Document LgKKxvz0L9Yq9aNYkEpLzrGDw

Health Policy Advisory Center No. 30 April 1971 HEALTH / PAC BULLETIN Would You Buy an Insurance Policy From This Man? Can a conservative president compete with his liberal rivals on their own ground - na- tional health insurance as a solution to the national health crisis? Amid denounce- ments from construction workers and farm- ers, President Nixon is hard pressed - to hold onto his inflation - ridden silent majority. Thus with the 1972 elections only a dice throw - away and with the Kennedy - labor axis in Congress gearing up for an all out - fight for federally sponsored - national health insur- ance, Nixon has been forced to present a plan of his own. As revealed in his February health mess- age to Congress, his plan sounds almost like national health insurance. Almost - be- cause the plan is neither " national " nor it is " health " insurance. It proposes at least three different programs: one for the gainfully- employed, one for the poor and near poor -, and one for the aged. Benefits and premiums will vary from group to group, and even within groups, depending on how the states and large employers respond to the new plan. The Administration's version of " national health insurance, " as the newspapers have mislabeled it, is actually more regressive in some respects than the AMA's " Medicredit " plan for national health insurance. At least Medicredit is a universal plan with uniform national standards for all economic classes and age groups. But then, the Nixon proposals were never meant to solve the health crisis faced by the American people. They were meant to solve the crisis faced by the American health in- dustry an industry whose unchecked prof- iteering has backfired into uncontrolled in- flation dangerous now even to the profiteers themselves. From the consumers point of view, the plan would only enrich insurance companies, hospital supply and medical equipment companies, doctors and hospitals, while penalizing workers and making med ical care less accessible and more costly to most Americans. Nixon's solution to the crisis emerges from the Republicans'philosophical approach to the health issue [see November, 1970 BUL- LETIN]. A central theme of this philosophy is that the " right to health care, " established by the Kennedy - Johnson Administration, is not the responsibility of the Federal Govern- ment. Health care is the province of private in- dustry and should remain so. As the Presi- dent put it in his message on health, " I believe the public will always be better served by a pluralistic system than by a monolithic one, by a system which creates many effective centers of responsibility- both public and private - rather than one that concentrates authority in a single gov- ernmental source. " In fact, the Republicans believe that the Federal government should retreat even from its present level of involve- ment in the health system and eventually restore the health industry to " unfettered free enterprise. " The Republicans place the blame for cur- rent medical inflation squarely on the shoul- ders of consumers. They hold that consum- ers, suddenly enriched by Medicaid and Medicare programs, put too much " demand " on the health system. Since the " supply " of health services is limited, all this new " de- mand " naturally led to higher and higher prices. The problem with this logic is that applica- tion of the free enterprise model to the health care marketplace is utterly specious. It neg- lects the most important economic fact about the health industry - that much of it is a monopoly and that prices in a monopoly rise to maintain profit rather than balance supply with demand. But the Republicans are not prone to blaming their profiteering friends in the health industry. Consequently, the Republican cure for medical inflation is a little harsh disciplinary medicine for the consumers to discourage them from placing too much demand on the health system. Nixon says in this health " message,,. we should remember that only as people are aware of those [medical] costs will they be motivated to reduce them. When consumers pay virtually nothing for services and when, at the same time, those who provide services know that all their costs will also be met, then neither the con- sumer nor the provider has an incentive to use them efficiently... " Can Nixon get the consumers'votes while disciplining them into a new " cost conscious- ness " about health at the same time? This is the problem that HEW technicians and others on the Administration staff have been wrestling with for months. Their answer, re- vealed in its mind boggling - detail in the President's health message, is a masterpiece CONTENTS 1 Nixon's Health Message 5 MOTF Report 6 Chicago Thus, despite the expenditure of about 100 $ a year in insurance premiums, a healthy family will get no help where they need it most for routine care and preventive medi- cine. Thanks to all the deductibles and co- insurance, such a family will retain an ad- mirable level of medical " cost conscious- ness. " They will thank hard before seeking medical care during the early stages of of public relations. There's something for illness. everybody -- the domestic, the industrial Now take a family with more serious worker, the welfare mother. It may be less health problems. With all the deductibles than what they have now, but never mind, and insurance co - , this family is liable for it's something. possible medical costs of some 1720 $ per OE For the GAINFULLY EMPLOYED the year, in addition to the 100 $ or so it pays out Administration proposes the National Health as its share of the insurance premiums. Insurance Partnership Program (NHIP). In When the bills reach above $ 5000 per year this program employers will be required to (before insurance), what the Administration contribute 65 percent, employees 35 percent is defining as a " catastrophic " level, the in- toward the purchase of a minimal package of private health insurance. By 1975 this will change to a 75-25 percent employer employee - package. The federal government will pay nothing. The total premium for a family is ex- pected to average about $ 290 a year, ap- surance will begin to be a big help, paying up to $ 50,000 per year. But an annual outlay of $ 1820 a year would be catastrophic enough for all but the five or ten percent of American families with the highest income levels. proximately $ 100 of which the family will pay itself. Nixon's insurance " partnership " does not mean a new kind of health insurance. At What benefits the package will contain best it means a new sickness insurance to has not yet been detailed, but the