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i HEALTH HEALTH Health Policy Advisory Center Volume 14, Number 4 PAC BULLETIN ape SS rd Capital Offense New York's Health Care in the Crunch A Mana Mottola INSIDE Doing a Job On Right Know - to - Is Sleep Necessary? Vital Signs sure is nearly seven times high- er for blacks than for whites in even a dispute about whether white women should be al- Meeting Needs Meeting " We were confronting the idea that black women are not interested in health, " declared the U.S., and the rate among blacks is higher among women. In Harlem more people die than are born, partly because infant mortality is 27 per thousand- more than twice the national rate. Homicide is a leading cause of death for black women in some age groups. The primary enemy, it was agreed, is racism. There was lowed to attend (they were, and a few men were also in evidence). " I feel there was a very strong feminist undercur- rent to the conference, " said one participant, " but it was not feminist in a'black and white women together'sort of way. It was feminism from a continued on p. 4 Bvllve Avery, initiator of the First National Conference on Black Women's Health Issues, and the more than 1500 women Health / PAC Bulletin July August -, 1983 who attended proved the scep- tics wrong. The conference, sponsored by the Black Women's Health Network of which Avery is director and the National Wo- men's Health Network, drew participants to Atlanta's Spel- man College from all over the country last June. In the two year planning period the or- ganizing committee had devel- oped workshops on topics rang- ing from patients'rights to birthing alternatives, from self- esteem to lesbianism. Board of Editors Tony Bale Howard Berliner Carl Blumenthal Pamela Brier Robb Burlage Michael E. Clark Barbara Ehrenreich Sally Guttmacher Louanne Kennedy David Kotelchuck Ronda Kotelchuck Arthur Levin Steven Meister Patricia Moccia Kate Pfordresher Marlene Price Virginia Reath Hila Richardson David Rosner Hal Strelnick Sarah Santana Richard Younge Richard Zall Editor: Jon Steinberg Staff: Roxanne Cruiz, Debra De Palma, Loretta Wavra. As this breadth indicates, the conference objectives were com- prehensive: to educate black women about health care and health facts; to present a cul- tural historical - perspective on black people and health: and to teach self help - skills. The emphasis was on reach- ing low income - black women. " It is they who are most vic- timized by toxic substances in the workplace that damage their health and reproductive Associates: Des Callan, Madge Cohen, Kathy Conway, Doug Dorman, Cindy Driver, Dan Feshbach, Marsha Hurst, Mark Kleiman. Thomas Leventhal, Alan Levine, Joanne Lukomnik, Peter Medoff, Robin Omata, Doreen Rappaport, Susan Reverby, Len Rodberg, Alex Rosen, Ken Rosen- berg, Gel Stevenson, Rick Surpin, Ann Umemoto, MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR AND SUBSCRIPTION ORDERS should be addressed to Health / PAC, 17 Murray St., New York, N.Y. 10007. Subscription rates are $ 15 for individuals, $ 30 for institutions. ISSN 0017-9051 1983 Health / PAC. The Health / PAC Bulletin is published bimonthly. Second class postage paid at New York, N.Y. and at additional mailing offices. capability, " declared Avery, " They need the information most. " she and others noted Design: Three to Make Ready Graphics / 1983 Cover by Maria Mottola. that black women, and blacks in general, have devastating health problems. Death before age 50 from high blood pres- Articles in the Bulletin are indexed in the Health Planning and Administration data base of the National Library of Medicine and the Alternative Press Index. 2 Health / PAC Bulletin Notes & Comment The proposed sale of McLean Hospital to the Hospital Corporation of America highlights interesting issues about the relationship be- tween academic medical centers and for profit - chains. Owned by Massachusetts General, one of the nation's most distinguished hospitals, McLean is the psychiatric teaching center for Harvard Medical School and one of the coun- try's leading teaching and research institu- tions in psychiatry. The move to acquire it by HCA, the nation's largest for profit - hospital chain, is part of a shift in strategy by all the major corporations in the field. Their acquisition and construc- tion programs of the past few years have cor- nered the acute care hospital market in the largely unregulated - South and Southwest. Penetration of the Northeast is generally blocked by tougher regulation - in New York, for example, legislation requires hospital owners to be state residents. Therefore to maintain their phenomenal growth the chains have turned to nursing homes, home care, and psychiatric centers, all of which tend to be less strictly regulated than hospitals. National Medical Enterprises senior vice president John Bedrosian recently revealed that psychiatric care is already his chain's most profitable market. Most of the patients Louanne Kennedy teaches Hospital Admin- istration at Baruch College, CUNY, and is a member of the Health / PAC Board. are private, he told the New York Times this July, and " It's an industry whose time has come... Society isn't getting any better, so this suggests demand will get greater. " If HCA is successful in acquiring McLean it will boost the prestige of all the chains enormously. A Harvard imprimatur would go far toward removing their stigma of seeking profits at the expense of quality. It could well also be a profitable investment in itself. McLean currently operates with only limited commit- ment to the uninsured and underinsured: these services would probably be reduced even further. HCA's promise is to maintain McLean's teaching and research mission, the primary concern of physicians and board members both there and at Harvard, and to un- dertake a vast capital improvement program. This should enhance the institution's already considerable reputation among those with means who seek care and those who refer them. Only the Massachusetts Department of Mental Health has expressed concern that the poor might suffer. There is, however, no state regulation that can guarantee or even pressure for provision of services to those unable to pay. Should HCA McLean / come into existence, its new board, two thirds Har- vard and one third HCA, would be able to jettison any service it wished. In competition with profits, the poor probably wouldn't come off very well. Louanne Kennedy Moving? Since the post office doesn't ordinarily forward magazines, be sure and let us know at least six weeks ahead so you will get your Bulletin. Please include your old address, with zip code. We regret that we can't replace issues not received if you haven't notified us in time. Mail any changes or corrections to Circulation Department, Change Division, Health / PAC, 17 Murray St., New York, NY 10007. Contents Vital Signs Black Women's Health Conference, Physicians Contest. Mississippi Health Care, Baltimore Free Clinic, HSA's Notes & Comment Capital Offense 2 Bulletin Board Doing a Job on Right Know - to - Legislation Legislation Legislation Media Scan Body English 3 Index to Volume 13 355 Books Received 17 19 23 25 27 28 30 & Health / PAC Bulletin 3 continued from p. 2 very black black woman's per- spective. " " I do not advocate a patho- logical preoccupation with blackness, " said Dr. Alyce C. Gulattee, Director of the Insti- tute on Substance Abuse and Addiction at Harvard Univer- sity, " but blackness is the one thing that melds us together for now and forever. " Dr. June Jackson Christmas, Director of the Behavior Sci- ence Program of the School of Biomedical Education at New York's City College, noted that while nine percent of all Ameri- can white families are poor, the figure jumps to 35 percent for black families; if the " near poor " are added, the figure is a staggering 80 percent. " Health is not only the absence of dis- ease, " she commented, " but a state of positive well being - physically, mentally, socially and spiritually. " Bad Medicine This is one contest we waited past the deadline before an- nouncing: " The Write Way to See Hawaii Medical Econom- ics Article Awards Contest for Doctors. " Physicians are asked to write " about 2500 words in an infor- mal, straightforward way. " The magazine suggests that " Arti- cles of your own may spring from titles of some outstanding 1982 entries. " Among those listed: " I Haven't Paid Taxes in 12 Years, " " We Can't Afford to Prolong So Many Hopeless Lives, " " How to Keep Your Staff Smiling and Your Office Humming, " and " Malpractice: Let's Stop Running Scared. " Grand Prize is an expenses- paid week's vacation for two at Hawaii's newest " world - class resort. " The deadline was Sep- tember 30. Some things are beyond parody. Turning a Bad Thing Into a Good Thing The 1981 Federal budget meant cutbacks for many peo- ple in health care, but the Mis- sissippi Coalition for Mothers and Babies turned one amend- ment into a significant victory. Previously, states wishing to provide Medicaid for the near poor had to cover all med- ically needy groups - the aged; the blind and disabled; and poor, single parent - families. The 1981 Omnibus Budget Re- conciliation Act allowed states to limit coverage to groups of its choice, although if it had any program ambulatory care services for children and preg- nancy related - services to wo- men had to be included. For states which had been in the medically needy program, the OBRA amendment offered an opportunity to cut back with- out withdrawing entirely. But Mississippi had not partici- pated at all, claiming it could not afford care for the full range of groups. The Coalition saw this as an excellent opportun- itv. With 1500 volunteers from 40 member organizations, in- cluding the Children's Defense Fund, the Mississippi Hospital Association, Catholic Charities, and the Mississippi Medical Society, it pressed the legisla- tors to begin a basic program. Even Mississippi, the Coalition declared, could afford a pro- gram for an additional 25,000 poor children and 3000 poor pregnant women which would cost only $ 3.9 million - the Fed- eral government would kick in $ 10 million more. The need was manifest. Mis- sissippi's infant mortality rate is 19.1 per thousand, the high- est in the country. In some counties the death rate for black babies is an extraordinary 45 per thousand. The Coalition also argued that preventing medical prob- lems would make the state not only healthier but wealthier. For each baby who died for lack of prenatal care, it noted, three would survive with men- tal or physical handicaps. This year the legislature got the message, although to help. balance the state budget it post- poned implementation to July 1, 1984. The Coalition is now pressing a campaign to increase the ceiling for eligibility in the medically needy program from the current $ 425 a month. Free Care Isn't Carefree " We sampled 153 people in the community, " related Bar- bara Aylesworth, a laidoff steel- worker in Baltimore, " Almost 67 percent had no health insur- ance. Seventeen percent needed immediate medical care. " The response of Aylesworth and several other unemployed. steelworkers was to organize a free clinic. According to the July August / issue of Mountain Life and Work, Dr. James Tay- lor, a 31 year old general prac- titioner, offers his services one night a week free of charge. " All equipment and medi- cine is donated, " according to Cathy Loeb, another partici- pant, " and time is volunteered. " The American Medical Asso- ciation believes that the solu- tion for unemployed workers who have lost their medical in- surance is to rely on charity care from physicians, but this has little in common with the free clinic in Baltimore. The clinic was started and is run by the unemployed themselves; the doctor does not decide who is worthy of free care and who is not; the participants did not establish their clinic because they are philosophically op- posed to government interven- tion on the contrary, they be- lieve that medical care should continued on p. 29 4 Health / PAC Bulletin Capital Offense New York's Health Care in the Crunch by Dan McCarthy with the Health / PAC New York Working Group The Health Systems Agency network of local health planning authorities has long been weak. Now it is crumbling, a victim of Reagan - era defunding. In most parts of the country this leaves only the statewide coun- terparts of the HSA's, the State Health Co- ordinating Councils, to review requests for major capital expenditures. Typically, these are dominated by major hospitals, the very institutions whose plans are most ambitious. The result is a frenzied nationwide rush by these institutions to submit capital project requests beyond the wildest dreams (or night- mares, as the case may be) of planners only a few years ago. Last February the New York Times reported that state officials around the country were seeing " a surge of investment proposals from hospitals responding to the Administration's attempts to remove controls on the construction of health care facilities. " It cited a study by Alpha Center, a private research group, which surveyed 35 states and found total capital outlays approved had leaped from $ 4 billion in 1979 to nearly $ 11 billion in 1982. The cost of these projects