Document Rj0EXbXgNjQ8kdpBgp6XNpa4B

HEALTH / PAC BULLETIN BULLETIN Policy HAedvailstorhy Center No. 60 September / October 1974 1 RN's Strike: BETWEEN THE LINES. Bay Area RN's take militant action. 7 Dear Dr. Pomrinse: NEXT TIME, I'LL GO TO BELLEVUE. The ex- periences of a nurse as patient at Mt. Sinai Hospital. 15 Media Scan: Blue Cross: What Went Wrong? Sylvia Law. 22 Vital Signs STRIKE RN's Strike BETETEHNE n June 7, 1974, 4,400 registered nurses LINES struck 41 hospitals and clinics in the San Fran- cisco Bay area. The RN's, all members of the California Nurses'Association (CNA), re- mained on the picket lines for 21 days. With the American Nurses'Association holding its annual national convention in San Francisco during the strike, the issues were discussed and brought back to every state in the nation. On one level the RN strike differed from typical management - labor disputes. The cen- tral demands were not for increased wages BAT and other bread butter - and - gains. Rather, RN's posed their fight in terms of control over 3 working conditions and the quality of pa- tient care. In addition, RN's and their profes- sional association, the CNA, displayed a new level of militancy in their willingness to con- front the administration on the picket line. On the other hand, the strike poses many problems and contradictions with far reach- - ing relevance for future struggles by hospital wokers. Given the existing hierarchical divi- sion of labor within the hospital, will bargain- ing along narrow skill lines by a relatively privileged group of professional nurses serve to create even more tension and divisions? And what is the meaning of the demand for workers'control when that demand is made for the sole benefit of a narrowly defined group? On a more pragmatic level, can any single classification of hospital workers win its demands without uniting with others - that is, can any one group muster enough clout to shut the hospital down and force the adminis- tration to capitulate? No Ordinary Demands In 1970 the CNA won a clause in its con- tract with Bay Area hospitals giving RN's the right to help determine how wards are staffed. The clause called for " participation of Staff Nurses in the assessment of patients'daily needs for nursing care and the basis upon which nursing personnel are assigned.. " By the time the contract expired on Decem- ber 31, 1973, neither the hospitals nor the CNA had moved in a significant way to implement this clause. When negotiations for the 1974 contract opened, management's position on the staffing issue became unequivocal - de- lete the clause and deny RN's any participa- tion in staffing matters. The staffing clause became the core of the strike: Who decides how many and what type of personnel should work on each unit? This issue is central to both hospital workers and patients. Understaffing makes workers un- able to perform all necessary tasks. Patients find that their needs are ignored for hours, and even then are met in a brusque and hur- ried manner. Administration, through the director of nurs- ing, distributes RN's, LVN's (licensed voca- tional nurses, also called licensed practical nurses in some states) and aides around the hospital according to the number of patients on each floor. Some hospitals use the more sophisticated " acuity " method of staffing, 2 which takes into account that some patients are sicker than others and need more staff time. But in all cases, the number of workers is determined by administration, and if the fiscal picture looks bad, staff can be cut back no matter how full or how busy the wards become. One RN, for example, tells of working a night on a floor with 30 patients, many acute- ly ill, staffed with one RN, one LVN and one aide. Thirteen patients had intravenous solu- tion bottles running. Each bottle had to be changed at different times, requiring close watching to prevent bottles from running dry. In addition one patient needed irrigation of the bladder with multiple bottles of fluid. Af- ter continued pleas from the beleaguered RN, the nursing office offered only one extra LVN --this despite the fact that hospital regulations do not allow LVN's to perform these tasks. Management was steadfast in its refusal to allow an RN voice in staffing. Hospital nego- tiator Arthur Mendelson warned physicians: " If we accede to the demands of the registered staff nurses and the California Nurses'Asso- ciation in this connection it is only one step away for the registered staff nurses to de- mand a voice in the way you treat your pa- tients with respect to admissions, discharge, treatment and length of stay. " The American Hospital Association, in an alarmist state- ment, took up the cudgels: " An issue with na- tional implications is at stake here. Under the banner of an interest in the quality of care, the striking nurses are attempting to gain con- trol over the number of nurses employed by each hospital... " In truth, the staffing demand was not near- ly as threatening as all that. The CNA was merely asking for participation in deciding staffing levels, not control over staffing. But the rhetoric of control was taken up by some RN's who defined the strike as a worker con- trol struggle, which in fact it was not. The staffing issue did, however, have im- plications for other hospital workers. Why shouldn't all personnel on a unit including - LVN's, orderlies and aides - be involved in staffing decisions? The strike could not deal with this question since the CNA is a profes- sional association separate from the union of other hospital workers, and as such can bargain only on behalf of RN's. Thus the de- mand for some control over staffing by RN's missed the mark of what real worker control might mean teams - composed of all workers on a floor deciding staffing patterns, division of labor between workers, and patient diag- nosis and treatment. A second strike demand was that adminis- tration not assign RN's without appropriate training to specialty units. The technological explosion in health care has brought with it increased specialization. Doctors carve out an organ or two as their exclusive area of con- cern. Technicians are increasingly split up into narrow functions. And with RN's operat- ing complex devices in intensive care units, coronary care units, renal dialysis, emergen- cy rooms and other specialized areas of the hospital, nursing is following suit. RN's at Bay Area hospitals flatly stated that administrators were staffing specialty units with unqualified " floating " nurses - nurses who spend different days on different floors. At Mt. Zion Hospital in San Francisco, admin- istration first denied the charge of improper staffing, but later reluctantly admitted to such staffing in case of " emergency. " An intensive care unit nurse responded, " If Mt. Zion does indeed assign untrained nurses to specialty care areas only in emergency situations, then these areas are in a constant state of emer- gency. " " Not only is this practice dangerous to pa- tients, but it is intolerable to hospital work- ers. One RN told of an orderly sent to a pedi- atric unit where he had never been trained to work. The orderly accidentally disconnected a life supporting - device. After some tense mo- ments, the child's condition was restored, but the orderly was distraught by what he had nearly done. Nevertheless, the specialty staff- ing demand would do nothing for this situa- tion since it applies only to RN's. Bread butter - and - demands were not alto- gether ignored. These included demands for every other weekend off for all RN's, a 5.5 percent pay increase and a living cost - of - es- calator clause. The CNA also asked for a pen- sion plan separate from other workers and portable from one hospital to another. Pen- sions were an issue because RN's frequently change jobs and do not benefit from the money they place into hospital - wide pension plans. The demand reflects the high degree of job mobility of RN's vis vis - a - other less mo- bile and less privileged hospital workers. Why a Strike? The precipitating cause of the strike was the hospitals'complete intransigence on the staffing issue. Hospital management had re- fused to negotiate until a few days before the contract expired at the end of 1973, and had failed to budge during the five months of talks in 1974. Administration not only wanted to delete the gains won by the CNA regarding participation in staffing in the 1971-73 con- tract, but pushed to include a management's rights clause. According to Burton White, CNA Director of Economic and General Wel- fare, " Management was trying to turn back the clock. That was too much. " The CNA had no choice but to give in or strike. Woven into the strike decision were several underlying threads. Staffing conditions in hos- pitals have tightened due to the excess of hospital beds and the federal wage - price con- trols, both of which have hurt the hospitals ' economic position. From management's point of view, there is a critical need to limit staffing -after all, each additional worker costs money. For management it would be unthink- able to allow hospital workers - who have no responsibility for keeping the hospital in the black to control levels of expenditure. From the workers'point of view, the economic pinch means speed - up - more work for each person to do and wages that fail to keep up with the rising cost of living. Two other Bay Area hospital strikes in the past year - at Kaiser and San Francisco General hospitals - reflect the workers'refusal to bear the brunt of the ec- onomic situation. Published by the Health Policy Advisory Center, 17 Murray Street, New York, N.Y. 10007. Telephone (212) 267-8890. The Health / PAC BULLETIN is published 6 times per year: Jan./Feb., Mar./Apr., May June /, July Aug /., Sept./Oct. and Nov./Dec. Special reports are issued during the year. Yearly subscriptions: $ 5 students, $ 7 other individuals, $ 15 institutions. Second - class postage paid at New York, N.Y. Subscriptions, changes of address and other correspondence should be mailed to the above address. New York staff: Barbara Caress, Oliver Fein, David Kotelchuck. Ronda Kotelchuck, Louise Lander and Howard Levy. San Francisco staff: Elinor Blake, Thomas Bodenheimer, Carol Mermey and Barry Roth. San Francisco office: 558 Capp Street. San Francisco, Cal. 94110. Telephone (415) 282-3896. Associates: Robb Burlage, Susan Reverby, Morgantown, W. Va.; Con- stance Bloomfield, Desmond Callan. Nancy Jervis, Kenneth Kimmerling, Marsha Love, New York City; Vicki Cooper, Chi- cago; Barbara Ehrenreich, John Ehrenreich, Long Island; Judy Carnoy, San Francisco. BULLETIN illustrated by Bill Plymp- ton. 1974. At the same time, many RN's have been in- fluenced by the women's liberation move- ment, acquiring a new self respect - and mili- tancy. Traditionally nursing has been wom- en's work - an extension of their caring, clean- ing and serving roles as mothers and house- wives (see BULLETINS, March, 1970, Septem- ber, 1970 and April, 1972). Socialized to be passive and to accept the devaluation of their contributions as workers, women have been reticent to speak up for their rights and push forth their demands at the workplace. Al- though feminist issues were not at the fore- front of this strike, women asserted leader- ship, reliance self - and confidence self - , taking themselves and their jobs seriously. A Kaiser RN stated, " If it weren't for women's lib, we wouldn't have been striking. " Another went on to say, " It definitely gave us the courage to speak up and express our opinions. ' Also underlying the strike was the CNA's response to the new militancy of the rank- and - file RN's. In Los Angeles, 600 public hos- pital RN's recently switched from the CNA to representation by the Service Employees International Union (AFL - CIO). In San Fran- cisco, the AFL CIO - and the Teamsters are the collective bargaining agents for increasing numbers of public hospital RN's. This year seemed like the CNA's last chance to pre- vent widespread defection of RN's into labor unions. A final condition underlying the strike was the fact that the RN's didn't know what they were getting into. The CNA had little experi- ence in conducting strikes and the RN's shared a widespread feeling that " We'll go out for a few days, win and be back on the job next Monday. " Prelude to the Picket Line In December, 1973 the CNA entered into contract negotiations with three groups of northern California hospitals: Affiliated Hos- pitals (most of San Francisco's private hos- pitals, banded together solely for the pur- poses of collective bargaining), Associated Hospitals (a similar grouping mainly in Oak- land and Berkeley) and the Kaiser hospitals and clinics. In January, 1974, the Bay Area Negotiating Council was created to represent the RN's BP. with each hospital electing two representa- tives to serve on it. The Council in turn se- lected 12 RN's to sit in on the negotiating Too Many Beds team. These 12 joined five paid CNA staff members, led by Burton White, a non - RN and Spoil the Budget experienced labor negotiator. Thus the CNA leadership (staff plus elected officials) was Why are Bay Area hospitals so insistent on under the surveillance of rank - and - file RN's understaffing in order to keep their costs at the bargaining table. down? The reason is that the hospitals have During the five months of weekly bargain- ing sessions, the Negotiating Council served as a communications link between the RN's gotten themselves into financial trouble by overbuilding. As the San Francisco Examiner (June 9, 1974) editorialized, " San Francisco and the CNA. Information about negotiations has too many hospitals occupying too much and strategies passed from the negotiating team to the Council, and the Council brought land, filled with too many beds, loaded with too many expensive medical devices and- questions and concerns from RN's at the in- dividual facilities. partly as a result of all these excesses - charg- ing too much for medical care. " In May, mass meetings attended by 1,300 RN's rejected a management proposal by a 95 percent vote and authorized strike action. On June 7, Negotiating Council member Joyce Boone declared, " We are a new breed of According to the Bay Area Comprehensive Health Planning Council, San Francisco and Oakland hospitals have occupancy rates around 65 percent. By 1978, San Francisco will have 1,412 unneeded beds. With an un- nurses, fighting for our rights and those of our occupied bed costing $ 50,000 to build and patients. " The same day RN's set up picket lines around over 40 health facilities. Meanwhile, contracts for LVN's, aides, housekeeping and dietary workers, represent- 20,000 $ per year to maintain (see BULLETIN, March / April, 1974), these excess beds are costing $ 28 million per year plus the initial construction cost of $ 70 million. ed by Local 250 of the Service Employees In- ternational Union (AFL - CIO), had also expired January 1, 1974. Negotiations dragged on for the first five months of the year. As the CNA prepared for strike action, management be- Since empty beds bring in no revenue, hos- pital management must make up the lost money by charging patients more and / or spending less on employees. The most effec- tive way to save is to cut back the total num- came increasingly anxious to settle with Lo- ber of workers. cal 250. Hospitals can manage without RN's; after all, LVN's do many RN tasks anyway (even though they are paid much less). But a simultaneous walkout by RN's and other With the empty bed crisis worsening, com- petition among hospital managements is in- tensifying. Already one San Francisco hospi- tal, Harkness, is closing down. To make sure hospital workers would be devastating. So shortly before the anticipated RN strike, management offered a 40 cent per hour (9- 12 percent) across - the - board increase to Local 250 members. The union, which had negotiat- his hospital won't be next, each administra- tor must look for new and better ways to ad- mit more patients, charge them more, hire fewer workers and increase their productivity. ed without rank - and - file participation, recom- mended acceptance of the offer. Withholding the terms of the agreement from its members until 45 minutes before the vote, the union achieved ratification and thereby helped it alone. Bearing signs declaring, " Patients are our business, " " We want to serve what management avert a combined strike. No at- tempts had been made by the CNA and Local 250 to coordinate or combine their strategies. Hospital administrators heaved a sigh of re- lief: Divide and conquer had worked again. you deserve, " " Qualified nurses for specialty units, " and " Better staffing equals better pa- tient care, " the RN's picketed the entrances to their hospitals. Some 50 to 95 percent of RN's participated in the strike, varying from Going It Alone hospital to hospital, a response far better than expected. The RN's encouraged other workers Unaware of the import of the Local 250 set- to wear blue armbands in support of the tlement on their own struggle, the RN's went strike but not to leave their jobs. 5 The CNA hoped to exert financial pressure on the hospitals by eliminating the profitable elective surgery and non emergency - admis- sions. But not forgetting the patients, the RN's initially maintained staffing of emergency and intensive care areas. Hospitals reported occupancies running 40 to 50 percent of nor- mal levels. Though these occupancy levels clearly hurt the hospitals financially, they were not low enough to bring the institutions to their knees. Three days after the strike began, 8,000 RN's gathered in San Francisco for the an- nual American Nurses'Association (ANA) convention. ANA delegates joined the picket line, raised funds and overwhelmingly passed a resolution in support of the strike. One nursing administrator at a struck hospital responded, " My spies tell me that this [strike] was planned three months ago in Kansas City " (the ANA headquarters), presumably as a staged show for the convention. On June 12, 200 Kaiser RN's rallied at the Kaiser Center in Oakland, and the following day several hundred RN's held a spirited demonstration in San Francisco. A week later, a march picking up RN's at each hospital converged on San Francisco's Civic Center Plaza for another major rally. Day after day, the strike was the leading story on local TV news broadcasts, with charges and counter- charges flying between the CNA and the hos- pitals. On June 20, with negotiations at an im- passe, the RN's upped the ante they - with- drew from the emergency and intensive care areas. Irene Pope, President and Acting Ex- ecutive Director of the CNA, charged that hos- pitals were assigning supervisory personnel to critical non - care areas because they had strikers available to staff emergency units. Others observed that patients who did not need critical care were kept in the critical care area. The pull - out from emergency units was the only tactic available to a professional asso- ciation that bargains for only a limited num- ber of workers in an institution. Strikes by all workers - closing down profitable but not emergency areas of hospitals - would have been more effective in advancing the RN cause than the emergency unit pull - out. But the CNA did not want support strikes by other workers. At least one group, the X ray - tech- nicians at Herrick Hospital, members of the 6 International Longshoremen's and Ware- housemen's Union, were on the verge of a sympathy strike when word came from Her- rick RN's that the CNA had rejected the sup- port offer, not wishing to be obligated to honor future X ray - technician strikes. One Herrick X ray - technician said, " We wanted to go out -there was sympathy with the RN's stand- ing up to the doctors and administration. But when the RN's told me they didn't want our strike, I pulled my blue armband right off. " The RN's did gain substantial public sup- port from other groups during the strike. Un- able to unite with Local 250 in their own work- places, the RN's did receive verbal backing from Local 1199 of the National Union of Hos- pital and Health Care Employees in New York City. The interns and residents organ- ization at San Francisco's Children's Hospital issued a statement of support, as did 63 mem- bers of Mt. Zion's house staff. Over 100 unit clerks, lab techs, LVN's, social workers and housekeeping personnel at Mt. Zion Hospital signed a petition of support. But in several hospitals, the atmosphere was hostile toward non - RN staff who sup- ported the strike. Many workers feel that RN's are the supervisors or the " foremen " on the floor, and the strike demands were seen as potentially increasing RN's power over other workers. Thus workers who donned blue arm- bands soon began to feel isolated. In fact, one Local 250 representative even threatened to fine armband wearers $ 50. As the strike wore on, RN's began to feel acutely the absence of their paychecks. The CNA leadership, fearing that RN's would straggle back to work, tried to hasten the bar- gaining process by edging the 12 elected RN's off the negotiating team. Told that they were too inexperienced to participate in this stage of the negotiations, the elected team members were forced to wait outside the ne- gotiating room. CNA staff negotiators justified their moves by instilling a Henry Kissinger aura upon the delicate sessions and con- vinced the team not to speak with their rank- and - file peers. On June 23, after several attempts to force management to sit down with third party - me- diators, the CNA finally succeeded in secur- ing the services of William J. Usery, Jr., chief federal negotiator and personal labor trou- bleshooter for then President - Nixon. Usery immediately called for around - the - clock ne- gotiations and a news blackout that extended (Continued on page 10) MOUNT