Document rBqXVEzeGOOqMVdQ96RqEbyqJ

PAC BULL N THE 1 Les OVER MASS Nat Health Policy Advisory Center ince its inception in 1968, the Health Policy Advisory S Center known - as Health / PAC - has served as a unique progressive voice for changing consciousness on domestic and international health priorities. Through the Health / PAC Bulletin and the books, Prognosis Negative and The American Health Empire, and in its outreach to a national network of grassroots activist groups, Health / PAC con- tinues to challenge a " medical- industrial complex " which has yet to provide decent, affordable care. PAC BULL IN IN THIS ISSUE The Massacre of MASSCARE David A. Danielson and Susan Abrams discuss the Dukakis proposal for universal coverage in Massachusetts.. 0.00 c cect cece eee eens 6 Anatomy of a National Health Program Leonard Rodberg explains why the Dellums bill is still valuable ............ 12 Holding the Line Lance Compa praises the occupational safety and health movement as a vanguard of industrial unionism..... 6... cencene e 17 The Clash over Quackery Ronald Caplan warns that anti quackery - legislation may be used to suppress alternative health care. 00600 to suppress suppress suppress 22 Uncle Sam Promotes the Marlboro Man Elise and David Ray Papke tell how the Reagan administration forced Taiwan to import American cigarettes.. 6 660 cece cece eee eee 28 Vital Signs Short pieces on the CDC's AIDS brochure, radium contamination, the APHA convention, and more 0... 0 6 cet cent eee t ee eees 30 Body English Arthur Levin questions the wisdom of cholesterol screening .............4. 32 Watching Washington Barbara Berney assesses the benefits of new right know - to - legislation ........ 33 Speaking of Health and Medicine Quentin Young suggests that doctors may be a valuable ally in the struggle for universal health care. cee een eee nee ees 34 Know News Nicholas Freudenberg spins a fantasy on the future of health education. 35 THE OVER MASSCARE Design Maggie Block, Three to Make Ready Graphics Typography First Galley Typography Printing The Print Shop Front Cover Photo Nurse feeds newborn at Boston City Hospital. Frank Curran. Back Cover Photo Meatpackers march for access to their medical records. Jeff Fiedler. Health Policy Advisory Center 17 Murray Street New York, New York 10007 212 267-8890 / Health / PAC Bulletin Volume 17, Number 6 December 1987 Board of Editors Tony Bale, Robert Brand, Ruth Browne, Robb Burlage, Anjean Carter, Robert Cohen, Sally Guttmacher, Feygele Jacobs, Mark Jobson, Louanne Kennedy, David Kotelchuck, Ronda Kotelchuck, Arthur Levin, Cheryl Merzel, Patricia Moccia, Regina Neal, Tammy Pittman, Hila Richardson, Judy Sackoff, Pam Sass, Herbert Semmel, Hal Strelnick, Ann Umemoto, Richard Younge. Executive Editor Joe Gordon Assistant Editor William Deresiewicz Volunteers Julie Friesner, Loretta Wavra Associates Carl Blumenthal, Pam Brier, Des Callan, Michael E. Clark, Mardge Cohen, Debra De Palma, Susan Edgman - Levitan, Barry Ensminger, Peg Gallagher, Kathleen Gavin, Dana Hughes, Marsha Hurst, Mark Kleiman, Sylvia Law, Alan Levine, Judy Lipshutz, Joanne Lukomnik, Steven Meister, Kate Pfordresher, Susan Reverby, Leonard Rodberg, Alex Rosen, David Rosner, Diane St. Clair, Gel Stevenson, Rick Zall. * 1987 Health / PAC. The Health / PAC Bulletin (ISSN 0017-9051) is published four times per year in June, August, November, and December. Second Class postage paid at New York, N.Y. Postmaster: Send address changes to Health / PAC Bulletin, 17 Murray St., New York, N.Y. 10007. The Health / PAC Bulletin is distributed to bookstores by Carrier Pigeon, 40 Plympton St., Boston, MA 02118. Articles in the Bulletin are indexed in the Health Planning and Administration data base of the National Library of Medicine and on the Alternative Press Index. Microforms of the Bulletin are available from University Microfilms International, 300 Zeeb Rd., Dept. T.R., Ann Arbor, MI 48106. MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR, AND SUBSCRIPTION ORDERS should be addressed to Health / PAC, 17 Murray St., New York, New York, 10007. Subscriptions are by $ 35 membership for individuals. Institutional subscriptions are $ 45. 2 Health / PAC Bulletin Winter 1987 Two Days in October t took less than eight hours, yet the great stock market crash jolted the nation's thinking. Our I most fundamental assumptions about the future and what we can expect from it were radically disrupted. Just eight days before, though, an event of a different sort occurred - the National Gay and Lesbian March on Washington, an event involving people, not profits, an event which offers hope for the future of grassroots activism and health care. Whether the market recovers from Black " Monday, " October 19, or plunges farther, one thing is clear: as long as Wall Street continues to control the capital that determines how, where, and to whom health services are delivered, patients and workers, not investors, will be the big losers. We will lose because the bulls and bears of Wall Street exist on a terrain of speculation and profits far removed from the needs of the tens of millions of Americans who have little or no access to our nation's health - care services. As we've long been saying in these pages, it is simply crazy, if not criminal, that a service as vital as health care is largely controlled by a financial commu- nity whose sole interest is its own profit. The future will be grim under such an arrangement: health care will follow the haves and avoid the have- nots as the public's access to affordable services con- tinues to evaporate. While we're certain of this progno- sis, we can only guess how the crash is likely to affect the fiscal condition of the health - care industry. But with all their scheming - and this is the important point - the corporate health giants failed even on their own terms. October 19 wasn't the first time the ground crumbled at their feet. Responding to low occupancy rates, low profits, and the industry's overextension into the insurance business, investors began backing away from health care two years earlier. On Oct. 2, 1985, the stocks of the four largest hospital chains lost $ 1.5 billion; within a year over one third - of their worth disappeared. Investors belief in full service - , vertically integrated - Demonstrators at the Gay and Lesbian March on Washington explore the monumental quilt memorializing nearly 2,000 people who have died of AIDS. More than half a million people marched Oct. 11 demanding a humane, national response to the epidemic. From Heyday to Doomsday Health care, like other sectors of the economy, shared in the profligate bull market of the Reagan Era. The growth of for profit - corporations and the proliferation of paper fortunes quickened to an astounding pace as the new corporate health stars won the confidence and dollars of Wall Street investors. Over the past 20 years- but particularly in the last 10 new - types of health - care organizations sprang up and were absorbed into the Medical Industrial - Com- plex. Their concern was finance, not health care: attracting capital, repelling mergers and takeovers, and spending fortunes on marketing, advertising, and real estate. In their hunger to satisfy the frantic greed of the affluent - as opposed to improving the quality and accessibility of health services - they siphoned money Visuals away from the bedside and turned patients away at the door. It's been getting worse for a long time, and those who Impact /Sjogner can tell you best are not the economists, but the hospi- tal workers - the nurses and aides and doctors whose ability to provide care has been crippled in the name of cost cutting - and profits. Rolf DAIL NEW YORKER -"** U.S.News GIANTS. AMERICAS PANIC!. Dow plunges through floor 508 pts DE GETS 6 MONTHS SMIN & Stre The New STRAP 04 MIL ION 3G YOU SA ME NEARLYP OI,N TSA York DOX DROP BLAN OF Times RELORD BIR TWIN \ Colog LL \ ^^ OY KAD MICEKRe NEW A VYIOCTRORKY FPORO SMUTG GERS! JOURNAL CRASH! STREET Wballalc Sktersete td'asy WAL THE rocks nation Visuals Month Juil Ar Goetz The New B Selin ' MAVI s 39 / YarusImpact BILINOR TINIUS NYUSD Anthony organizations that would pay big dividends was now in full retreat. The once profitable - chains'rapid expansion was curtailed severely, as were their dreams of domi- nating America's health - care. On " Black Monday, " decline turned into free fall for many of the larger corporations. The stock of the for- profit HMO chain Maxicare dropped a whopping 37.2 percent, the Hospital Corporation of America's fell 31.9 percent, Humana's declined 16.2 percent, and those of Beverly Enterprises and Manor Care, the huge nursing home chains, lost 26.8 and 14.1 percent. More Cuts Ahead Sweet though the sound of the fall of the mighty might be, the loss of investor confidence - coupled with the diminished ability of markets to raise money - will probably make it harder to obtain financ- ing for any kind of health - care organization, for profit - and voluntary alike. The crash also created the prospect of further deep cuts in government health programs, leading to new hardships for patients and more belt- tightening for providers. The president and Congress have already proposed severe reductions in funding for Medicare and research as part of deficit reduction - measures designed to placate financial markets and foreign lenders. Yet these very measures may well set off a deep reces- sion, stripping even more Americans of insurance cov- erage and intensifying the crisis of access triggered by the first Reagan recession. Some analysts contend, moreover, that a recession could actually benefit the large HMO chains, since employers and consumers will be seeking health care at the lowest possible cost, accelerating the consolidation of the HMO industry around these corporations. The drought of a coming recession, though, may prove to be a wellspring of reform. As greater and greater segments of our population are locked out of What the papers didn't say: The crash's impact will be most dearly felt by workers, the poor, and the medically indigent. health care, the public and its elected representatives may finally understand the need to reorganize health services around more publicly accountable financing and delivery. In reaction to the proliferation, and ulti- mate failure, of for profit - organizations that grew wealthy on public funds, the pendulum may well swing back towards the public's interest, towards effi- ciency and equity. Already, pressures are intensifying to develop a broad federal, state, and local response to the AIDS epidemic and the huge unmet need for long- term care and broader health coverage. It is therefore crucial that progressives continue to insist on fun- damental reform amid the fiscal austerity and recession that looms ahead. n Sunday, October 11, more than half a million O people, outraged over the nation's response to the AIDS epidemic, took to the streets of the capital. The March for Lesbian and Gay Rights was a response to the homophobia that has permitted the malign neglect of Congress and a reckless administra- tion, and to the hysteria which has fired a " second epi- demic " - the attack on liberties in the name of " public health. " October 11 was a day on which an increasingly visible group of Americans demanded full health and * civil rights from the nation. The march thus held out the promise of a broad- based health and civil rights movement, one through which women, minorities, and workers can win uni- versal entitlement to health coverage and constitutional protections against discrimination. If the energies har- nessed in the march can be joined to those of the civil rights and labor movements, we can finally make sure 4 Health / PAC Bulletin Winter 1987 that no one, neither people with AIDS nor the unem- ployed nor the homeless, is denied access to our nation's health services any longer. The need for a movement that seeks to guarantee basic health, economic and civil rights became all the more apparent only three days after the demonstration, when the Senate overwhelmingly banned the use of federal funds for educational materials on AIDS that " promote or encourage, directly or indirectly, homo- sexual activities. " Even as the epidemic's death toll mounts, the prohibition further frustrates efforts to inform people about safer sex. Such a discriminatory attack not only endangers " at risk " populations, but, in legitimizing legislation by bigotry, jeopardizes every- one's health rights. The nation is at a critical turning point. We cannot allow conservatives to use the collapse of Wall Street to gut health programs even further. We must stop the reactionary victim blaming - that continues as the cor- porations and the financiers struggle to recover their losses. Now, while Reaganism is in decline and the victims of Reagan's policies are about to experience even fiercer attacks on their fragile supports, we must not waste any opportunities to act on our agenda as health progressives. We must stop the diversion of health - care funds from the poor, the elderly, and the unemployed to the pro- prietary health - care corporations. We must make it clear that health is not a commodity to be bought or sold in the marketplace but a state of being that is created in the way people live, build their communities, and use services to make themselves whole and well. We must insist on basic economic rights for all - a health imperative - so that people can exercise greater control over their own lives. It is our responsibility to show how issues of access, equity and rational financ- ing can be advanced in this shifting and unsteady eco- nomic climate. Faced with the depth of our economic and social problems, we cannot view 1988 as just another year of presidential politics, or any other kind of politics - as- usual. Health - care advocates and analysts must be ready to recognize and act on the new opportunities to forge a health and civil rights coalition to create, at long last, a national health program that meets the needs of all the people. -The Editors Baby girl in stroller and man in wheelchair were among the many people with AIDS who demonstrated. 0 Foarn dL ove For Life Visuals Do you CARE, / BinderImpact Dona REALAN The Massacre of MASSCARE Dukakis'Insurance Health - Plan and Why It Was Defeated DAVID A. DANIELSON AND SUSAN ABRAMS The authors critique the health insurance - plan proposed by Governor Michael Dukakis, and recount the uproar that fol- lowed its introduction into the Massachusetts legislature this past fall. With Dukakis having emerged as a leading con- tender for the Democratic presidential nomination, and with much hope for fundamental reform of our nation's health - care system hinging on the outcome of this year's elections, the plan, and its fate, may well provide a taste of things to come. 