will ultimately fall on taxpayers, through Medi- caid and Medicare reimbursements, and on those who pay skyrocketing private health insurance premiums. Last fall Health / PAC commissioned a Spe- cial Report on the New York State situation after learning that four major New York City teaching hospitals were seeking approval for projects that would cost a total of more than $ 2 billion. This sum is so huge that state officials privately predicted that, if approved, the projects would eat up all available capi- tal reimbursement the state could afford for years to come. An HSA study released this September recommends that less expensive alternatives be considered. The Health / PAC Special Report was con- ceived to go beyond critiques of these capital projects in isolation; it views them from the perspective of the health needs of residents of New York State. The study was undertaken by Daniel McCarthy of the Municipal Research Institute, working under the direction of Health / PAC's New York Working Group. McCarthy, who has served as a program ana- lyst in the City's Office of Management and Budget, filed his report in May: a complete copy is available from Health / PAC for $ 2.50. The following article is a summary and up- date of its findings. On February 17, 1983 the New York State Hospital Review and Planning Council ac- cepted the major finding of the Governor's Health Care Capital Policy Advisory Commit- tee that the State cannot continue a pattern of open ended - funding for hospital capital ex- penditures. To enable the State to decide how much capital investment it can afford and to establish new mechanisms for setting priori- ties, the Council voted 22 to 1 to place a one- year moratorium on all major new capital ex- penditures by hospitals. This Council action was unprecedented in its history. The Nature of The Crisis Underlying and preceding the vote was one agreed fact: a virtual boom is underway in proposed hospital capital expenditures both nationally and in New York State. By 1984 New York hospitals will submit to the State in excess of $ 5 billion in new applica- tions for capital construction, according to the projections of New York State's Office of Health Systems Management (OHSM). This is nearly as much as the total amount invested in hospital construction nationally in 1980, and comes on top of an already staggering growth in statewide hospital construction ex- penditures, up from $ 250 million in 1979 to over $ 1 billion in 1982. The soaring rate of increase and the sheer Health / PAC Bulletin 5 Gena Glover magnitude of these recent applications may precipitate a funding crisis for the State. Even more serious is their potential long term - im- pact on the already existing imbalance in New York's health care priorities. The Big Four Most of the $ 5 billion involves proposals from institutions in New York City; at least $ 2 billion in Manhattan alone. The largest proj- ects involve the " big four " (called so - for the size of their current applications; there are, of course, other major teaching hospitals in Manhattan.): 1. Presbyterian Hospital proposes to: (a) construct a new 750 bed - facility and increase its critical care component; total beds at the current site would number roughly 1,100 (a 100 bed reduction); (b) construct a new, 300- bed community hospital in the Inwood sec- tion of Manhattan: (c) establish an 80 bed - resi- dential health care facility at its current site; and (d) establish a home health care agency. Total cost is projected at $ 485 million; the resulting increase in its daily reimbursement rate is calculated at $ 80. (The construction costs and scope of renovation work cited here represent the most recent data publicly avail- able.) 2. The Mt. Sinai Hospital proposal involves constructing 800 replacement beds, increas- ing the number of intensive care beds, and retaining 400 existing beds. The total cost would be $ 458 million. This is projected to mean an increase in the daily rate for patients of $ 140-145, to a total of over $ 1000 a day in 1988. [The New York City Health Systems Agen- cy in its 1982 publication, Medical Facilities. Resource Component (MFRC) Phase II, esti- mates that the actual cost of the Presbyterian and Mt. Sinai proposals alone may amount to $ 3 billion, including interest costs of $ 2 bil- lion.] 3. St. Luke's Roosevelt - Hospital has not com- pleted its proposal, but the final draft is likely to include construction of 800 new beds at the Roosevelt site downtown and renovation of 400 beds at the St. Luke's site uptown. The total cost is projected at $ 434 million, leading to a $ 136 increase in the daily rate. 4. New York Hospital is also still working. on its plans, and many details are not known. They appear to involve a major bed replace- ment project at an estimated cost of $ 450 mil- lion. This would be in addition to a $ 120 million project currently under construction. The big " four " projects would raise reim- bursement rates at these institutions an aver- age of over $ 100 a day. In the aggregate, that would mean at least $ 250 million in addi- 6 Health / PAC Bulletin tional reimbursement annually. This is twice the annual budget of the New York City's Department of Health and exceeds the annual budgets of all but a few of the City's major medical centers and their affiliated institu- tions. Clearly, the State's decision on these proposals will be extremely significant - par- ticularly when its Medicaid budget, which pays a large share of patient reimbursement, is already strained. OHSM conservatively estimates that if all pending applications for New York City were approved and constructed $ 800 million would be required annually to reimburse additional capital costs alone. Put another way, this would involve an annual increase of up to 20 percent in inpatient expenditures for New York City. What Are The Alternatives? When initially submitted, there was little evidence that either the institutions them- selves or the State had given adequate con- sideration to cheaper alternatives for renova- tion or replacement of their existing facilities. These certainly exist. The original Columbia- Presbyterian application projected $ 234 mil- lion for construction, not counting architec- tural, engineering or financing costs. Upon review of the proposal, OHSM suggested that Columbia Presbyterian - consider two cheaper, more cost effective - building programs, one costing $ 101 million and the other $ 60 million. Since the moratorium took effect, OHSM has undertaken much closer scrutiny of the big four applications preliminary to their for- mal resubmission. In addition, new capital spending limits proposed in separate legisla- tion promise to place an absolute limit on the amount the State will approve (and later re- imburse) for all capital projects each year. (See Box, " Capital Update "). Nevertheless, it is clear that the search for more cost effective - investment of the public's health dollar is still being conducted with blinders favorable to large existing providers. The need for more cost effective - alternatives is twofold: institutional plans could be and - no doubt will be scaled - down, and consid- eration of alternative uses for such public in- vestment is long overdue. Perhaps it isn't surprising that a health planning system largely dominated by a " big hospitals are better " mentality would fail to consider alternative investments. But given the current fiscal climate, the grandiosity of some aspects of the big four proposals is somewhat breathtaking. Mt. Sinai, for exam- ple, brought in world - class architect I. M. Pei, whose design includes a " bubble " enclosing the entire Mt. Sinai campus striking - , but hardly the economy model. (For a look at cheaper alternatives, see Box). After all, it has been the hospital industry itself that has repeatedly claimed in recent years that medical technology changes so rapidly that facilities become obsolete in only one or two decades. With that premise, prefab buildings and the cheapest legal materials and methods would be used in any other in- dustry. If the big four's plans more closely resemble marble, glass and steel monuments, it is because other recent trends lie behind the current drive for new construction. Inappropriate Expansion of Tertiary Services The concentration of capital spending in large, expensive, highly specialized " tertiary " care institutions such as the " big four " both reflects and exacerbates a growing imbalance of resources between high technology insti- tutions on the one hand and those that pro- vide more routine services on the other, such as small community hospitals; public hospi- tals; and providers of preventive services (e.g., the New York City Department of Health), primary care (routine outpatient services), and long term - care (nursing homes and home care providers). Plans to invest $ 2 billion in four of the country's most specialized and expensive Glover Gena Health / PAC Bulletin 7 private institutions follow a decade in which New York State, in the name of cost control, has eliminated over 5000 beds in 35 hospi- tals. Many of the institutions closed were small community hospitals located in or near poor neighborhoods. While some were of dubious quality, many offered adequate care at modest cost. Some offered significant vol- umes of out patient - services, and their clos- ing has worsened the shortage of routine pri- mary care services in areas since designated as " Medically Underserved Areas. " Mean- while, the average capacity of remaining New York City hospitals grew from 366 beds in 1972 to 428 in 1982 (the average nationwide is 170 beds). The Need for Primary and Preventive Services It is in the area of preventive and primary care that this imbalance is clearest. There is abundant evidence in the health care litera- ture that primary care services are used more often, are more directly related to health status, and can contribute more to reducing unne- cessary, later stage - illnesses than other types of care. Indeed, the New York State Health Plan for 1982 states, " lack of access to pri- mary care services, the type of health care most people need most often, remains a sig- nificant yet unattended problem in New York State. " The plan goes on to document that Gena Glover over 3.5 million people in the State live in areas considered to be medically underserved. Although the State Health Plan proposes a number of programmatic efforts to fill this gap, it is significant that nowhere in the cur- rent debate has there been serious discussion of either the capital requirements of such pro- viders or the possibility that they may repre- sent better use of scarce funds. The question of who will build or rebuild - and with what funds the needed public health department clinics, the community health centers, the health maintenance organizations, the com- munity and the public hospitals would ap- pear to be at least as urgent as the claims of the " big four. " Shifting the City's health care system away from tertiary care and toward greater emphasis on primary care would require more than a shift in capital investment priorities. It would also require major changes in reimbursement policies, which to date provide inadequate compensation for primary and preventive services. If the big four's plans are approved- even in downscaled form these - changes will become even more difficult, if not impossible. The Crunch on the Poor How the capital crunch discriminates against hospitals in low income - neighbor- hoods is perhaps best illustrated by looking at the municipal hospitals operated by the New York City Health and Hospitals Corporation (HHC). By law, HHC facilities must serve the City's poor and medically indigent: they do not have the option of " marketing out " to a more prosperous clientele. The HHC Capital Needs Assessment Report of February 1982 pegs the ten year - capital needs for HHC's 14 facilities at $ 1.22 billion. Over 70 percent of that is for " comprehensive catch - up " to bring physical plants up to current standards. For fiscal year 1984 alone, HHC deemed $ 225 million in capital projects " essential. " Despite this com- prehensive statement of need, HHC's fiscal year 1983 budget included only $ 85 million for capital projects. Capital needs are daily transformed into operating crises at pre 1950's - institutions such as Queens General and Kings County hospitals and cause difficulties even at 1950's facilities such as Bronx Municipal, Elmhurst, and Coney Island hospitals. Meanwhile, HHC's recent initiatives to reorganize ambu- latory care may die a premature death for lack of funds to convert many outpatient depart- ments badly in need of capital improvements into environments that can offer quality pri- mary care to the City's poor. 00 Health / PAC Bulletin Capital Cap Update New York State has a one year moratori- um on health care capital spending. This means no capital construction projects can be undertaken during 1983 outside of cer- tain routine equipment replacements, state code deficiency corrections, and other emergency needs. The effects will be most sharply felt in New York City (see The Manhattan Big Four box). The moratorium is best understood as a way to allow the State Department of Health and the legislature time to impose a state- wide capital spending ceiling, known as a " capital cap. " This process has thus far had two aspects: 1. The State has placed a surcharge on the gross revenues of hospitals, the pro- ceeds of which are to provide up to $ 2 million per year to support the state's eight Health Systems Agencies (HSA's). Hospi- tals can obtain state reimbursement for this surcharge, so the money effectively comes from the state's general revenues. This will ensure the continued existence of locally - based health planning, with its data collection and provider oversight functions, and even tighten its connections to the state health planning apparatus - all this in the face of Reagan Administration efforts to eliminate or substantially modify the HSA system nationally. New York's HSA's are currently collecting data from all state licensed - health facilities on cur- rent and projected capital needs. This in- formation will be invaluable in setting a . 