SINAI HOSPITAL Dear Dr. Pomrinse: NEXT What follows is the somewhat abbreviated TIME text of a letter from a patient to Dr. S. David I'LL Pomrinse, Director of New York City's Mt. GO TO Sinai Hospital, an 1,150 - bed voluntary teach- BELLEVUE ing hospital that joins with the Mt. Sinai School of Medicine to form the Mt. Sinai Medi- cal Center. A " Consumer Guide to New York City Hospitals " published by New York mag- azine includes this description of Mt. Sinai: " One of New York's great teaching hospitals, Mt. Sinai has the distinction of being both a specialty referral center and a primary hos- pital for its community. Its large number of superspecialists attracts a highly qualified house staff.......... Emergency department is highly recommended. " The letter, whose au- thor is especially well trained to evaluate the adequacy of hospital care, throws a some- what less glowing light on what it concretely means to be a patient in such a distinguished institution. Dear Dr. Pomrinse: From Thursday evening, November 15, 1973 to Monday, November 19, I was an inpatient at Mt. Sinai Hospital. I am writing to you about my stay because of your position and the fact that I am a graduate of the Mt. Sinai Hospital School of Nursing and devoted close to five years of working experience to Mt. Sinai after my graduation in Adult and Child Psychiatry. On Wednesday, November 14, I went to see my own physician because of a leg in- fection which had become quite severe. On Wednesday evening I had cold, shaking chills and a temperature of 103.6 degrees. On Thurs- day afternoon, I phoned my doctor and he urged me to go to the Emergency Room of Mt. Sinai and be admitted. He notified the Emer- gency Room and the chief medical resident there. I went into the ER, informed them who I was and that I was to see the chief resident. They stated that they had no knowledge of this mat- ter, became quite belligerent and hostile to me and told me I had to go to the admitting office. I stood there with my friend (also a former staff member) at a loss. After some minutes, a volunteer agreed to call the chief resident. She returned in a few moments to 7 inform me that he had stated that he didn't know anything about it. At that point the doc- tor walked by, heard the conversation and ig- nored it. Some minutes later, my friend went to the door of the staff area and asked what was to be done, and at that point the chief resident acknowledged having spoken to my doctor and took me into the treatment area. He informed me that he did not think I should be admitted. He said he could either admit me or we could wait until he spoke with my doctor on the phone to discuss it. The Agony of Admission At this point, I should say that I was very ambivalent about admission. I felt physically ill and had a great deal of leg pain, making it almost impossible to walk; however, I was in great financial difficulties and knew a hospi- talization would be a great added burden at this point. Five months ago I completed my graduate degree in Psychological Counseling. While a student I worked part time - in nursing and other capacities to support myself. From last June until about two weeks before hospitali- zation, I had been unemployed, working only part time - as a nurse counselor - in an abortion facility, and had no health or hospital cov- erage. I had incurred many debts, including government loans necessary to see me through graduate school. Two and a half weeks before hospitalization, I had begun working as an individual and family thera- pist at a facility for adolescents. Hospital cov- erage in this position would not begin until February 1974, and of course I was concerned as well with whether I would be allowed to keep my position or get sick time benefits since I had just begun working. For these rea- sons, I told the resident I would wait until he conferred with my doctor. The resident then disappeared for over an hour and I sat and waited. On his return, the resident got in touch with my doctor, who had been trying to return his call for some time. After consultation, it was decided that I should have an incision and drainage and if most of the difficulty was due to an abscess, I should be sent home; if, however, most of the problem was from the cellulitis in my leg, I should be admitted. The resident took me to a surgical intern. I had blood cultures drawn and an incision and drainage. Up to this point, the only person who had spoken to me as a 8 human being was the surgical intern. It was I went to admissions and was informed that unless I was prepared to pay $ 1,400 I could not be admitted. obvious that the emotional as well as physi- cal trauma I was experiencing was of no consequence to any member of the Emergen- cy Room staff. The surgical intern felt, after doing the in- cision and drainage, that I should be admit- ted. The majority of the inflammation was cel- lulitis. He looked for and paged the medical resident, who never appeared and could not be found. The intern told me the surgical res- ident (who had walked into the treatment room for approximately 60 seconds, looked at the incision and drainage and left) had stated that I should not be admitted but would have to return daily to the ER to have my leg taken care of, packing changed, etc. I informed the intern that this was not feasible for two rea- sons: I refused to be put through such a de- humanizing and degrading experience daily and I live alone on the fifth floor of a walkup apartment, and going up and down those stairs was not possible in my condition. The resident said that was my problem, there was nothing he could do about it if I wanted treat- ment. The surgical intern suggested that I go home; he could not find the medical resident and saw that I was obviously in pain, fever- ish and distraught. I accept my mistake in having left at this point. On returning home, I called my doctor and told him of my experiences. He called the resident, and I was told to return to the emer- gency room for admission. I refused, feeling physically and emotionally drained and hav- ing no desire to see that staff again. I was told to go directly to 4 North. When I arrived there, I was told to go to admissions. This was approximately 10 or 10:30 p.m. I could hard- ly walk, I had not eaten for some time and I was quite weak and upset. I asked if some- one from admissions could come over there and without investigation was told no. I went to admissions and was informed that unless I was prepared to pay $ 1,400, I could not be admitted. I explained my finan- cial situation and informed them that I was a graduate of the School of Nursing. After again conferring with my doctor, I returned to the Emergency Room on foot. I was at this point put in a wheelchair, to be brought to 4 North. Up to that point the only thing I had been given was a $ 10 ER bill. I arrived on 4 North at 1:30 a.m. Friday. The Inpatient as Outcast I was given the usual physical and a case history was taken. I also informed the doc- tors of my history of reactions to medications. I was given no medication, although I had been put on Oxycillin by my doctor. Finally, at 11 a.m., after inquiring of both nursing and medical personnel, I was given my first dose of Oxycillin since arriving. I had met several of the house staff but had no idea who was in charge of my case and soon found out that there was a complete lack of communication between any of the staff. If I asked about the medication or any- thing else, I was put off or told that " the doc- tor " would be told. He (whoever he was) never was informed. For the three days I was hos- pitalized, it was only by hitting the right per- son by luck that anything was communicated. Even then frequently nothing was done. By Friday afternoon I had severe, explo- sive diarrhea and severe nausea. I had not eaten anything for some time and never did eat during the entire hospitalization. I asked to see the doctor about these symptoms, and many hours later kaopectate was ordered. The doctor never acknowledged what I had told him about the nausea and retching ex- cept to say that my symptoms weren't dra- matic enough for him to do anything about, it was just the infection. I have had this type of reaction with other antibiotics, but he would not believe it was from the medication. When I told him I had eaten nothing (he had not been told by the nursing staff, although they had removed my trays and commented about it during these three days), he laughed and said, " You haven't eaten? " He told me he would give me nothing. His manner was al- ways flippant, arrogant, patronizing and ego- tistical. This seemed to be the attitude of sev- eral of your medical house staff from my ob- servation of their behavior toward myself and my roommates. I discovered also that the nursing staff, es- pecially on evenings, were totally uninvolved and uncaring of the patients. I received re- marks to the effect that I could change my own dressing. Although at home I kept my leg elevated, fixed a cradle to keep the blan- kets off my bed, fixed a doughnut to keep my heel from being irritated, kept myself on bed- rest and made some clear fluids, in the hos- pital I was for the most part ignored and none of these things were done or even offered. Even my temperature and blood pressure, which were ordered four times a day, fre- quently were not checked more than twice a day. Twice during my stay, in the evenings, He was not being called away for an emergency, he just seemed totally uninterested in talking to a patient. I put on my light to ask for something for nausea. The bell was turned off at the nurses ' station, and no one ever acknowledged it. My roommates had to help me back to bed from the bathroom several times. Friday evening I went to the nurses'station to ask the chief resident what was happen- ing. I stood there, talking to the resident; an- other resident came by and interrupted our discussion. They then proceeded to go off to- gether. The chief yelled back over his shoul- der, " Oh, I'll be back in a while. " I was dumb- founded. I was angry and stated that I wasn't finished talking. He was not being called away for an emergency, he just seemed to- tally uninvolved in talking to a patient. Saturday morning, when a few doctors made rounds, I again asked for something for the nausea. They looked at me and said, " Nausea, since when are you nauseated? " They didn't know. I don't know if there was anything written in my chart by either nurs- ing or medicine, whether they hadn't read it or whether they just weren't concerned. They left with, " We'll order something, " and that was the last time I heard anything about it. At this point I should say that I was very emotionally upset about this whole experi- ence. When I was in nursing school we learn- ed that sick people, especially patients in a hospital, are more vulnerable and need help not only physically but also emotionally, so- cially, religiously and