'n September, Governor Michael Dukakis submitted I I plan to the Massachusetts legislature designed, in his words, " to assure that high quality - , affordable health care is made available to all citizens of the Com- monwealth. " It's been called Duke Care by the press, the Mass Health Partnership in the Senate, and " dead in the water " by the House of Representatives. We've dubbed the proposal MASSCARE. While its future is still in doubt, political pundits consider the passage of , at least a scaled - down version likely soon. Crisis in the Commonwealth Of Massachusetts'six million people, one tenth - have neither public nor private health insurance. The prob- lem of the uninsured here, as across the nation, has worsened as employment has shifted from the union- ized manufacturing sector to the service and trade industries. Of Massachusetts'workers in finance, transportation, and manufacturing, only four percent are uninsured. By contrast, 52 percent of workers in trade, 25 percent of those in services, and 12 percent in construction lack coverage. in One third - of the uninsured - some 220,000 - are chil- dren. Fifty eight - percent of uninsured adults are employed, 13 percent are unemployed, 12 percent are classified as homemakers, 10 percent are students, and 6 percent are disabled or retired. These are the stated targets of the Dukakis proposal. Massachusetts is in an admittedly fortunate position. In the nation as a whole, 16-17 percent of the population, about 40 million peo- ple, lack health insurance, and another 18 million have such poor coverage that they are " effectively outside of the medical care system. " 2 The state's unemployment rate is about one half - of the national average, and its David A. Danielson, founder and director of the Committee for a National Health Program, is a consultant for the New York City Health and Hospitals Corporation. Susan Abrams is the committee's coordinator and writes on health - policy issues. The committee's address is 15 Pearl St., Cambridge, MA 02139. budget shows a substantial surplus. .3 Governor Dukakis has acknowledged that a less wealthy state with a greater percentage of uninsured citizens could not enact his program; it was Candidate Dukakis who said " We've asked the uninsured in Massachusetts and 40 milllion others in this country to wait long enough. The time is now. " 4 Footing the Bill The original proposal is quite simple: employers would be required to pay 80 percent of their employees ' medical insurance. The proposal also outlines mini- mum standards for that coverage. In order to cover the unemployed, businesses would continue to pay the surcharge on health insurance - premiums that funds the Massachusetts free care - pool, which currently sub- sidizes hospital care for all the uninsured. These contri- butions, which reached 13.6 percent in 1987, would be capped at around 12 percent initially, and would con- tinue at rates set annually by the administration. Although the major costs of the Dukakis proposal would be absorbed by employers, workers would have a large burden to shoulder, too. Employees working more than 17.5 hours a week, and earning $ 4.19 per hour or more, would pay 20 percent of their insurance premiums. Of Massachusetts'six million people, one tenth - lack public or private health insurance. But that's not all. MASSCARE also includes a deductible: $ 250 for individuals, $ 500 for employees with dependents. After that is met, employees would pay a 20 percent copayment on all medical costs up to a maximum of $ 1,500 per year for individuals, and $ 3,000 for families. While that requirement would not apply to prenatal or well baby - care, the plan would pro- vide no coverage for medication, medical devices, or routine and preventive care, nor could expenses for these be used to offset the deductibles and copayments. No major taxes are proposed, but some new trickles 6 Health / PAC Bulletin Winter 1987 Globe Boston The /Motern John of revenues are opened up by the bill. For the first time, the premiums paid to HMO's, Preferred Provider Organizations, and health insurance companies (with abundant loopholes) would be taxed (at 2.3 percent). The state would maximize its revenues from the federal government by continuously enrolling eligible individ- uals in federal health programs and monitoring federal policies and Medicaid rates to obtain every federal dol- "ar available to the state. The plan also incorporates user fees and special assessments against hospitals and insurance companies. Other forms of creative financing abound in the bill. All full time - college students, for example, would be required to carry health insurance - coverage, with colleges billed for any use of the free care - pool by uninsured students. Colleges and universities would thus, in essence, be required to levy a health insurance - tax on students and their parents in the form of increased fees. Gov. Michael Dukakis testifies before the Massachusetts legislature in September on behalf of his bill for state wide - universal health insurance coverage. The rate would rise as needed to cover the state's cost for providing insurance. Employers would pay an addi- tional surcharge, one sixth - of one percent, to fund insurance for persons receiving unemployment com- pensation. Employers already offering medical benefits meeting or exceeding those required by MASSCARE would be exempt from these surcharges. Bureaucratic Leviathan Dukakis proposes to operate MASSCARE through a mega agency - endowed with administrative, regulatory, and rate setting - functions. In addition to running the new program, the agency would take over Medicaid, now in the Welfare Department; the state employees ' One Small Problem Dukakis'initial proposal hinges on Congress grant- ing Massachusetts exemption from ERISA, the Em- ployee Retirement Security Act of 1974. ERISA prohibits state regulation of employment contracts. Although members of the Massachusetts delegation are well- placed by committee assignment to pull off the legisla- tive legerdemain needed to get the exemption, many concerned parties in the state doubted that they would, in the end, pull it off, and insisted that Dukakis formu- late a fallback plan, which has been dubbed Plan B. The alternative seeks to have business pay for insur- ance indirectly, through taxes. A surcharge, set initially at 12 percent of the first $ 14,000 of each employee's wages, would be imposed on the contributions to un- employment insurance already paid by all employers. MASSCARE would not cover medication, medical devices, or routine and preventive care. benefit program; and the health segment of the inde- pendent Rate Setting Commission. It would be charged with administering Medicaid (including a new " buy - in " for disabled people who return to work, allowing them to be employed without losing services), setting up Winter 1987 Health / PAC Bulletin 7 health insurance - plans for residents not covered for specific benefits by their own policies, and operating an insurance plan, directly or through intermediaries, for small businesses unable to obtain health insurance at competitive rates. The agency would also control its own budget and have sweeping powers to determine hospital charges and rates of reimbursement for health services provided to state employees. 5 Contracts signed by Blue Cross / Blue Shield with hospitals or HMO's would require the approval of the agency, both for content and for rates of reimbursement. Busy with his presidential campaign, Dukakis failed to line up adequate support for his bill. Finally, the agency would be responsible for provid- ing technical assistance to hospitals reorganizing the use of their beds (as explained below) and for setting up retraining programs for laid - off hospital employees, giving special attention, in designing such programs, to patient - care services and the nursing shortage crisis. Cost and Quality Medical costs are sky high in Massachusetts - hos- pital costs, for example, are 25-30 percent above the national average.6 Cost containment, therefore, is an important feature of Dukakis'proposal. Its linchpins are a cap on the rate at which hospital charges may rise (two percent above the national rate of medical infla- tion), and strong incentives to convert hospital beds not needed for acute care to other health, rehabilitative, and social purposes. (The administration has accepted estimates by health planners that there are 5-10,000 excess hospital beds in the state, and a " secret list " of 27 hospitals whose survival is in doubt is circulating at the State House.) Other methods of cost containment, such as reducing profits for insurance carriers, stream- lining health - care bureaucracies, and reducing paper- work, are either ignored or not fully developed in the proposal. Dukakis'proposal also addresses the need to assure that high standards of care are maintained. The existing powers of the Professional Review Organizations and the Board of Registration in Medicine would not be changed, but the role of the state Department of Public Health (DPH) in assuring quality would be signifi- cantly expanded. The governor promised to request major funding for a new unit within the department to evaluate quality of care, while DPH will also be empow- ered to enforce the state's sweeping Patients'Rights Act, and to take action on complaints arising from the DRG (Diagnosis Related Groups) program in hospitals. As a partial corrective for the bill's evisceration of existing regional health planning, DPH would be allowed to li- cense hospitals on a service service - by - basis and to attach conditions of quality and access to such licen- sure. (These proposed powers provoked strong opposi- tion from the Massachusetts Medical Society, which has gone along with most of the governor's other pro- posals to improve access to medical care.) Special Interests on the Attack Governor Dukakis introduced his proposal on Sep- tember 16, just two weeks before the expiration, under a " sunset clause, " of the legislation that created the hospital pool four years ago. Urging " speedy " passage, Dukakis had the assured support of many key legisla- tors, but, busy with a campaign for the presidency and enmeshed in the Biden affair, he failed to line up ade- quate support for his bill. The hospitals, having always fiercely and effectively resisted any cap on their charges or change in their practices, were the first to come out against the bill. At stake, for many of them, is their survival. For the hundreds of thousands of hospital workers - hospitals are Massachusetts'second largest employer - jobs, sta- tus, independence, and future salary increases are all seen as riding on the containment cost - provisions in the governor's bill. Attempts by the administration to split the Massa- chusetts Hospital Association (MHA) have not worked. These ruses included a proposal to set aside $ 60-100 million for some strategically located community hospi- tals, and an agreement to continue a special adjustment for the teaching hospitals that compensates them for their high levels of occupancy. The industry has stuck together, exerting political pressures upon the state leg- islature unsurpassed in at least 20 years, loosing thou- sands of its white coated - troops on the State House. The administration, supported by some consumer groups and hospital workers in the Service Employees International Union (SEIU), has publicized the hospital industry's good financial health profits - increased Urged on by shills for the hospital industry, legislators proceeded to dismember the proposal. from $ 63 million in 1981 to $ 127 million in 1986 - but nevertheless failed to outweigh the political mass of the MHA.6 The hospitals succeeded in eliminating from the bill all the measures designed to contain their costs. Businesses, which will bear the lion's share of MASS- CARE's CARE's cost, have been just as fierce in their resistance, pushing an agenda that is the direct opposite of that of the hospitals. The large multinational corporations and their trade associations originally supported the plan 8 Health / PAC Bulletin Winter 1987 Massachusens FEALTH CARE QUALIT HEALTH CARE QUA HEAL CAF Massach H CONTROLS ON REVENUE A ~ ADVERSELY AFFECT PATIENT CARE. TCHING 5m STOP THE CAP DUKE CAPS CATASTROPHE FOR UNDER FINANCED HOSPITAL: W NO ACCESS CARE TO HEALTH AND Childre WOME Hospit STAFF TO CARE FOR PATIENTS OPPOSE REVENUE CAP G because of its cap on contributions to the hospital pool and other strategies for " getting tough " on spiralling hospital costs. But support from corporations dissi- pated as the legislators caved in to the hospitals'pres- sure. Businesses failed to stay on board the bandwagon even when legislators acceded to their main demand: lowering employers'contributions to the price of insur- ance from 80 to 50 percent of premiums. Small businesses, predictably, came out strongly against the plan. Working with larger employers re- nowned for their greed, such as the fast food - and super- market chains, their strategy was to pry open loop- holes exempting companies from covering part time - workers (under 25 hours a week), seasonal workers (less than four months on the job) and workers in small companies (fewer than 50 employees). Through their trade organizations, they put pressure on every legisla- tor, conjuring visions of hometown businesses boarded up and of jobs being exported up Route 93 to the " banana republic to the North " - New Hampshire. The private insurance companies, working behind the scenes, have demanded - under the slogan of " cre- ating a level playing field " - an end to the preferred sta- tus enjoyed by the Blues. Meanwhile, they supported those provisions which would gut the Certificate - of- Need process and place decisions about capital invest- ment in private hands. In their one public flexing of Asociatn Hospital ia ' Maschuets Over 7,000 hospital employees rally outside Boston's State House Sept. 16 to oppose a provision of the Dukakis bill setting a cap on hospital charge increases. The rally was organized by the Massachusetts Hospital Association. muscle, they forced the governor's staff to announce publicly that the MASSCARE mega agency - would not compete with private health insurers, thereby forcing Dukakis to go on record with a preemptive surrender to the insurance industry and its unhindered escalation of the costs of premiums. The Blues, under competitive pressures from HMO's and under attack by the commercial insurers, waffled temporarily but finally opposed the legislation. In a full page ad in the Boston Globe, they declared that the bill would be unable to control hospital costs and claimed that it would result in a 17 percent - rise in insurance premiums next year. The ad went on to say that MASS- CARE would destroy protections against balance billing (the direct billing of patients for amounts above Blue " Cross / Blue Shield rates, now prohibited in Massachu- setts), place an unfair burden on businesses, and put the populations that the Blues now enroll in MEDEX- Medicare Supplemental Insurance - at risk. The media divided sharply over MASSCARE. The Globe hailed Dukakis'reforms as " bold " and " vision- ary, " while the Herald, the city's other daily, and the in- Winter 1987 Health / PAC Bulletin 9 MASSCARE's Flaws Dukakis'original proposal for statewide access to health services had major problems. It became subject, in the state legislature, to intense pressure from private