2. Action on a cap stalled during the spring session of the legislature, but the bills introduced had several points in com- mon and can be viewed as a template for future legislative efforts. Among the major provisions were the following: @ Specific statewide capital limits would. be set up. (In one version, the limits were set at $ 800 million in 1983, $ 850 million in 1984, and $ 900 million in 1985.) S` Money would be allocated regionally. by health service area, based on state - ap- proved health systems plans. @ Funds not used in one year would accrue to the same region the next year. @ The moratorium would end on Decem- ber 31, 1983 and the cap would expire at the end of 1985. @ A small proportion of the capital money set aside would serve as a reserve to be used at the discretion of the Commis- sioner of Health for emergencies and state- wide priorities. @ The value of any application could. not exceed the regional allocation and the project would have to be consistent with the regional health systems plan. S` Reimbursement would be prohibited for costs in excess of those approved in the application, i.e. cost overruns would be the responsibility of the applicant. There are some subtle but extremely sig- nificant points about this draft legislation. that deserve mention: 1. These proposals mandated that any equipment costing over $ 400,000 would be subject to review under the certificate of need process and be included in the re- gional caps. This would limit the ability of private physicians to purchase expensive equipment, e.g. CAT scanners or the new NMR scanners. Previously physicians were completely exempt from the CON process. 2. Most approved projects have actually cost more than twice their initial budget. The State could save significant amounts of money if it got tough on these overruns as proposed. 3. These bills have not yet been debated within the legislature. It seems likely that they are the strongest expression of state cost containment - sentiment; amendments are likely to make their provisions more favorable to the powerful hospital industry. The State Department of Health may at- tempt to impose its own capital spending target if the legislature fails to act soon. This could precipitate a rush to the courts by the hospitals. In the current political climate, it is cer- tainly possible that the moratorium will turn out to be no more than a delay and the capital spending cap an idea whose time has not come. L. | Health / PAC Bulletin 9 05 Gena Glover Given its large percentage of medically in- digent patients, especially in the ambulatory clinics, HHC is at a disadvantage in raising capital in the tax exempt - bond market. It suf- fers another disadvantage in competing for capital funds for the foreseeable future be- cause the City, which owns the HHC facilities, still has limited access to capital markets due to the fiscal crisis of the mid 1970's - . The City allocates whatever capital funds it raises itself through a system which pits hospitals against capital needs for water, sewers, schools, and highways. Under the current system institutions seek- ing major capital expenditure approvals must also secure financing for the proposed expen- ditures. Like New York City's municipal hos- pitals, by virtue of the disproportionate num- ber of poor patients they serve, small com- munity hospitals and primary and preventive care providers are at a substantial disadvan- tage in gaining access to financing, since their precarious operating margins and lack of capital reserves make them poor risks for potential investors. Thus, many providers are precluded from financing needed projects. Nebulous Needs The health planning system regulates capi- tal projects through the so called - " Certificate of Need " process, whereby applications for new projects are first reviewed by local HSA's and then by the statewide SHCCs. But the concept of " need " has so far been a highly nebulous one. In practice, most Certificate of Need Applications in New York State have been approved. Neither the local HSA's nor the State have, to date, systematically com- pelled institutions to provide new services in areas of unmet health needs as a condition for approving applications. Reimbursement Structure Although the State has failed to scrutinize new capital expenditures with any degree of skill, New York has become one of the most powerful regulators of reimbursement rates in the nation. On the operating side of the budget, which accounts for 94 percent of all hospital spending, New York is known with- in the hospital industry as a fierce regulator. Historically, the State has controlled both Medicaid and Blue Cross reimbursement, dictating what these will pay for and how. In 1978, it extended this control to commercial and self - pay patients. This year, on an experi- mental three - year basis, it received Federal waivers allowing it to bring the last major category of third party reimbursement- Medicare under state control. In 1976, under pressure from city and state 10 Health / PAC Bulletin fiscal crises, New York State implemented a stringent hospital cost control program. Through prospective reimbursement (deter- mining payments in advance, rather than basing them on a hospital's costs) and a series of " efficiency - related " penalties, the State slashed hospital cost increases to one of the lowest rates in the nation. Because " excessive beds " were identified as generating a pattern of " unnecessary " demand or " overutiliza- tion " and thus contributing to spiraling costs, the State used its rate setting - powers to deny increases to over 50 hospitals that had been targeted for closings. This " planning by bankruptcy " which got rid of 5000 beds weakened and / or eliminated many small, community hospitals and left the State's large teaching institutions intact. The kicker is that while it has been strin- gently controlling reimbursement for operat- ing costs, the State has treated capital ex- penses as a " pass through ", meaning they are not subject to penalties for excessive expense. but are reimbursed in full. This has created a powerful incentive for capital investment. Once a project has received certificate of need approval, full reimbursement of related capi- tal expenses is guaranteed via future reim- bursement of both the actual repayment of the debts incurred and an annual depreciation allowance. The latter is also allowed as a cost in calculating reimbursement rates, and in some cases, hospitals actually realize a cash surplus from the depreciation allowance - a point noted by the Governor's Capital Policy Advisory Committee in calling for a change to new york city the bandaid man has come tin cup and brass band has come to serve the wounded of his own war. sticky ends to end sticky blood flowing: in and out of your veins, in and out of your brains. the bandaid man has comeL bright stars and bright strips has come to clean up to make pretty, not to cure- cosmetics instead of corrective surgery: remnants of once being - adhering without meaning. the bandaid man has come : with yards of dirty gauze has come to cover over gaping holes in your fabric to seal your slashed being: oozing life onto the street to be trampled by his feet. the bandaid man has come. the bandaid man has come long lines of adhesives has come to fasten your beginning to his ends, your goal to his purpose: the rhetoric of repair for things he mismanaged now structurally damaged. the bandaid man has come. the bandaid man had to come: the surgeon is on holiday. the hospitals all shut today. there's no one left with a role to play. the bandaid man will have his say resticking the pieces of what was his fun in any old way. the splinters and fragments of the castles he broke, the bodies and remains that were left from his joke: a hodgepodge patchwork of his own design: In his own mind thing's ev - er - y - fine. the bandaid man has come. TM jenny green 1975 Health / PAC Bulletin 11 in reimbursement for depreciation. Overdue Reforms Faced with limited resources, the State must make some basic decisions about the size and shape of the health system to which it will commit future reimbursement dollars. It was in this context that the Governor's Health Care Capital Policy Advisory Commit- tee recommended the one year - moratorium on new capital projects. The Committee made a number of other recommendations to ad- dress the failures of the capital allocation. process, including: Establishment of institutional and state- wide five year - plans reflecting determinations of need and available resources: @ CON decisions based on the criteria of relative need and affordability, rather than utilization and obsolescence: Broadening the representativeness of health planning bodies: S` Reimbursement of debt amortization, not depreciation: and @ A loan guarantee program to make capi- tal financing available to some financially distressed institutions. These measures have merit, but by them- selves are insufficient to reform the capital allocation process. There is no assurance that the large tertiary care institutions will not continue to dominate the capital allocation process envisioned by the Governor's Com- mittee. Two specific recommendations of the Com- mittee require comment. First, the recom- mended elimination of reimbursement for depreciation and reimbursement of debt amortization only could well hurt the institu- tions in most need of aid small - community hospitals, many of which rely upon the ex- cess of annual depreciation reimbursement over actual debt amortization to subsidize operating costs. Although this use of depreci- ation reimbursement for operating needs is technically inappropriate, and required State approval, it has become one of the vital survi- val strategies employed by distressed hospi- tals in recent years (as well as a source of surplus for stronger facilities). The recommendation for a limited loan guarantee program - already in question be- cause of fiscal considerations raised by the State's Division of the Budget - would not help public hospitals because they are ineli- gible under the Committee's plan. Even if implemented, such a limited loan guarantee program would not be sufficient to equalize access to capital. Beyond the Governor's Committee Report While the Governor's Advisory Committee should be praised for its initiative in calling for a moratorium, we must go beyond the themes identified by the Committee if the more basic health planning issues are to be seriously confronted. Recommendation 1: The State of New York must legislatively establish a ceiling on all institutional health care capital expenditures as a first step towards correcting imbalances in health service priorities. The total amount of resources available for capital spending must be known in advance in order to determine what is affordable and what is not. Only then can the priority of a specific expenditure be assessed. [As noted earlier, the State has begun to move towards such a " capital cap " since the moratorium.] Recommendation 2: New York State must develop a formula for allocating and approv- ing capital expenditures for health care ser- vices that is based on two major components: A. An objective methology for determining relative capital needs The principal problem with current esti- mates of " need " is their source -- i.e., institu- tions'own projections. A truly objective methodology, although difficult to design. can be developed. The State Office of Health Systems Management (OHSM) has for some years generated estimates for hospital bed needs in each of the State's various health regions. Without endorsing the specifics of the particular OHSM formulas, it would seem that the problem of assessing the aggregate volume of capital needs in each of these re- gions would not appear to be inherently more complex than assessing whether the region has surplus beds. In order to objectively assess relative needs. the total renovation and replacement needs- by category or modality - must be calculated periodically both for existing service provid- ers for each region and for new construction for facilities not now in existence but for which needs can clearly be demonstrated. To relate these estimates to existing service levels in each region, the State must develop a second major component for its capital needs allocations formula: B. Specific objectives and timetables for