sometimes economical- ly. We were taught to see and respect the whole person. What I was seeing was a lack of concern about any of these areas, includ- ing the physical. I know I wasn't the sickest patient at Mt. Sinai, but there is no excuse for the lack of concern and caring on the part of all disciplines of the supposed team. Saturday afternoon I did by chance meet a very nice resident, whom I begged to help me. Having been a patient at Mt. Sinai him- self on previous occasions, he seemed to un- derstand and spent a few moments talking with me and did order something for my symptoms. Finally Saturday evening the anti- biotic was discontinued. This was done only because my own doctor had come up to the unit and I informed him of my symptoms. The house staff had told him nothing, despite the fact that he was the attending on the unit.... Enter the Bill Collector On Monday I asked to see the social work- er. I told her of my financial difficulties, and she told me to go to patients'accounts. I was still not well and still shaky on my feet. I walked to patients'accounts, was kept wait- ing for some time, was passed from one per- son to another. I told the man who finally spoke to me about my financial situation and asked about Medicaid. He excused himself, saying he was going for a pad of paper; he returned 20 minutes later to inform me not only that I could not receive Medicaid, but also that he had spoken to my place of em- ployment and stated that I was employed there. (I had not denied that I had started working there two and a half weeks before.) He then informed me in a very nasty tone that I owed Mt. Sinai $ 200 per month until my bill was paid. I told him this was impossi- ble, asked if the payments could be less per month and again explained my financial dif- ficulties. He refused to compromise in any way and would not let me go until I signed a paper stating that I owe Mt. Sinai $ 200 per month.... This experience was a nightmare for me; it angers me, it dehumanized me. I know it was worse for me because I am a nurse with med- ical knowledge of what can be done for pa- tients; because psychology is my field and I'm aware of feelings and attitudes more in myself and others; because I'm a woman who felt surrounded by men who haven't be- gun to understand people; because I spent three years being educated at Mt. Sinai, learn- ing and believing everything in the opposite way from the way I was treated; and because I speak up for what I believe in and this, I am sure, was a threat to a lot of the staff. I am left with three things after my hospi- talization. The first is an eight pound - weight loss (which I appreciate), the second is in- formation I am utilizing in writing an article and the third is the sad knowledge that one does not enter a hospital to get better, one enters to not get worse hopefully - ! Yours with concern, Nancy Shamban, R.N., M.A. Nurses Strike (Continued from page 6) to the striking RN's. With the breakdown of the democratic process, some RN's began to shift their anger from management to the CNA. On June 26 a settlement was announced. At 7 p.m. on June 27 the striking RN's, with- out having been allowed to see the settle- 10 ment assembled, at San Francisco's giant Cow Palace. Some of them angrily demanded in- dividual hospital caucuses to discuss the agreement before voting on it. But after a short period of confused debate, a vote was forced. The RN's accepted the package by a vote of 1,670 to 494. Victory or Holding Action? The CNA leadership touted the strike set- tlement as a major victory for RN's. Most im- portantly, management failed to delete the key staffing clause from the existing con- E B.Phyrphon tract. Concerning the specialty units, the new agreement provides that " Except in case of emergency, nurses without appropriate train- ing and / or experience shall not be assigned to such areas. " The first five words are those of management, and whether this clause is a victory or defeat for the RN's depends on how " emergency " is defined. Management decides what is an emergency unless the CNA can overturn their definition by filing and winning grievances. The hospitals also agree to provide training for specialty care. The RN's won a whopping 11 percent pay boost, felt by some to be an overt attempt to buy them off. In fact, the figure represents the 5.5 percent raise asked for plus a one- shot 5.5 percent living cost - of - adjustment to cover inflation since January 1. (The RN's failed to win a continuing cost living - of - esca- lator clause.) The demand for alternate week- ends off was compromised, and the portable pension plan was not granted but was sub- mitted for study. Management conceded to the opening of certain issues for renegotiation on January 1, 1975. Rather than a victory, the settlement is ac- tually closer to a successful holding action. With the economy in decline, hospitals like all industries are trying to squeeze more work out of their employees at lower cost to them- selves. The retention of the staffing clause provides the RN's with at least some leverage to fight against understaffing and speed - up. The pay increase slows the rate at which RN's incomes fall behind inflation. The spe- cialty staffing clause, provided that the RN's fight for its implementation, is the only sub- stantial move ahead. Given management's 11 refusal to yield the slightest decision - making authority to the RN's, the staffing portions of the new contract are of little use without con- stant grievances and battles for enforcement by the RN's at each hospital. The New Consciousness After five months of negotiating and 21 days of striking, the RN's won a holding ac- tion but made few advances in changing their objective conditions of work. RN's have re- turned to find the wards still understaffed and themselves still overworked. And the tensions manifested during the strike between RN's and those who take orders from them, such as LVN's, orderlies and aides, have not magically disappeared. Nevertheless, for the RN's the strike had significance that went past the bargaining table and changes in objective conditions of work. The most marked achievement was the mobilization of the RN's from the wards to the picket lines and the development of a sense of unity, militancy and self reliance- - the antitheses of the passive role women are socialized into in nursing school. Equally important was the way the strike served to break down the isolation among RN's. There are many structural organiza- tional reasons for hospital workers to be iso- lated from one another: Wards are physically separate, some jobs are more prestigious than others, some pay more and people on differ- ent shifts seldom see each other. Moreover, the assigned workloads are often so heavy that merely getting one's work done is diffi- cult. Working together during the strike gave RN's a chance to get to know and trust one another as well as to develop collective strat- egies and solutions. An obstetric nurse at Ala- meda Hospital stated, " The strike has given us a new sense of unity. " The strike also served to show the true face of the CNA. Throughout the five months of negotiations and for the first part of the strike the CNA was remarkably democratic, allow- ing for participation by rank - and - file RN's. RN's were represented on both the negotiat- ing team and the Negotiating Council, bring- ing the latest developments and management offers back to RN's at the hospitals they rep- resented. In the last week of the strike, how- ever, the CNA reverted to top down - , heavy- handed tactics, which many RN's found in- 12 furiating. Reflecting this anger, a committee of RN's at Mt. Zion Hospital sent the follow- ing letter to the CNA: " We at Mt. Zion feel that we were sold out. ... The most charitable view expressed has been that the team members had hit a low point in their motivation and energy and that they were afraid to let Usery leave without a settlement.... The other, less charitable opinion is that the strike was, from the first, a grandstanding maneuver by the paid of- ficials of the CNA; a tactic to tighten their hold on jurisdiction over RN's in the Bay Area,.... " We feel that these questions must be spok- en to by the leadership of CNA. We ask for the support of all CNA members in working to ensure that this betrayal of democratic principles in our organization does not repeat itself. We are willing to work within CNA to make the leadership more responsive to our needs and to strengthen their commitment to the democratic process. We are willing to work to use the contract to make whatever progress is possible on the issues of staffing, patient care, and professional self determina- - tion. We hope that our analysis of the situa- tion will provide food for thought for all CNA CNA Professional - Standard Bearer The California Nurses'Association (CNA) was incorporated in 1907 to advance the pro- fessional status of nurses. Its overall purposes and philosophy are identical to those of the American Nurses'Association (ANA), of which it is a constituent group: " to foster high standards of nursing practice, promote the pro- fessional and educational advancement of nurses to the end that all people may have better nursing care. " Membership is limited to registered nurses (RN's): thus the CNA fights for better wages and benefits, improved job conditions and upgrading of standards, sta- tus and education for only the elite of the high- ly stratified, predominantly female health la- bor force. LVN's, aides, orderlies and a long list of other workers directly and indirectly in- volved in curing and caring are set apart both in terms of occupational status and bread- and butter - issues. members returning to work under this con- tract. " Democracy, however, is far from the cen- tral issue regarding the CNA. What is at ques- tion is the difference between a professional association and a hierarchial non - , anti pro- - fessional organization of workers fighting for their own power and interests. Historically the CNA, while making minimal support gestures in other hospital workers'struggles, has not even honored picket lines during their strikes. By choosing to go it alone, the CNA not only loses a powerful bargaining weapon, but keeps RN's separated from the majority of hospital workers. The Old Contradictions While on the one hand the strike raised the level of consciousness of the RN's, on the other hand it manifested and exacerbated the existing tensions and contradictions found in the hospital workforce - namely the race, class and sex antagonisms upon which the hierarchical division of labor rests. At the top of this hierarchy are the male administrators and physicians, enjoying high status, income and power. Next come RN's, predominantly white female professionals, who in this case were demanding a piece of the pie. Beneath them are LVN's, aides, orderlies and other low paid -, predominantly Third World