interests and turned into a full fledged - disaster. The following table summarizes MASSCARE's most serious shortcomings. The benefits are meager. The proposal specifically excludes payment for preventive care services, except, as required by federal guidelines, for chil- dren up to the age of six. Other essential services are not covered, including long term - care, rehabili- tation, home care, occupational health services, prescription drugs, and medical devices. The costs to low income - workers are exorbitant. Between deductibles and copayments, a worker with dependents could end up paying over $ 3,500 a year. Add to this 50 percent of the cost of an insurance premium and it's clear that the poor will ~ have to shoulder what will be for many an intoler- able burden. The financing is both inadequate and regressive. . Income from taxes on businesses and the near- poor will not be adequate to cover the costs of the plan, especially now that the major proposals for containing hospital costs have been gutted. Small businesses are burdened unfairly. Imposing a 12 percent surtax on wages places a major bur- den on employers. Small businesses may be forced to close, while others may transfer health- insurance costs to their employees in the form of wage reductions, reduced overtime, and delayed raises, or increase their reliance on part time - and temporary workers. Accountability to citizens and communities is absent. Leaving control of the funds involved to the private, and largely unregulated, insurance in- dustry, absent effective cost controls, will be a fiasco. -D.A.D. & S.A. This October cartoon from the Boston Globe followed the Dukakis team's bungling of the now infamous " attack video - " on Joe Biden, an incident which " hospitalized " the Governor's presidential campaign. Yoo Hoo YOU'VE GOT A ROOMMATE. - DADO DUKAKIS CAMPAIGN DUKAKIS HEALTH BILL WASSERMAN THE BOSTON GLOBE fluential suburban newspapers excoriated them, playing to the public's fears of big government, social- ized medicine, and the closing of local hospitals. Meanwhile, Back at the State House Under such attack, the proposal was sent to the House Ways and Means Committee, whose Chair, Richard Voke, was previously Chair of the Joint Health Care Committee. The bill was prettied up and sent to the floor in early October with more than one hundred amendments, most of them designed to placate the hospitals and small businesses. Also corrected were some clauses in the governor's proposal that consu- mers had most opposed; it even contained a thoughtful program extending comprehensive care to near poor - women and children. Its arrival on the floor of the House of Representatives was inauspicious. A Repub- lican motion to delay any action for six months was barely repelled. Many key supporters of the governor were conspicuously absent from the chamber, and even Chairman Voke himself strolled off the floor, reportedly to go to lunch. Urged on by shills for the hospital in- dustry, legislators proceeded to dismember the propo- sal in a series of lightning moves until the Democratic leadership rescued it and remanded it back to commit- tee [see table]. Round One is over. Responsibility for further action now rests with the Senate, specifically with Patricia McGovern, the Chair of the Senate Ways and Means Committee. In late October the House of Representa- tives was forced to extend the legislation for the free- care pool to allow funds to continue to flow for the care of the indigent. Ironically, that bill, now in the Senate, will serve as the vehicle for a renewed attempt to enact the Dukakis proposal. By attaching a scaled - down ver- sion of the governor's plan (and, perhaps, elements of Senator McGovern's previously introduced Health Partnership Program7) to the House bill, supporters would send MASSCARE to a conference committee dominated by legislative leaders loyal to the governor, not back to the contentious lower house. It is too early to say if the efforts of Senator McGovern, and of David McKenzie, a member of her staff, will eventually result in a MASSCARE program or yet another massacre in the Senate. The MASS- CARE mega agency - and measures for containing hospital costs, especially, have an uncertain future. Regardless of what happened, the Committee for a 10 Health / PAC Bulletin Winter 1987 National Health Program will reintroduce its own progressive plan for truly universal, comprehensive coverage in the coming year.8 The Progressives'Dilemmal By referring to health care as a basic human right and proclaiming the need for universal coverage even as he puts forth flawed, regressive proposals for implement- ing those ideas, Dukakis has simultaneously drawn attention to progressive health - policy goals and co- opted them. Even the meager benefits proposed, while inadequate to produce enthusiastic consumer support, were costly enough to provoke daunting opposition from the powers that be. We progressives find ourselves in an all familiar - too - dilemma regarding the Dukakis proposal: Do such re- formist measures advance the goal of a comprehensive national health program or do they merely distract the public and the media from the real issues involved in this debate? Those who point out the dichotomy be- tween the rhetoric and reality of the proposal can easily appear to be rejecting the aims progressives worked so hard to have accepted by voters and public officials. Dukakis has both drawn attention to progressive health - policy goals and co opted - them. We've found ourselves being viewed as churlish and impractical for pointing to the weaknesses in MASS- CARE and fighting for improvements in a glossy pro- gram that exploits the very people it proclaims to help. Having been viewed until this point as pie sky - in - the - idealists who want the best of all possible health plans, we need now to present ourselves as the true realists. We need to persuade others that a well thought- o-ut program would cut costs by opening up access and tak- ing care of needs when they arise - not after they've developed into more expensive illnesses. Will MASSCARE represent an irreparable setback for the cause of a national health program, or a first step towards its attainment? If the woefully - flawed bill passes, can we in Massachusetts enlist the help of legis- lators in correcting its more egregious errors, or will its inevitable failure discourage legislators from consider- ing more comprehensive proposals in the future? Lessons and Hopes The fight over MASSCARE has given us a foretaste of the attacks that powerful interest groups will launch if elected officials ever take seriously progressive propo- sals to restructure the medical - care system. We've be- come more aware how important it is to deepen public support for such proposals and to build a much broader coalition if the general desire for improved access to medical care is ever to be translated into reality. A 1986 Massachusetts referendum, calling on Con- gress to establish a national health program, passed by 2 to 1 through the efforts of a network of grassroots organizations. It was one of several developments that provided the impetus and public backing for efforts by Dukakis and members of the legislature to develop a state plan [see Bulletin, Spring 1987, p. 16]. Could strong grassroots support possibly have counter balanced - the enormous lobbying efforts of the Massachusetts Hos- pital Association? It seems vital, in this regard, to inform the public about the vast profits and exploitative practices of the insurance industry. It is equally apparent that progres- sives need to seek allies in the business community, which could well become a proponent of broad public funding of health benefits. Among the many other questions we need to con- sider are these: How can we educate the public and the media more effectively so that the progressive point of view won't be largely ignored, as it was this time? How can we make people aware that universal coverage means coverage for everyone, with no if's, and's or but's? Not even having made clear yet what universal access means, how best do we begin to explain what a comprehensive program means? Otner industrialized nations have learned that truly universal and comprehensive care is more economical in the long term and a better way to maintain health than insurance - based systems, with their high over- head and large profits. The governor and legislature in Massachusetts- and, indeed, elected officials across the country - need to face that reality squarely. Advocates for progressive change, meanwhile, need to think more carefully about models that could serve as transitions toward a true national health program. We need to have such alternatives in hand, carefully analyzed as to cost, to counter such rhetoric - laden, meager, competition - oriented models as that suggested for Massachusetts. Discouraged as progressives may feel now about how little impact we've had on this specific proposal in this oh progressive - so - state, we might just come out of this better able to make health care a major issue in the 1988 presidential campaign. We should be forewarned and forearmed to head off a similar massacre in the next state that tries to make health care a right, not a privilege. Y' 1. The Massachusetts Health Partnership, a Senate Ways and Means Report, David McKenzie and Senator Patricia McGovern, July 2, 1987. 2. Melvin Glasser, Executive Director, Committee for National Health Insurance, public address, Boston, Mass. October 28, 1987. 3. New York Times, Matthew L. Wald, p.1, August 21, 1987. 4. Testimony of Governor Michael S. Dukakis, Gardner Auditorium, State House, Boston, Mass., September 22, 1987. + 5. Senator Edward Burke, Senate Chair of the Joint Health Care Com- mittee, has vowed to retain budgetary control and oversight func- tions in the legislature; these provisions will not appear in the final bill. 6. Boston Globe, Richard Knox, p. 29, August 23, 1987. 7. The Massachusetts Health Partnership Program, Senate Bill 1639, State House, Boston, Mass., July, 1987. 8. " The Massachusetts Health Security Act, " Journal of Public Health Policy, Summer, 1986. Winter 1987 Health / PAC Bulletin 11 Anatomy of a National Health Program Reconsidering the Dellums Bill after 10 Years Bernstein LEONARD S. RODBERG Dan years ago Representative Ronald Dellums Ten (CCao nDg r-e.ss). iDnetsrpoidtuec etdh eh icso nHteinaulitnhg Sfearivliucree Aocft hiins colleagues to take up serious discussion of the bill, Dellums has reintroduced the legislation every two years, with the convening of each Congress. With the exception of his stubborn persistence in making the case for national health, progressive health politics has virtually shut down in Washington. Now, however, with the approaching end of the Dark Age of Reagan, many of us anticipate a resurgence of progres- sive health activism. To help us prepare for this coming period of struggle around national health policy, I would like to review the objectives of the Dellums bill, and the reasoning behind its design. Since the issues we addressed in the mid -'70's remain the most critical problems facing health care today, the design put for- ward then is a valuable guide to a renewed progressive approach to health policy. The Dellums bill was the first legislation ever intro- duced into Congress to create a national health service. Although those who participated in its development Leonard Rodberg teaches urban studies at Queens Col- lege CUNY / . In the mid - 70s, while at the Institute for Policy Studies in Washington, DC, he coordinated the drafting of the Dellums Health Service Act and was a founder of the Coalition for a National Health Service. were charged with being utopian, we were under no il- lusion that the bill would be enacted quickly, or even that it would soon be widely debated in the media. Our objective at that stage was not to pass legislation, but to create a vehicle for educating the public on the need for a new way of organizing and delivering health services. There were other reasons, too, why the charge of uto- pianism was mistaken. The Dellums bill did not spring from the heads of a few beat off - ideologues, but was an outgrowth of the progressive movements of the 1960's and early'70's. When Dellums decided to prepare such legislation in 1972, he asked the Medical Committee on Human Rights, an organization of health workers allied with the civil rights movement, to prepare a draft of the principles that should underlie a national health. program. That draft became the basis for the Health Service Act. As the legislation evolved, many other groups, representing the elderly, minorities, women, social workers, trade unionists, public health - professionals, TM and health - policy analysts, became involved in its. preparation and gave it their support. The bill was backed by the American Public Health Association, the National Association of Social Workers, the Gray Pan- thers, and the United Electrical Workers, among others. Above, a public health nurse and sharecropper in Bolivar County, Mississippi, 1967. 