reshaping service delivery patterns to better meet community needs. Official estimates now exist of surplus ser- vices in the City and the State. Although these require analysis and refinement by type of care (e.g., medical - surgical beds, pediatric beds, obstetrics gynecology -) , they suggest 12 Health / PAC Bulletin ... that total State resources do not only consist of new expenditures. Where surpluses can be identified by service, the State should adopt specific, annual plans for each health region for achieving needed reductions in each. It is to be expected that major areas of surplus will be found in service categories widely reported in the health planning literature to be over- abundant in other areas of the country - e.g.. subspecialty surgical services. The State should also adopt specific, annual plans in each region for creating needed services that are not now in place. Again, it is likely that such shortages will be documented in areas widely reported in short supply in the U.S. as a whole, including preventive services, pri- mary care, home and other forms of long term - care. In order to assure actual construction of facilities and delivery of needed services, the State can invite applications for creation of new services. Where such applications fail to materialize, the State could either move di- rectly to create its own delivery facilities or invite interested groups or agencies to do so. Implementing this approach would mean, in effect, that projected State expenditures would be earmarked for categories of priority facilities and services in each region. It might be determined, for example, that 200 $ mil- lion would be allocated for primary care renovation replacement / plus new construc- tion in New York City, out of a statewide Glover Gena total of $ 1 billion for all capital renovation / replacement plus new construction. Recommendation 3: The State should ex- pand its capacity to initiate capital financing projects through the creation of a New York State Health Care Development Authority. Such an Authority would allocate funds on its own initiative to designated providers (e.g., community health centers, public hos- pitals. community hospitals) in a particular region, based on the assessment of relative need under existing State priorities. Its staff functions would be located in OHSM, which currently has responsibility for reviewing capital applications. Its legislative mandate would require allocation based on accepted standards of need in keeping with priorities in the regional State health plans. The new agency would differ from the exist- ing Medical Care Facilities Finance Agency and the Dormitory Authority - which already provide State backing for the financing of health care projects - in that it would not act merely as a conduit for tax exempt - financing for private institutions but would serve as an initiator of new projects. The Authority would enable the State to take an active role in reshaping the health system. This Authority could be funded through such alternative revenue sources as: @ A general surcharge on the gross operat- ing revenues of our major academic medical centers. Health / PAC Bulletin 13 The Manhattan " Big Four " The general issues surrounding the $ 2 billion - plus capital investment proposals of the Manhattan " big four " have by now been well publicized. Articles have pointed out that if they are approved their gargan- tuan size would pre empt - much, probably most, of the funding for all such projects in New York State for years to come. It has also been noted that paying for these proj- ects would push costs per patient day up by over $ money 100 which would be re- imbursed by Medicaid, Blue Cross, and, to a small extent, private insurors. The total annual cost, $ 250 million, is twice the an- nual budget of the New York City Depart- ment of Health and more than the budget of most New York City hospitals. However beneath and beyond these stag- gering figures are more specific questions which have received less attention from the public. In keeping with State and HSA efforts to reduce hospital beds, these four projects do not increase their number. They do involve expansion and upgrading of the most technologically sophisticated (and most expensive) sectors of these institu- tions. This is most evident in the increase in critical care beds. Aside from the question of whether or not this is the best use of limited capital resources, it can reasonably be asked if there are less costly architectural and pro- grammatic alternatives to cope with the facility needs and problems which these institutions have complained of. Here are some specifics of the original " big four " proposals and their more mod- est successors: 1. Columbia Presbyterian's - 750 - bed fa- cility, projected at a cost of $ 485 million, would have increased the critical care com- ponent of the hospital while slightly re ducing total beds. Facilities to be demol- ished to make way for the proposed " main- frame " building included recent construc- tion. This proposal has been scaled down to $ 298 million. In response to State urging to consider local needs, a 300 bed - community hospital was added. The suggested location is the northern tip of Manhattan adjacent to Co- lumbia's Baker's Field. This facility would be very convenient for injured Columbia football players, could become a heliport destination for prosperous New Jersey and Westchester patients and their physicians. and would serve the wealthy Riverdale section of the Bronx just across the river. It is not, however, near public transportation. The poor of Washington Heights and West Harlem (who have lost community hospi- tals recently), as well as neighboring Inwood. would have difficulty getting to its door outside an ambulance. The heliport concept is not fanciful. Co- lumbia Presbyterian - is intensifying its mar- keting efforts to bring in patients from Westchester and Northern New Jersey. Its program to leapfrog the " municipal hospi- tal population surrounding its vast Wash- ington Heights complex also includes the new East 61st Street Medical Associates doctors'office building, set up with a pri- vate real estate group. This location, just off Park Avenue, was chosen to establish a toe hold - on the East Side, one of the wealth- iest neighborhoods in the world and the site of " bed pan alley, " the world's highest concentration of non public - hospital facil- ities. Another part of the development plan. is a Columbia University / College of Physi- cians and Surgeons biotechnology research park, to be located adjacent to Columbia- Presbyterian on the site of the old Audu- bon Ballroom. Exxon is among the corpo- rations already involved. The Ballroom is best known as the place where Malcolm X was assassinated; there is some question over whether this is the memorial he would have chosen. All of these projects are very expensive. Columbia University has boldly underta- ken the largest fundraising campaign in the history of higher education, and the Health Sciences Complex is its $ 150 mil- lion dollar centerpiece. The plans include Presbyterian's " touch high - " 80 bed - residen- tial care facility, a home health agency, and physician " homesteading " in areas of need as part of an " ambulatory care net- work, " but the cost of such programs is dwarfed by the expenditures on the major projects and Columbia's commitment to them is questionable given the thrust of the overall scheme. 2. Mt. Sinai Hospital (and Medical School)'s " bubble dome " proposal was de- 14 Health / PAC Bulletin signed by I. M. Pei to envelope the An- nenberg " black box " building, itself only a decade old. Without the dome the plans become less expensive, but their purpose is still to increase intensive care beds rather than to provide the ambulatory, commun- ity, and geriatric care most needed by the surrounding East Harlem community. Consultants advised Sinai officials that a more modest $ 250 million project would cover their needs (if not the Annenberg Building) but they stuck with the larger figure in their certificate of need (CON) proposal to the State, apparently as a bar- gaining position. Unlike some of the other major institu- tions, Sinai can boast that it knows how to run a hospital business. Over the past few years it has generated major cash surpluses, in large part through tough bargaining with unions and staff cuts in maintenance as well as frontline care. Keeping neighboring health institutions. at arms length has also helped. Rather than providing a regional backup role for Metro- politan City Hospital, North General com- munity hospital, and community health centers nearby in East Harlem, Sinai main- tains affiliation ties with Beth Israel on the Lower East Side and Elmhurst City Hospi- tal in Queens, which has a larger propor- tion of white working class patients. Future prospects are also good. Sinai has vast real estate holdings in its Upper East Side neighborhood, where gentrification. is nibbling away at El Barrio, and is full sail into a $ 100 million - plus fund drive. Its plans for real estate, equipment product. and other projects impressed Modern Health Care enough to win Sinai Board Chairman Alfred P. Stern the magazine's " Trustee of the Year " award for fundraising and stra- tegic planning. Stern's high powered - op- eration includes paid advisors such as David Winston of Blyth Eastman Paine Webber, who has served as a health ad- visor to President Reagan. New York Hospital (with Cornell Medi- cal Center) is putting the finishing touches on a $ 450 million in fill - and wing extension - high - tech proposal which includes an 11 story atrium, a state - of - the - art elevator sys- tem, and underground parking. Putting this together barely gave the hospital's planning staff time for vacations after completion of a $ 120 million project. strengthening ambulatory care and diag- nostic and support services. This was fi- nanced with the help of State bonds and a top Moody's bond rating for the hospital itself, based on its location in a prime in- come and physician office zone. The hospital is currently in the midst of a three - year, $ 125 million fund drive. Among its selling points is its success in becoming the first hospital in New York to win State approval for an MNR unit as part of an additional center under construction in collaboration with Sloan Kettering - Me- morial Cancer Center. Cornell Medical Col- lege wants to build 200,000 square feet of additional space in the same complex, two thirds of it for research. A pooling of the depreciation allowances that now accrue directly to hospitals. New earmarked taxes on cigarettes, liquor, hazardous wastes, or health insurance pre- miums above a certain value. @ A new state wide - grant program similar to the Federal Hill Burton - program. Only by stepping into a new role as active. initiator and catalyst for needed services will New York - and most states - begin to address not only the health needs of all its citizens but its own costs crisis as well. 'a The A rt of Contributions Readers who have discovered the therapeutic value of art or simply enjoy drawing are always needed by the Bulletin. Do you have any work which could enliven these pages? We can't guarantee immediate publication, but we would be grateful for any additions to our graphics file. ee Health / PAC Bulletin 15 HEALTH PAC BULLETIN THE HEALTH CARE HIERARCHY WE The Health / PAC Bulletindoesn't have to boast that it's better than the competition; there is no competition. No one else offers independent analysis of health policy issues from prenatal care to hospices for the dying; covers medical carelessness for women and on the job poisoning; offers incisive international reports and lively briefs on domestic health developments. If you already know all this and have a subscription, why not do a friend a favor and fill in his or her name on the form below before you run out of 20 stamps? Remember, nine out of ten radical doctors recommend the Health / PAC Bulletin for fast relief of health care policy mystification. Please enter. Check: Y' Individuals $ 17.50 '] 2 years $ 30 (I_ nstit] utio ns $ [ 35 ] 2 years $ 70 (Foreign subscribers add $ 8 per vear) Name Address _subscription (s) for the Health / PAC Bulletin City State_ Zip. Y' Bill me (plus postage and handling) Y' Charge: Y' Visa Y' Master = Expiration date No. Signature Send your check or money order to Health / PAC Bulletin, 17 Murray St., New York, N. Y. 10007 16 Health / PAC Bulletin Bulletin Board Bringing It All Back Home All About Home Care: A Consumer's Guide is a new booklet put out by the National Homecaring Council and the Better Business Bureau of New York. It describes basic home care services, lists agencies, and offers advice on how to judge agencies and their employ- ees. The Council address is 235 Park Avenue South, New York, NY 10010. Don't Feel Sore The literature on herpes could fill a book- case by now, but there is only one booklet to our knowledge that focuses on the emotional problems associated with it and offers sim- ple, basic advice on what herpes sufferers can do to assuage them. Coping with Herpes: The Emotional Problems, by Vincent B. Green- wood, Ph.D., and Robert A. Bernstein, Ph.D., in cooperation with the American Social Health Association is published by the Wash- ington Center for Cognitive Behavioral - Ther- apy. Single copies are $ 2.95 from WCCT, P.O. Box 39119, Washington, DC 20016. Please add $ 1 for postage and handling, which in- cludes a discreet envelope. Bulk rates are available. Burning Issues District Council 37 of the American Federa- tion of State, County and Municipal Employ- ees has published a manual for stationary firepersons in boiler rooms and incinerators. Fired Up for Safety and Health by Alice Freund is concise, easy to read, and graphi- cally superb. There is a small section on New York laws, but the rest of the manual will be valuable for workers in any state. Copies are available from Safety and Health Training Unit, DC 37 Education Fund. 125 Barclay Street, New York, NY 10007. Make checks for $ 1 payable to the DC 37 Education Fund. Rape and Cancer Rape Crisis / , unlike many television films on the subject, does not portray a rape. It con- centrates on the consequences, intermingling actors with police, prosecutors, doctors, nurses. and rape crisis center workers in Austin, TX. It is well suited to classroom use. Color. 