President has mentioned both ambulatory care (phy- sician or clinic services) and in patient - hos- pital care. However, let's examine the fine print. In addition to his 35 percent contribu- tion to the cost of insurance, the employee will have to pay the first $ 100 of doctors ' bills out of his own pocket, for each member of the family, up to $ 300. (This is called a $ 100 " deductible. ") Also, the first two days of hospital stays per year are deductible, or pay your - - own - way (easily an expense of $ 150 to 200 $ per family member). Once the employee has gone beyond the $ 100 of doc- tors'bills and two days of hospital care, he still can't expect a free ride. From then on, he pays 20 percent of the bills himself, up to an annual cost of 5000 $ per person. (This is called 20 percent " insurance co . -") This health insurance program is in many cases worse than the benefits many employ- soften the impact of the most catastrophical- ly prolonged and expensive illnesses - and this only after it has laid the entire financial burden of early detection and treatment on the shoulders of the consumer. For most Americans, the financing of this new insurance will also be remarkably re- gressive the same amount of contribution 35 (percent of the premium) whether the employee is the janitor or the executive vice president. In the words of United Auto Work- ers President Leonard Woodcock the pro- posal is " a backward and intolerable im- prisonment of medical care financing in the operations of the insurance industry. " For those who are self employed - or who work for very small employers (such as gro- cery clerks and housekeepers), it is not clear what Nixon's plan will mean. Since insur- ance companies consider these people a greater risk and do not like to sell insurance ees have already won through collective bargaining. Take the average family of four with moderately good health, most of whose medical bills are for visits to doctors'offices. to them, Nixon is proposing that each state set up some sort of an insurance " pool, " with some state contributions to the premi- ums, as an inducement to the insurance com- This family now spends about $ 140 per year on doctor visits, and about 60 $ per year on dentist visits, (somewhat more in New York and Los Angeles). This family would never exceed its total of $ 300 worth of deductibles panies. Benefits and premiums for these peo- ple will very likely vary with the generosity of the state, and are likely to add up to a skimpier package than that offered to other workers. on ambulatory care and never get to cash in on its hospital care benefits. Dental costs, drugs, and of course, psychiatric care will not be covered at all. OE For the POOR AND NEAR POOR ,- Nixon has the Family Health Insurance Plan (FHIP). Previously almost all of the poor, and in some states the near poor -, receive 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, 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 their health benefits through Medicaid. Nixon proposes to replace these relatively compre- hensive benefits with a federal subsidy to purchase private health insurance for the poor. For the very poor, those with incomes under $ 3000 for a family of four, the govern- ment will pay the full cost of their insurance premiums. For the " working poor, " those with family incomes between $ 3000 and $ 5000 the government will partially subsidize the cost of their insurance premiums. They will have to contribute a variable sum in proportion to their income. FHIP will be com- pulsory for both groups. Key questions about FHIP remain unan- swered: What benefits would it provide? The President says vaguely that it will pay " for " basic medical costs. " Would it be as comprehensive as Medicaid, covering dental care, drugs, eyeglasses, mental care, etc.? Would it be as inadequate as NHIP for the working people? Or would it be even less comprehensive than NHIP? How much will the working poor be required to pay for their own insurance? How will they pay for it. The Administration is suspiciously unclear on these points. @ For the AGED, there will still be Medi- care - a relic of the Johnson Kennedy - Health New Deal - but in slightly revised form. Pres- ently, Medicare is a federal program of in- surance for those over 65, made up of Part A for hospital care (paid for through Social Security taxes) and Part B for ambulatory care which is paid for by a monthly premi- um, shared by the individual and the gov- ernment. With its gaps in coverage, deducti- bles, and monthly premiums, Medicare has been so inadequate in meeting the rising health costs that the aged still pay more out of their own pockets for medical care than any other age group. Nixon plans to give a little and at the same time take a little away from the shrinking pocketbooks of the old. He will merge parts A and B and give $ 1.4 billion to finance the Part B premiums which the aged presently pay themselves (5.30 $ per month). How- ever, in the interest of promoting " cost con- sciousness, " he will take away $ 400 million by adding still more deductibles and co in- - surance. The net effect of all these changes is unclear. If properly deployed, his new deductibles and insurance co - could wipe out the gain made by total government financ- ing of Part B. These are the pieces - NHIP, FHIP and the " New " Medicare - which the Administration hopes to pass off as new federal health strategy to rival the liberals'National Health Insurance proposals. The beauty of the plan, from the Republican point of view, is that it seems to deal with the problem of medical inflation without stepping on the toes of any medical providers. Nowhere, in his discus- sion of the new insurance schemes, does Nixon mention controls or limits of any pro- viders'prices. He barely chides the providers for their lack of " cost consciousness, " while the consumers, through the host of proposed deductibles and co insurance - plans, will be brought to a more acute level of " con- cost - sciousness. " They will become so conscious of the costs of their own health care that they may well be forced to go without it. The Administration has proposed one de- vice to encourage " cost consciousness " on the part of the providers the celebrated " HMO " (Health Maintenance Organization). Briefly, an HMO is a group of doctors plus a hospital or hospitals which band together to provide comprehensive, prepaid care to a given population [see the November, 1970, BULLETIN for a full explanation]. The government, in the case of Medicare, or an insurance company, in the case of NHIP or FHIP, will contract with an HMO to provide care to a certain population