevant to hospitals; the former presents the AMA outlook on these issues. 1. Hospital Literature Index, avail- able in libraries or by subscription from the AHA at $ 10 a year, indexes articles about hospitals available in the periodicals above as well as in a few hundred lesser mag- azines. One use of this familiarity - with how the index is organized permits you to find articles about specific hospitals or hospitals in specific cities. There is also an index by author, so you can find damning quotes from your favorite enemy in the hospital world. (5) Hospitals do collect extensive data on themselves, both for internal purposes and for Medicare, Blue Cross, etc. (For ex- ample, see the questionnaire at the back of the Hospitals Guide Issue which is the basis for their figures; not all the information re- ported is published). Knowledge that they have the information may be a tool for pry- ing it out of them. (6) Publicly - owned chains (i.e., those that sell stock) must have an annual report and a prospectus for their stock offering. They must also file certain information with the US Securities and Exchange Commis- sion (SEC) on stock holdings of officers, etc. Available from SEC, the company or stock- brokers. g. The Department of Health Educa- tion and Welfare Publications, Medical Care: b. Power Structure (1) Board of directors and administra- Financing and Utilization and Medical Care. tion: names are usually available from the 4 hospital. If they are recalcitrant, items in I.C.2.a.3 and I.C.2.a.4 above will provide them. Information on these people is avail- able through Who's Who in America, Poor's Register of Corporation Directors and Execu- tives, and various other sources see (NACLA Research Methodology VIII.B.2) for de- tails on tracking people down. The Boards of big protestant hospitals generally tie in to the city (and sometimes national) power structure; smaller hospitals and Jewish and Catholic hospitals'boards tend to tie in to more restricted and more minor elements of the power structure and are likely to be relatively hard to track down. Of special in- terest are tie ins - and interlocks with other health institutions, health financing and plan- ning agencies, and health products indus- tries. Note: the board of directors is rarely keyed to the day day - to - decisions in the hos pital. Directors are generally concerned with fund raising, building plans, investment of endowment, etc. But often a few members do play an influential day day - to - role as well. Also, knowing who the directors are may suggest tactics for pressuring hospitals. Note, also, that legally, the board of directors is responsible for everything that the hospital does. (2) The Medical Board and the Di- rector: (Note - the Director may be called Administrator, Executive Vice President, or other similar title). Day to day power gen- erally lies in this group. Names are often available from the hospital or from a friendly doctor who is employed by or who has ad- mitting privileges at the hospital. Try Amer- ican Men of Medicine and American Men of Science for information on them. But unravel- ing who wields what power in the informal power network that these guys are involved in generally requires inside sources - again, interns and residents, friendly doctors with admitting privileges, or even medical stud- ents and nurses may have an idea how things work (see also III.B.). C. Real estate ventures: Hospitals are generally big real estate owners in their neighborhoods neighborhoods.. The The difficulty in tracking down their holdings is that they are likely to operate through a front. One route to in- vestigating whether a particular building is owned by the hospital is to check the city registrar of deeds or other city departments which maintain public records on who owns a given property - the clerk will show you how to use the records. Then, if the owner is a company, check it out: its incorporators, and its officers and directors are porbably on file with the State Secretary of State or Attor- ney General and are probably available by mail. These should then be checked for over- lap with hospital board of directors and offi- cers. A short cut: if you know the hospital has bought up a certain building, its owner- ship (from the City) tells you who the man- agement company or other front is. Or check the hospital directors and officers in local business directories; Dun and Bradstreet's Middle Market Directory, etc. (see NACLA Research Methodology for details on doing this) to try to identify other firms whose boards they are on. Finally, a friendly local real estate agent can save you a lot of trouble. d. Research activities (1) Most research grants that a hos- pital is likely to get are from the National Institutes of Health or the National Science Foundation, both US Government agencies. Both of the latter publish annual lists of grants awarded, broken down by individual and by institution. (2) The hospital is probably proud of its research - it's good for raising money- and will probably provide a list itself. (3) Check the names of Chiefs of De- partments at the hospital in the various medical and biological abstract volumes available at science oriented and university libraries (Biological Abstracts, Science Cita- tion Index, Index Medicus, etc.) This is tedi- ous and uncertain, but it will provide infor- mation on the nature of the research a year or so after they've done it. . II. Health Education Institutions Over the past decade, there has been the growth of health science centers, consisting of medical schools, dental schools, nursing schools, social work schools, and other bio- science careers schools, all based within the university framework. These health science centers are not merely educational institu- tions; they shape the delivery of health ser- vices in a profound way. Through teaching affiliations with university hospitals, munici- pal or county hospitals, Veterans'Adminis- tration hospitals and other community hos- pitals, the university - based center (called an empire by Health - PAC) exercises control over the delivery of health services and garners the needed " teaching material " (pa- tients) to discharge its educational function. A. The University: most medical schools and many nursing schools are part of the university and must be researched in this context. The methodology for such research has been extensively developed (i.e., see NACLA Research Methodology). B. The Medical and / or Dental School 1. Separate Incorporations: Although most medical / dental schools are part of a university, very often they are incorporated separately - i.e., there is a different board of trustees for the university and the medical 5 eet school. This means that the medical / dental school has its own power structure, its own real estate holdings and its own research ac- tivities (see I.C.2). The relationship between the university and the medical / dental school -boards, financing, real estate - may sug- gest revealing interconnections. 