work- ers who make up the majority of the work- force and take their orders from the RN's. While RN's are in supervisory roles and make more money than other hospital em- ployees, they are still wage workers and are exploited as such. The ideology of profession- alism promotes elitism on the part of RN's, but in fact they have more in common with other workers than with doctors or adminis- trators. The RN's are pawns in the hospital hierarchy, placed in positions in which they must assume responsibility for running a floor and give orders to other workers. They are forced to act as a buffer for the doctors and administrators, becoming, whether they like it or not, the most visible authority figures, who do the dirty work of the administrators and boss other workers around. Reactions of other workers during the strike underscore these tensions and hostilities. An LVN at Alta Bates Hospital said, " I'm glad they're out, this will give us more space to The structure of the CNA is similar to that of any other professional association. The gov- erning body is the House of Delegates, which meets every other year. The Board of Direc- tors, composed of the president, vice presi- - dent, secretary, treasurer and ten directors, conducts the business of the CNA. Daily ac- tivities of the Association, ranging from mem- bership recruitment to public relations, are carried out by regional associations. Mem- bership in the CNA requires payment of dues - 25 $ to the ANA and $ 55 to the CNA, as well as the amount specified by each regional as- sociation. (Provisions are made for reduced dues classifications such as unemployed, part- time, or new graduate.) Having come a long way from its early - day legislative battles merely to gain recognition, pass licensing laws and put a ceiling on the numbers of hours of work for nurses and nurs- ing students, the CNA in 1966 dropped the strike no - clause then in its by laws - ; since then it has become an active collective bargaining agent for RN's. Along with this has come a new aura of militancy - CNA nurses march- ing and chanting on the picket line, demand- ing control over working conditions and en- gaging in hard nosed - bargaining with sea- soned management negotiators. Despite this new image, the basic philosophy of the CNA and ANA remains unchanged - to move their constituents up the professional ladder vis - a- vis physicians and administrators, to get a little bigger piece of the pie in terms of auton- omy, decision - making and financial remu- neration. " The'day of the nurse as handmaiden to the physician is ending, " was the message given to thousands of RN's at the recent ANA convention by Wilma Scott Heide, a former nurse and past President of the National Or- ganization of Women. She went on to talk about a new role for nurses, calling for the creation of " joint practices " between doctors and nurses. Instead of calling into question the power and privilege at the apex of the medical hierarchy, such a demand asks to be part of it. While such views may not repre- sent those of the rank - and - file RN's, there seems to be little doubt as to where the aspira- tions of the CNA leadership lie. 13 move. " A worker at Children's Hospital in San Francisco added, " We're better off with- out them here. " Another worker characterized the strike, " The attitudes of the nurses dur- ing the strike seem to have been taken over from doctors - union anti -, pro professional - , specialization pro - . They were competing with doctors to gain more decisions over patient care by raising their level of professionalism to that of doctors. " In the final analysis, RN's alone cannot shut hospitals down and bring significant change to their workplaces. In the long run, demands for professional upgrading by RN's are made at the expense not only of other workers but of the RN's themselves. The RN strike has made clear the tremendous ob- stacles to success that exist when different hospital workers'groups fight their own bat- tles in isolation and even opposition to those of other health workers. -David Gaynor, Elinor Blake, Thomas Bodenheimer and Carol Mermey. (David Gaynor, a hospital administration student at Cornell University, was an intern at Health / PAC's San Francisco office this summer.) More on Women and the Health System WOMEN AND HEALTH These articles outline some of the problems faced by both women health workers and women health consumers in the American health system. It includes three back issues of the BULLETIN (March, 1970, September, 1970 and April, 1972). $ 1.50 (.75 $ each for individual Bulletins.) WITCHES, MIDWIVES, AND NURSES: A HISTORY OF WOMEN HEALERS by Deidre English and Barbara Ehrenreich. A 45 page - illustrated booklet on how women healers were sup- pressed and how the male medical profession rose to dominance. $ 1.25 each. COMPLAINTS AND DISORDERS: THE SEXUAL POLITICS OF SICKNESS by Barbara Ehrenreich and Deidre English A dynamite 94 page - booklet analyzing how women have been historically put down - physically and emotionally, by the medi- cal profession. $ 1.50. each. Write: Health / PAC 17 Murray Street New York, N.Y. 10007 (For orders of $ 5.00 or less add 20% postage; for orders over $ 5.00 add 10%.) 14 Media Scan BLUE CROSS: WHAT WENT WRONG? By Sylvia A. Law (New Haven & London: Yale University Press) The presentation of a Blue Cross card is often both an ad- mission ticket to most Ameri- can hospitals and an exit visa as well. Many people covered by Blue Cross find hospitaliza- tion financially painless. Be- cause patients never see the in- terchange between Blue Cross and the hospital, they remain oblivious to the connections be- tween the financing mechan- isms and the cost and quality of the care they receive. Who is the main beneficiary of this seemingly smooth, well- oiled, impersonal system? Blue Cross asserts that it " has one objective: to protect people in terms of the hospital care they need. " But Sylvia Law, in her carefully documented, well- reasoned book, Blue Cross: What Went Wrong?, sees an entirely different purpose. " In a nutshell, this book finds that Blue Cross is most accurately characterized today as the financing arm of American hospitals. " What is Blue Cross? Child of the economically pressed voluntary hospitals, born during the Depression, Blue Cross has grown to ro- bust, if impaired, maturity. It now provides about half of all hospital income. The 74 Blue Cross plans have a total en- rollment of 80 million subscrib- ers, four of every ten Ameri- cans. As designated fiscal in- termediary for most of the pub- licly funded Medicare and Medicaid programs, it admin- isters insurance benefits for an additional 32 million people. The Blue Cross operating budg- et alone, about 6 percent of revenues, is equivalent to the cost of maintaining roughly 150,000 beds in US hospitals. Blue Cross advertises itself -at subscribers'expense - as a public service organization, benevolent and munificent, that takes the worry out of hos- pital bills. Whether people ac- cept this projected image, or see Blue Cross as an insurance company pure and simple, neither perception is accurate. Misconceptions of the true nature of Blue Cross, however, do have an effect on its opera- tions. For example, its rate in- creases are rarely challenged by subscribers. Payroll deduc- tions and employer contribu- tions blunt the impact of pre- mium payments. Since health insurance payments come from potential rather than ac- tual wages, few notice, much less respond to, rate increases. And because most workers are enrolled in group plans, an in- dividual who does understand the significance of Blue Cross on the functioning of the health industry is powerless to act alone. Finally, Blue Cross dis- courages organizing around such issues as rate increases because of the complexity of the collection mechanism and the relative obscurity of the hospital payment system. Blue Cross functions to en- courage both these responses -apathy and impotence. It is a near perfect mechanism for the hospital industry - it bol- sters occupancy and revenues while keeping at bay those who pay the bills. The Peculiar Institution Commercial health insur- ance dates back to the mid- 15 19th Century, when families paid a few cents a month to indemnify against income loss due to accidents or sickness. There wasn't much point in buying coverage for hospital or doctor bills because medi- cine was incapable of curing disease and hospitals were places where the poor went to die. True to its beginnings, commercial health insurance has remained basically a per- sonal indemnity plan. That is, subscribers are reimbursed a fixed amount for specified med- ical expenditures, for example, $ 100 per day of hospital care. The extent of each person's re- imbursement is directly related to the amount paid in premi- ums. Blue Cross operates on an entirely different principle. Its benefits are paid directly to the provider, and reimbursement rates are pegged to the pro- vider's costs. Regardless of whether a Blue Cross subscrib- er is hospitalized at a fancy academic hospital where care costs $ 180 a day or at a small community hospital where it only costs $ 80 a day, his cov- erage is exactly the same. Blue Cross reimburses the hospital, while commercial health in- surance indemnifies the pa- tient. Professor Law and her asso- ciates at the Health Law Proj- ect trace the history and de- velopment of this peculiar in- stitution. It begins during the Depression, when hospitals, which had proliferated in the early years of this century, faced bankruptcy. Between 1929 and 1930 hospital receipts fell from an average of $ 236.12 per patient stay to $ 59.26. Oc- cupancy, however - since peo- ple continued getting sick - fell by only 10 percent in the same year. Thus many institutions 16 found themselves treating peo- ple who couldn't pay. Dr. Ford Kimball, Vice President of Bay- lor University, came up with a solution for his University's hospital. In 1929, he convinced a group of Dallas school teach- ers to prepay for hospitaliza- tion. By collecting only 50 cents a month from each teach- er, Dr. Kimball was able to guarantee Baylor Hospital's solvency and to alleviate the teachers'financial worries about possible hospital bills. With the active encourage- ment of the American Hospital Association (AHA), the plan spread rapidly. Showing con- siderable foresight, the AHA registered the Blue Cross trade- mark, first used by a group of hospitals in Minnesota, and Blue Cross became a subsid- iary of the AHA. In 1938 Blue Cross promulgated its stand- ards for nonprofit prepayment health plans. No group could use its trademark without the approval of the AHA. (Since 1972 the Blue Cross trademark has not been owned by the AHA; in that year the formal tie between Blue Cross and the AHA was amicably dissolved.) It was no coincidence that 22 of the 36 local plans existing in 1938 had been entirely cap- italized by the