at a fixed, prepaid price. If the costs of providing the care exceed the prepaid price, the HMO will have to make up the deficit itself. If, on the other hand, it keeps its costs under the prepaid amount, the HMO keeps the differ- ence as a profit. Unlike providers who are reimbursed by insurance plans on a fee for- - service basis, the providers in an HMO will be fanatically cost conscious. For them, the profits will lie in holding services to a mimi- mum, especially expensive inpatient serv- ices. In effect, then, HMO's are just one more way of reducing consumer demand. Con- sumers covered by NHIP, FHIP or Medicare may choose to apply their benefits to mem- bership in an HMO plan or to seek care from conventional providers. In the latter case, the deductibles and insurance co - built into their insurance will discourage " excess " use of health services. In the HMO the providers themselves will be the watchdogs over " ex- cessive " consumer demand. For the time being, however, HMO's should be seen more as a public relations gimmick than as a serious program. In his health message, the President called for $ 23 million to finance HMO formation, only enough to pay for setting up about 40 HMO's, each serving 35,000 people, na- tionwide. But even at this low level of dollar commitment, HMO's serve an important function: they make it seem as if the Ad- ministration is dedicated to the reorganiza- tion and not just the financing - of the health care system. NHIP, FHIP and Medi- care have been termed a " layer three - cake " insurance system, and HMO's are the attrac- tive, liberal frosting. So far we have examined the Administra- tion's strategy from the least flattering per- spective - the consumer's point of view. To be fair, one must also look at the Nixon plan from the point of view of those it is really intended to help - the insurance companies, the hospitals and doctors and the health products and hospital equipment industries. @ The INSURANCE COMPANIES are far and away the clearest beneficiaries. Under NHIP, employees will be required to spend $ 2.5 billion more than they are presently spending on health insurance premiums. In 3 addition, 20 percent of the population under 65 presently has no health insurance what- soever. FHIP will deliver these people - near- ly 35 million directly into the hands of the private insurance market. How much of these premiums are paid by the government and how much by the poor themselves makes little difference to the insurance companies. problem of the " between in - " people - those too rich for Medicaid and too poor to pay their bills themselves. Whereas, before they often simply defaulted on their bills, now the hospital will be assured of at least pay- ment through the patients'mandatory private health insurance. To maintain their teaching and research On top of that, spending required to launch FHIP will add $ 1.2 billion to the $ 5 billion now spent annually by the government on Medicaid. subjects in the past many large teaching hospitals have been forced to serve poor peo- ple free or below cost. Now this expense will be covered in part if not in full by FHIP, and Not only are the insurance companies again with no strings attached. promised this vast infusion of new funds and customers, but through its array of deducti- bles and co insurance - provisions, Nixon's And there will be no strings so long as Blue Cross maintains a near monopoly - on the health insurance industry. No one will be program simultaneously promises to cut snooping into how the hospitals spend their utilization of the health care system. The money or set their prices. At least the com- program will actively discourage consumers mercial companies have a vested interest from using health services and therefore (their own profits) in keeping down hospital from cashing in on any insurance benefits. costs. But Blue Cross is a " profit non - " Increased income, decreased expenses- agency, run largely by and for the hospitals, Nixon's program promises chiefly to insure and thus has neither the ability nor will to the profits of the insurance industry. And the monitor hospital costs [see March, 1971, primary recipient of these benefits will be BULLETIN]. So a very large part of the prof- Blue Cross. its delviered to the insurance companies will Business Week comments, " When Presi- be handed over, no questions asked, to the dent Nixon fired off his long awaited - health hospitals and medical providers. ~or care message to Congress late last week, no OE Indirectly, the HOSPITAL EQUIPMENT one was listening more raptly than Walter J. COMPANIES stand ready to reap the bene- McNerney, the 45 year - - old president of the fits of the only aspect of NHIP which can be Blue Cross Association, the Chicago - based considered at all generous. This is the level overseer of the nation's 74 local Blue Cross at which the heavy, expensive technology plans. " The President's health care package promises to add at least $ 3 billion to the $ 14 billion that the nation now spends on health insurance. That should mean a bonanza for Blue Cross which writes nearly as much health coverage as all the 1500 commercial insurance companies in the field combined. Further, the President's package is aimed at easing the crisis in health care that now grips the country. That plainly would help Blue Cross, which as the largest single payer of medical bills, has felt the effects of the crisis as keenly as anyone. " (Emphasis added.) One would almost think that the Presi- dent's health message was a personal note to McNerney, who chaired Nixon's recent Task Force on Medicaid and Related Pro- sold by the hospital equipment industry comes into play - the heart - lung, cobalt therapy, kidney dialysis machines, etc. A NHI subscriber may not be able to afford a $ 20 check - up, but he'll be in good shape should he ever require a kidney transplant. So the hospitals will feel free to invest in even more prestigious, high technology - , sel- dom utilized - equipment than they already have. In addition, the President threw an extra bone to the equipment industry. He is in- structing HEW to explore and promote equipment for automating diagnostic pro- cedures, such as computers and monitoring machines, since " they can help us deliver more effective, more efficient care at lower prices. " " But Nixon's strategy will be of no more grams. use in the long - run to the health industrialists OE HOSPITALS AND OTHER PROVIDERS than it is in the short - run to the consumers. will obviously benefit from any form of health insurance. As medical costs have spiralled, providers are finding it harder and harder to get consumers