2. Regional Planning: Medical schools have developed a special relationship to the Regional Medical Programs RMP () of the federal government. Some medical schools have used this program to consolidate their hegemony over state or regional health ser- vice delivery institutions. Look for the local medical school's role in this program (see V.D.2). 3. 3. Associations: Medical schools have traditionally been accredited by the Amer- ican Medical Association. But in recent years, they have achieved increasing independence from the AMA, as indicated by the growth in importance of the medical school's own na- tional organization, the American Association of Medical Colleges (AAMC, One Dupont Circle, Washington, D.C.). AAMC publishes a monthly Journal of Medical Education (15 $ a year) which is useful for its opinions on national legislation and its statistics on med- ical school admissions. C. The Nursing School 1. Nursing education is in transition: In the past, most nursing education was done through hospital - based programs. But re- cently, there has been a move to make it a part of the university. In most universities, however, nursing does not have the endow- ment, independence and power of the med- ical school. 2. Types of nursing education leading to RN degree a. Hospital - based nursing education: these are three year nursing programs- called diploma schools - conducted within the hospital and leading to a certificate of nursing. These programs were used by large hospitals as a cheap source of nursing labor, since students often work in the hospital dur- ing their training and several years after- ward to pay back the cost of their training. b. University - based nursing educa- tion: these are four year - college programs- called Baccalaureate Degree programs --- leading to a B.S. degree in nursing. Gradu- ates tend to become supervisory nursing per- sonnel, nurse educators or more independent public nurse practitioners. C. Junior college or community col- lege nursing education: these two year - pro- grams called - Associate Degree programs- are the most rapidly expanding form of nurs- ing education. However, two year - graduates are very clearly tracked. They usually be- come staff nurses and rarely enter super- visory or teaching positions. In many large urban areas, these programs have a concen- tration of black and Puerto Rican graduates, in contrast to three- and four year - graduates who are largely white. 3. Licensing: Licensing of nurses is a state function. The State Nurses Association, in many states, has developed strong ties to the licensing process. 4. Organizations: Nationally, nurses are represented by two organizations. The Amer- ican Nurses Association (ANA) sets stand- ards for nursing practice (see VII.B.1). It is comprised entirely of nurses. The National League for Nursing (NLN, 10 Columbus Cir- cle, New York, New York) sets educational standards for nursing and accredits nursing schools. It consists of doctors, nurses, as well as others. The League publishes a monthly magazine, Nursing Outlook, (6 $ a year) which gives opinions on national legislative issues and trends in nursing education. 5. Student Groups: The Student Nurses Association (10 Columbus Circle, New York, New York publishes a quarterly magazine, Imprint ($ 3 a year). Nationally it is the student wing of the ANA, but locally there is considerable variation among chapters, with some groups actively involved in community service projects. III. Doctors cians, Hospitals and Hospital Beds in the United States (by census region, state, city, and Their and metropolitan area); Survey of Medical Groups in the United States; Physician Char- Associations acteristics, 1963 and 1967. 2. Government publications: The US Doctors and the AMA have lost some of their government publishes similar studies - gen- power over national and local politics and erally done by the Public Health Service in health policies in the last decade but still re- HEW. See, for example, Health Resources main, in many instances, as the chief ob- Statistics: 1969. State and local health de- stacle to change. partments and county and state medical sta- A. Doctors in general tistics numbers - , distribution by area, dis- tribution by specialty, etc. (E.g., you could 1. The AMA (535 N. Dearborn, Chicago, get statistics from the city to document that Ill. 60610) publishes various statistics and ghetto areas have far fewer doctors per studies. For example: Distribution of Physi- capita than middle class areas.) 6 3. Other publications: The American generally contain listings by the doctor's Medical News and Medical Tribune (or Hos- name. The various abstracts discussed in pital Tribune) -- see I.C.l.e. for addresses- that section are most useful here. (For as well as Medical World News (weekly, 299 Park Ave., New York, New York 10017) contain technical news in semi popularized - numerous other sources of biographical in- formation see the NACLA Research Method- ology). form, legislative news of studies about doc- tors, news of conferences, etc. C. Doctors'Associations B. Individual doctors 1. National: The AMA is, of course, the big one. The American Medical News, the 1. Reference books: American Men of Medicine and American Men of Science AMA publication, is a good source on cur. rent goings on, policies. Several expos available in the reference section of most books exist on the AMA, and any book or libraries, are limited, but sometimes useful. article on history of health legislation, recent or ancient, will have information in its 2. Newspapers and magazines: News- policies. paper files may have news items in which a person you are interested appears. Check the New York Times Index and The Readers 2. State and local: There are also state and local medical societies and societies of Guide to Periodic Literature. 