87 minutes. 16mm and video rental. $ 125: pur- chase is $ 875 16mm, $ 475 video. The Cancer War is a critical look at Ameri- can cancer research, raising questions about its direction, how much progress has been made, and the value of traditional cancer therapies. Prominent experts interviewed in- clude Dr. Vincent DeVita, Director of the Na- tional Cancer Institute; Dr. Samuel Epstein. author of The Politics of Cancer. and Dr. Linus Pauling. Available in video only (color). Rental is $ 90: purchase $ 750. Both productions are among the 240 cur- rently available from Cinema Guild, 1697 Broadway, Room 802. New York, NY 10019. Perils of Drinking Are you worried about the water you drink? Well, you should be. If you're not. a good source of information is the special May issue of Environmental Action, " Troubled Waters Ahead. Single issues are $ 2.50; ten or more for $ 1 each from Environmental Action, 1346 Connecticut Ave., Washington, DC 20036. Poor Women, Poor Health Two new and very attractive pamphlets provide a lively. concise, critical look at the condition of a good portion of the world's population. Poverty in the American Dream: Women & Children First, by Karin Stallard, Barbara Ehrenreich, and Holly Sklar, and Wo- men in the Global Factory by Annette Fuentes and Barbara Ehrenreich were both produced with activists and a popular audience in mind. Single copies of either are $ 3.75 plus $.75 postage from the Institute for New Communi- cations, 853 Broadway, Room 905, New York, NY 10003. Here Today, Orgone Tomorrow The Wilhelm Reich Museum has an exten- sive collection of his writings on health and, other subjects. For a catalogue of what is available, send $ 1 to the Reich Museum Book Store, Box 687-5, Rangeley, Maine 04970. Health / PAC Bulletin 17 Bulletin Board Chip Tips Here's some information you won't learn fNroormt ht hCea rAotlairin aD eOmcoccurpaattsi opnuablli sShaefde tbyy atnhde Health Project. Microelectronics: Safety and Health in the Workplace contains an illus- trated description of semiconductor manufac- turing and soldering processes and their health and safety implications: information about worker rights under OSHA and hints on work- place organizing: suggestions for evaluating working conditions; and data on solvents , acids, bases, and metals used. postage : Copies are $ 3 plus 75 postage each from NCOSH. P.O. Box 2514, Durham, N.C. N.C. 27705. Asbestos Alert The White Lung Association, organized in 1979 by victims of asbestos exposure at Los Angeles shipyards, welcomes contacts from people who have worked at the Brooklyn Navy Yard and faced dangerous exposures to asbestos. They can call the at (212) 596- 4S2t0a7t ioro nw.r ite to Brooklyn, P .NOY. B1o1x2 B0o2x. :WL A 1061, Cadman Plaza ] Join the Health / PAC Party Our annual celebration at the American Public Health Association conference should be the best ever. Guests include Jim Hightower, author of Eat Your Heart Out, who now heads the Texas Agriculture Commission. The food should be good, and hearing Jim is a real treat. The party will be Tuesday, November 15, at 8 p.m. Place to be announced. i a NEW 1983 Policy, Politics, Health, and Medicine Series Series Editor: Vicente Navarro VOLUME 4 VOLUME 5 WOMEN AND HEALTH | HEALTH AND WORK The Politics of Sex in Medicine UNDER CAPITALISM Edited by Elizabeth Fee, An International Perspective The Johns Hopkins University Edited by Vicente Navarro and " This is an excellent collection of articles on an Daniel M. Berman extremely important subject. It places women's health issues in a broader political and historical context. and provides valuable reading for all those concerned with combatting patriarchy in medicine. " heartily " I this this . It is an invaluable heartily to endorse those engaged book in the daily invaluable struggle for a safe weapon and healthy workplace workplace. The book confirms the daily experience of millions of workers as), as a Lesley Doyal, Senior Lecturer, machinist, know from my own experience. " Polytechnic of North London Author, The Political Economy of Health Lou Pardo, Chairperson, Chicago Area Committee on Occupational Safety and Health ISBN 0-89503-034-9 1983 Soft Cover $ 14.50 prepaid 264 pages plus 1.50 $ postage ISBN 0-89503-035-7 1983 Soft cover $ 16.50 prepaid 312 pages plus $ 1.50 postage Y' BaywoodP ublishing Company, Inc. 120 Marine Street * Publishing P.O. Box DiFarmingdale Publishing DiFarmingdale, N.Y. 11735 18 Health PAC Bulletin Doing a Job on Right - to - Know Legislation by Richard Kazis In the current debate on " know right - to -" laws, opponents frequently charge that the cost of complying will be so high that em- ployers will close facilities, eliminating jobs. Based on a year's research into " jobs vs. envi- ronment " and " jobs vs. health protection ' claims (the results of which are presented in our book, Fear At Work: Job Blackmail, Labor and the Environment, by Grossman and Kazis), we believe that this kind of regulation poses no such threat. In fact, it is our belief that right know - to - laws make a positive contribu- tion, not only to public health, but also to economic well being - and business efficiency. Time and time again business leaders threat- en that if a particular protective measure is enacted, the result will be higher costs to consumers and significant job loss. Invariably these predictions of disaster prove unfounded. One reason is the tendency of industry sources to overestimate regulatory compliance costs. For example, when four B.F. Goodrich work- ers died of liver cancer in Kentucky in 1974, prompting the Occupational Health and Safety Administration (OSHA) to propose an emer- gency standard for vinyl chloride exposure, an industry sponsored - study estimated com- pliance costs at $ 65-90 billion. However when the standard was imposed, the industry com- plied at a total cost of well under $ 1 billion. Not one job was lost. Not one plant closed. Chemical Week trumpeted, " Polyvinyl Chlor- ide Rolls Out of Jeopardy, Into Jubilation. " Similarly, Energy Secretary James Schlesin- ger concluded in 1978 from industry supplied - estimates that beryllium producers would have to shut down if forced to clean up car- cinogenic dusts and fumes. But instead of the Richard Kazis is Director of Research for En- vironmentalists for Full Employment (EFFE). This article is a revised version of testimony he gave to the Massachusetts Legislature. $ 150 million the industry had claimed it would cost, the actual cleanup was done for well under $ 5 million - an expense the pro- ducers easily absorbed. What is the actual impact of existing en- vironmental and public health laws on prices? The Congressional Joint Economic Commit- tee concluded in 1976 that environmental. health, and safety regulations had little impact on price inflation. In 1981, Data Resources. Inc. estimated in a study for the Council on Environmental Quality that the broad spec- trum of Federal environmental laws added an annual average of 0.3 percentage points to the Consumer Price Index. Thus, in 1980, when the CPI rose 13.4 percent, only three percent of that increase - an insignificant portion- could be attributed to the cost of complying with environmental laws. a MORE JOBS safe jobs,N ow cpf / Regwerd LIBERATION NEWS SERVIC LNS Health / PAC Bulletin 19 The legislation included in these studies- clean air and water laws requires - firms and municipalities to install sophisticated and costly pollution abatement equipment. In con- trast, right know - to - laws require only some increase in paperwork and personnel hours. If the comparatively high compliance costs of air and water pollution control legislation. has had minimal effect on prices in the na- tional economy, it is highly unlikely that right know - to - laws will have any adverse ef- fect on the competitiveness of a state's firms. Implicit often explicit - in industry warn- ings of exorbitant costs is the threat that new regulations will cost jobs. In 1979, a lobbyist for the Associated Industries of Massachusetts warned that the state's high technology - firms could " be in North Carolina tomorrow if things do not go the way then want them to. " They're still in Massachusetts, along with hundreds more. Actually, the past decade's environ- mental laws have led to the creation of several hundred thousand new jobs. The Environmental Protection Agency es- timates that fewer than 3,000 workers a year since 1971 out of a workforce of more than 100 million are even alleged by their em- ployers to have lost their jobs because of en- vironmental regulations. The Industrial Union Department of the AFL - CIO has concluded that " environmental regulations have not been the primary cause of even one plant shutdown. " For all its complaints about alleged layo fs and job loss due to environmental and occu- pational health and safety laws, the business community has generated no data of its own on actual experience. One economist for a national trade association told me, " As an economist, I find it irritating that [industry] will spend a million dollars on public rela- tions, putting some editorial in the newspaper. and not one penny on collecting any hard data. " By contrast, more than 100,000 new jobs have already been created because of clean air laws, and more than 200,000 new jobs have been generated by clean water regulations. If pre 1980 - standards and timetables had been maintained by the Reagan Administration, more than 520,000 new jobs would have been created by 1987 in construction, manufactur- ing, research and development, design and operation and maintenance of pollution con- trol systems. The charge that overregulation has cost jobs and that new regulations such as right- to know - bills will cost more jobs - is not based on fact. Rather, it constitutes job blackmail. an attempt to manipulate public and political opinion by threated, and livelihood. # stifle opposition an agendas that are set Listen to Frol ple, private derest. Pe Public Service Company d tee uilder of the Seabrook ra bes efine in the Public Relations a. 3 Coe tia facts once in a whil nagues. " Counter the acais closed factory gi. dark houses and as tots he # with wdearcd Job blackmail oo. melters in New gk bears bat I to shut down and throw thede ei work if forced to change jas Py ba eliminate the stem Lo bo anads, When the City Bes 5 cal EPP, however, the muiter non', Dyes top process that solved it. the. 24 lenny and kept workers on the wa 8 es 1aSS and often governmed besa, al to cut short a public discus (bet rae es to " business as usual, " the toss eae it it conard Woodcock, former presidera at the United Auto Workers, has called " the same tired line cost that any alternativ the ic priorities will cost jobs. One variation of job, blackmail herd fre- quently in state legislatures is the claim that a proposed regulation will will favetapanies favetapanies to move to states where regulations are less stringent. The evidence is chear however. that existing environmental and public health regulation has not been a significant factor in corporate flight from one state to another. A recently published bree - year study by the Conservation Foundation in Washington, D.C., entitled Siting New Industry: An Envi- ronmental Perspective Perspective, concluded concluded. " We could unearth no evidence that ens mental and land - use laws had caused +1 diaion movement of industry from states perceived to have strong environmental laws to those thought to be more permissive. In the vast majority of cases, we found that environmental regula- tions were of very minor influence when it came to choosing a location, important per- haps only in breaking a tie between two sites that were otherwise about equal. " The study noted that California, a state with some of the strictest environmental lasts in the country and a reputation for enforcing them, outstripped all other states in total gain in manufacturing employment during the 19-0's Environmental regulation is way way at the bot- tom of the list of criteria used by firms in deciding where to locate lien to close facili- ties, when to move to another state or another 20 Health / PAC Bulletin country. Again, it must be emphasized that the