to pay their bills. Nixon's NHIP and FHIP promise to fill three Basically, Nixon's program is far more in- flationary than the Kennedy plan for univer- sal, federally - financed, cost controlled - health insurance (which the President is labelling " inflationary "). The President cannot control of the providers'largest gaps. NHIP promises the hospitals assurance of payment in the case of " catastrophic " illness requiring prolonged and expensive treat- ment of a patient. Under NHIP $ 3400 of the first $ 5000 in medical bills is guaranteed and the program covers all expenses up to $ 50, - 000 a year after that. FHIP is a partial answer to the hospitals ' medical inflation by controlling the consum- ers. He cannot because they are not the cause of that inflation. The real cause is the profiteering of the health industry, which the Administration plans to boost rather than to control in any way. In effect, medical costs will continue to soar, spelling crisis for the health industrialists just as surely as it spells medical indigency for the consumers. 4 What Was MOTF's Motive? After fifteen months of meetings and an ex- penditure of over $.5 million in taxpayers money, the Mayor's Organizational Task Force (MOTF) for Comprehensive Health Planning (CHP) has finally announced its long awaited - plans for New York City's CHP agency. But after all this, MOTF has pro- duced a plan which continues the private domination of the health scene and the pub- lic planning process. MOTF is the planning agency set up to plan a planning agency. Originally all health planning in New York City was con- trolled by the Health and Hospital Planning Council (HHPC), a private planning body dominated by Blue Cross and the voluntary hospitals. Established during the Depression, the HHPC has grown to a powerful agency which has been granted state and federal authority to review and in essence control all hospital construction and renovation in New York City. But, the federal Comprehensive Health Planning Act, passed in 1966, mandated the establishment of local Comprehensive Health Planning agencies which would provide " a true partnership for health among consum- ers, providers of health services and munici- pal agencies. " ' In New York City, a protracted struggle ensued between advocates of a publicly con- trolled CHP agency and the old provider- dominated HHPC. The result was a stand - off: New York City established MOTF, a provid- er and consumer group to plan for a CHP. But it is clear who has won the stand - off. MOTF has become the mechanism for con- tinued private provider domination of health planning. Little wonder that MOTF director Frank Van Dyke has nothing more to say when introducing the report than that it is " not a utopian plan. " MOTF's experience is a reflection of the history of health planning in the United States. CHP can be described as a wonder " drug " created to end an illness that, in the end, is not going to change the condition of the patient. What is the illness? It was and is famil- iar to most ordinary Americans seeking health care. The American Health system it- self is ill. As a system to deliver health care, it is fragmented, a jumble of scarce, expen- sive, seemingly uncontrollable " sickness " services, institutions and programs. This jumble is a system only to those who derive profits or prestige from it. Although we spend more money per capita than any other na- tion in the world on health care, the United States remains far down the list on most world - wide indices of health. How could the planners then cure this " diseased " system? The prescription was the Comprehensive Health Planning Act and its subsequent " Partnership for Health " amendments. Recognizing the seemingly " planless " condition of the American health care system, the legislation declared that no less than " the fulfillment of our national purpose depends on promoting and assuring the highest level of health attainable for every person. " To implement this vision grants were authorized for the development of both state and local level planning agencies. Early en- thusiasts for the legislation argued that a strong public role in planning efforts seemed cetrain, since the law required majority con- sumer representation on each local board or its advisory body. It soon became evident, however, that CHP agencies at both the state and local levels lacked the operational powers or authority to rationalize existing patterns of health care delivery. For one thing, the pow- er to plan health facilities (e.g. approve the construction, size, and location of all new health facilities hospitals -, neighborhood health centers, etc.) invariably remained in the hands of older planning bodies long- dominated by private provider groups such as HHPC in New York. The new CHP agencies, lacking real pow- er, settled into an investigative and advisory role, infrequently attempting to coordinate or catalyze more rational, people oriented - local services. With the coming of 1970s, the Comprehen- sive Health Planning movement all but evaporated. Federal support for the CHP " cure " never really emerged under the Nix- on Administration, as the Washington agency languished for months with no full- time director. Meanwhile the Nixon camp tooled up its own " treatment " for the failing system [see accompanying article]. Recently, the appointment of former Ag- new aide, Robert Janes, as national CHP di- rector confirms this assessment of the CHP cure. Informed sources within the agency suggest that Janes'role will be to quietly remove the " C " and the " P " from future CHP efforts, relegating state and local agencies to the status of " booster clubs " for improving health services. Outside Washington, signs abound that the CHP vision was never quite what it seemed anyway. Many of the health plan- ning " experts " who originally touted the CHP " partnership for health " have since re- vealed what they really had in mind all along: plans for all private - , multi hospital - mergers on the local level. For example, nationally - known health planner Robert Sigmond, an early champion of health planning, was a key figure in the preparation of the Perloff Report recently adopted by the American Hospital Associa- tion. The Perloff Report advocates the for- mation of private hospital conglomerates called " Hospital Corporations " with little or no public accountability. These corporate en- tities supercede any role for the public in hospital planning. 