12 Health / PAC Bulletin Winter 1987 The experiences of these groups, and the specific improvements they sought in health services, were reflected in many provisions of the Dellums bill. This support made it clear that the concepts which underlie the Dellums bill had a significant constitu- ency. It was not a constituency that counted for much in American politics, but it was substantial and it was broad. Polling data indicated that, if the bill's provisions could be made widely known, they would gain the support of a much wider part of the population; when the public is asked its views on the nation's health sys- tem, between 30 and 40 percent consistently say they favor making the government responsible for providing health care. Pragmatism in Service of Ideals Finally, the Dellums bill was realistic because it pro- posed a system which could actually solve the prob- lems it addressed. Those of us who supported a na- tional health service found that our principal debate was with the advocates of national health insurance. (Those who opposed a significant government role in health care refused to engage either of us in debate!) In our view, the supporters of NHI were the utopians, but because of well publicized - proposals like the Kennedy bill, the general public now identifies national health with NHI. It is therefore important to differ- entiate between such a scheme and a true national health program. National health insurance would not offer significant benefits to more than the 15-20 percent of the popula- tion which now lacks insurance or is underinsured. While these people surely need help, they lack health insurance precisely because they have no political power. Are they likely to generate the political power needed to achieve passage of national health insur- ance? Our opposition to NHI was thus a matter not only of ideals but of realpolitik, as well; only if the sys- tem had something in it for everyone - not just for the poor and uninsured - would it garner the kind of politi- cal backing needed for adequate funding and longevity. The issues the bill addressed in the mid -'70s remain the most critical problems facing medical care today. We felt the system had to be designed to serve every- one and be available to all, regardless of income or citizenship. Under our plan, health care would be the right of every resident. This country had been the first to establish the idea that education is a basic human right; it would now catch up with the rest of the indus- trialized world by assuring access to health care for everyone. The Dragon of Cost The three primary issues we sought to address in designing the Health Service Act were cost, access, and democratic control. First came the issue of cost, not because it was central to our concerns, but because it was the primary issue in health care 10 years ago, as it is today. Upon assuming power, the Carter administration set up a 40 member - task force to develop a national health plan; one mem- ber was a physician, 39 were economists. Recognizing that most policymakers, and the mass media, believed the problem with American medical care to be simply one of expense, we made sure to propose a plan that would not add fuel to the inflation of medical costs. Under our plan, health care would be the right of every citizen. It is instructive to recall how others were addressing this problem 10 years ago. The liberal solution was to impose some regulatory mechanism that would con- strain cost increases without tampering with the organization of health care. Conservative economists, ironically, agreed with us that such a strategy was futile, and that the problem of cost was deeply embed- ded in the structure of American medical care. That structure married fee service - for - payment, in which payment is made on the basis of the type and quantity of service delivered, to third party - insurance coverage. This mix of an entrepreneurial market with third- party reimbursement inevitably touched off an explo- sion of costs. The conservative solution was to retain fee for- - service and make " consumers " (as patients have come to be called) responsible for holding down costs. Whether by accepting higher deductibles and co- payments, paying taxes on health related - fringe benefits, choosing the least expensive providers, or dis- continuing high - cost in patient - services when their DRG's are used up, patients would shoulder the bur- den of costs. Our alternative was to replace fee service - for - with a budgeted plan. It made no sense to continue to act as if medicine were still a cottage industry. The massive _ institutions which today dominate medical care require a constant stream of capital to remain stable; payment has to be assured in advance. The growing popularity of pre paid - health plans attests to the recognition of this on the part of both consumers and many members of the health - care industry. Fee service - for - payment, moreover, arose when medicine was oriented toward acute, curative care. This Winter 1987 Health / PAC Bulletin 13 Svec Joseph Clinic care at Cooke County Hospital in Chicago. may have been appropriate practice a century ago, or even 25 years ago, when infectious and viral diseases were the principal threats to health. As Milton Terris has forcefully shown, however, the principal illnesses we face today cancer - , heart disease, stroke- require long term - preventive action aimed at both the individual and society [Health / PAC Bulletin, Vol. 17, No. 5]. We need a reorganization of the health - care system that emphasizes prevention as well as cure while providing the financial stability that health - care institu- tions require. Although circumstances forced us to focus first on the problem of cost, no less central to our concern was the severe maldistribution of medical resources. Large numbers of people in this country lack access to ade- quate health care. According to the federal government, 50 million people - nearly a quarter of our population- live in medically underserved areas. This problem was, in fact, the principal one for the constituencies most responsive to the proposal we developed. We felt, too, that the medical - care system needed a dose of democracy. It was not being run with the partic- ipation of the people who used it or worked in it. Hospital boards did not represent the people who use hospitals, and physicians behaved as private entrepre- neurs. We needed a process that would assure demo- cratic control over the health - care system, that would make the system more responsive and accountable to the people who worked in it and the communities which it served. Applying Federalism to Health Care The bill calls for the creation of a community - based national health service. Our intention was to design a national system without creating a giant bureaucracy. (Neither we nor anyone else wanted a large and unac- countable agency running our medical - care system.) Instead, the Dellums bill seeks to apply federalism, the principle of involving each level of government in an appropriate way, to the health - care system. While the proposed health service would be funded nationally and mandated by the federal government, it would rest on a network of community - based pre paid - health plans coordinated at the regional level. The system would be funded nationally so that eco- nomic inequality would not be a barrier to the equitable provision of health services. It would be mandated fed- erally to guarantee access to residents of every com- 14 Health / PAC Bulletin Winter 1987 munity. Regional coordination would ensure that both general and specialized services would be available to every region on a rational and equitable basis. A firm basis in the community would provide the core of dem- ocratic control we believed to be essential. Finally, the network would be built on a pre paid - health program, to replace the obsolete and inflationary fee service - for - system with one that would be prospectively budgeted and oriented to prevention. Our intention was to design a national system without creating a giant bureaucracy. Under the Dellums bill, health care would be funded through federal tax revenues. Funds would be dis- bursed on a per capita - basis, so that low- and middle- income communities would have the same access to quality medical services as would wealthier communi- ties. Money would not be distributed, as it is in an insurance system, based on the fees institutions charge, but on the number of people served. A sup- plementary fund would be provided for the elderly and the poor, whose more extensive needs would require more funds per capita than the national average. Ser- vice would be provided by salaried workers, although the bill would not attempt to eliminate private practice. Funds would be made available through annual bud- gets for capital and operating expenses, placing the establishment and provision of medical services on a secure financial footing. From the Bottom Up The geographic organization of the system would follow the rationale espoused by nearly every health planner. Primary care would be offered through com- munity - based facilities, making it accessible to people in the localities where they live and work. General inpatient services would be provided on a somewhat broader level, and specialized services on a still- broader, regional level. Strategic planning and basic research would be conducted at the national level. The plan envisions, then, a four tiered - structure beginning with what we called the Community, an area of between 25,000 and 50,000 people where primary care would be provided. Our inspiration for this arrangement was the community health center, of which there are now hundreds throughout the country, mostly in low income - areas. The plan does not require each community to build a physical structure called the " community health center. " Instead, it views the com- munity health system as a network of primary - care providers integrated so that people can find their way through it without the kind of turmoil and confusion that patients experience today. The second level of organization would be the Dis- trict, serving approximately a quarter of a million peo- ple with general inpatient hospital services. Above the District would be the Region, serving a metropolitan- sized area with specialized inpatient services (e.g., trauma services, organ transplants). Regions would also be responsible for the education of health workers. The national level would establish standards for the provision of care and priorities for research. Medical schools, nursing schools, and other training programs would be integrated into this national health system. A community - based, prevention - oriented approach would inform the education of health - care workers. Much of their training would take place in primary - care settings, rather than in tertiary - care facili- ties providing specialty services. The legislation also provides for ladders of training, through which health workers could progressively expand their skills and acquire broader responsibilities. In an attempt to deal with the current dominance of medical care by physi- cians, the bill envisions teams of health - care workers, in which the supervision of patient care would be a collec- tive responsibility. Physical therapist and patient at Connecticut's Mansfield Training School. News_ 1 9 / Blaisdel Virgina Assuring Accountability Democratic control of this system would be provided by a governing structure operating in parallel with the medical - care structure. Each community would elect a health board, in the same way school boards and the boards of community health centers are presently cho- sen. Voting would coincide with Congressional elec- tions in order to maximize participation. Boards would be composed of representatives of users of the system and representatives of those who work in it, with the former outnumbering the latter by two to one. The Dellums bill remains relevant in spite of the changes that have occurred. The Community Health Board would not only ad- minister local health facilities, it would act as a " health advocate " for the community. Because the entire sys- tem rests on the belief that the health problems facing us are best dealt with through prevention, a primary responsibility of the community health boards would be to press local governments to take action to eliminate health risks. District health boards would be composed of repre- sentatives from the community health boards, regional boards of representatives of districts, and the National Health Board of regional representatives. These boards would be responsible for allocating funds to the institu- tions under their respective supervision. Control would therefore run from the bottom up, and those who use the system, and those who work in it, would be represented at every level. The Dellums Health Service Act was devised as a vehicle for education, using concepts that had been developed in the civil rights movement and in other progressive movements. The Act has been used across. Withers O. George California Congressman Ronald Dellums. Progressive stalwart on capitol hill. the country to show a different, progressive vision of how medical care can be organized. The Act remains relevant in spite of the changes that have occurred in health care since its preparation. The problems it escalating addresses - escalating cost, maldistribution of resources, lack of emphasis on prevention, absence of democratic control - are with us still, exacerbated by the growth of the corporate, for profit - medical industry. The Dellums bill still describes the kind of health care system pro- gressives ought to want. If it is, in fact, what we want, we should organize to get it. Y' 16 Health / PAC Bulletin Winter 1987 Holding the Line Labor's Safety & Health Movement LANCE COMPA THINK he rash of fines recently inflicted on major corpo- T rations by the Occupational Safety and Health Administration (OSHA) has put the state of the American workplace higher in the national conscious- ness than it has been since the early, crusading days of the Occupational Safety and Health Act of 1970. IBP, the nation's largest meatpacking company, was slapped with a record $ 2.6 million fine for falsifying records at its Dakota City, Neb. plant. Chrysler's penalty for safety and health violations at its Newark, Del. facility ex- ceeded $ 1.7 million. General Dynamics, Caterpillar Tractor, and John Morrell & Co. were each fined over half a million dollars for various violations of the health and safety statute. Is OSHA finally enforcing the law after years of laxity? Or, as most activists and analysts involved in safety and health believe, do the high profile - penalties constitute an attempt by OSHA to shore up its reputa- tion? A recent independent federal study, the conclu- sions of which were confirmed by the agency's own consultants, found OSHA in a state of " total paralysis. " Another, private, study by the National Safe Workplace Institute showed that OSHA's inspections are inade- quate and untimely, that the agency consistently fails to insure that what hazards it does uncover are cor- rected, and that it often and unjustifiably reduces its fines against firms that willfully and repeatedly violate the law. OSHA's surrender of its responsibility, moreover, began at the same time as the " Get OSHA Off Our Backs " campaign conducted by business during the early 1980's - a campaign which combined political rhetoric with pseudo academic - complaints about over- regulation. The Right has had license under Reagan to suffocate the issue of occupational safety and health from both within government and without. But the issue has refused to go away - the persistence of death, disease, and injury in the workplace has made sure of that. Equally important to maintaining Lance Compa is the Washington representative of the United Electrical Workers Union. SAFETY NOT Visuals Impact /Kufman Michael public concern over workers'safety and health - con- cern that ultimately led OSHA to levy its face saving - fines- has been the work of occupational safety and health activists. For while the labor movement as a whole has suffered a sharp decline in membership and strength over the past two decades, labor's safety and health activists have refused to retreat. Indeed, the enduring vitality of the occupational safety and health movement has provided much of the energy driving labor's efforts to reverse its fortunes and grow again. Hard Times for Labor The unions'decline has been acknowledged not only in the press, but by the labor movement itself. Thirty years ago, unions represented more than one third - of Above, member of the Independent Federation of Flight Attendants pickets outside the TWA terminal at New York City's Kennedy International Airport. Winter 1987 Health / PAC Bulletin 17 the American workforce; that figure has fallen below one fifth -. With strikes rarer than ever, concessionary bargaining marks the strategies of many of today's labor negotiators. Perceptions of Big Labor as a powerful political and legislative force turned to skepticism in the wake of the Mondale debacle and a long series of