participating hospitals. Five others were par- tially financed by the hospitals. By 1938 these plans had en- rolled a total of 1.4 million peo- ple. During these early days the AHA sponsored state enabling legislation to exempt its fledg- ling enterprise from state and local taxes and from the laws regulating the operations of traditional insurers. The hospi- tals, strapped as they were for cash, were unwilling to share the wealth with their host states. The AHA lobbyists suc- cessfully argued that as a serv- ice to nonprofit hospitals and as a public service willing to enroll all comers, Blue Cross was substantially different from other insurers. This spe- cial privilege has been over- ruled in court challenges in four states. But in others, Blue Cross still maintains its sepa- rate and superior status. The essential difference, of course, is that Blue Cross passes its profits along to the hospitals, whereas other health insur- ance companies distribute div- idends. Of the first 39 Blue Cross plans, 22 were entirely capitalized by hospitals. Blue Cross Falters Blue Cross'situation is not, however, as cozy as it was back in the 1930's. Until World War II, Blue Cross had a vir- tual monopoly on prepaid hos- pitalization insurance. But the wartime wage freeze under- scored the potential profitabili- ty of hospitalization insurance; health insurance and other fringe benefits were the only items open to collective bar- gaining. Instead of being sold to the undifferentiated public, health insurance could be sold to a pool of relatively young and healthy unionized work- ers and their families. The commercial insurance actuar- ies calculated that these peo- ple would provide more pre- mium payments than they would collect in benefits. At the time, Blue Cross was still operating under a com- munity rating system which divided liability among all sub- scribers, young and old, sick and healthy. This egalitarian risk spreading - had been one of its major selling points to state legislatures. Community rating, even with Blue Cross ' tax advantage and reserves exemption, allowed the com- mercials to offer cheaper in- surance premiums for similar coverage. Blue Cross attempted to recoup its losses by switch- ing to a similar experience rat- ing system for all groups of over 100 people. This did not stop the encroachment of the commercials, whose alle- giance is to their shareholders and not the hospitals. They sold less comprehensive cov- erage at lower cost, and many groups were willing to gamble on possible hospital bills. By 1955 the commercials had cap- tured more than 50 percent of the health insurance market. Competition from the com- mercials was not the only in- hibition to Blue Cross'growth. Its inflationary imperative was another. Professor Law's ex- planation of precisely how the Blue Cross system is inflation- ary is one of the outstanding contributions of the book. A health insurer, like any other type of insurance com- pany, makes its money by holding down utilization. Blue Cross, however, was created by the hospitals to insure their revenues. Since hospitals spend about two thirds - as much on an empty bed as on a full one, high occupancy with paying patients must be main- tained in order to meet ex- penses and produce the sur- plus with which to expand. In order to serve its masters, Blue B. Plympted Cross had to promote utiliza- tion. Thus, against the interest of its own solvency, it limited benefits to in hospital - expenses while it would have been far cheaper to expand coverage of ambulatory care. Since revenues were guaran- teed for a large part of the po- tential patient population, hos- pitals indulged in expensive equipment, high professional salaries and expansion of bed capacity, thus creating the need for even greater income. In other words, because reim- bursement rates are deter- mined by expenditures, hospi- tals can only take in more money if they spend more money. The more they spend, the more they get. Blue Cross could therefore not behave like a typical cost conscious - insur- ance company. This inflation- ary imperative nearly forced Blue Cross out of business. It was and is constantly appeal- ing for rate increases in order to match its expenses. A final force curtailing Blue Cross'growth was increasing public disaffection with its op- erations. By the 1960's health activists had begun raising questions about the ethics of hospitals owning and controll- ing their financial mainstay. The very people who spend the money coming into the hos- pitals sit on the Blue Cross boards that determine the amounts they will be given to spend. The AHA Standards of Ap- proval required that the boards of directors of local Blue Cross plans include at least one third - provider representatives. Ac- cording to Sylvia Law, this us- ually worked out to be a ma- jority. The rest of the board members were most often lo- cally influential businessmen who often had their own con- flicts of interest. The Massachu- 17 The rosters of Blue Cross directors " read like Who's Who of the Western World. " Blue Cross advertisement setts Blue Cross board of 1969 is an illustrative example. Of the 31 members, 11 were either trustees or directors of partici- pating hospitals. Others were executives or directors of ma- jor corporations that had other corporate officers sitting on hospital boards. Two were doc- tors on the staffs of prominent Boston hospitals and two were former directors of hospital supply companies. Of the re- maining nine, one was presi- dent of Massachusetts Blue Shield and another ran a hos- pital consulting business. Despite some legally man- dated changes, health care pro- viders still dominate Blue Cross boards. Law cites 1970 Blue Cross Association figures that show that 56 percent of local board members were provid- ers. Most of the remaining 44 percent so called - consumer representatives were selected by incumbent boards. In 21 states, the non hospital - repre- sentatives are selected out- right by the provider members. Although the reality of board composition has not changed much, the rhetoric has. Blue Cross no longer boasts, as it did in 1966, of boards whose " rosters read like the financial Who's Who of the Western World. " It has discovered that the byword of the consumer conscious 1970's is " maximum feasible participation. " Before the Hart Committee in 1971, Walter McNerney, President of 18 the Blue Cross Association (BCA), gave testimony to this ideal. " To assure that care is rendered at a time and place and in a way satisfactory to the consumer, the consumer must participate in decisions. " There is no evidence that Blue Cross boards have switched their allegiance from the hos- pitals to the consumers. All they have done is play a game of modified musical chairs, keeping the same players and adding a few new seats. Raiding the Public Till Finding its growth stymied by these developments - com- petition from the commercials, enormous benefit payments and public disaffection - Blue Cross turned to a new source of income. Just as Dr. Kimball found the Dallas teachers, BCA found the public till. In 1962, for the first time in their his- tory, Blue Cross and the AHA formally called for the enact- ment of publicly assisted health insurance for the poor and the elderly. Sylvia Law details the story of how the Blue Cross - AHA axis parlayed this policy turn- about into many millions of dollars. The fear of a provid- ers'boycott had been offered by succeeding national admin- istrations as the reason why no national health insurance pro- grams were ever enacted. With the promise of support from the AHA and Blue Cross, Presi- dent Kennedy incorporated them into the legislative draft- ing process, and his legislation was written by a joint HEW- AHA - Blue Cross task force. A new concept was introduced into an old idea. For the first time in the half century of pro- posals for federally funded health insurance, the idea of a fiscal intermediary - an ad- ministrative layer between the government and the providers Lwas introduced. The only or- ganization that fit the bill as it was written was Blue Cross. Having written itself into the legislation, Blue Cross went forward to use the income it generated from its Medicare / Medicaid business to supple- ment its revenues from other sources. According to Profes- sor Law, public programs in 1970 accounted for more than half of Blue Cross payments to hospitals- $ 4.9 billion from Medicare, $ 1.9 billion from Medicaid and an additional $ 545 million from other federal health insurance programs. Far greater than originally es- timated, the size of Medicare / Medicaid expenditures is a log- ical consequence of the reim- bursement mechanism. The Congress mandated the Secre- tary of Health, Education and Welfare to promulgate stand- ards for payments to hospitals and other providers. If the Sec- retary had any intention of revising the established meth- od by which Blue Cross forked over cash, the law instructed him otherwise. It instructed him to " consider, among other things, the principles generally applied by national organiza- tions or established prepay- ment organizations. " Not sur- prisingly, the only " national organization " that met this def- inition was Blue Cross. The Principles of Reimburse- ment adopted by HEW were nearly identical to those em- ployed by Blue Cross. Both the Medicare program and Blue Cross reimburse providers on the basis of " reasonable costs. " In the words of the Social Se- curity Administration chief, Robert Ball, this meant, " What- ever it costs, that would be paid. " In the lexicon of reimburse- ment, reasonable costs are de- fined as those that are allow- able. Allowable translates to any cost incurred by an insti- tution that can be related to the delivery of patient care. The only major categories of hospital expenditures that fall outside this definition are re- search and training, although, as the book shows, these costs are often channeled into allow- able budgets. All of the backroom wheel- ing and dealing is not just un- ethical; it's expensive. Hospi- tal costs have increased by 147 percent since the enactment of Medicare and Medicaid, while the Consumer Price Index for all items has gone up 44 per- cent. There is some debate over whether Medicare and Medi- caid have resulted in better health care for the beneficiar- ies, but there is no question that all of us now pay more for the same health services. The Nixon Administration's chief health economic advisor " Whatever it costs, that would be paid. " Robert Ball, Social Security Chief has summarized the net result of this arrangement: " Unfor- tunately the production of high cost hospital care is a self - re- inforcing process: the risk of very expensive hospital care stimulates patients to prepay hospital bills through relative- ly comprehensive insurance, while the growth of such in- surance tends to make hospi- tal care more expensive. " (Martin S. Feldstein, " The