3. Other sources: The sources of infor- mation on research at a hospital (see I.C.2.d) specialists, all of which are likely to have local branches. Publications are common but not universay sometimes technical, but often newletter - like. IV. Health Financing Institutions Almost two thirds - of the cost of personal health services is borne by insurance com- panies, government, Blue Cross, etc. These are the called so - third " parties " (The patients and the providers are the first two parties). With the private mechanisms (Blue Cross, commercial insurance) failing to cover health needs of Americans, government financing has become increasingly important during the'60's (Medicaid and Medicare). The out- look is for more of the same, but look for the private third parties to control profits from new government financing mechanisms. (For example, they now serve as " intermediaries " administrators for the Medicare and Med- icaid programs). A. General Information 1. For historical perspective: see Herbert and Anne Somers, Doctors, Patients, and Health Insurance (Brookings Institute, Wash- ington, D.C. 1961); Herbert and Anne Som- ers, Medicare and the Hospitals (Brookings Institution, Washington, D.C. 1967); and Eugene Feingold, Medicaid: Policy and Poli- tics (1968). 2. For statistics: see Department of HEW, Medical Care: Financing and Utiliza- tion, and Medical Care: Financing and Utili- zation (Revisions). More recent figures are in the Social Security Bulletin (put out by the Social Security Administration) which has an annual review on the subject (gen- erally by L. Reed and co workers -) . Cost indexes can be found in the Bureau of Labor statistics monthly, The Consumer Price Index, or in slightly less detail in the Department of Labor's Monthly Labor Review. 3. For industry data: see Health Insur- ance Institute (227 Park Ave., New York, New York, 10017 -publishes) an annual Source- book of Health Insurance Data. (It's free). B. Blue Cross 1. Nationwide network: There are 70 odd - Blue Cross's, each providing hospitalization (not medical, Blue Shield does that) insur- ance in a state or part of a state. The various Blue Cross's are linked by the Blue Cross As- sociation (840 N. Lake Shore Drive, Chicago, Illinois 60611) which lobbies, collects data and performs studies, runs a bank which per- mits travelers to use their Blue Cross benefits out of their region, etc. Note that the Blue Cross Association address is the same as that of the AHA. In general, Blue Cross is tightly tied to the big voluntary hospitals, bothe locally and nationally. Blue Cross lo- cally is also often tied to the State Insurance Department, which supposedly regulates them. See American Health Empire, Ch.10, for more on Blue Cross. 2. Non profit - status: Blue Cross is a non- profit, tax exempt - health insurance agency. It is set up in most states under special en- abling legislation, generally providing that it should be regulated by the state insurance department. In some states, it must submit to a public hearing before raising its rates. To the extent that its records are public, the state insurance department is the place to look. The information available in New York State includes fairly detailed financial information, either gathered routinely or in connection with rate hike requests. Watch out though- the latter information is designed to prove a case and may be seriously distorted. 7 3. Publications: The Blue Cross Associ- Washington, D.C. 20005), which publishes ation publishes several periodicals and news- material on many of the plans, a newsletter. letters. etc. 4. Note: many local Blue Cross's may E. Government Financing have some other official name. In New York City, it's " Associated Hospital Service of New York. " 1. Generally: Government at all levels finances close to 40% of health care expend- itures. These expenditures include those for C. Commerical Insurance operating patient care facilities (city and 1. Power structure interlocks: Several hundred companies, generally life insurance state hospitals, Public Health Service and V.A. hospitals, clinics, etc.); public health ac- tivities; aid for construction of health facilities companies, write health insurance (both hos- pitalization and medical), but the business is dominated by a half dozen or so (Prudential, Equitable, Aetna, Metropolitan, Connecticut General, etc.). Power structures of these com- panies overlap with medical schools and hos- pitals, and participation by insurance com- (the Federal Burton Hill - act, etc.); as well as Medicare (federally sponsored and sub- sidized health insurance for the aged) and Medicaid (federal - state - local matching funds for health care for the poor). A summary of the Federal role including detailed statistics can be found in The Federal Role in Health, pany big wigs - on government policy making or advisory boards on health matters is increasingly common (see Health - PAC BULLETIN, November, 1969 or American Health Empire, Ch.7). Insurance companies a report of the Sub committee - on Executive Reorganization, Committee on Government Operations, US. Senate, 91st Congress. Sta- tistics on the various programs can be found in the Statistical Abstract of the United States are also becoming involved in setting up health services, generally in cooperation with medical schools (see Health - PAC BULLETIN, January, 1971) as in Boston, St. Louis, and Baltimore. (annual, US Government Printing Office, Washington, D.C. - an indispensable vol- ume), in periodic articles in the Social Se- curity Bulletin, and in state Statistical Ab- stracts (a list of which can be found at the 2. Financial data: Industry - wide finan- cial data is available in references above (see IV.A.2). On individual companies, an- nual reports are available from the com- panies in The Insurance Almanac (annual, Underwriting Printing and Publishing Co., New York, New York) in the library. 