5 It is not surprising then that New York's communities. MOTF report emerges as something far from OE A CHP agency without consumer or a dramatic cure. The eloquent but innocuous public control Consumers have a 51 percent 84 page - report lays out a scheme for the majority on the proposed 71 member board. City's CHP agency that amounts to the fol- But who are these consumers? All 36 consum- lowing: er representatives are to be appointed by the OE A CHP agency with no real operating Mayor: 13 will represent CHP district units power or authority. According to the report, " it will " review,'monitor ", " " coordinate " and and 11 will represent city wide - consumer groups. Of the remaining 12 consumer " inventory " health services and needs in the slots ', " the Mayor is mandated to appoint city, but its power to implement planning three municipal officials, one person repre- goals is nowhere established. The possible senting regional planning organizations; and conflict of roles between the CHP agency one person representing commerce and in- and HHPC is " resolved " by leaving the dustry - not a very grass roots bunch. If the critical powers of veto and approval of providers are united, they won't find it hard health facilities planning in the hands of the to get a few of these consumers to join them Health and Hospital Planning Council, safely for a majority decision - making block. out of the public reach. It has become clear that CHP, once highly @ A CHP agency that will create decen- proclaimed as the means to rationalize and tralized CHP districts without any powers. democratize the health system, was never In an apparent gesture toward decentraliza- conceived to do so. It will not rationalize the tion, but not community control, the report health system because it was never granted suggests health planning districts serving the powers to do so. Nor will CHP demo- an average of 300,000 people each (in most cratize the health system since the private areas encompassing several neighbor providers maintain their control. CHP has hoods). These " local arms of the CHP agen- become, in New York City as in other cities cy " have no independent powers of their own across the country, just another public sub- and are clearly designed as co optive - , pub- sidy for a privately managed - and controlled lic relations - " feelers " reaching into local American health system. Health Movement: Storm in The Windy City Like their natural counterparts, the seeds of political struggle sometimes flourish in the toughest ground. Or so it seems with the health movement in Chicago. " Welcome to Chicago, Richard J. Daley, Mayor. " " Chicago is a beautiful ci* ty keep it that way... don't litter, Richard J. Daley, Mayor. " The billboards of Chicago are a constant reminder of a central political reality: Richard J. Daley is Mayor. As most Americans know, he and his machine have long controlled the " public " life of the city; serious and successful challenges to his power have been nil. There is another, less obvious fact about the city: it is the home of the American Medical Association, American Hospital As- sociation, the Joint Commission on the Ac- creditation of Hospitals, and the Blue Cross Association of America. In short, Chicago is a sort of a Pentagon for the Medical - Indus- trial Complex. It is in the shadow of these the strongest of the vested interests in the American health system and the strongest political boss of any American city that - the Chicago health movement erupted. It's three main thrusts are the opening of free clinics, unionization of health workers and organization of stu- dents, interns and residents. These programs have galvanized the Chicago health com- munity and challenged the bosses'control. Chicago's " free clinic " movement, the size of which is unparalleled in the nation, was originally stimulated by efforts of the Black Panther Party to open a local community health center in the fall of 1969. As other local groups joined the health issue, the once barren - wasteland of Chicago's black, brown and Appalachian white ghettos be- came fertile soil for the budding movement. Chicago's health system has been domi- nated almost entirely by the private sector. There is only one public hospital, Cook County, and virtually no community - based health services. By early 1970, however, ten free health centers existed. They joined to organize a " People's Health Coalition " that included a variety of groups - black, brown and white, from organizations with highly- ' identifiable political ideologies such as the Black Panthers, Young Lords and Young Pa- triots to groups of welfare mothers and hous- ing project groups. But as an independent health service system sprang up, Daley saw a possible crack in his machine's control over public service - based patronage. Daley's first response was predictable: police harassment of the free clinics. At the Young Patriots'Uptown Community Health Service, agents of the Chicago Police Depart- ment Subversive Activities Squad harassed doctors and patients, raided medical staff meetings, and finally pressured the landlord into evicting the clinic. Similar tactics fol- lowed against the Young Lords'and Black Panthers'clinics. Yet, the free clinics grew. Literally thousands of people came for treat- ment. 6 Daley next resorted to the written law in provided in its own V.D. center. an attempt to eliminate the clinics altogether. Last year Chicago experienced a diphthe- His immediate goal was to find a legal basis eria outbreak revealing the lack of any for continued police harassment. A 1939 city realistic immunization program in the City. ordinance governing " free clinics and dis- Recent cuts in City funds for a high - risk pensaries " was dusted off and revived. The maternity and prenatal program have left law mandated that clinics be furnished with thousands of women without prenatal or de- cuspidors and comply with other ancient livery arrangements. " public health " measures. Most devastating The Mayor soon moved to counter this for the clinics, the law allowed the Board of blow to his Board's image. He announced Health or its representatives to inspect clinic plans for eight new comprehensive care cen- records at any time. Thus, a once reasonable - ters to be sponsored by the Board of Health. public health statute for protecting the quali- That the mayor chooses this time to get into ty of medical care was turned into a repres- health is no coincidence. He has had money sive tool. Personal information collected on for the clinics since the passage of a 1966 any patient using the free clinics could be bond issue for health care. Significantly, four used against that patient in his neighborhood of these centers are to be located in areas or on the job. which are now served by free clinics. Clear- Board of Health inspectors