Med- ical Economy, " Scientific Amer- ican, September, 1973; also see BULLETIN, May, 1973.) The main beneficiary of this system is the health industry. Except for Blue Cross it was doing quite well before the enactment of Medicare and Medicaid; it is now doing even better. Hospital expenditures in 1964-65 were $ 13 billion; in 1971-72 they had nearly tripled to 32 $ billion. The more hospi- tals spend, the more other parts of the health industry profit. Drug companies sell more drugs, supply companies sell more supplies, construction firms build more hospitals, doc- tors make higher salaries and so on. But not only were hos- pitals spending more money, they were also clearing more money. According to AHA fig- ures, cited by Law, the surplus of net revenues over expenses for all US hospitals in 1964 was $ 115 million. In 1969, three years after the implementation of Medicare and Medicaid, net surplus had climbed to $ 400 million. National Health Insurance Guaranteed - Income Even the health industry, with its outward appearance of robust growth and immunity to economic crisis, is subject to pressures it cannot control. Health expenses have been consuming an ever increasing - share of the federal budget. In addition, as insurance premi- ums go up, unions are hesitant to trade off more benefits for lesser wage increases. The gov- ernment in very tentative ways has been attempting to control health care inflation through such direct devices as the price freeze and smaller appropria- tions, and indirectly through utilization controls (see BULLE- TIN, July August / , 1974). This brings us to the ques- tion of national health insur- ance. Unfortunately, Sylvia Law's book - after skillfully and carefully documenting the nature of power relationships in the health industry, the abuse of public funds by Blue Cross and most importantly the continued denial of decent care to the majority of Ameri- cans then lapses into vague, Naderesque prescriptions for national health insurance. By some mystical process, not spelled out in the book, Law sees a national health insur- ance scheme that, having wrested power from the vested interests, will administer a pro- gram for the public good. " What is needed, " she sug- gests, " is a structure that will enable those citizens who have a particular interest in health services to participate in the formulation of local health de- livery systems within the framework of a national health system that makes basic allo- cations of available resources in response to local expres- sions of need. " This sounds like a good idea. But which Congress is going to enact this legislation? Which bureaucracy is going to over- see it? Will it be the same Con- gress and bureaucracy that al- lowed Blue Cross and the AHA to tailor Medicare and Medi- caid to their own needs and then wrote the regulations to suit them? Why should those who have power give it up and let public spirited citizens take over? The Blue Cross Association is undaunted by Professor Law's utopian scenario. It knows that the same people who wrote Medicare Medicaid / will also enact national health insurance. It has been prepar- ing for this eventuality for some time. In 1971, BCA's chief 19 Washington lobbyist, George Kelley, outlined the Associa- tion's national health insur- ance game plan. In a secret memo to local Blue Cross plan directors, he laid out BCA's strategy to insure the inclusion of Blue Cross as fiscal inter- mediary in whatever program is enacted. Kelley explained: " Based on an experience of many years, it was decided that an indirect approach - con- ducted primarily in the key person's home surroundings where he is relaxed and recep- tive would be the most effec- tive means of communication. " These key persons are " the 100 or so decision makers in Con- gress. " The tactics, as Kelley wrote, pivoted around the use of locally influential political backers and brokers who would approach the Congress- man, " someone who is person- ally known by the Member, one he will listen to with re- spect. " The goal of this effort was to counteract what Kelley char- acterized as " the campaign to nationalize health care, " i.e., enact federally administered national health insurance. Blue Cross was not planning to lob- by for any particular proposal. Of course, the bigger the bene- fits, the larger would be the cut for Blue Cross. But whether Kennedy, Mills, Long, Ribicoff or Nixon got the credit, it was immaterial to Blue Cross so long as it was assigned a role akin to its role under Medicare and Medicaid. Kelley likened the mission of the lobbying task force to " that of John the Baptist, to make straight the path. " The Congress will not ignore the advice it gets from Blue Cross and its legion of lobby- ists. It's not that Congress doesn't understand what's go- 20 ing on. Even before the Medi- care and Medicaid programs were enacted, Wayne Morse warned his colleagues of the consequences of their actions. Speaking to the nation of a fis- cal intermediary, he said: " These are non governmental - agencies whose basic commit- ment is not to the beneficiaries of the program, but to whom Medicare is an incidental, prof- itable and subordinated sup- plement to other business. *.. Blue Cross is essentially a crea- ture of the hospitals... it can- not possibly serve as the agent of government. Blue Cross sim- ply cannot meet the require- ment that it deal'at arms length.'' BCA carries weight with the Congress, despite eight years of experience with its gross and subtle raids into the pub- lic till, because of the political clout of the voluntary hospi- tal system. This the Congress- men will have to weigh against the inflationary imperative ap- parent in Medicare and Medi- caid. They might decide to as- sign the fiscal and administra- tive responsibility to a govern- ment agency - HEW, SSA or a newly created one. But this de- cision will be based on what makes sense both economical- ly and politically in the limited arena in which they operate. What hospitals charge non Medi- - caid patients " is of absolutely no con- cern to us under the bill. " Wilbur Cohen, Undersecretary of HEW, 1965 Balancing the demands of Blue Cross against the fiscal needs of the government is the task now facing the drafting com- mittees. They will have to make some deals with the com- peting interests - BCA, AHA, commercial health insurers, the American Medical Associ- ation, the medical schools and the drug and hospital supply industry. So far, as Sylvia Law has described, the Congress has been the advocate of the Blue Cross - AHA axis in the health industry. The only fac- tor now standing in the way of the continuation of this inti- mate relationship is the fiscal crisis of the American econo- my. Whatever the outcome, it is unlikely that national health insurance will be designed to promote the people's health. That sort of program would necessarily include provisions for reallocation of health re- sources and guarantees of free or low cost - high quality and accessible care. There is little in any of the national health insurance proposals providing for such an outcome. Rather all of the proposals concen- trate on the administrative ap- paratus and the extent of bene- fits. The Congress is concerned with getting the contending forces off its back. People's anger at institutions that provide inadequate, im- personal care or at doctors who rip them off does not read- ily translate into organizing around such issues as who ad- ministers national health insur- ance. The system is organized to keep the financial interac- tions as far away as possible from the patient provider - inter- change. Most people do not see that this level of health indus- try activity does, in fact, affect those things they are most an- gry about. " Blue Cross simply cannot meet the requirement that it deal'at arms length. " " Senator Wayne Morse, 1965 Blue Cross is a front for the hospital industry; it does not deliver care but it does the bid- ding of those that do. Confront- ing this insulated power struc- ture only through its faade is like trying to open the door by stripping the paint. Only if na- tional health insurance is pub- licly administered - that is to say, Blue Cross is excluded- will we even have a fighting chance. At the very least, we will have more access to the kind of information Sylvia Law and her associates spent sev- eral years researching. But, again, no national health in- surance proposal, with or with- out a fiscal intermediary, con- fronts the issues of maldistri- bution of resources and per- sonnel training of health work- ers, profits in the monopolistic health industry and the priori- ty of teaching and research over patient care. Ultimately, Blue Cross: What Went Wrong? is less impor- tantly about Blue Cross than it is about how the hospital sec- tor manipulates public policy. Sylvia Law has performed a needed service. By dissecting the skin, she has left the mus- cles open to view. -Barbara Caress Books Received Osofsky, Howard J. and Osof- sky, Joy. (eds.) The Abortion Experience: Psychological and Medical Impact. Hagerstown: Harper and Row, 1973. 668 pp. 25.00 $. Rutstein, David D. Blueprint for Medical Care. Cambridge: MIT Press, 1974, 284 pp. $ 8.95. Tushnet, Leonard. The Med- icine Men: The Myth of Qual- ity Medical Care in America Today. New York: St. Martin's Press, 1971, 217 pp. $ 7.95. Willard, Harold and Kasl, Stanislav V. Continuing Care in a Community Hosptal. Cam- bridge: Harvard University Press, 1972. 192 pp. $ 8.00. Townsend, Claire. Old Age: The Last Segregation. New York: Bantam Books, 1971. 229 pp. $ 1.95. Landau, Richard L. Regulating New Drugs. Chicago: Univer- sity of Chicago, 1973. 297 pp. $ 5.25. Berki, Sylvester E. Hospital Economics. Lexington: Lexing- ton Books, 1972. 270 pp. Mills, Richard. Young Out- siders: A Study of Alternative Communities. New York: Pan- theon Books, 1973. 208 pp. 6.95 $. Hauser, M. M. The Economics of Medical Care. London: George Allen & Unwin, 1972. 334 pp. Levey, Samuel and Loomba, N. Paul. Health Care Admin- istration: A Managerial Per- spective. Philadelphia: J. B. Lippincott, 1973.603 1973.603 pp 17.00. $ . Hollister, Robert M., Kramer, Bernard M. and Bellin, Sey- mour S. Neighborhood Health Centers. Lexington: Lexington Books, 1974. 349 pp. Milgram, Stanley. Obedience to Authority. New York: Har- per and Row, 1974. 224 pp. $ 10.00. Silverman, Milton and Lee, Philip R. Pills, Profits and Poli- tics. Berkley: University of California Press, 1974. 403 pp. $ 10.95. Walbert, David F. and Butler, J. Douglas. Abortion, Society and the Law. Cleveland: Case Western Reserve University Press, 1973. 395 pp. Caplan, Gerald. Support Sys- tems and Community Mental Health: Lectures on Concept Development. New York: Be- havioral Publications, 1974. 267 pp. Kennedy, Edward M. In Crit- ical Condition: The Crisis in America's Health Care. New York: Simon and Schuster, 1972. 