3. Trade association: The trade associa- tion for the health insurance companies is the Health Insurance Institute, (see IV.A.B.) back of the Statistical Abstract of the US The Senate hearing referred to above also has extensive statistics. For local and state government expenditures, try the state sta- tistical abstracts. Also, the state and local operating (or expense) budgets and the capital (or building) budgets are public in- formation. They are generally available in larger libraries or in municipal or state refer- ence libraries. If you are lucky (in New York City you are), there will be a summary ver- 4. Publications: The business press (e.g., Wall Street Journal, Forbes, etc.) cover developments in the field, since it's big busi- ness (billions a year in premiums). Try the Wall Street Journal Index and the Business Periodicals Index in the library. The latter covers trade journals, major stock analysts reports, etc. There are several insurance sion of the budget available as well as the detailed line item budget. For specific pro- grams, both budgetary and programatic, the agency that runs the program will generally be the major source. They may or may not be cooperative, but summary information, at least should be fairly easy to come by. 2. Specific funding: On Medicare and trade journals oriented toward insurance Medicaid, Hill Burton - , etc.: Detailed statist- brokers, but they are not very useful. D. D. Independent Private Insurance: A small part of the nation's health insurance is writ- ten by independent, generally non profit - plans, e.g., the Kaiser Health Plan in Cali- fornia, Oregon, Denver and Cleveland; Health Insurance Plan of Greater New York (HIP), some independent union plans such as that of District 65 in New York. Legally, these are usually incorporated under the same enabling legislation as Blue Cross and must file similar reports with the state insur- ance department. Research can be done along similar lines to Blue Cross research. Many of these plans are some variation on prepaid group practice (see Health - PAC BULLETIN, November, 1970), and have a ical reports appear periodically in the Social Security Bulletin. Changes in the legislation and in the regulations are well covered - by the hospital and medical trade journals (see I.C.l.e and III.A.3). If you are really gung - ho about following it, HEW will put you on the appropriate list for releases about the pro- grams. The Hearings on Medicare and Med- icaid, and the Staff Report on Medicare and Medicaid: Problems, Issues, and Alterna- tives of the Senate Committee on Finance, 91st Congress, are a current discussion of the programs. On Hill Burton - , the program itself (in HEW) puts out a fairly endless array of reports, surveys, histories, etc. F. Philanthropy: Philanthropy is no longer a major factor in financing hospital trade association, the Group Health Associ- operations (less than 2% of total operating ation of America (1321 14th Street, N.W., funds of hospitals, although for a few indi- 8 vidual hospitals it may be much more). It is a major source (about 30% nationwide) of funds for capital (buildings and major equipment) needs. Nevertheless, the hos- pital boards of directors are still generally set up to obtain philanthropic donations and to give power to the philanthropists (e.g., to sit on the board of many major New York hospitals, an annual donation of 5,000- $ 10,000 $ or more is both necessary and suffi- cient). Hospital annual reports often list all major contributors; look for overlaps with the board of directors and also for representa- tives of big health industries (drug com- panies, etc.). A considerable chunk of philanthropy is centralized in fund raising organi- zations, which service several hospitals and nursing homes, e.g., in New York, the United Hospital Fund (UHF), the Federation of Jewish Philanthropies, and Catholic Chari- ties. These organizations are major meeting places for various hospital interests (e.g., the United Hospital Fund Board is made up of representatives from big voluntary hospitals of the city; in turn, the UHF Board overlaps with and plays a major formal role in se- lecting the Blue Cross Board of Directors). These agencies prepare statements on hos- pital needs, compile statistics, maintain health libraries, etc. They have annual reports. V. Governmental 3. Regulatory agencies and Quasi Govern- - . HEW does some regulation in the guise of regulating Medicare and Medicaid. mental Agencies Government, at all levels operates services, finances the health system and to a limited degree, regulates it. For example, there are some (minor) cost controls in these programs. To be reimbursed under these programs, the hospital must pass certain quality standards (generally set by Joint Committee on Accreditation of Hospitals approval- (see V.D.3 below). A. Federal Government b. The Food and Drug Administration 1. Note: According to federal law, vir- tually all documents and records except those " necessary for national security " are public information. The problem is knowing that the documents even exist, or who has them. A lawyer or the threat of one may help in prying documents loose; agencies don't like the law. (FDA) and the Federal Trade Commission (FTC) regulate drug research, quality, and advertising. There have been many exposes of the failures of the agencies. See, for ex- ample, Morton Mintz, By Prescription Only, (HOUGHTON - MIFFLIN COMPANY, 1967) and the series of articles in Science mag- azine on the Panalba and cyclamate stories (1969-70). For more details, see Report of the 2. Operating agencies (Fountain) Subcommittee of the House of Representatives Committee on Government . The Veterans Administration: oper- Operations (1970). The Pharmaceutical ates a chain of hospitals for veterans. Manufacturer's Association Newsletter Com- Some, but not all, are pretty grim - see the mentary and Bulletin (free, from PMA, 1155 Life Magazine expose, summer 1970. 15th Street, N.W., Washington, D.C. 20005) b. The Department of Defense: oper- ates medical facilities for men on active duty in the armed forces and their dependents. C. Department of Health, Education and Welfare: funds research through the National Institutes of Health (NIH) and Na- tional Institute of Mental Health NIMH (). Both are part of the Public Health Service (PHS). It operates hospitals for Indians and several other groups through the PHS. It ad- ministers the Comprehensive Health Plan- ning and Regional Medical Programs through the Health Services and Mental Health Ad- ministration HSMHA () and it administers the Medicare program through the Social Security Administration, and Medicaid through the Social and Rehabilitation Ser- vice. d. Other agencies: A lot of miscella- provide a detailed and biased commentary on FDA and FTC affairs, hearings, proposed changes in regulations and laws, etc. 4. Policies: The hospital and medical trade journals (see I.C.l.e and III.A.3) are reliable and generally adequate guides to what's going on in Washington, health - wise. They