set- backs in Congress. Most analysts blame the downturn in labor's fortunes on structural changes in the economy. The service sec- tor is growing, traditional union bastions in basic in- dustry are shrinking, and what growth in manufac- turing is taking place occurs largely in non unionized - sectors, such as high technology. As massive, old urban factories employing thousands of workers reach the end of their useful lives, companies are replacing them with smaller plants in semi - rural areas devoid of union history and sentiment. The demise of the union, however, stems from more than just economic restructuring; business has hurried the process. During the postwar economic expansion, industry could afford to accede to some of labor's demands. Unions returned the favor by expelling their left wing - members and wedding themselves to the Cold - War, free enterprise - philosophy embraced by both government and business. But when American domi- nation of the world economy began to falter in the 1970's, companies returned to a time tested - method of juicing up profits: union bashing - . Many employers are now not just resisting union organization in new facili- ties by hiring union busting - consultants who specialize in stopping organizing drives, they're even trying to rid themselves of incumbent unions through decertifica- tion campaigns and strikebreaking. Internal weaknesses, too, have contributed to labor's difficulties. Many union leaders are now questioning labor's ideological commitment to capitalism, fearing it has disarmed them of clear alternatives to the corporate agenda. Others argue that, as lawyers and economists have taken over the functions of organizers and mobil- izers, labor has become bureaucratized, its grassroots character poisoned. Finally, political action has been largely confined to rote support for Democratic candi- dates, with few attempts at independent political action. Energy and Commitment While labor has stalled, though, its safety and health movement has pressed forward, serving as a core of activism while organizing, bargaining, and problems political work are in turmoil. With all their problems, many unions were able to stay on the offensive over safety and health issues. Thousands of young workers who might otherwise have been made cynical by their unions'stumbling have instead become labor stalwarts thanks to their involvement in health and safety advocacy on the shop floor -. Safety and health staffers hired to run new union programs brought with them an energy and commitment that local union leaders and members had not seen for decades, while a flood of conferences and publications educated local unionists about workplace hazards and about their rights under - both OSHA and their contracts - to fight for a safer workplace. Several successful efforts at unionization started as disputes over occupational health. The education of workers and the public about the hazards of cotton dust by members of the Amalgamated Clothing and Textile Workers Union contributed mightily to the union's success in organizing J.P. Stevens & Co. in the late 1970's. Safety and health problems became key organizing issues in the United Electrical Workers'suc- cessful effort at the Litton microwave - oven plant in Sioux Falls, S.D., the United Steelworkers'break- through at the Newport News Shipbuilding Company in Virginia, and last year's victorious campaign by the United Food & Commercial Workers Union to organize thousands of catfish processing - workers in the Missis- sippi delta. The hazards of the workplace were critical issues in strikes by meatpackers, miners, and others. Under the guidance of the AFL - CIO, unions have stopped OSHA's attempts to relax standards governing the presence of lead and cotton dust in the workplace and to weaken regulations mandating access to medical records. The unions have pushed OSHA to propose standards for the safe manufacture of ethylene oxide, asbestos, formaldehyde, benzene, ethylene dibromide and other chemicals. Galvanized by the conviction, for murder, of executives of a film processing - plant in Illinois who deliberately allowed their employees to be poisoned, state and local prosecutors are bringing new criminal actions against other managers of un- safe workplaces. The issue of occupational safety and health, more- over, has linked the labor movement to community groups, environmentalists and feminists. In many cit- 18 Health / PAC Bulletin Winter 1987 A Workplace Victory Visuals BAINER Impact /MGlyn 51 Katherin Fish processing - workers, like these in Rockland, Me., have a high incidence of skin disease from performing repetitive tasks with their hands immersed in water, chemicals, and fish. ies, local coalitions on safety and health, known as COSH groups, have united union and community acti- vists in creating programs to promote health in the workplace and the environment. In many states and cities these groups have successfully campaigned for " know right - to -" laws and ordinances, which require companies to disclose the nature and effects of chem- icals and other materials used in the workplace and which have forced OSHA to issue its own right - to- know standards for the manufacturing industries. The AFL CIO's - Industrial Union Department has formed the OSHA Environmental - Network to defend, through joint action by labor and environmental activists, regulations relating both to occupational health and to environmental protection. The Network's support for the federal High Risk Notification Bill, which requires industry to disclose information about dangerous workplaces, helped get the legislation through the House of Representatives last October. Unions and communities worked together to stop the Schweiker bill, a 1980 OSHA " reform " measure that would have gutted the Act; the effort remains a model of grassroots political action that taught val- uable organizational and lobbying skills to thousands of workers. And just as the issue of safety and health has helped the unions, the presence of unions helps workers win gains in safety and health. A recent study by Harvard's In 1986, workers in the central supply department of Washington Hospital in Washington, Pa. de- cided they'd had enough. For several years they had been experiencing burning, itching, and numbness from working with the hospital's ster- ilizing equipment, and suspected that some of their former co workers - had developed cancer for the same reason. But the hospital agreed to take action only after the workers confirmed that they were being poisoned by ethylene oxide gas (EtO), a sterilant and carcinogen, and cam- paigned to stop it through their union's safety and health committee.: The workers'first move was to contact Laura Job, director of the Occupational Safety and Health Program of 1199, the National Hospital Union. Job analyzed the federal standard designed to protect employees from EtO and created a checklist which the workers used to gauge the extent of the violations. Together, they documented 14 violations in all. They also com- piled a list of workers with complaints traceable to -to exposure and another of those suspected to have developed cancers from the gas. Armed with these specifics, the committee organized union members at the mid sized - rural hospital around the goal of winning maximum protection. " Quickly it became a union - wide - issue, " reports Job. Workers campaigned until management agreed to meet and remedy the problem. " I told [management] if they wouldn't give us what we needed, I'd just grab onto their jackets, or their pantlegs, or take them by the hand until they gave in, " Twila Martin, a worker at Washington, told the union's newsletter Occupational Health Matters. The hospital agreed to install a new sterilizer, provide protective equipment, conduct regular examinations and tests to detect any effects of exposure, and draft an emergency plan against the occurrence of a gas leak or spill. Even before the plan was completed, however, a leak occurred that exposed one worker directly and indirectly exposed several others. The workers, already trained by their committee, evacuated the central supply office and went directly to the emergency room for examination. None had been harmed. " Workers realize that it is foolish to rely on management or the government to protect them. They know they have to protect themselves, " Job told the Bulletin. " The safety and health arm of our union is anything but a library; it is an organizing force which strengthens and educates workers about their rights and powers. If safety and health is about anything, it's about empower- ing people. " -Joe Gordon Winter 1987 Health / PAC Bulletin 19 MORE PLACE DEATH HERI GO TO WORK JOMOF EAN CANT Cul ET Visuals Center for Business and Government found that union representation gives workers dramatic advantages in OSHA proceedings. While union employees exercised their " walkaround " right - their prerogative of accom- panying OSHA inspectors on tours of their workplaces and assisting them in identifying hazards - in 70 per- cent of inspections of union sites, only four percent of non union - workers exercised this critical right. The presence of a union in large workplaces, moreover, vastly increases the probability of inspection: non- union companies with more than 500 workers face a 16 percent chance of receiving an OSHA inspection each year, while for a comparable site that is organized, the likelihood is 95 percent. And when inspections do occur, the typical OSHA official devotes 24 hours more to his or her inspection of a unionized workplace than to that of a non union - plant. In part because safety and health activists kept fight- ing during the lean years, the crisis of trade unionism has eased. In June the nation's 11,000 air traffic con- trollers voted to form a new union; their earlier one, PATCO, was smashed by Ronald Reagan during their 1981 strike. Though many had been strikebreakers, the controllers, forced to collective action by traditional union issues such as workload, work pace, mandatory overtime, and mistreatment by management, voted for renewed union representation by a margin of two to one. In the same month, over 2,000 workers at a print- ing plant in Kingsport, Tenn. voted to reorganize 25 years after their original union had been ousted follow- ing a broken strike. A Brightening Outlook These notable returns to unionism reflect a discern- ible shift in labor's fortunes. The decline in member- ship, which neared half a million a year in the early 1980's, dropped to just 21,000 in 1986. The typical union member got a raise in pay of $ 21 a week last year, com- pared to one of $ 10 a week for his or her non union - /W eImspatc t Jim UAW members strike Chrysler's Highland Park, Mich. plant, demanding adequate blower systems to ventilate carcinogenic dust created in the modeling of plywood plastics. There was a high incidence of cancer deaths in the plant, where workers won safety gains in the 1983 action. counterpart. " Her " indeed: the number of women in unions actually rose by 70,000 last year, a sign that the most significant social migration of this century- half -cen tury- the movement of women into the workforce - is attract- ing new converts to unionism. All over the country union staffers report a lift in prospects for organizing and bargaining. The paralysis of the Reagan presidency has played a part in this. While Reagan was riding high, his reputation as an anti labor - president made workers wary of agitating for their rights. With the president slipping out of his sad- dle, workers have gained new confidence, believing that what happened to the air traffic controllers can no longer happen to them. The shift in the national mood has political conse- quences for labor. Unions played a key part in winning the Senate from Republican control in 1986, and with the Democratic Party having a good chance of recaptur- ing the White House in 1988, labor's political apparatus -the one that took such a licking in 1984 - is now geared for work with a tough campaign's worth of skills and experience at the ready. Labor's role could be deci- sive in the election, paying dividends in the policy fights to follow. There is good reason to think all this new opti- * mism is not misplaced. The American labor movement has taken the worst blows an anti labor - administration in Washington and an anti union - offensive by employ- ers could throw at it and - still it stands, ready to swing back. Occupational safety and health activists, further- more, have not only fueled the resurgence of the labor 220 Health / PAC Bulletin Winter 1987 movement, they have formed an ideological vanguard, as well, by confronting the philosophical choices that will determine the future of the labor movement. Industrial Unionism vs. Enterprise Unionism Union professionals who deal with health and safety, for instance, sharply debate the extent to which their issues are politically neutral - that is, capable of being solved regardless of which economic system predom- inates. They argue over the merits of joint labor man- - agement committees where safety and health concerns are seen as a shared interest, as opposed to indepen- dent, union - only committees that approach safety and health problems as an issue resolvable through adver- sarial bargaining. Finally, they discuss the danger of " technocratization, " of their becoming specialists in a highly technical field, whose job consists of relieving rank and file workers of, rather than involving them in, safety and health matters. All these are dilemmas which the larger community of labor activists will have to face soon, if they are not facing them already. In many respects these discussions are tributaries of the most important debate going on in the labor move- ment, the debate between industrial unionists and enterprise unionists, a struggle whose outcome will shape the labor movement into the next century. The new industrial unionists want to revive CIO style - militance, industry - wide structures for organizing and bargaining, and independent, class based - political action in the labor movement. Enterprise unionists see the CIO model as outmoded in today's economy and today's society. For them, unions must cooperate with management, tailoring their strategies for organizing and bargaining to the needs of the firm in question and taking responsibility for that firm's financial success. The tying of increases in wages to productivity and profits, the presence of workers on boards of directors, their participation in management, and their owner- ship of stock these - , according to enterprise unionists, are the new initiatives that unions must turn to if they are to survive and prosper in the 21st century. Clearly, the movement for occupational safety and health lies squarely in the camp of industrial unionism. The movement has created a community which cuts across the jurisdictional lines that bedevil the labor movement, bringing unions together in struggles for stronger legislation, tougher enforcement by OSHA, and environmental protection. There is no surprise in this: a machine operator swallowing