252 pp. $ 6.95. McCleery, Robert. One Life- One Physician. Washington, D.C.: Public Affairs Press, 1971. 167 pp. $ 5.00. Thorwald, Jurgen. The Pa- tients. New York: Harcourt Brace Jovanovich, 1972. 43 pp. $ 10.00. Somers, Anne R. (ed.) The Kaiser Permanente Medical Care Program: A Symposium. New York: The Common- wealth Fund, 1971. 238 pp. Meek, Ronald L. (ed.) Marx and Engels on the Population Bomb. Berkeley: Ramparts Press, 1971. 215 pp. 1.95. Atkinson, Ti Grace -. Amazon Odyssey. New York: Links Books, 1974. 257 pp. $ 4.95. Havinghurst, Clark C. Requ- lating Health Facilities Con- struction. Washington, D.C.: American Enterprise Institute for Public Policy Research, 1974. 314 pp. $ 4.00. Gitelson, Maxwell, Psychoan- alysis: Science and Profession. New York: International Uni- versities Press, 1973. 439 pp. $ 12.50. Zimmerman, David R. Rh: The Intimate History of a Disease and Its Conquest. New York: Macmillan Publishing, 1973. 371 pp. $ 8.95. 21 banks with which they are af- filiated. (See also Health / PAC Vital Signs reprint of Washington Post se- ries on Washington area hos- pitals, 30 .) . While the court failed to find = WATERGATE IN WHITE Even the hospital industry has its bugging and break - in scandals. In late August, the owner, attorney and adminis- trator of the Clinton Communi- evidence of a conspiracy and did not recommend that the trustees be removed, it did es- tablish guidelines concerning the financial duties of hospital trustees. These include respon- ty Hospital in Prince Georges County, Maryland were ar- rested for conspiring to bug and break into a local physi- cian's office in an attempt to prevent the construction of an- sibility for supervision of of- ficers, employees and others making day - to - day financial decisions, prohibition against self dealing - and failure to dis- close conflicts of interest, and other hospital he was setting up, reports the Washington Post. The three had engaged the services of a private inves- responsibility to carry out their duties " honestly, in good faith, and with a reasonable amount of diligence and care. ' tigator to steal documents and gather information that might CHP STEPS ON prevent the building of the HALLOWED TOES new hospital. The investigator arranged a job for his wife with the physician in question so Comprehensive Health Plan- ning (CHP) is carrying it just a bit too far for the Wisconsin that she might spy on him; the endeavor even included plans State Medical Society. A new amendment to the Social Se- to crash - land a small plane on the new hospital site to demon- strate that it lay dangerously close to the flight path of An- drews Air Force Base. The pri- vate investigator, a long stand- - ing friend of the physician, turned the case over to the curity Act requires state plan- ning agency approval for any capital expenditure exceeding $ 100,000, any change in bed capacity or substantial change in services if the health facility in question is to receive Medi- care or Medicaid reimburse- county district attorney early in the game. To date no word of pardons, presidential or otherwise, is in the wind. ments for depreciation. The def- inition of a health facility was apparently left unclear, and now the Wisconsin state plan- TRUSTEES GET TROUNCED A US District Court in Wash- ning agency is extending the regulation to doctors'offices. The outraged Medical Society ington, DC has ruled that trus- is appealing to HEW. Said a tees of Sibley Memorial Hos- pital have breached their fi- spokesman, " The society fears these rules could be used to duciary duty to supervise man- control the movements of doc- agement of the hospital's funds tors from one location to an- and investments. The case was other. They could prohibit the brought by a former patient who charged that the trustees addition of partners to a group, limit the equipment a doctor arranged to have the hospital's could purchase, and restrict money deposited in accounts the services a doctor could pro- 22 yielding little or no interest at vide his patients. " Hmmmmm. UPS AND DOWNS OF NATIONAL HEALTH INSURANCE Prospects for the passage of national health insurance (NHI) this year have gone up and down like a roller coaster. Most observers would agree that the roller coaster is down at the moment, but no one's taking bets on the future. NHI started the year with a great deal of momentum, fueled by compromise stands taken by all its major propo- nents and the renewed interest of then President Nixon. But then it, together with most ma- jor legislation, was overrun by the tide of Watergate and im- peachment events. The fires were lit anew, however, when Ford entered as the new presi- dent, putting NHI high on his legislative agenda and indicat- ing a new Administration will- ingness to compromise. With that Wilbur Mills, in whose House Ways and Means Committee such a measure must originate, went to work with a fury. He threw out ex- isting proposals on which the Committee had earlier heard testimony and attempted to steamroller through a new Pa te Pas eae 0d Fad CF Ans ~ ] puoP as compromise proposal. The new measure resembled the old Nixon and Kennedy - Mills plans in that it consisted of a four - tier system: (1) basic cov- erage paid for by employers and employees; (2) coverage for the poor superseding Medi- caid, administered by the states and the federal government; (3) Medicare for the elderly with expanded benefits com- mensurate with the rest of the plan; and (4) catastrophic cov- erage for medical expenses over 6,000 $ to be paid for by payroll taxes borne mostly by employers. The plan would in- clude a graduated scale of co- insurance and deductibles. The measure was designed to please liberals in that it is man- datory and offers fairly gen- erous benefits for the poor, and to please conservatives in that basic coverage is handled en- tirely by the insurance indus- try. In the end, however, the measure pleased no one, and Mills scotched the whole en- deavor, concluding that at the moment there is no basis for consensus. CHEATING THE CHILDREN The decline in the number of children receiving immuni- zations is alarming some health authorities. In 1973, 5.8 million preschoolers were un- protected against either polio, measles, rubella, diphtheria, pertussis or tetanus. Polio im- munizations have actually dropped from a high of 84.1 percent in 1963 to 60.4 percent in 1973; only 40.3 percent of nonwhite urban children were adequately protected against polio, compared to only 68.3 percent of suburban children, according to a 1972 survey. Similarly only 61.2 percent of preschoolers received measles immunization in 1973, down 1 percent from the year before, 23 and only 34.7 percent were im- munized against the mumps. Consequently some 18 health organizations, coordinated by the U.S. Public Health Center for Disease Control, are spon- soring an Immunization Action Month to publicize the need. FLEEING THE PROBLEM In a study of why doctors choose to practice where they do, the Department of Health, Education and Welfare last year asked medical school graduates to rank the undesir- able aspects of rural and inner- city practice. They found lead- ing reasons that young doctors choose not to work in rural areas to be: lack of continuing education programs (19 per- cent), long hours of practice (17 percent), and distance to support facilities (14 percent). Leading reasons for not choos- ing the inner city included risk of assault or bodily injury (19 percent), lack of desirable neighborhood to live in (18 percent), and risk of damage to office or theft (14 percent). PHP PHYSICIANS - ' HEFTY PROFITS Prepaid health plans (PHP's), California's model for saving money while making profits on poor patients, have fallen on bad days, reports Medical World News. Using Medicaid and acting as HMO's for the poor, privately - run PHP's have been hailed by the Reagan Ad- ministration as cost saving - in- novations in providing care for the poor, and some 53 have sprung up across the state in the last three years. But PHP's have instead pro- vided a political scandal for the Reagan Administration. Three of the largest PHP's or PHP networks have been sued 24 to stop illegal pressure tactics in recruiting patients, which have ranged from intimidation to misrepresentation to forgery, with recruiters often being paid on a per head - basis. The state auditor found that of $ 56.5 mil- lion being paid 15 PHP's in three years, 52 percent went into administrative costs or profits. Now poor patients are disenrolling faster than they are enrolling. And more than that, PHP's have now lost even their cost saving - allure for the State. Responding to protests that some PHP's were favored by the State, the Health De- partment has established flat, county - wide rates. The effect has been to boost the revenues of many groups as much as 25 percent and to cost the State more than it paid under the old cost reimbursement - system. All of this has sparked the inves- tigative interest of the Los An- geles District Attorney, the In- ternal Revenue Service, the Government Accounting Office and several state agencies. TREATING AT ARM'S LENGTH Blue Cross - Blue Shield of Minnesota has blacklisted a Minneapolis clinic for the el- derly because of " the way it is set up. " The clinic, sponsored by Abbott Northwestern - Hospi- tal and the Minnesota Age and Opportunity Center, serves el- derly persons with incomes un- der $ 4,500 and states that it will accept as full and final payment only what Medicare will provide. The clinic was quickly swamped and Blue Cross - Blue Shield, which administers Med- icare, balked, refusing to pay many claims. Minutes of a re- cent meeting between Blue Cross and the clinic quotes Blue Cross officials as saying, " We are being discriminatory against you because of the way you are set up. " The clinic has been " singled out because you have opened your arms and said to everybody, come to us we - will take care of your problems. " WHY NORTHGATE ISN'T CALLED GOOD SAMARITAN " Where do you stop once you start going outside the hos- pital walls? " the administra- tor of Seattle's Northgate Hos- pital countered when asked why the hospital refused to aid a man who lay bleeding in a lot half a block away. The man was discovered by a hospital security guard who ran to the hospital's 24 hour - emergency room, reports the July 11 Washington Post. The hospital refused assistance, cit- ing the hospital's inability to render adequate treatment out- side its walls, lack of person- nel and fear of liability. " My staff and facilities are designed for patients to be cared for within the confines of the build- ing, " replied the administrator. The man died. PHP Packet A 50 page - packet, " Materials on Prepaid Health Plans (PHP's), " has been prepared by Health / PAC. It reproduces documents and articles de- scribing a California innovation in health care financing. $ 1 including postage from Health / PAC, 558 Capp St., San Francisco, Cal. 94110.