Conservation Foundation study and others like it focus on regulations which cost Ameri- can industry tens of billions of dollars each year, yet still have little impact on job loss, inflation, and plant siting. The cost of com- plying with right know - to - laws is infinitesi- mal in comparison, so there is no reason to assume that they have any noticeable impact on corporate flight. Companies do move, and companies go out of business, but government regulation is not to blame. Economists Barry Bluestone and Bennett Harrison have shown that between 1969 and 1976 plant closures occurred with about the same frequency in all areas of the country - those with a reputation for strict regulation and those believed to be laxer. (The odds that an establishment existing in 1969 would still be in business in 1976 were estimated at 0.57 for the Northeast, 0.54 for the Northcentral region, and 0.57 for both the Mases , New Evergod Philip South and the West.) From this evidence it is logical to conclude that enactment of right- to know - protections is unlikely to have any impact on shutdowns. Another popular argument made by busi- ness lobbyists is that right know - to - legisla- tion poses a serious threat to corporate trade secrets. Some even argue that the threat is so serious that it may lead a firm to choose not to locate in a state with a right know - to - law. Again, the business community is exaggerat- ing. Right know - to - laws do not require firms to divulge the chemical processes in which the toxics are used but only to report the names and health hazards of the toxics them- selves. Most companies are able to analyze the chemical compositions of their competitors ' products and in so doing find out much more information than right know - to - laws provide. The trade secrets argument is a smokescreen. To cite one example of its use among many, Health PAC Bulletin 21 the 3M Company told a Minnesota local of the Oil, Chemical and Atomic Workers that it would not turn over the names of substances in the plant because trade secrets were in- volved. When the National Labor Relations Board ordered the release of the information, according to the union's health and safety newsletter, it was " shown that out of 700 generic chemicals produced at the plant, there was only one substance whose identity might provide an advantage to competitors. " Legislators must, of course, consider the costs to business and to the public of issuing new regulations and legislating compliance with new rules. But they also have another responsibility - that is, to consider the cost of not regulating to the state, to its workers, con- sumers, and communities. Occupational health and safety problems are also pervasive in American workplaces. About 100,000 people die each year from job- related diseases. As many as 390,000 people contract occupation - related diseases each year, according to the U.S. Public Health Service. At least one of every five Americans has had contact at work with hazardous substances regulated by OSHA. A 1968 study by the Chi- cago Institute of Medicine found that workers in 73 percent of Chicago's workplaces were exposed to one or more potentially hazardous materials. In 1980, the Federal Toxic Sub- stances Strategy Committee concluded that between 22 and 38 percent of all cancers may be job related - . The cost of this level of illness and accident is staggering. What is the cost to society of a worker whose exposure to workplace hazards forces him into early retirement and cuts short his life? What is the cost to the nation, to the state, to the community, to the individuals involved, when people at work and in their communi- ties contract any of the diseases associated with excessive exposure to chemical liquids, dusts, mists, fumes and vapors - from rashes, lesions and skin desease to bronchitis, em- physema and lung disease to liver and kidney damage, to urinary, circulatory and nervous system disorders, to cancer and genetic de- fects? Obviously much of this cost is immeas- urable, but we do know the financial outlay is enormous. In 1971, the Federal government estimated the expense of treating an individual cancer patient at $ 30,000 5,000- $ . Given the rise in medical costs, that estimate can be at least doubled today. Dr. Samuel Epstein of the School of Public Health at the University of Illinois in Chicago estimates the recognized cost of cancer to be in the region of 30 $ billion each year, a figure which does not include related costs such as'vorker's compensation payments, medical malpractice suits, and victim compensation suits. Nor, of course, does it include the cost of non cancer - health problems or lost workdays, increased work- ers job dissatisfaction, and decreased produc- tivity. Community environmental problems are pervasive and expensive. We are all aware of the recent Federal government decision to purchase the town of Times Beach, Missouri, because of dioxin contamination. The EPA will spend $ 33 million for the town, exclu- sive of compensation to residents who develop health problems from their exposure. The Love Canal clean - up has cost over $ 87 mil- lion in Federal and state funds. The EPA esti- mates that between 1,200 and 2,000 of the over 30,000 hazardous waste disposal sites in this country may pose significant risks to hu- man health and considers a minimum of 29 to be at least as dangerous as Love Canal. Chemically - related health problems will not simply go away. In 1940, about one bil- lion pounds of synthetic organic chemicals were used in the U.S. By 1976, total produc- tion had soared to 162.9 billion pounds. Cur- rently 700 new chemicals are introduced into commerce each year. In this era of cutbacks in Federal and state funding for enforcement, public education, and inspection of environmental and occupa- tional health problems, we need to look for efficient, effective ways for people to protect themselves, their health and their jobs. Pre- vention is cheaper and better than cure. And prevention can avoid problems for which there are no cures. If workers and citizens can avoid hazardous substance exposure or re- ceive speedier medical treatment because a container is labelled xylene rather than X 255 -, society benefits. We must keep sight of the central issue in terms of the right know- - to - that is, whether chemical labeling and work- er community / access to safety data promotes public health and safety and enables people to play a greater role in protecting their own health and safety. The evidence is clear that right know - to - legislation does not impose significant com- pliance costs and, once passed, will not cause plant closings. Claims to the contrary are ef- forts to introduce fear into an important public policy debate. Rather than get lost in a maze of job loss rhetoric, legislators should take a careful look at the economic and social bene- fits of establishing the right to know. oO 22 Health / PAC Bulletin Media Scan technical, although down to earth and clear. Compare these introductions: Winning the Right to Know: A Handbook for Toxics Activists, 1983, Delaware Valley Toxics Coalition, $ 5 for activists, DVTC Education Fund, 1315 Walnut Street # 1632, Philadelphia, PA 19107. Dumpsite Cleanups: A Citizen's Guide to the Superfund Pro- gram, 1982, Environmental De- fense Fund, $ 5 organizations, $ 10 individuals, EDF Toxic Chemicals Program, 1525 18th Street, NW, Washington, DC 20036. This reviewer rates environ- mental groups by the follow- ing rule of thumb: how much weight they give smoking as a cause of disease. The Delaware County Toxics Coalition (DVTC) and the Environmental Defense Fund (EDF) both win top grades by saying smoking is the lead- ing cause of cancer. They rec- ognize that facts are more elo- quent than propaganda, even if they aren't always heard im- mediately, and know that giv- ing smoking its due is no rea- son to ignore the many work- sites and communities endan- gered by toxic chemicals. As this indicates, both guides are eminently practical and only occasionally rhetorical. Toxics activists would do well to get both, since they are com- plementary in their coverage. The authors of Winning the Right to Know mix advice with a blow blow - by - account of their own and other victories. Dump- site Cleanups is general and In Wissinoming, Pennsyl- vania, middle - aged women lounged in lawn chairs in the hot August sun while their children scampered down the block. But it was not a typical day in Wissinoming, a working- class neighborhood of Philadel- phia. The lawn chairs were blocking a major intersection and many of the kids wore signs saying " No PCBs. " (Winning) Hazardous waste dumpsites present serious problems... it takes a hard fight to get the things done you want done. This fight is now going on at dumpsites throughout the coun- try. (Dumpsite) Unfortunately, the need for both kinds of approaches will probably continue to grow, since prevention still has little political force as an abstract is- sue. DVTC, which helped pass the first worksite and commun- ity disclosure bill in the coun- try (Philadelphia, 1981), warns in its handbook that right - to- know legislation may be pre- mature if citizens are not al- ready aroused by an occupa- tional or environmental prob- lem such as high cancer rates (Philly and Cincinnati), chem- ical fires (Vallejo and San Die- go), or contaminated drinking water (Santa Monica). Once there is a groundswell, a careful reading of the politi- cal situation is still vital in de- termining what type of bill has a chance of passage. Should it include public disclosure of hazards or workplace disclo- sure only? Coverage of chemi- cal transportation and disposal as well as use? Reporting by small businesses or just the larger manufacturers? DVTC itself dealt with these and other questions by laying the ground- work for an equal citizen - labor alliance. The Ohio River Val- ley Committee on Occupation- al Safety and Health designed its bill primarily to serve the needs of its union base. Despite their different ap- proaches, these groups and others described by local lead- ers in the handbook attribute their success to strong organi- zation, aggressiveness, flexibil- ity, credibility, and good timing. Readers will learn a great deal about what to do from their accounts. Activists may be disappointed that little is said about what not to do; there is no list of danger signs gleaned from campaigns that went as- tray. They might like to know what happens when you do everything " right " and still lose. The handbook could also have noted that although an enemy is a powerful motivator, the nature of the opposition varies. It fails to mention, for example, that the folks in Cin- cinnati benefited from a split in the ranks of the Chamber of Commerce. True, this and much other information might be ob- tained from the listings in the well annotated - bibliography. There is, however, one vital story missing which the authors were uniquely qualified to pro- vide, a detailed account of the DVTC's important role in shap- ing the regulations implement- ing the Phildelphia law. Sad experience has shown that vic- tory in the battle for a bill is often followed by defeat in the regulatory war. Preventing regulatory attri- tion is precisely the object of the Environmental Defense Fund Guide. Many of the prob- lems are readily apparent in the Environmental Protection Agency's regulations. Among Health / PAC Bulletin 23 them: " adequate protection " of public health is defined site by site: cleanup will take place only at top priority " dumps: and all solutions to hazardous waste problems must be cost- effective. In general, the Super- fund cleanup program is tech- nically complex and mandates little input from citizens about decisions which effect their lives. The Dumpsite introduction declares that organizing is act- ing, not waiting for things to happen to you. But eager read- ers will soon discover that the EDF image of an activist is someone who understands the difficulty of cleaning up a site almost as well as the difficulty of living nearby. Getting the facts, the authors emphasize. is crucial: " A bad (health) study, which produces false results, is worse than no study at all. " Another Love Canal, in which homeowners took the White House by storm, may well be impossible. The Guide's authors appar- ently think so: they pack a wealth of technical data into a concise, readable format with checklists and questions to challenge the diagnoses and remedies of the opposition ex- perts. For every category of disease, for example, Dumpsite lists several diagnostic tests - and explains why their results will be inconclusive. Readers might despair of ever finding defini- tive evidence of toxic damage, but the Superfund law requires only proof of potential harm. " It is prudent, " the guide ad- vises, " to assume that any and all toxic effects may have oc- curred at your site. " This may be good advice when beginning an investigation, but judgements must be made on accurate cri- teria: the table of toxic effects included overstates some cases, e.g. calling dioxin a mutagen when the evidence is inconclu- sive and not distinguishing be- tween animal and human im- pacts. Certainly such questions would come up at some point if the local group seeks outside expertise, as the guide