cutting oil fumes at a lathe in a Rockwell plant in California has the same problem as a worker at the same lathe in Baltimore's Bethlehem Steel plant. They need a single solution to their problem, not one solution at Rockwell and another at Bethlehem Steel, each dependent on the relative profitability of their employers. Occupational safety and health activists, from the epidemiologist and the industrial hygienist on union staffs, who study the problem at its broadest level, to the shop floor steward taking up a specific health- related grievance, are critical players on a team of organizers trying to rebuild democratic industrial unionism in the American labor movement. Y' Unhealthy and dangerous working conditions are rampant among migrant farmworkers. Here a nine year - - old labors with family members on a Maryland cucumber farm. Visuals Impact /Dekr Philip The Clash over Quackery Protecting Alternative Care RONALD L. CAPLAN While energy pills, panaceas, and snake oils belong to a vanished past, the greed and naivet that per- J mitted them are with us still; quack- f ery is bigger business today than 4 ever before. The incidence of medi- cal fraud in the United States has increased more than fivefold over Grey the past 25 years; in 1986 alone Americans paid over $ 10 billion to Alex unscrupulous promoters of fraudu- lent medical therapies, remedies, and gadgets. Those who suffer from chronic or terminal diseases - particularly arthritis and cancer, and now, AIDS - are the easiest marks, often willing to buy anything that promises cure or symptomatic relief. The Pepper Report The lid has been pulled off quackery only recently, through an investigation by the House Select Com- mittee on Aging, a study which undoubtedly stands as the most comprehensive ever undertaken. Between 1980 and 1984, the committee held hearings in half a dozen states; reviewed mountains of books, periodi- cals, newspapers, and correspondence; examined and investigated scores of suspect devices, therapies, machines, and compounds; conducted hundreds of in- terviews and surveys; and worked closely with a large number of public and private organizations, including the American Medical Association and the Food and Drug Administration. Following the committee's findings, Chairman Claude Pepper (Fla D -.) introduced three pieces of anti- quackery legislation in Congress in July 1984. The bills called for the creation of " a clearinghouse for consumer health education and information, " and for greatly in- creased criminal penalties for those who willfully sell or try to sell drugs, devices or medical treatments know- ing them to be unsafe or ineffective or " unproven for safety or efficacy. " They also sought to establish a strike force to investigate the sale and promotion of these unsafe or unproven drugs, treatments, or devices. But in his zeal to bring the hucksters to justice, Pep- per cast too wide a net. The bills'language effectively discredited all types of'nonscientific'medicine, not only out and - - out quackery. The release of the commit- Ronald L. Caplan, PhD, is Assistant Professor of Urban Studies at Rutgers University. tee's report and the introduction of Pepper's bills instigated an uproar in the holistic health - care commu- nity. Advocates of a whole host of alternative forms of health care from acupuncture to Zen opposed - the bills as a serious threat to any unconventional health- care practice and immediately launched a nationwide campaign to defeat them, largely in response to which the bills were withdrawn. The threat the bills embodied, however, remains. In September 1985, the FDA, the Federal Trade Commis- sion, and the U.S. Postal Service cosponsored a na- tional conference on health fraud, the first since 1966, to publicize the Pepper committee's findings. Three months later, the FDA and the Pharmaceutical Adver- tising Council launched a campaign in the national media against quackery which relied heavily upon the work of the committee. During 1986, the FDA held regional conferences on health fraud to build support for legislation modelled after the Pepper bills. Since Quackery is bigger business today than ever before. such legislation will likely soon be introduced in Con- gress, we ought to reexamine the holistic community's objections to the original bills, and clarify the purpose of any anti quackery - legislation. The Vice - like Grip Pepper's efforts to identify and eliminate fraudulent practices within the health - care industry appear, at first glance, beyond criticism. In defining medical quackery as the " promotion of remedies known to be false, or which are unproven, " his committee seems to have taken a sensible approach. The bills also employ a seemingly straightforward and effective strategy in call- ing for both the education of consumers and the jailing i of offenders. Most practitioners of alternative healing, however, regarded Pepper's proposals as an attempt by the prac- titioners of conventional medicine to continue their domination of American health care. Their suspicions were well founded - ; for over 50 years, the medical com- munity, led by the AMA, has opposed nearly every 22 Health / PAC Bulletin Winter 1987 form of health care that has significantly differed from - or seriously competed with conventional - med- icine. At one time or another, the AMA has denounced homeopathy, osteopathy, optometry, acupuncture, self- care, chiropractic, midwifery and lay analysis as being either dangerous, or fraudulent, or both.2 While the AMA eventually shifted its position on some of these therapies, the principal aim of the organi- zation has not changed. In setting the boundaries of legitimate health care, the AMA has consistently dem- onstrated a far greater concern for the financial well- being of its members than for the health of the Ameri- can people. Its primary objective remains the control of both the theory and practice of American health care. The result is the existence of a medical - care monopoly that, multiplying inefficiency by inequity, distorts the proper allocation of resources and consistently pro- vides less health care at a higher price than would exist in a more competitive environment. 3 Moreover, this medical elite has erected formidable barriers to practice, such as overly strict licensing laws, that, together with its close alliance with the insurance industry, help maintain its position and perpetuate these distor- tions 4,5 [see box]. These tactics assured that alternative health - care providers were, for many years, largely denied access to consumers.6 A Growing Constituency Yet despite the systematic suppression of alternative medicines, a steadily growing segment of the American people has, since the 1970's mid -, openly challenged - and even rejected - many of the doctrines and prac- tices of conventional medicine. A significant number of Americans are, in fact, seeking alternatives in " unscien- tific " and " unproven " therapies, from chiropractic to psychic healing.7 Many of these alternatives are now the preferred choice of millions of consumers and enjoy a well satisfied - and loyal constituency.8 The Pepper approach implicitly denies the validity of health - care paradigms different from, but not necessar- ily less scientific than, the model that dominates American medicine. The committee's report acknowl- edged that " some of what is unproven may yet prove of benefit " and cautions against a blanket condemnation of all " unproven therapies. " But by branding as quack- ery any health - care practice which is known to be false or which is unproven, the committee failed to heed its own advice. Clearly, not all unconventional forms of health care are " sciences in the making. " By the same token, not every health - care practice opposed by the medical es- tablishment is, in fact, medical quackery. The definition of medical quackery is always socially determined -- the product of interactions among economic, political, and cultural factors that extend far beyond the laboratory and the examination room. The real problem, of course, is how to separate the true charlatans from those healers who practice an as yet unproven, but neverthe- less efficacious, form of health care. The exclusion of alternative approaches from the medical marketplace is intimately related to judge- ments about their legitimacy as therapy. The hegemony AMA Herholist Chiropractic R. LEE ACUPUNCTURE HEALING TOUCH MIDWIFERY Grey Alex of conventional health care remains largely unchal- lenged precisely because orthodox medicine wraps itself in the mantle of science and brands as unsound all opposing outlooks. At a time when competition within health care is intensifying and the relative status and income of physicians are on the decline, it is simply unwise to give undue influence to the medical estab- lishment's views on quackery. We must not repeat the mistake of the Pepper Committee by allowing physi- cians and their allies to determine the design of anti- quackery legislation. Wheat from Chaff While the vultures who prey on disease and fear must be caught and punished, safe and effective forms of alternative health care should be supported as legiti- mate substitutes for- or complements to conventional - medicine. The question is, how do we separate one from the other? The definition of medical quackery is always socially determined. A prudent place to begin is with those healers who have already amassed a large amount of evidence demonstrating the safety and effectiveness of their practice and who claim to have logical theoretical bases Winter 1987 Health / PAC Bulletin 23 Alex Grey, The Psychic Energy System, 1980 24 Health /PAC Buletin O86 "uayshs Winter ASsauq 1987 2Yy2Asg ayy 'Aad rary 24 Health/PAC Bulletin Winter 1987 for their treatment. Chiropractors, homeopaths, and acupuncturists are clearly among the leading candi- dates. To be fairly judged they must be evaluated on their own terms - that is to say, according to their own scientific principles, which are not necessarily those governing " scientific " medicine.9 A great deal of costly research will be needed to test these methods adequately, and practitioners of alterna- tive medicine and the organizations which represent them lack the resources to undertake it. Nearly all the major sponsors of related health - research are closely identified with the theory and practice of conventional medicine and rarely fund projects that depart from the mainstream; the money will clearly not come from them. Therefore, the federal government should spon- sor a series of studies (patterned after its recent assess- ment of bone marrow - and artificial - heart transplants, elective hysterectomies, and psychotherapy) to deter- mine the efficacy and cost effectiveness - of the more promising forms of alternative health care. 10 At one time or another, the AMA has denounced optometry, acupuncture, self care -, chiropractic, midwifery, and lay analysis. Our nation's " irregular " practitioners have been legitimately challenged to " demonstrate that their the- ories are sound, their diagnostic techniques accurate and their treatments effective. " 11 They should not be forced to lose by default. Those who succeed should be accepted as legitimate therapists and integrated into the mainstream of delivery and reimbursement. Those who fail, along with those who simply refuse to try, should be blocked from the marketplace, for they will have been exposed as the real quacks and charlatans of American health care. The value of a particular health - care practice may be judged by the rigor and persuasiveness of its scientific underpinnings, the quantity and quality of its empirical evidence, and, if it is to reach those it can help, the size and scope of its popular appeal. If all forms of health care are to receive fair judgment in accordance with these criteria, the power and influence of the AMA and its allies will have to be greatly curtailed. At a time when the dominant paradigm in American medicine is being challenged by a growing constituency, the gov- ernment should not, either intentionally or unwit- tingly, remain its unquestioning ally. The protection and development of the most promis- ing alternatives to conventional medicine is an in- dispensable part of progressive health - care reform. A new and improved division of labor within the health- Barriers to Alternative Practice While some physicians truly believe that all alter- native healers are cultists or quacks, much of the recently rising opposition of conventional med- icine to alternative care - and the consequent gov- ernmental suppression of such care - originates in the increasing economic squeeze practitioners are feeling. At the federal level, the most recent clash between the two philosophies has centered around the Pepper bills. At the state and local level, the conflicts have revolved around licensing and malpractice. oo Some states, encouraged by the medical estab- lishment, have enacted a very broad definition of medical practice, thereby necessitating certifica- tion for a much wider spectrum of practitioners. In 1978, authorities in California, at the urging of the State Medical Society, arrested the operator of a health - food store for practicing medicine with- out a license. Her offense appears to have in- volved giving nutritional advice to her patrons. Since then, two owners of health - food stores in Indiana were charged with a similar offense. The Alaskan State Medical Board recently outlawed midwifery and naturopathy, ruling that they con- stitute unlicensed medical practice. As health- care reform increasingly comes to mean cost con- - tainment, alternative healers will inevitably be subject to greater scrutiny, and greater censure. With the deregulation of the medical market- place has come an explosion in the number of malpractice cases and in the cost of premiums for liability insurance. Some practitioners, unable to afford adequate protection, are going out of busi- ness. Physicians and hospitals, fearful of esca- lating rates, are practicing defensive medicine; even those who have used and supported uncon- ventional therapies or techniques in the past are now much less willing to do the so - risks have become too great. This new timidity is most evident among obste- tricians, who pay the highest rates for malpractice insurance and are most likely to be sued. Hereto- fore open minded - obstetricians feel tremendous pressure to follow strict protocol by performing routine fetal monitoring and " medically indi- cated " cesarean sections. Natural childbirth, which minimizes intervention, is now often re- garded as too risky for the patient and the physi- cian. The crisis in malpractice insurance, while not yet directly affecting most practitioners of alternative therapies, may yet become another formidable barrier to their integration into the mainstream of care. -R.C. Winter 1987 Health / PAC Bulletin 25 Halmndris Marilu care industry would be achieved if various types of practitioners - physicians, chiropractors, homeopaths, nutritionists, and others - could work together for the betterment of their patients'health. Unfortunately, any legislation which follows the thinking and recommen- dations of Congressman Pepper's report would move us in exactly the opposite direction. Y' 1. " Medical Quackery: The Target of New Public Service Drive By FDA & PAC ", Pharmacy Times, February 1986, 27-29. 