were denied ly, the free clinic movement has made access to the health clinics operated by the health a major issue in Chicago. Young Lords, Young Patriots, Black Pan- The intent in the Mayor's response is ob- thers and the Latin American Defense Or- vious: no independent polictical bases ganization (LADO). All four clinics refused around health services will be permitted. to apply for licenses as " free clinics, " Community control in any form threatens the thereby blocking the legal foundation of the Daley machine. Board of Health's inspection powers. Despite A (recent Board of Health application to the fact that many clinics, including the uni- HEW for additional funding, for example, versity teaching clinics, had operated for was rejected by the Comprehensive Health years without Board of Health licenses, court Planning agency for the Chicago region, action was initiated against the four clinics based partly on the lack of hospital coopera- for failure to register under the law. tion and inadequate planning of services. But the court action merely widened the But the decisive issue was the total absence crack in the Daley machine. In July, 1970, of community participation in the Board of the Circuit Court of Appeals ruled that the Health's plans.) " ordinance was so vague and indefinite as to be unenforceable " in the case of the The experiences of two Chicago neighbor- Young Patriots'clinic. The case against the hoods again illustrates the anti community - Black Panther Party was thrown out of court stance adopted by the Board of Health, for defective subpoenas. which excludes participation by any local Still, the Board of Health doggedly pursued organization. its prosecution of the Young Lords and LADO The Kenwood - Oakland Community Or- under the law. Finally, when the Chicago Sun Times - , a major establishment newspap- ganization (KOCO) is a neighborhood group, semi independent - of the Daley ma- er, published an editorial entitled " Don't chine, located in one of the Model Cities Badger the Clinics ", it was obvious the areas on Chicago's South Side. KOCO re- Mayor's tactic has failed. But Daley is an in- cently negotiated an agreement with Mi- ventive man when his control is questioned. chael Reese Hospital, the major medical cen- On December 4, 1970, exactly one year ter in the area. It won recognition as the after the murders of Panther leaders Fred community board for any future neighbor- Hampton and Mark Clark, the Mayor him- hood health center affiliated with Michael self introduced a new ordinance governing Reese. Each of the Model Cities areas is to the operation of free health clinics. In the have one Board of Health Center funded by ordinance, which is still pending, he called Model Cities. Logically, the center in the for access to patient records as well as open- KOCO area should be affiliated with Michael ended regulatory powers over free clinics by Reese Hospital. Yet, the Board of Health has the Board of Health. The new law would ap- refused to sign a contract with Michael Reese ply to any clinic " not solely owned or op- erated by physicians, " a clear statement of because of the hospital's prior agreement with KOCO. Daley's opposition to community control. Another example of the Board's denial of By focussing his strategy on the Board of community participation can be seen in its Health, however, Daley shifted the unwel- attitude towards the Uptown Community come glare of publicity onto the Board itself. Health Association (UCHA). UCHA was Several groups, including the Medical Com- created by poor community residents, repre- mittee for Human Rights, began to inquire senting blacks, Latins, Indians and Appa- into the performance of the Board of Health, lachians and is located in another Model uncovering a virtual indictment of the Board Cities area. It managed to win backing from for mal- and non practice - . They found, for ex- the local hospital planning council, as well ample, that: as the Model Cities community advisory Veneral disease is epidemic, yet the Board of Health refuses to pay for treatment not board as the Uptown health consumer group. Yet the Board of Health has adamantly re- 7 fused to recognize UCHA as the community anticipation of government grants for pre- health board for the temporary Comprehen- paid health insurance. sive Health Center opened last year by Mod- It was to these private bastions of health el Cities in Uptown. care that the free clinics brought their de- Attention was brought to the Board of mands for responsibility to the community's Health refusal only after the Young Patriots needs. In the Uptown area, the Young Pa- together with other community groups staged triots pressed Weiss Hospital, a local institu- a " heal - in " and takeover of the temporary tion reserved for " paying " patients for emer- center, resulting in 43 arrests. Although the gency back - up and the opportunity to make action failed to prompt Board of Health rec- referrals to specialty clinics. Weiss Hospital ognition of UCHA, it did invoke promises of agreed. When another group, the Young increased health services in Uptown. Lords, aproached a north - side local institu- tion, Grant Hospital, however, they were As the free clinic movement developed, it flatly refused similar privileges. The demon- opened cracks not only in the " public " sector strations that followed failed to shake the of Chicago's health system, but in the bas- hospital's refusal. tions of private medical power as well. In Perhaps the most serious challenge yet to contrast to New York City, medical empire- the pricate health establishment occurred building has been less aggressive in Chi- when the Pedro Alviuz Campos Center for cago. The division of " turf " among the large the People's Health took its demands not to a Chicago medical centers in less clear. But, local hospital, but to the patrician center it- some patterns are emerging. self, Northwestern. Sponsored by the Latin Northwestern University Medical School American Defense Organization LADO () , and Center (including Wesley and Pasavant the Center asked not only for back - up serv- Hospitals), situated on the wealthy Gold ices, but also for participation in the health Coast, has long claimed the conservative planning process. And they won! role of defending private practice. Northwestern agreed to include LADO in Meanwhile, the University of Chicago any health planning by the medical school School of Medicine, sunk ostrich - like into which involves the community served by the : research, has resorted to building fences and clinic. Of course, this victory is yet to be parks on its periphery to prevent any