recom- mends. But there is plenty the group is expected to do on its own following the steps laid out, everything from critiques of field investigations to neigh- borhood health surveys. Here examples of previous experi- ences would have been parti- cularly helpful, since although these these tasks tasks are are rated rated by by diffi- diffi- culty and importance a group of volunteers might well won- der how it can manage to ob- tain so much information. Even if it does, there is bound to be tension. Opportunities for participation in Superfund decision - making are limited. The possibility of a split with- in the group between techno- crats and political activists is not entertained by the authors; they advocate legal and politi- cal action only if the deck is stacked unfairly against the citizen group or the process stalls. In general, suggestions for action are spelled out in check- lists -- for organizing, site as- sessment, cleanup, medical diagnosis, and law suits -- rath- er than meshed as part of an overall strategy. The guide contains a great deal that is valuable, but con- sidering how much is missing, it is odd that this is one of the rare how - to books without case studies, a bibliography, or an organizational listing, although some valuable appendices and a few reference book citations appear in the text. Granted, the EDF and the two other contribu- tors to Dumpsites, the Citizen Clearinghouse on Hazardous Waste and the Environmental Action Foundation, have more experience in the area than anyone else, but there are other phone numbers and addresses which activists might find useful. Perhaps the guide's looseleaf format was chosen because this information will be forthcom- ing. Certainly we can hope and expect that it will be, if not from the Environmental Defense Fund then from many other ac- tivists who sit down to share what they have learned in their efforts to prevent and clean up toxic hazards. Carl Blumenthal Carl Blumenthal is a member of the Health / PAC Board and worked on a 1982 national survey of grassroots environ- mental groups at Hunter Col- lege in New York. CAT TESTTH Revolutin Candian 24 Health / PAC Bulletin Is Sleep Necessary? by Arthur A. Levin Fred shifts his arm, his leg: he lies in bed thinking of a missed opportunity, the report due tomorrow; staring at the ceiling, feeling his nerves frizz like the graph of an electrocar- diogram, he yearns for the sleep stretching just beyond reach like a great Pacific Ocean. For Fred, as for tens of mil- lions of others, falling asleep is a discomforting inner combat. Scientific inquiries into the prevalance of sleep disorders show that one third of all Americans complain of having had " trouble " sleeping during any given year, although only two percent characterize their problem as " insomnia. " Phy- sicians report that some 17 percent of their patients have difficulty sleeping: they treat over half of them with prescrip- tions. Insomnia, or unsatisfactory sleep, as most victims seem to prefer to call their affliction, is a subjective condition. Most of us spend about one third of our lives asleep, but how much is " normal " varies enormously for individuals as well as in different stages of life older people usually sleep less than younger. If a Henry Kissinger gets up fully rested after sleep- ing four hours in 24, clearly insomnia is not one of his prob- lems. A more useful description is " a stressful period of being awake which results in the in- dividual being tired and / or un- Body English comfortable. " Within this def- inition are several distinct sleep problems better understood in the past decade. There is abundant evidence that a period of rest is natural within every revolution of the sun. Plants and flowers change their leaf movements. Frogs and lizards grow still. Butter- flies fold their wings and cling to a blade of grass. Birds and mammals, including us, sleep. Unlike most creatures, hu- mans brazenly sleep through the night sometimes - quite soundly. For most of our his- tory as a species the only clock we had, externally or internally, was the turning of the earth. People were truly diurnal, waking with the sunrise, work- ing, playing, and otherwise oc- cupying themselves through the day, and then sinking back into sleep. The development of artificial light, and very re- cently of rapid long distance - communication and high speed - transport has naturally, or rath- er unnaturally, created prob- lems, including jet lag and dual time zone watches. But we still sleep, and if everybody and everything is doing it, that is good reason to believe that it serves some im- portant biological or ecological function. The question is, what might that be? The short an- swer is, we don't know. An article in the November 12, 1981 issue of New Scientist posed the problem sharply: " Does sleep restore us from the wear and tear of wakefulness? Is it a redundant instinctive behavior of little restorative value, but which keeps us oc- cupied during the dark hours, and helps to conserve some energy? " The authors went on to note that although both pos- sibilities have supporters, most sleep researchers subscribe to the restorative hypothesis. One strong argument is evolution- ary evidence. The bottlenose dolphin, for example, is able to sleep with only one cerebral hemisphere shut down at a time; during wakefulness the hemispheres are synchronized. Elaborate mechanisms such as this to facilitate sleep indicate there is some need for it. It is also known that during the first few hours of sleep the human brain releases large amounts of growth hormone: Many believe that this supports the restorative hypothesis that is, that sleep promotes tissue growth and repair. However recent studies indicate that this hormone is only slowing down tissue loss, and in many other mammals - cats and rats, for example it is not released in large quantities during sleep. After water, the main com- ponent of tissue is protein. Con- trary to what was expected, new research has discovered that rather than increasing during sleep protein synthesis actually decreases. The major factor in protein " turnover " appears to be eating; the drop during sleep may have more to do with the night - time fast than with rest itself. At this point, even if we ac- cept the restorative hypothesis we still don't know what is re- stored, the body, the brain, or some combination. Nor is it clear if the restorative effect comes from sleep only or if rest could be sufficient. The tech- nology for measuring brain nerve growth is not yet available. Electroencephalogram (EEG) tests do show that the cortex can be very active even when we lie still with our eyes shut. It appears to rest only during non dreaming - sleep. This is about three quarters of the total; the dreamy balance, known in the jargon as Rapid Eye Move- ment (REM) sleep, can get pretty stimulating. Health / PAC Bulletin 25 Whether it is necessary is another question. There is a story that someone once re- proached Nijinsky, saying, " I sleep half as much as you do; think of all the extra time that adds to my life, " and the great ballet dancer replied, " Yes, but when I'm awake I'm more awake than you ever are. " Nijinsky may have been cor- rect, but his wakefulness seems to have had little to do with the amount of time he spent sleep- ing. Studies in sleeping labora- tories have shown surprisingly little impairment of the ability of individuals to function nor- mally, both physically and mentally, when they are de- prived of some sleep. (It is pos- sible that organs of the body are affected in ways we are as yet unable to discern, and that the controlled laboratory set- ting of most sleep studies may bias results, since people sleep differently in their own beds and / or with their lover or teddy bear.) Still, it is interesting that al- though the cortex is considered the part of the brain most in need of sleep, researchers have found that the most demand- ing of mental tasks can be ac- complished after considerable sleep deprivation if the subject is offered sufficient motivation. When sleeping time is reduced to the point where it does ef- fect performance, the deterio- ration is noticeable first in pro- tracted or mundane tasks rather than in complex ones such as playing chess or taking an IQ test. Most people who participate in sleep deprivation experi- ments don't seem to need to make up all their lost sleep. They do experience changes in their sleeping behavior. The subject who endured the long- est period of experimental sleeplessness (11 days) was al- lowed to sleep as long as he wanted after the wake portion was concluded. Normally a six and a half hours a nighter, he slumbered an extra eight hours on the first night, four on the second, and two and a half on the third. By the fourth day he appeared to be functioning nor- mally and sleeping his custom- ary six and a half hours. In several California studies sleeping time was reduced by 30 minutes each night. When the participants, who had been accustomed to seven - eight hours, were down to six they had difficulty getting up in the morning, but there was little evidence of impairment of nor- mal functioning. When they were reduced to five hours, physiological and psychologi- cal difficulties became evident. At this point most of the parti- cipants took their pillows and went home. Even so, their contribution to sleep studies has been inval- uable. The study found when sleeping time was down to five hours there was no reduction in deep sleep, but REM sleep, the last and lightest part of the sleep cycle, had declined by two thirds. Even more signifi- cantly, in a followup one year later the researchers found that the participants had voluntar- ily reduced the amount of time they slept by up to two and a half hours and reported that they suffered no ill effects or increase in daytime fatigue. This may indicate that the last hours of sleep are at least par- tially unnecessary. The evidence that the brain of mammals needs sleep is much greater than that the mammal body does, although the process is still so mysteri- ous that any firm conclusions are impossible. Fortunately, this doesn't preclude the pos- sibility of improving our un- derstanding of the various sleep disorders and their treatment. These will be discussed in the next column. Arthur A. Levin is Director of the Center for Medical Con- sumers, publisher of Health- facts: and a member of the Health / PAC Board. cpf Health / PAC Readers in the New York City area might enjoy listening to the Health / PAC radio show on WBAI. Our new time is every second and fourth Tuesday at 11:30 a.m. 26 Health / PAC Bulletin Index to Volume 13 A J Abortion Rights.. .No.4 Agency Nursing. .Nos.5,6 Agent Orange. .No.3 Alcohol Ingredients .No.2.No.2 American Hospital Association. .No.5 Asbestos.. .No.5.cNeeo .ee5e .No.5 Athletic Injuries. .No.5,6 Australia .No.5.No.c5ee. No.5 B Jones, James .No.2.0N.o0 .ce2c.e No.2 L Labor Movement. .No.2 Lead Poisoning .No.2.No.0200 .No.2 Lidcombe Workers Health Centre .No.5.No.5 Long Island .............-. .No.2.No.2 Bangladesh *. No.5.N2o000. e5 ce.e No.5 Bronx. cee .No.4.No.4 Budget Cuts.. .Nos.3,4,6.Nos.3,4,6 Bureau of Labor Statistics .No.2.No.2 C California.. cee cence ee .No.1.No.1 Canada .No.4c.ccN cocc. c4e .ceNe o.4 Cancer.. 0... ccc .No.6.No.6.No.6 Cape Cod Health Care Coalition .No.3.No.3 Children's Comprehensive Care Services. .No.2c.c Ncoe.e 2.No.2 Children's Defense Budget .No.2.No.2 Cigarette Smoking .No.6.No.6 CoalitionsHeal. th Care. .. No. 3.No.3 Competition Model for Health Care...Nos. 3,5 Computers.. 00... ccc cece eee .No.6.No.6 Coronary Artery Disease .No.1.No.1 Coronary Heart Disease. .No.4 D Darvon.. 2...N.o .6e.eNe o. 6.No.6 Diagnostic Related Group (DRG) Programs .No.60..0N...o c. e6ee. No.6 E M Manville Corporation .Nos.5,6.Nos.5,6 Massachusetts. .No.2 Mazzocchi, Tony. .No.2 Medicaid .Nos.1,2,4,6.Nos.1,2,4,6 Medical Technology. .. No.3 Medicare.. .Nos.1,2,4,5,6 Moffet, Representative Toby .No.5.No.5 Monito0r .00s c . ee . ee. .N o.3.No.3 Mystic River Bridge. .No.2.No.2 O Occupational Hazards. .No.2 Occupational Safety and Health Administration (OSHA) ..No s 1,2,3,6. Ohio Nurses Association .No.5.No.5 Oraflex.. 