2. Coulter, Harris L. " Divided Legacy: A History of the Schism in Medical Thought, " Science and Ethics in American Medicine: 1800-1914. Washington: Weehawken Book Co., 1973, Vol. 3. Russell Jacoby, " The Lost Freudian Left: The Repression of Psychoanaly- sis, " The Nation (October 15, 1983), 341-345. 3. For an economic explanation, see Peter Asch and Rosalind Seneca, Government and the Marketplace. New York: Dryden Press, 1985, 51-78. 4. Andrews, Lori B. " Deregulating Doctors: Do Medical Licensing Laws Meet Today's Health Care Needs? " People's Medical Society, 1983, 1-14. Howard S. Berliner, " A Larger Perspective on the Flex- ner Report, " International Journal of Health Services 5 4: (1975): 573-592. Congressman Claude Pepper examines an Oxydonor, a gadget purporting to cure arthritis and rheumatism, at a 1980 hearing of the House Select Committee on Aging that investigated unproven drugs, devices, and medical treatments. 5. Bachop, W.E. " Controlled Clinical Trials, Third Party Payers and the Fate of the Chiropractor, " Journal of Manipulative and Physiologi- cal Therapeutics 3 (1980): 93-96. 6. Caplan, Ronald L. " Pasteurized Patients and Profits: The Chang- ing Nature of Self Care - in American Medicine, " (Ph.D. disserta- tion, University of Massachusetts, 1981), 2, 438-443. 7. Caplan, " Pasteurized Patients, " 228-368. 8. Caplan, Ronald L. " Chiropractic, " in Alternative Medicines: Popular and Policy Perspectives, ed. J. Warren Salmon. New York: Tavistock, 1984, p. 88. 9. Briggs, J. and F. Peat, Looking Glass Universe: the Emerging Science of Wholeness. New York: Simon and Schuster, 1984. 10. The Implications of Cost Effectiveness - Analysis of Medical Technology, Office of Technology Assessment, Washington, D.C. (1980, 1981, 1982). 11. Relman, A.S. " Chiropractic: Recognized But Unproven, " The New England Journal of Medicine 301, No. 12 (1979): 659-660. 2266 Health / PAC Bulletin Winter 1987 THESE ISSUES ARE STILL HOT Back issues of the Health / PAC Bulletin are available for $ 5 each (12 $ for institutional subscribers), postage paid. To order, send your name, address, the issue (s) desired and your check or money order to: Health / PAC Back Issues 17 Murray Street New York, NY 10007 Visa and MasterCard will be accepted for orders of $ 15 or more. Please be sure to include the full account number and expiration date. cy Advo HEALTH Spw Doub PAC BULLETIN Health Care and Revolution hewn El Salvador Vicemgwe HEALTH / PAC BULLETIN DTAhRe IwNwGw TO CARE $ 5 Special Double Issue on Health Care and Revolution: Nine Reports on: The Sandinista Health Campaign Health Care and Human Rights in El Salvador How the U.S. Invasion of Grenada Affected Health Care Vol. 17, 4 # Special Issue on South Africa Interview with the President of NAMDA The Story of a South African Nurse The Karks'community- health innovations U.S. health related - corporations in South Africa HEALTH Hvaoglhu mNeu m1b6e.r Roy Adwory Lense PAC BULLETIN WOMEN'S HEALTH ISSUES Vol. 16, # 6: Women's Health Issues: Baby Doe Debate Assessing the Prejudice Against Mid Life - Childbearing The Cervical Cap: Test Case for U.S. Regulatory Policies HEALTH POLICY ADVISORY CENTER JIN JIN Wa 1 No Spring Issue HEALTH / PAC BULLETIN With DITH Sher Cammy THE RUBBLE IN ST LOUIS the put in each on warm Whos minding 1050 - The Mass referendum Catasimphu coverage Querini Young on Look County health Vol. 17, 3 # " Health care is Sick in St. Louis ": the privatization of a city's system Professional Review Organizations and Prospective Payment (Part 3 of 3 on PPS) Massachusetts ' Successful Referendum on National Health Vol. 16, # 2: Black Health in South Africa Notes from a Nurse's Journal Defending Children's Health Right Know - To - Laws Winter 1987 Vol. 16, 3 # (Reprint): Six Myths of American Health Care: What the Poor Really Get The Tragedy of Medi - Cal Birmingham's TB Care Goes Private Who's Making Fortunes in U.S. Health Care Politics of AIDS Research Vol. 16, # 5: Fighting Back Against the Empires: Hospital Construction in NYC South Carolina's Medically Indigent Assistance Program Lead Poisoning and Public Policy Generic vs. Brand Name Drugs Vol. 17, # 1: How Prospective Payment is Transforming Hospital Care (Part 1 of 3 on PPS) States'Programs for the Uninsured Health Care Under Fire: Interview with Dr. Myrna Cunningham of Nic- aragua Public Health Roulette in Nevada Vol. 17, # 2: How the Reagan Administration Failed on AIDS Quality - of - Care Problems Under Prospective Payment (Part 2 of 3 on PPS) The Crack Scare Health / PAC Bulletin 2272 Uncle Sam Promotes the Marlboro Man American Cigarettes Come to Taiwan ELISE AND DAVID RAY PAPKE n Taiwan, young women in miniskirts pass out com- pllimieknet aKrye nptl iamenndt aMray rplabcokrs oo fv iWein sftoorn oant tceintyt isotnr eeitns . Brands maga- zines and on posterboards. Phillip Morris and R.J. Reynolds attach their names to sporting events in re- turn for sponsorship. Common occurrences in the United States, these phenomena have come only recently to the Republic of China as part of the Reagan administration's efforts to inflict the benefits of the American tobacco industry on our Far Eastern - allies. Ultimately, the influx of Ameri- can cigarettes reflects the administration's efforts to reduce the trade deficit, but the resulting political gains and corporate profits come at the expense of public health - of people's lungs and lives abroad - . In recent years Taiwan has run up annual surpluses of $ 10-15 billion in trade with the United States, its most important commercial partner. In 1985 the Reagan administration began looking for ways to correct the imbalance. In addition to opening direct negotiations with Taiwan, the government listened to plans put forth by several American industries, each hoping to be promoted as an exporter. The tobacco industry, with its powerful lobby, spoke loudest of all. Having recently lost ground to public health - advocates in the United States, the industry has reason to look hungrily at the Taiwanese market. Not So Fast On the other side of the Pacific, the Taiwan Tobacco and Wine Monopoly Bureau put up a stiff resistance. The bureau, which generates an astounding 11 percent of the government's revenue, relies on heavy import tariffs to restrict the entry of foreign cigarettes, beer and liquor into Taiwanese markets. American champions of the " free trade " which fills the coffers of the tobacco industry negotiated with the bureau for over a year. While Taiwan agreed early in the talks to remove its tar- iff on cigarettes, negotiations foundered on two related issues: pricing and advertising. With tobacco, as with other nonessential goods, a subtle combination of the two incubates desire and urges purchase. In October of 1986, American negotiators got nasty. They threatened to invoke the 1974 Trade and Tariff Act, Elise Papke has an MPH from Yale University. David Ray Papke is Associate Professor of Law and American Studies at Indiana University. which permits retaliatory measures against nations using " unjustifiable and unreasonable " means to harm American commerce. The president went as far as sign- ing a preliminary determination judging Taiwan to be so acting, and the administration prepared to retaliate against Taiwanese industry. The strong - arm tactics worked immediately: the exporters of garments, shoes, and electronics put pressure on their government and an agreement was hammered out by December. The tobacco industry has reason to look hungrily at the Taiwanese market. Since the agreement went into effect on January 1, 1987, 120 brands of foreign cigarettes have entered the market, with American makers leading the charge. Prices for those are comparable to those in the United States, about 50 percent more than the cost of local brands (one of which is named " Long Life "). Prohibited from advertising on local television and limited to 120 magazine ads annually for each brand, American com- panies have been forced to become more resourceful. In addition to sponsoring sporting events, they have pasted their logos and advertisements on every street- corner and, in the case of Phillip Morris, have devel- oped plans to build a raceway. R.J. Reynolds (makers of Winston and More) and Brown and Williamson (Kent) have budgeted $ 4.9 million for advertising between them. The budget for Phillip Morris'Marlboro, the most visible brand on the island, would add millions more to that figure. When Reynolds unveiled a tactic that has become old hat to Americans - the distribution of free cigarettes by attractive young women - the company stirred up more attention than it had expected. The women, who sta- . * tion themselves in Taipei's discos as well as on the streets, have been denounced by one local legislator as " pretty little devils. " The Taiwan Housewives Federa- tion has started patrolling the discos in response, pro- voking several ugly scenes. Meanwhile, the National Health Administration has allocated new funds to what had been a lagging anti smoking - campaign, and citi- 28 Health / PAC Bulletin Winter 1987 U. S. 4 IN MADVE / / In MA Rincari Ken zens groups have sponsored an anti smoking - day and an anti smoking - month, formed an " I Quit Smoking Club, " and distributed information explaining how to Images of happy smokers riding Marlboro steeds have created new smokers. use acupuncture to kick the habit. But in the face of the deluge of advertising, such energetic and noble coun- termeasures seem doomed to fail. Profits Before People Just over a year after Taiwan opened its markets to American cigarettes, it's already clear who the winners and losers are. The American tobacco industry has access to a large new pool of users (and the administra- tion has attempted to open markets in Japan and South Korea as well). Republicans have an example of the benefits of free trade to wield against protectionist Democrats, and well justified - expectations of future contributions from the tobacco industry. And even the Taiwan Tobacco and Wine Monopoly Bureau is smiling. Despite fears that American cigarettes would capture 50 percent of local sales, the market for domestic cigarettes has actually expanded slightly. Images of happy smok- ers riding Marlboro steeds or strolling through Salem's green fields, it seems, have created new smokers. Some, after an initial fling with American brands, settle for cheaper domestic cigarettes. The losers are the people of Taiwan and any Ameri- cans who think our nation's trade policies should respect public health as much as they do corporate profits. The American Institute in Taiwan, our de facto embassy, has insisted in official publications that " health is not the issue. " But it should be. The seduc- tion of " free trade " has obscured the most important fact about the tobacco industry: its products kill. Y' Winter 1987 Health / PAC Bulletin 29 Vital Signs Edited by Tammy Pittman 1171 Rincari Ken 3500 That Ole Radium Show The radium industry's travelling cleanup circus came to New York last fall after stops in northern New Jersey [see " A Brush with Justice, " Bulletin, Vol. 17, No. 5]; Athens, Geo. (where the show cost over $ 600,000 before it closed); and Ottawa, Ill. (a $ 6.5 million production). The only thing left of the famous industry, which once gave us radioactive mouthwash and hair tonic, are the radium dumping grounds continu- ally being discovered and the halting efforts to clean them up. Now, the show's moved to a highly contami- nated storage plant in Queens. The question is, who will pay? In Georgia and Illinois, the state and federal governments, having borne the cost of the cleanups, are now in court trying to recover their money from the responsible parties, the Radium Chemical Company and its owner, Joseph Kelly, Jr. New York State Attorney General Robert Abrams has learned his lesson: last October he forced Kelly to promise to reduce radiation in and around the plant to legal levels as quickly as possible, to remove thousands of vials of radium from the premises, and to develop a plan to decontami- nate the plant completely. Although the agreement saves Kelly and Ra- dium Chemical from a civil suit, the government isn't sure they have the money to fulfill it. In any case, the 75 year - - old company, which has left a deadly trail of its radioactive spoor across the country, may also face criminal charges. Although New York State ordered the company to vacate and decon- taminate its facility in 1983, appeals delayed the process for four years. The plant, which bristled with environmental and safety violations of almost every imaginable type, would have precipitated a major dis- aster in the event of fire. As the appeals process droned on and the plant sat there radiating, public offi- cials kept New Yorkers in the dark. Only after Maurice Hinchey, an upstate assemblyman who con- _ ducted an investigation of the mat- ter, held a dramatic press conference at the plant in September to an- nounce his shocking findings did public outrage force appropriate Health / PAC Bulletin action. When it will be cleaned up, and who pays, remain to be seen. Next stop? -Tony Bale APHA: Health Care for People Jesse Jackson picked up the pro- gressive health banner in an address to the American Public Health Asso- ciation last October in New Orleans, labelling the state of American health care " immoral, " and calling for a national health program. Speaking to a crowd of several thousand at the organization's 115th annual meeting - a session which no television network or major news- paper bothered to attend - Jackson argued for " a living wage " for home health workers and greater govern- ment funding for AIDS education and prevention. He blamed hospi- tals for rising medical costs and lam- basted the galloping trend toward for profit - health care. " I am not opposed to legitimate profits, " he declared, " but I am opposed to greed. " Jackson's words echoed the meet- ing's theme: " Health Care for People or for Profits? ", an idea which found expression in a resolution opposing the growth of investor - owned or -operated health - care institutions. In other resolutions, the APHA urged government not to shrink from including explicit information about sexual practices in its educational material on AIDS, and recom- mended that the president's AIDS commission, as currently con- stituted, should be barred from meeting. The APHA also came out strongly against the Reagan admin- istration's decision to withhold fund- ing from family planning - programs which provide abortion counseling. The resolution urged Congress to " reaffirm its historical commitment to the principles of informed con- sent, " and asked medical, public- health, and women's groups to add their voices in opposition to the decision. The APHA went on record as op- posing aid to the Nicaraguan con- tras, testing of nuclear weapons, and development of the Strategic Defense Initiative (Star