en- tested. But since such agreements are rare croachment from the surrounding black in the history of the health movement, it is community. worth examining what and who prepared Only Presbyterian - St. Luke's Hospital, now the way for Northwestern's concession. At the site of reborn Rush Medical College, has least some of the groundwork was laid by shown faint signs of empire building - be- students within Northwestern itself. havior. Through involvement in the OEO In the spring of 1970, as a direct result of neighborhood health center at Miles Square, their work in free clinics, nursing and medi- Presbyterian - St. Luke's learned how public cal students at Northwestern Medical Center grants can be used to finance imperial ex- organized the Northwestern Health Collec- pansion. More recently, it has begun to line tive. The free clinic experience made stu- up community hospitals for " affiliations " in dents conscious of the huge gap between the SEPARATE AND It is hard to believe UNEQUAL: that centers of liberal CHICAGO LYING - IN medical excellence, such as the Univers- ity of Chicago, still embody " apartheid health care ". This is what that school's Student Health Organiza- tion (SHO) charged and proved in November, 1970. Since 1931, Chicago Lying - In Hospital, a division of the University of Chicago Medical Center, has operated an obstetrics and gyne- cological outpatient clinic, divided into East and West wings. Through their investigative efforts, SHO found that this division has far more significance than mere architecture. The West Clinic is clearly designed for the poor. Its waiting room is dreary, stocked with long benches resembling a subway station. It is staffed by medical students, interns and residents, as well as faculty physicians. Pa- tients rarely see the same doctor twice. Unan- nounced birth control films are shown. The East Clinic, on the other hand, is de- signed for " different " patients. Its waiting room is somewhat cheerful, with patterned wallpaper and chairs. Medical students are not permitted to " practice " on the East clinic patients. Interns, residents and attending physicians assure some continuity of care. Birth control films are never shown. What determines which patients are seen in each clinic? The channeling process is based on the all American - principle - those that can pay more deserve more. Patients are assigned to the wings on the basis of registration fees: West Clinic- $ 29; East Clinic- $ 44. Appointment fees in both clinics are $ 15 / visit. Scratch a little deeper and find that wel- fare patients are assigned to the West Clinic. Patients referred by private doctors go to the East Clinic. While the registration office claims that all paying patients are given a choice of clinics, black patients in the West Clinic charge that they were never inform- ed of the option. The result is de facto, if not deliberate segregation. West Clinic patients are largely 8 health needs of the people they had seen and the research and teaching priorities of the medical center. As students at the med- ical center, they assumed the special respon- sibility of challenging the institution's priori- ties from within. Student concern culminated on May 11, 1970 with the takeover of the administrative offices of one of the medical school deans. Over thirty students announced the creation of a " People's Health Free University " inside the dean's office. In the following 24 hours of occupation, community leaders and health workers were brought in as instructors of the Free University. They rapped about com- munity health needs and the necessity to change institutions to meet those needs. The Northwestern Health Collective listed 25 demands as the basis for its actions. These demands fell into three categories: institu- tional racism, patient care for the poor, and student oppression. The specific points ranged from the establishment of new ad- missions requirements and procedures, such that third one - of the entering class be black, Latin or low income - whites, to the right of students to review and to respond to all evaluations by their instructors. Sixty - five percent of the student body signed a petition in support of these demands and an ad hoc faculty committee published its own pro- posals in consonance with the original de- mands. During the subsequent negotiations, the Medical Center administration, made several notable concessions. First, an " Urban Doctors Program " was established, a result not only of the occupation, but also of pressure from the caucus of black medical students. This program is designed to admit black, brown, cago's low income - areas into the medical Indian and poor white students from Chi- school. The first class of 25 students under this program will enroll in the fall of 1972. The program features an M.D. degree six years after high school graduation. North- westeren has agreed to take responsibility for recruiting and remedial training (if nec- essary) of students from various poor popu- lations within the city. Second, Northwestern began to develop programs around community health. A De- partment of Community Medicine, which had only been on the drawing boards, was of- ficially activated. The process of education about community issues, begun at the Health Free University, continued in an accredited course developed by many of the students in- volved in the free health clinics. Constant surviellance of the department's activities by students has resulted in increased coopera- tion with community - controlled health serv- ices, particularly the free clinics such as that run by LADO. Following the spring actions at Northwest- ern, student activism began to emerge in health science schools throughout the city. At the University of Illinois, involvement with the free clinics spurred the formation of a student group similar to the Northwest- ern Health Collective. At the University of Chicago the Student Health Organization moved successfully to end a segregated sys- tem of OB GYN - outpatient clinics. A nurses ' collective at Wesley School of Nursing de- veloped a program of minority admissions. It is presently seeking a nursing student bill of rights. A group of students from the Illinois College of Optometry initiated a vision proj- ect to serve the free health centers, with hopes of involving their school in commu- nity controlled - health efforts. The health movement has also grown to include health workers, interns and resi- black, East Clinic patients are largely white. The clinics cannot even be described as " separate but equal ". The black and the poor are victims of teaching and research. Depart- ment Chairman, Frederick