cover everything from new laws to why the President doesn't like the Secretary of HEW's tie all - a suitable tribute to the twenty - odd billion dollars in health money that comes from Washington. If your budget is limited, Modern Hospital and the American Medical News alone are indispensable and will enable you to know more than the aver- age hospital administrator. If you are rich or have access to a library, the Washington Re- port on Medicine and Health (60 $ a year, National Press Building, Washington, D.C. 20004) and the American Public Health Asso- neous agencies operate smaller programs. ciation's Washington Newletter (40 $ a year For a complete run down - , see the hearings on from APHA, 1740 Broadway, New York, New The Federal Role in Health (see IV.E.1). York) are even more up to date and com- 9 plete. The Congressional Quarterly (in libra- ries) helps keep track of where health legis- lation is, and the AFL - CIO News (815 Six- teenth Street, N.W., Washington, D.C.) pro- vides the labor viewpoint, often not unim- portant in health matters and neglected by the hospital journals. B. State government 1. State laws: Various states have differ- ent laws relating to health care. In the case of New York State, the laws are detailed and far reaching. The state licenses doctors and facilities, runs hospitals, sets standards, run inspections, can veto even private hospital construction, sets regulations and pays part of the bill for Medicaid (as well as determ- ining coverage and eligibility), and can even order a hospital to start providing a service or to buy a piece of equipment. Many of these powers are seldom used. The state also collects voluminous information on the health system, prepares studies, etc. You can get on their mailing list and get them all. 2. Other sources: State legislators are generally accessible. Ask them to put you on the list to receive reports, mailings, press re- leases from the Legislative Committee deal- ing with health legislation. Local community service organizations may also have a con- tinuing watch on health legislation. In New York City the Community Service Society of New York prepares reports on pending legis- lation and an annual prospective report on Health Legislation in New York State (both free from the Society, 105 E. 22nd Street, New York, New York 10010). C. Local government 1. Power structures: Again, local laws and practices vary, but don't be fooled. Health policy is almost invariably controlled by pri- vate interests - either by the local power elite in general or often, by the private hospitals and / or county medical society. The mechan- isms and implications of such private sector domination is the central area for research on urban health policy, far more than the ins and outs of local laws: i.e., who controls ap- pointments, the make - up of advisory commit tees, who sets policy, etc. For more on re- searching local power structures, see the NACLA Research Methodology; Lamb, How to Research your own Hometown; Hamburg, Where It's At: A Research Guide to Com- munity Organizing; and Minnis, The Care and Feeding of Power Structures (all but Lamb from New England Free Press, 791 Tremont Street, Boston, Massachusetts 02118; for Lamb, try Radical Education Project, P.O. Box 561A, Detroit, Michigan 48232; it was originally published in Human Organization, summer 1952). 2. Other sources: Information on policy shifts can be found in local newspapers (they may have an annual index - e.g., New York Times Index), in the mayor's annual budget message, in speeches by local health or hos- pital department officials (check the Hospital Literature Index under their name; see I.C.l.f). There also have been special commis- sions with reports on health policy, which have been published (e.g., in New York City, the Piel Commission Report which was one of the building blocks for setting up the re- cent Health and Hospitals Corporation). Mayors and city departments gener- ate lots of public relations material. Try the public relations office of the city Department of Health and also the Mayor's office. If you get on their list, your problem will be sifting through the daily stack of press releases. There may be public hearings on va- rious health issues. For example, in New York there were hearings on recently proposed changes in the regulations governing the performance of abortions. Some public agencies or departments may have an annual report. These reports are half public relations, half political speech, but they do give the department budget, some operating figures, and possible hints of policy directions. They are also good sources of quotes to hang people with, and if you're lucky, you can discover and reveal the outright lies. D. Quasi governmental - agencies 1. Planning agencies: During the post war - period there has been a movement to de- velop various kinds of health planning agen- cies. The 1940's Hill Burton - Act, which pro- vided Federal funds for hospital construc- tion, required that each state set up an agency which would have to approve appli- cations for Hill Burton - money. Although vested with governmental status through their Hill Burton - role, the agencies that were set up were generally private non profit - or- ganizations. The spread of these agencies came about because it was in the interest of the large voluntary hospitals and Blue Cross. For both, maximum economic advan- tages were found when hospitals operated at close to full capacity; this required a mechanism to ensure that bed supply would be kept limited. In a few states, most notably New York, the resulting agency was granted legally binding veto power over all decisions to build new hospital facilities. These agen- cies are called " facilities planning agencies " since their planning role extends only to facil- ities, not to programs, organization of ser- vices, etc. In general, these agencies have been pawns of the big voluntaries and Blue Cross. In 1965, the Federal " Partnership for Health " act provided money for states to set up comprehensive health planning (CHP) agencies (which would now take on pro- grams, etc.). Under the law these agencies were to be a partnership of government, health care providers, and consumers, with consumers being in the majority on the boards of directors. In most places, one of two things has happened. Either the old vol- untary hospital dominated - facilities plan- 10 new CHP agency, with an expanded board Greater