6. cece eee .No.5.No.5 P Pharmaceuticals. .Nos.1,5,6 Preventive Medicine. .No.4 Profits in Health Care. .No.3 Public Health Service. .No.1 Public Hospitals .No.1.No.1 Exercise .Nos.4,5.cNcocs e.e4e, 5.Nos.4,5 F Feminist Women's Health (FWHC) 000. Center .No.4.No.4 H Health Budget. .No.1.No.1 Health Care Distribution .No.3.No.3 Health Systems Agencies (HSA's). .No.6 Hospital Closings. .No.4 Hospital Expansion. .No.4 Hospital Industry.. sect .No.2.No.2 R Radiationc. ee . .Nos .3,6.Nos.3,6 Reagan, Ronald .Nos.1,2,3,5,6 Right Know - to - Legislation .Nos.3,4.Nos.3,4 S Sencer, Dr. David... .No.2 Service Employees International Union (SEIU) .No.5. No. 5 Strabane, Pennsylvania .No.6.No.6 Stress Test .No.10....N c oce. ee1e .ceeN o.1 Health / PAC Bulletin 27 T Tallahassee .No.4.0.0N.0o0 .e 4eee. No.4 Toxic Chemicals. .Nos.2,3,4 Tuskegee Syphilis Experiment .No.2.No.2 U United Citizens Awareness of Radioactive Exposure (UCARE). ..No.6 V Visiting Nurses Association (VNA). .No.5 W Wheelchairs .No.3.No.3 Women's Occupational Health Resource Center (WOHRC) at Columbia University.. .No.6 Y, X rays - ee. n ... No.3..No.3 HEALTH STUDY AND RESEARCH PROGRAM IN CUBA FROM PRIMARY CARE THROUGH HIGH - TECH IN HAVANA, CAMAGUAY, CIENFUEGOS, SANTIAGO FEBRUARY 3-17,1984, departs MIAMI Two FULL weeks (Fri. to Fri.) All air ground / transportation, lodging, food and rest in DeLUXE accommodations. COMPLETE PRICE $ 1275. Professionals in ALL areas of HEALTH CARE AND TRAINING, and JOURNALISTS may travel to CUBA under regulations BILINGUAL Visits with professional counterparts. FOR REGISTRATION FORMS WRITE: U.S. - CHE c / o S.J.GLUCK, Treas. Room 1201, 202 West 40 Street, New York, NY 10018 (or) PHONE: (212) 840-7222 (24 Hr.Service) REFUNDABLE 150 $. RESERVES PLACE Books Received Zola, Irving Kenneth, Missing Pieces: A Chronicle of Living With a Disability (Phila- delphia: Temple University Press, 1983) Lewy, Robert, M.D., Preventive Primary Medi- cine: Reducing the Major Causes of Mortality (Boston: Little, Brown & Co., 1980) Bishop, Eric, Dental Insurance: The What, the Why, and the How of Dental Benefits (New York: McGraw - Hill Book Company, 1983) Drake, Alvin W., Stan N. Finkelstein and Har- vey M. Sapolsky, The American Blood Supply (Cambridge, MA: The MIT Press, 1982) Romanucci - Ross, Lola, Daniel E. Moerman, Laurence R. Tancredi and contributors, An- thropology of Medicine: From Culture to Method (So. Hadley, MA, 1983) Mizio, Emelicia and Anita J. Delaney (Eds.), Training for Service Delivery to Minority Clients (New York: Family Service Assn of America, 1981 Dunn, Martha Davis, Fundamentals of Nutri- tion (Boston: CBI Publishing Co., Inc. 1983) De la Pena, Agustin, M., The Psychobiology of Cancer: Automatization and Boredom in Health and Disease (So. Hadley, MA: J.F. . Bergin Publishers, Inc., 1983) Starr, Paul, The Social Transformation of American Medicine (New York: Basic Books, Publishers, 1983) Freund, Peter E.S., The Civilized Body: Social Domination, Control, and Health (Phila- delphia: Temple University Press, 1983) Arnold, Charles, B., M.D. (Ed.), Advances in Disease Prevention, Volume 1 (New York: Springer Publishing Co, 1981) Rodgers, Harrell, R., Jr, The Cost of Human Neglect: America's Welfare Failure (Armonk, NY: M.E. Sharpe Inc., 1982) McKinlay, John B., (Ed.) Health Maintenance Organizations (Cambridge, MA: The MIT Press, 1981) Rousseas, Stephen, The Political Economy of Reaganomics: M.E. Sharpe Inc., 1982) Glauber, I. Peter, Stuttering: A Psycho - ana- lytic Understanding (New York: Human Sciences Press, 1982) Joskow, Paul L., Controlling Hospital Costs: The Role of Government Regulation (Cam- bridge, MA: The MIT Press, 1981) 28 Health / PAC Bulletin continued from p. 4 not the budget. However effec- be a right, not a privilege, for the past two guaranteed to all but - because the government is not helping to meet their community's health care needs. tive planners may have been, yearst hev ery idea of (democratic) planning has been attacked. The Waxman bill shows that de regulation - has not been able to deliver a Planning Ahead With medical costs still soar- ing and pro competition - bills stumbling in Congress, health planning seems destined for a reprieve after two years of threatened extinction. Rep. Henry Waxman's (CA D -) Ener- gy and Commerce Committee reported out H.R. 2934 on May 17; the full House is likely to act on the " Health Planning Amendments of 1983 " this summer. In former years, the Waxman bill would not have been con- sidered a resounding victory for health planning. The latest tally shows only 131 of the original 204 health systems agencies (HSA's) still Federal- ly funded. (Some others are currently " supporting self .- " ) Twelve states have no local HSA's and Waxman's bill would allow more to drop them. The thresholds for certificate of need (CON) applications would be raised 25-100 percent, al- lowing more capital spending to flow unexamined - noticed. In addition, HSA participation in CON review - the touchstone of democratic planning - would be decided by each state. The program would be authorized until October 1, 1985; CON participation would expire the following year unless reap- proved by Congress. Citizens who feel that HSA's during the Carter years prom- ised much and delivered little will wonder if with these addi- tional constraints the program is worth the $ 64.8 million sug- gested for fiscal year 1983, a more than 50 percent cut from the late 70's. The key issue, though, may be the principle, knock - out blow, but planning forces are still struggling to re- tain their teeth. Keeping CON review in planning and keep- ing planning out of a block three year authorization would also be a great victory, since the program has survived since 1979 on yearly continuing reso- lutions. Even if H.R. 2934 remains intact, the Federal government will be little more than a con- duit of funds for the next two years. President Reagan has shifted the burden of planning to the states at a time when a lot of fat chickens are coming home to roost. According to Bill O'Donnell, director of con- gressional gressional relations relations for for the the American Health Planning As- sociation, the defeat of Presi- dent Carter's hospital cost con- tainment bill opened a " win- dow dow of of vulnerability vulnerability " " through through which hospital administrators have leaped with billions of dollars in new spending pro- posals. Between 1979 and 1982 capi- tal expenses approved increased by nearly 80 percent after ad- justment for inflation, accord- ing ing to to a a report report by by the the Alpha Alpha Center for Health Planning. Ten states are so concerned they have placed moratoria on capi- tal tal spending spending.. Whether Whether health health systems agencies and state planning authorities slowed. the pace of this assault or rolled over and played free market is debatable. (O'Donnell admitted that studies allowed you to " pick your side. ") It is certain- ly true that the HSA practice of reviewing CON applications separately, rather than compar- atively, has never been sound planning. One solution is tying capital planning to prospective reim- bursement (paying a set amount for each type of case - see Bulle- tin, March - April 1983). the main tool for controlling oper- ating budgets. Although the link is not explicit in the Wax- man committee's HSP bill, the Medicare prospective payment bill passed in March does make such a connection. Some health planners argue that even if pros- pective reimbursement controls costs it may do so at the expense of the neediest institutions and communities, so planning is necessary to ensure that cap- ital is distributed equitably as well as efficiently (see Today in Health Planning, May 13. 1983.) While the CON process has been an inefficient way of achieving this goal, some states are trying to improve it. In New York Governor Cuomo intro- duced an " affordable limits bill, " which would have set re- gional capital caps based on demography and health status. The HSA's in each region would have made recommen- dations about capital plans af- ter ranking proposals by need. Although defeated in this ses- sion of the legislature, the Governor is considering im- plementing such a program administratively. In Massachusetts, which last year established the most strin- gent prospective reimburse- ment system in the country, capital spending is the next target. The North Shore Health Planning Council has adopted a one percent cap on the amount of operating increases which can be passed on from hikes in capital spending - a first in the country. The state health de- partment is following suit by seeking to establish a one and a half percent ceiling adminis- tratively. Jonathan Pomazon, senior planner at the North Shore Council, admits that set- ting such limits does not guar- antee the participation of HSA's; Health / PAC Bulletin 29 the state is not sure how in- volved HSA's should be in creating priorities for certifi- cates of need. As other states consider si- milar approaches, this ambi- valence is bound to recur, re- flecting the longtime tension between central and democra- tic planning, between goals of efficiency and of equity. Thirty thousand strong at their peak, those citizen planners - who re- main HSA members are " more committed than ever " in the words of Bill O'Donnell. Rather than being self serving - , this as- sessment undoubtedly reflects the departure of dissenters on the left and right, who have given up or been ousted. None- theless HSA's are one of the most important experiments in democracy of the past two decades. The fastest growing consti- tuency of health planners is business, because rising work- ers'health care costs are affect- ing production and profits as never before. The Business Roundtable, for example, fa- vors a competitive medical market in the long run, but en- courages members to help HSA's rationalize the system now both in and outside work- places (see " An Appropriate Role for Corporations in Health Care Cost Management, " Feb. 1982). While historically some social reform has been a neces- sary part of such rationaliza- tions e.g., workmen's compen- sation, the economy is now so unpredictable that business people may feel less generous toward the needy. If so, " capital redistribution " may just be another bromide to relieve the pain of the latest cost controls favoring big rich private institutions over poor little public ones. It could also become a useful tool for balanc- ing cost and need, for reviving democratic planning. Instead of waiting for the answer, this is the time to create it. Books Received Maier, Mark and Dan Gilroy (Eds), Reading Lists in Radical Social Science: An URPE / MR Project (New York: Monthly Review Press, 1982) Waitzkin, Howard, The Second Sickness: Contradictions of Capitalist Health Care (New York: The Free Press, 1983) Doherty, William J. and Maca- ran A. Baird, Family Therapy and Family Medicine: Toward the Primary Care of Families (New York: Guilford Press, 1983) $ 22.50 Doyal, Lesley with Imogen Pennell, The Political Econo- my of Health (Boston: South End Press, 1981) Mullan, Fitzhugh, Vital Signs: A Young Doctor's Struggle with Cancer (New York: Farrar- Straus Giroux - , 1982) $ 12.50 Greenspan, Miriam, A New Approach to Women & Thera- py: Why current Therapies fail Women and what women and therapists can do about it! (New York: McGraw - Hill, 1983 1983)),, $ 7.95 16.95 $ Navarro, Vicente, (Ed.), Imper- ialism, Health and Medicine (Farmingdale, N.Y. 1979) $ 13.95 Turner, Samuel M. and Russell T. Jones (Eds), Behavior Mod- ification in Black Populations: Psychosocial Issues and Em- pirical Findings (New York: Plenum Press, 1982) Fee, Elizabeth, (Ed.), Women and Health: The Politics of Sex Acosta, Frank X. and Leonard in Medicine (Farmingdale, A. Evans, Effective Psycho- N.Y., 1983) paperback $ 14.50 therapy for Low Income - and Garbarino, James, S. Holly Minority Patients (New York: Stocking & Associates, Protect- Plenum Press, 1982) ing Children from Abuse and Neglect (San Francisco: Jossey- Bass, Publishers, 1980) $ 18.95 Armstrong, David, Political Anatomy of the Body: Medical Knowledge in Britain in the McFarlane, William R., Family Therapy in Schizophrenia (New York: The Guilford Press, 1983) $ 25.00 Twentieth Century (New York: Cambridge Univ. Press, 1983) $ 29.95 Cohen, Nancy Wainer and Lois. Heron, Ann (Ed.) One Teenager in 10: Writings by Gay and Lesbian Youth (Boston: Alyson Publications, 1983) Freeman, Roger K. and Susan J. Estner, Silent Knife: Cesarean Prevention & Vaginal Birth Af- ter Cesarean (So. Hadley: Ber- gin & Garvey Publishers, Inc., 1983) C. Pescar, Safe Delivery: Pro- Carboni, David K., Geriatric tecting Your Baby During High Medicine in the United States Risk Pregnancy (New York: and Great Britain (Westport, _McGraw - Hill paperbacks, 1982) Ct: Greenwood Press, 1982) 30 Health / PAC Bulletin Europeans cry NO "! " American first strike - weapons on the doorstep of the Soviet Union are the most appropriate fuse for touching off a nuclear world war. Americans, we beseech you: Do not deploy Pershing II and Cruise Missiles in Europe! For the sake of humankind- Don't do it! Ichael i,, MARSHAL Francisco da Costa GOMES GENERAL (ret.) Michael N. HARBOTTLE GENERAL (ret.) | Former President of the Republic of Portugal United Kingdom Michiel Hermann von MEYENFELDT Netherlands Past Past mino GENERAL (ret.) Nino PASTI Senator of the Republic of Italy Mnster for Vollmer GENERAL (ret.) Gnter VOLLMER Federal Republic of Germany George Kaawanako Antoine Sanquinath GENERAL (ret.) Georgios KOUMANAKOS = ADMIRAL (ret.) Antoine SANGUINETTI Greece France Generals GENERAL (ret.) Miltiades BAPATHANASIOU Generals Greece Generals GENERAL (rNAeTO t. Get BASTIAN NATO NATO Germany Generals Christie Michael Tombopoulos GENERAL (ret.) Johan CHRISTIE GENERAL (ret.) Michalis TOMBOPOULOS . Norway Greece Former For further information: Riverside Church Disarmament Program, 490 Riverside Drive, New York, N.Y. 10027 Mobilization for Survival, Midwest Field Office, Milwaukee, Wisconsin 53233 Disarmament Resource Center, 942 Market Street, Am. 708, San Francisco. Calif. 94102 initiated by: BERLINER COMPAGNIE c o / Action Reconciliation, 4920 Piney Branch Road, N.W., Washington, D.C. 20011 Health / PAC Bulletin 31 Health Health / PAC Health Policy Advisory Center 17 Murray Street New York, New York 10007 2nd Class Postage. Paid at New York, N.Y. X - 523