Zuspan declares, " Current needs of the Department of Obstet- rics and Gynecology are in the general cate- gories of education, basic research and applied patient research. " When confronted by SHO, the administration said they recognized the problem years ago. In 1968, they established a committee to plan a new OB GYN / clinic. They regretted to ad- mit that an impasse had been reached, in part due to lack of funds. The committee ceased to meet. The students pointed out that in the same period the administration had funds for a new life sciences research building, renova- tion of the accounting department, reorgan- ization of the records room, a center for the history of medicine, and an conditioned air - animal quarters. SHO called a public meeting to discuss the clinic. A proposal was drawn up for eliminat- ing segregation without additional expend- iture: random distribution of all patients, staff and medical students to both wings. When the administration refused to re- spond to the proposal, SHO took their case to the patients. The patients were outraged and began to raise questions to the nurses, secretaries and doctors. The administration reacted swiftly. The deans confronted the students in the clinic, accused them of " dis- rupting the doctor patient - relationship " and threatened them with disciplinary suspen- sion. The students had brought the situation to a boil. Patients and community groups were aroused. In February, Dr. Zuspan announced plans for a single system of patient care in the clinic. A sliding fee scale, based on ability to pay was introduced. Chicago Lying - In has moved one small step toward living up to its motto: " The best medical care in the world for all women regardless of financial means, race, creed or color. " 9 dents. At Cook County Hospital, for example, the housestaff is fighting for better working conditions and improved patient care. The obstacles they face are formidable. Cook County is the only municipal hos- pital in Chicago and the largest short - term hospital in the United States. It serves as the " dumping grounds " for the poor and other " undesirable " patients throughout the city. It has a house staff totalling over 500, the largest in the country. Within the house staff a Residents and Interns Association (RIA) has been formed. But of these 500 doctors, more than 65 percent are foreign trained - , cre- ating natural divisions among staff members that the hospital has been only too glad to exploit in the past. By threats of deportation and visa retraction, the hospital was able for years to stifle political activity by the foreign residents and interns. It was this oppressive tactic that RIA first attacked by establishing the rights of aliens through legal advisors. By fighting the chau- vinism and racism they had experienced di- rectly, the Association fostered a sense of multinational strength among Cook County's house staff. From t. his position of strength the RIA stepped up its political activity, and attacked Cook County Hospital's new Governing Com- mission. This " independent " Governing Commission was created by the Republican- controlled state legislature in an attempt to wrest control from the Daley machine. As it became clear that the change had merely brightened Cook County's public re- lations image without improving its patient care, RIA promised to " initiate legal action on behalf of our patients against the appro- priate party when the right of patients at Cook County Hospital to quality health care is deprived due to deficient equipment, sec- ond rate laboratory and x ray - facilities, un- sanitary and unsafe ward conditions, or understaffed medical, nursing or paramed- ical care. " In keeping with this resolve, RIA exposed to the press the complete travesty of psy- chiatric services at the hospital. Due to understaffing, RIA asserted that " psychiatrists are not available to visit patients on the Medical, Surgical or Pediatric Wards even in dire emergency. As a result, many suicidal or dangerously disturbed patients must be treated by doctors basically unprepared to handle mental diseases on wards not designed for psychiatric patients. To prevent physical harm to the patient or other nearby nonpsychiatric patients, doc- tors at present can only tie the patients to his bed or knock him out with drugs, while wait- ing for help that isn't there. " RIA's activities culminated in contract talks with the hospital that have since been stalled for 18 months. RIA plans to hold a job action if contract demands are not met. It is not only the interns and residents but Chicago's health workers in general who are beginning to move. While efforts at unioniza- tion have made headway in a few hospitals, elsewhere the resistance has been fierce. For example, the fight for a union at Wes- ley Hospital within the Northwestern empire has been waged for over two years. In Sep- tember, 1970, workers struck the hospital, calling for better wages and in hospital - training programs. The hospital responded with massive firings, intensive scabbing and a series of injunctions - all of which worked to break the strike in December. Although the hospital has lost several court appeals, it persists in refusing to negotiate with the union. When one steps back to look at Chicago as a whole, however, it is clear that the health movement has come to the windy city. Its development and future growth, of course, will depend on the ability of existing groups to develop continuing strategies that can sustain them in the face of the city's hostile medical and political environment. But it is clear that the health movement is here to stay Barbara. - Bishop, Student, Northwestern Univ. School of Medicine THE AMERICAN HEALTH EMPIRE: POWER, POLITICS, AND PROFITS A REPORT FROM THE HEALTH POLICY ADVISORY CENTER Our first book, this is an angry and hard hitting - analysis of the American Health sys- tem who - profits from it and who loses. It follows the growth of the health system from " cottage industry " to today's Medical Industrial Complex, exposing the ruthless priorities of the medical empires and corporations which dominate today's health scene. It documents - with vivid case studies - the bankruptcy of recent health " re- form " programs, from Medicaid to National Health Insurance. It reports from the front lines of ongoing community and workers struggles for humane and democratic alternatives in health. A must for BULLETIN readers, and anyone else who cares about the quality, and quantity, of American life. The book is published by Random House and available at your bookstore in hard cover for $ 7.95. The Vintage Paperback is $ 1.95. 10