New York, Inc. " For more on the giving " consumers " (like as not a bank program and on the New York experience, president is listed as a " consumer ") a theo- see American Health Empire, Ch 13 and 15. retical majority. Or there has been a strug- The National RMP office in (HEW) puts out gle between local government and the old a newsletter describing policy, local deci- facilities planning agency which has re- sions, local grants, etc. Some of the local sulted in a compromise, such as both join- RMP organizations also put out newsletters. ing in setting up an agency to plan the new The various hospital and medical magazines CHP agency. (The latter is what happened carry some RMP news, primarily at the na- in New York City). For more on facilities tional level. planning agencies and CHP agencies, see American Health Empire, Ch.13 and 14. These agencies, in any case, may play a major role in setting health policy, and are often a mechanism for private health inter- ests to exert power over the city's health re- sources, both public and private. They also collect and publish useful statistics and other studies. The New York agency, the " Health and Hospitals Planning Council " (3 E. 54th Street, New York, New York), puts out an annual report with useful information about the council itself and with a review of 3. Joint Commission on Accreditation of Hospitals (JCAH, 925 N. Michigan Avenue, Chicago, Illinois). This is a group, made up jointly of representatives from the AMA, the AHA, and several medical specialist organ- izations, that is the medical profession's self- policing agency to maintain hospital quality. Every two years, hospitals are inspected, and if they pass (most do), they are " accredited. " The standards for accreditation have recently (1971) been revised (available for $ 5 from JCAH). Groups such as the National developments on the health scene in New York City and State in the past year, as well as of upcoming issues. 2. Regional Medical Program (RMP): Welfare Rights Organization have attacked the JCAH, demanding a consumer role in the accreditation process, publicization of the results of the JCAH studies of individual hospitals, etc. A few big city hospitals (Cook Another 1965 law provided money for med- County, Boston City, etc.) have recently ical schools and other existing health re- either lost their accreditation or been put on sources to set up " regional cooperative ar- probation potentially serious in terms of rangements " to improve patient care and obtaining staff and of being eligible for bring the fruits of research to day day - to - Medicare and Medicaid payments (not to medical practice more rapidly. Medical speak of what it suggests about the quality schools and medical societies moved to set of care in these hospitals). The Hospitals up such regional organizations, which they Guide Issue (see I.C.I.a) tells whether a par- oy have since used almost solely for their own ticular hospital has JCAH accreditation. If advantage and not to any great extent for it doesn't, finding out why may be useful. the purposes of the act. The New York The demand for access to the JCAH report on Metropolitan area RMP organization, dom- the hospital favorable or not, and for partci- inated by the city's seven medical schools, pation in the next evaluation may be useful is the Associated " Medical Schools of organizing issues. VI. Health Products Industries The health products industry is a multi - bil- lion dollar sector of American capitalism. Prominent trends are increasing integration among the various sub sections - of the indus- try; diversification of health products com- panies with other fields and or outside com- panies into health products; growing inter- locks between health products companies and health delivery institutions; and a grow- ing interest of health products companies in health policy issues. A. For general information on the whole industry. See American Health Empire, Ch.7, or Health - PAC BULLETIN, November, 1969. Also, Fortune, January, 1970. Stock analysts ' reports (Value Line, etc.) and stock broker- ages (the late Goodbody & Co.) put out inter- esting surveys of the industry, with both general information and statistics and details on individual companies. Also, check the New York Times Index, the Wall Street Journal Index, and the Business Periodicals Index for survey articles (the last of these indexes major stock analysts reports as well business magazine). B. Sectors of the Industry 1. Drug Companies a. General references (1) Morton Mintz, By Prescription Only (2) Estes Kefauver, In a Few Hands: Monopoly Power in America (3) US Department of Education and Welfare, Second Interim Report of the Task Force on Prescription Drugs, and background papers for the report, especially The Drug Makers and the Drug Distributors; The Drug Prescribers; and The Drug Users (all 1969). These make up a very useful and current survey of the industry and some of the issues -although it's hardly very penetrating or radical in its analysis. 11 (4) US Senate, Subcommittee on Anti- trust and Monopoly of the Committee on the Judiciary, Report on Administred Prices of Drugs (1961). This is the Kefauver report. There are also volumes of hearings. (5) US Senate, Subcommittee on Mo- nopoly, Select Committee on Small Business, Hearings on Competitive Problems in the Drug Industry (14 volumes so far, 1967-70). (6) American Health Empire, Ch. 7, or Health - PAC BULLETIN, November, 1969 have sections on the drug industry. (7) Rick Barnhard, The Drug Industry (mimeo, 1970). Available from Health - PAC. b. Trade associations (1) The PMA (see above) puts out weekly Newsletter and occasional commen- taries and Bulletins. (2) Several publications aimed at re- tail pharmacists carry industry news. Try Drug Topics (330 W. 34th Street, New York, New York 10001), American Druggist (224 W. 57th Street, New York, New York 10019) and Weekly Pharmacy Reports, (1152 Na- tional Press Building, Washington, D.C. 20004). 2. Hospital Supply Companies . General References (1) Electronics for Hospital Patient Care, U.S. Government Printing Office. (2) Technology and Manpower in the Health Service Industry. Lots of information and references on technological change in health services, ranging from automated laundries to patient monitors. (3) Health - PAC BULLETIN, American Health Empire and Fortune. See VI.A. (4) To get sense of the kind of prod- ucts available, check the ads in any of the hospital journals. 3. Hospitals and Nursing Homes for profit: General references see I.A.1.c. C. Specific companies: Again the various business periodicals indexes (see VI.A) and stock analysts and brokers reports are useful. Annual reports are available from the companies with no hassle. Poor's Register of Corporations, Moody's Industiral Manual, Standard and Poor's Corporation Records, and other similar volumes are readily avail- able in libraries and are useful. See the NACLA Research Methodology for more details. VII. Health Workers and Their 3. US Government Printing office: The Statistical Abstract of the United States con- tains summary figures on health manpower. Organizations 4. The American Nursing Association (ANA, 10 Columbus Circle, New York, New Health workers, including hospital work- ers, technicians, nurses, social workers, etc., are growing n unmbers and power within the York 10019) publishes a lot of material on nursing, including the annual compilation of statistics, Facts About Nursing. health system. 5. The New Careers Association (Rm. A. Sources of information on health 238, 239 Green Street, New York, New York workers, other than doctors 10003) is primarily concerned with the move- ment for training community people as para- 1. The US Department of Labor puts out professionals; it also deals with the develop- various studies on health manpower. For ex- ment of training and upgrading programs ample, Health Manpower, 1966-1975 (a sur- (i.e., " career ladders "). It publishes a news- vey); Technology and Manpower in the letter and occasional papers. Health Service Industry, 1965-1975 (a useful study of the impact of developing health technology on various types of health workers); Industry Wage Survey: Hospitals (a detailed study of hospital wages, issued every three years). 2. The US Department of Health Edu- 6. The various hospital and medical journals (see I.C.i.c. and III.A.3) have articles on changing manpower practices, new types of jobs (like physicians assist- ants), on unionization of hospital workers, etc. The Hospital Literature Index (II.C.l.f.) is useful in locating these. cation and Welfare put out similar studies. For example, Health Manpower Perspective: 1967; Health Manpower Sourcebook (Sec- tions 1-19) (each section deals with another 7. H. I. Greenfield, Allied Health Man- power (Columbia U. Press, 1969) is a good survey of health manpower other than aspect of health manpower and new sections nurses. continue to appear. HEW will send you a list of the entire series.); Health Resources Sta- tistics (an annual compilation of statistics B. Organizations of Health Workers 1. Professional associations: The most on all the major health occupations - num- bers, distribution, etc. with a short essay on important is the American Nursing Associa- tion (10 Columbus Circle, New York, New shifts, future supply, changes in training York). In addition to the material referred to requirements.) above (see VII.A.4), the ANA publishes 12 the monthly American Journal of Nursing, which carries both technical articles and workers). It organizes both skilled and un- skilled hospital workers, but has concen- news on changing nursing education as well trated mainly on the less skilled. In New as ANA affairs. There are also state nursing York City, it represents most workers in the associations in every state. In recent years, city hospitals. the ANA and its state units have come to act ft increasingly like a union: it enters National Labor Relations Board representational elec- tions, engages in collective bargaining and signs contracts for its members, wages strikes, and increasingly cooperates with AFL - CIO unions. It still has an extensive overlay of professionalism, however, with su- pervising nurses and staff nurses sharing the C. Service Employees International Union (SEIU), AFL - CIO is a union of service workers in all sorts of institutions. In hos- pitals, it concentrates on less skilled em- ployees. In New York City it is restricted to proprietary hospitals and nursing homes, but elsewhere (as in San Francisco and Chi- cago) it is not so limited. same organization. Virtually every other health profession or quasi profession - (e.g., practical nurses, X- ray technicians, lab technicians) have their own professional organization (check the Directory of National Trade and Professional Associations in the United States to locate them). These are likely to compile statistics and material on current developments in the trade. 2. Unions: Unions are big news in hos- pitals these days. See Health - PAC BULLETIN, July August - , 1970, for brief history and an- d. Others: Everyone and his brother is out for hospital workers. The Teamsters and the American Federation of Government Em- ployees probably have the largest number of hospital workers enrolled in this category. There are no good sources of information and no useful single study on hospital unions. Unions themselves publish news- papers - but the statistics they provide tend to be unreliable. The hospital journals have had a series of poor and biased articles on the hospital unions, but their news sections do often carry news of organizing drives, alysis. Several major unions are organizing strikes, etc. hospital workers. 3. Radical health workers organizations: . National Union of Hospital and In a number of cities, there are now radical Nursing Home Employees, a division of the groups of health workers active in hospitals. Retail, Wholesale and Department Store The local Medical Committee for Human Union, AFL - CIO. It is better known as 1199, after the original and largest local in New York City. Locals in other cities are called 1199A, 1199B, etc. - the latter in many cases relating to the name of the city. The union seeks to organize primarily voluntary hos- pitals and nursing homes, although in a few cases it has been involved in government or proprietary institutions. 1199 has also organ- ized university workers. It organizes all levels of hospital workers except doctors and registered nurses. On 1199, see Health - PAC BULLETIN, July August / , 1970. b. American Federation of State Rights (MCHR) chapter is likely to be the organization or to be able to guide you to it (see VIII. C.l.c.). Revolutionary Unity Movement (HRUM, 150 Fifth Avenue, Rm. 843, New York, New York) is a third world health workers group organizing within the hospitals. HRUM pub- lishes an occasional newspaper, " For the People's Health. " In addition, social workers groups around the country are turning to health issues. The Social Welfare Workers Movement (SWWM, Box 2492, Cleveland, Ohio 44112) publishes a bimonthly news- paper, Hotchpot. Social Work Action for Wel- County and Municipal Employees (AFS- fare Rights (SWAWR, 242 East 14th Street, CME), AFL - CIO, as its name suggests, is New York, New York 10003) is a New York active mainly in city, state, and county hos- City group which publishes an occasional pitals (as well as other types of government newsletter. VIII. Libraries, General Reading, Organizations A. Libraries 1. In addition to university and public libraries, there are more specialized health libraries. Medical school libraries usually have some material. Local Blue Cross, fund raising organizations, facilities planning councils, etc. are good bets. In New York, try the United Hospital Fund reference li- brary (3 E. 54th Street,) the Department of Hospitals library (125 Worth Street) and the New York Academy of Medicine library (101st Street and 5th Avenue) (at the last, tell them you are " general public ", not a stu- " dent "). There exists a Directory of Special Libraries and Information Centers, edited by A.T. Kruzas, available at the library, to help you find such libraries locally if the above organizations fail you. On local government, there often is a municipal reference library. B. General Reading 1. The American Health Empire: Power, Profits, and Politics. A Health - PAC Book (Random House, New York, 1970) is an ex- pansion of a series of articles from the 13 Health - PAC BULLETIN $ (7 a year, Health- Pa. 19146 plus numerous local chapters. PAC, 17 Murray St., New York, New York 10007). Many of the chapters are available in earlier and less complete versions in indi- d. Health - PAC, 17 Murray Street, New York, New York 10007. vidual issues of the BULLETIN, and, of course, subjects covered by the BULLETIN since early 1970 are not included. The only systematic and more or less complete radical analysis. 2. Student Organizations: There are two dominant national student organizations: the Student Health Organization (SHO, 1613 East 55th Street, Chicago, Illinois) started as a liberal organization and has transformed 2. NACLA Research Methodology Guide (North American Congress on Latin America, P.O. Box 57, Cathedral Park Station, New York, New York 10025; $ 1.25). itself into a locally - based, more radical group. Its constitutency is not only medical students, but also nursing, social work and dental students. The present orientation of SHO is to build loAcamlelyr -i cbaasned health collec- 3. Raoul Tunley, The American Health tives. The Student American Medical Asso- Scandal (Dell Publishing Co., 1966). A popu- ciation (SAMA, 2365 Flossmoor Road, larized expose on the sorry state of the Amer- Flossmoor, Illinois) is a medical student or- ican health system, with chapters on foreign ganization which has traditionally been a health systems. conservative group. Recent attempts at liber- alization have resulted in SAMA's involve- 4. Fortune, Jan. 1970, a special issue on ment in some community service programs. Our Ailing Medical System. The corporate The New Physician is its monthly magazine. liberals speak. 3. Legal organizations: There have been 5. Milbank Quarterly. January, 1968, several groups formed to work on issues Part 2, Dimensions and Determinants of of health law. These groups have much of Health Policy. A compilation of a dozen or the expertise in health legal matters. so articles on various aspects of health policy, generally from the point of view of " health liberals " open to change in the health system as long as it doesn't go too far, Gi. National Legal Program on Health Probelms of the Poor is an OEO financed center that has concerned itself with issues (contrasted with the reactionary or stand- of medicaid, housestaff organizations in mu- 1 fast attitudes of the AMA). nicipal hospitals and the JCAH. Write to: 6. Herbert and Anne Somers, Doctors, Patients, and Health Insurance (Brookings Laurens Silver, UCLA School of Law, 405 Hilgard Avenue, Los Angeles, California 90024. Institute, Washington, 1961), is dated in its statistics but is a good history of health b. Health Law Project (o c / Ed Sparer, financing and related matters. The same au- University of Pennsylvania Law School, 133 thors'Medicare and the Hospitals (Brook- S. 36th Street, Rm. 310, Philadelphia, Pa. ings Institute, Washington, D. C., 1967) along 19104) is a newly formed group of lawyers with Eugene Feingold's Medicaid: Policy and in Philadelphia concerned with issues of Politics bring the story almost up to date. quality and the dual system in health care. Beyond that, magazine articles such as Health - PAC BULLETIN, January, 1970 (or American Health Empire, Ch.12) are re- quired. 7. Women and Their Bodies (distributed C. Columbia Center on Social Welfare Policy and Law (401 W. 117th Street, New York, New York 10027) is concerned largely with medicaid and medicare litigation around issues resembling welfare litigation by, the New England Free Press, 791 Tremont of the mid 1960's - . Street, Boston, Massachusetts 02118 for $ 0.75). A comprehensive booklet prepared d. Health Advocates (c / o Health- by the Women's Health Collective of Bread PAC see VIII.C.l.d) affiliated with Health- and Roses of Boston. It includes chapters on PAC a new group of lawyers concerned birth control, pregnancy, abortion, sexuality, with offensive legal strategies for community and women and the health system. organizations concerned with health. C. Organizations 1. Liberal and Radical: There are several e. Martin Luther King Health Advo- cacy Program (o c / Liery Wynn and / or Bob Borsody, 400 E. 196th Street, Bronx, New liberal or radical organizations active in the York 10456), concerned with patients'rights health field who will provide information. issues. Try: 1. The National Institute for Educa- . American Public Health Associa- tion in Law and Poverty publishes a monthly tion, 1740 Broadway, New York, New York. Clearinghouse Review which has articles b. Physicians Forum, 510 Madison Avnue, New York, New York 10022. C. Medical Committee for Human and citations on health law cases. Copies may be obtained from the National Institute, Northwestern University School of Law, 25 West Chicago Avenue, Suite 500, Chicago, Rights, (1520 Naudain Street, Philadelphia, Illinois 60610. -John Ehrenreich 14