Wars). Reaffirming its opposition to South Winter 1987 Africa's racial policies, the associa- tion criticized the South African Nurses Association for its passive role in opposing apartheid in health facilities, including its refusal to campaign publicly against the poor working conditions in black hospi- tals. Compromise with the racist regime was ruled out: the APHA " strongly urged the international nursing and medical community to sever ties with the South African Nursing Association until apartheid is abolished. " -Sally Guttmacher The Sounds of Silence One of Washington's best kept - se- crets this year has been the federal government's AIDS education - cam- paign, launched in late 1987, the seventh year of the epidemic, and marked so far by thundering indecision. Sadly, the loudest AIDS related - noises coming from the government have been those of the presiden- tial commission on AIDS breaking apart. Add to those the sound of Congress squelching educational efforts by approving the Helms amendment to withold funding from materials " appearing to con- done homosexuality, " and the dying gasps of the Centers for Disease Control's AIDS information - bro- chure, and the sum, from the point of view of public health, is cacophany. The brochure, carrying the inspi- rational title " America Responds to AIDS, " was produced by a Madison Avenue advertising firm at a cost of $ 4.5 million. Originally intended for mailing to every household in the country, the pamphlet required the approval of the president's commis- sion before distribution could begin. But at their very first meeting on Sept. 9, the members of the commis- sion decided they weren't ready for such a controversial decision. Since then the brochure, cornerstone of the government's AIDS education - campaign, has been gathering dust. The pamphlet, one imagines, would contain frank discussion of high - risk sexual practices for it to have so thoroughly intimidated the commission. Far from it. According to Science magazine, which obtained a draft, the pamphlet does not use the word " homosexual " even once, nor does it mention anal intercourse. The word " condom " appears three times, less frequently than the phrase " mutu- ally faithful, single partner - relation- ship, " and the word " family " or " families " appears 12 times. " Having sex with an infected person " is the full explanation offered of how the disease is transmitted sexually. Dis- playing a deep understanding of human sexuality and feeling, the authors of the brochure invoke the famous Reagan dictum in their ad- vice to the young: " Just say'no ', " they intone. For adults they recom- mend monogamy, or, failing that, urge that you " at least be sure to reduce your risk by using a condom. " The fate of the glossy brochure and its air brushed - analysis of AIDS transmission is uncertain. Instead of mailing it to everyone directly, the CDC may distribute it through supermarkets, drugstores and com- munity organizations, according to a spokesman for the Centers. If so, the CDC would be following the lead of the presidential commission in minimizing its responsibility for the dissemination of life saving - , but apparently politically unacceptable, information. -T.P. Improving Prenatal Care A report released last September by the U.S. General Accounting Office found that poor women are continuing to get insufficient prena- tal care in most states. As Congress permitted in 1986, 19 states have expanded Medicaid eligi- bility to include pregnant women earning up to 100 percent of the pov- erty level. These states, according to the report, have seen notable im- provements in access to prenatal care. In the states that have not expanded eligibility, many women continue to receive little or no prena- tal care and run a high risk of bear- ing low birthweight - babies. The 1,157 women interviewed in eight states, all uninsured or Medicaid - insured, were found to be 63 percent less likely to obtain suffi- cient prenatal care than women who Winter 1987 Health / PAC Bulletin have private insurance. In 20 of the 32 communities studied, more than half the women interviewed re- ceived inadequate care. Women who were uninsured, poorly educated, black or Hispanic, under 20 years old, or from large cities were the most likely to receive inadequate care, according to the report. The barriers to care most fre- quently cited were lack of money, lack of transportation, and lack of awareness of pregnancy. Women who are covered by Medicaid were more likely to have sufficient care than uninsured women and less likely to cite inadequate funds as the most important barrier to care. Of the babies born to the interviewed women, 12.4 percent were of low birthweight. The national average is 6.8 percent. The report recommended that all states raise the level of eligibility for Medicaid - funded prenatal care to the federal poverty line, and cited a study by the Congressional Budget Office that estimated the cost of such action at $ 190 million. This figure does not, however, take into account the savings that would be gained from the reduced need for intensive and long term - care. A study by the Institute of Medicine conservatively estimated such savings at three dol- lars for every one dollar spent. The GAO's report is entitled Pre- natal Care: Medicaid Recipients and Uninsured Women Obtain Insufficient Care, Sept. 1987, GAO HRD 87-137 -. It is available by writing to the United States General Accounting Office, Washington, D.C. 20548. Y' -T.P. 31 Body English Out, Out, Damned Fat! Arthur A. Levin Arthur Aaron Levin is president of the Health / PAC board and director of the Center for Medical Consumers, pub- lisher of the newsletter HealthFacts. 987 may be remembered as the year in which we were 1 told to say no not only to drugs and sex, but to fat as well. The nation's public- health policy makers are gearing up for a major campaign to clean up our diets and clear up our bloodstreams in an attempt to reduce the inci- dence of public health - enemy num- ber one: coronary heart disease. While the effort is being heartily endorsed by the American Heart Association (AHA) and the National Heart, Lung, and Blood Institute (NHLBI), controversy abounds over its clinical merits. Such an effort, moreover, would consume a tre- mendous amount of resources at the expense of other primary - care programs. This past June, a panel of experts convened by the AHA, kneeling at the altar of primary prevention, re- vealed the new anti - fat gospel in a study entitled " Cardiovascular Risk Factor Evaluation of Healthy Ameri- can Adults. " Reaffirming the dogma of cholesterol as evil, the study provided practioners with a liturgy of treatment. In October, the NHLBI issued similar guidelines through its National Cholesterol Education Pro- gram (NCEP). The new guidelines recommend routine, periodic cholesterol screen- ing for all adults and treatment of those found to have " elevated " cholesterol levels. Treatment - in- volving 25-50 percent of adults- would begin with dietary modifica- tion, followed by drug therapy where necessary. Efforts to screen for cholesterol began picking up steam only four years ago. In 1984 the Lipid Research Clinics concluded a 10 year - study involving 3,806 men, aged 35 to 59, with blood cholesterol - levels in the highest 5 percent of the general population. The men were divided, at random, into two groups: one received the cholesterol - lowering drug cholestryamine, the other a placebo. At the end of the study, the cholestryamine - treated group had significantly lower levels of blood cholesterol, fewer symptoms of heart disease and fewer deaths from heart attack. That same year, the NHLBI joined the AHA and others in efforts to 32 Health / PAC Bulletin promote the so called - " prudent diet. " The diet's goal: lowering the daily consumption of fat of every American to no more than 30 per- cent of total calories, of saturated fat to no more than one third of total fat, and of cholesterol to no more than 300 milligrams. Until last June, however, there was no study that showed just how low- ering cholesterol levels reduced the risk of heart disease. That month, the Cholesterol - Lowering Arterio- sclerosis Study (CLAS) was pub- lished amid great media hoopla and provided what was purportedly the first visual - angiographic evidence - that treatment could slow the growth of, and in some cases even reduce, arterial lesions. But despite the power of direct evidence, any extrapolation from this study to a policy appropriate for the general population requires a leap of great faith. The study's participants were men who had undergone coronary bypass surgery - hardly a represen- tative sampling of healthy adults. In addition to special diets, half were given two cholesterol - lowering drugs (niacin and colestipol), half placebos. Only the former group showed any significant reduction in cholesterol levels or stabilization or improvement in the condition of coronary arteries. Aggressive screening for and treat- ment of elevated cholesterol levels represents a major public - health committment - a sort of war on fat. It has been said that this policy will cause major changes in the way that medicine is practiced, yet many doctors are less than enthusiastic about it. Y' Winter 1987 ' n October, 1986, Congress reauthorized the EPA's super- fund legislation, including in it a new section called Title III, the Emergency Planning and Community Right Know - to - Act. The new law, which requires factories to disclose the chemicals they store and manufacture, is a major victory -the first such federal right know - to - statute. The initial filing deadline arrived last fall, though, and with it disturbing signs that Title III might not deliver all that it had promised. Still, the passage of Title III gave us much to be proud of - it was the direct result of years of activism. Workers, supported by environmen- talists, began agitating for RTK ten years ago with acts of guerrilla theater opening - vacuum - sealed cans at city council hearings and pasting day glow - stickers demand- ing, " What's in this stuff? " on pipes and drums in factories. Ultimately, these coalitions won RTK laws in 24 states. Then came Bhopal and Chernobyl and the poisoning of the Rhine. Confidence in government's and industry's commitment to control- ling toxic substances was shaken by the reign of Watts and Gorsuch- Burford, and by the discovery of Love Canal, Times Beach, and many other hazardous - waste sites. With progressive activism, widely- publicized tragedies, and a growing awareness of the inadequacy of American plants and transportation facilities to handle toxic materials, Congress'hand was forced. One result is Title III. Title III mandates the creation of state and local emergency response commissions (SERC and LERC), re- quiring their membership to include hospital officials, environmentalists and public health - professionals. Fac- tories must provide these commis- sions with information on the hazardous materials they store, use, and release. The initial reports, sub- mitted either as material safety data sheets (MSDS) or as a list of MSDS chemicals, were to be filed by Oct. 17, 1987. Factories are also required to disclose emergency, as well as rou- tine, release of toxics. The law provides for a national data base to store this information. Ideally, the data base will be de- signed so that anyone will be able to go to the local library and discover what chemicals are being stored at or discharged by a neighboring plant Watching and what the health hazards of those chemicals are. The data base might even allow us to pinpoint the Washington source of various air pollutants, compare the emissions of compa- Know Your nies producing similar products, and even estimate the carcinogenic risk of using one's lungs in South Rights Central Los Angeles. Industry, however, is not rushing Barbara Berney to comply. Only 10 percent of facili- ties covered by Title III met the dead- line for filing the MSDS reports, according to a source in the EPA. And industry has plenty of allies in government. The Senate has appro- priated $ 10 million for the legisla- tion, but, according to Senate staffers, the money may not survive a joint House Senate - conference because many in Congress see Title III as unwieldy and burdensome. Moreover, the Office of Manage- ment and Budget, which must ap- prove the forms used in the regula- tory activities of government agen- cies, has rejected some of Title III's paperwork, making the statute tem- porarily unenforceable. Hank Cole, Director of the National Coalition Against Toxic Hazards, says that " we cannot rely on EPA and OSHA, but can our- selves use the available data to expose and control hazards. " The information gathered under Title III will provide ammunition with which to confront companies, mount media or legislative cam- paigns, pursue lawsuits, and build coalitions between workers, com- munity groups and environmen- talists. Indeed, RTK may bring workers and citizens closer to win- ning the right to inspect worksites, demand improvements, and shut down dangerous operations. " Having won the right to know, we must now use it to shift actual decision - making power, " says Ger- ald Poje of the National Wildlife Fed- eration. Title III's greatest value will be to show people how their lives are directly affected by corporate decisions about what and how to produce, and to encourage them to demand their right to participate in those decisions. Y' Barbara Berney is a consultant on health care and occupational health in Washington, D.C. Winter 1987 Health / PAC Bulletin 33 ome two decades ago, I delivered an address at a Speaking S meeting of the Medical Committee for Human of Rights in which I heaped attack upon vitriolic attack on the Health & reactionary medical establishment, so redolent of racial discrimination, professional arrogance, and down- Medicine right venality. As I rose loquaciously to my jeremiad, excoriating Ameri- can physicians to the point, virtually, of banning them from the company of decent folk, I was interrupted by a Dealing With tug at my sleeve. Turning to my side, I saw Desmond Callan- now a pri- Doctors mary care practitioner in upstate New York crooking - his finger to Quentin Young draw my ear close to this whispered plea: " Quentin, remember, they are the only doctors we've got. " In the years since, dramatic and destabilizing events have reshaped the power, prestige, and position doctors formerly enjoyed. Their once exclusive - ranks have been swelled by ever greater - numbers of medical school graduates and immi- grant physicians: the so called - doc- tor glut. Educational supports from the federal government, including the wonderful National Health Service Corps, have been Reagan- ized into extinction; the newly- trained physician now leaves the hallowed halls of medical school Quentin Young is a physician and the president of Chicago's Health and Medi- cine Policy Research Group. wearing a saddle of mega - debts and micro options - . Cost controls and market strategies have voided their cushy deals, devastated their comfy cottage industry, and broken up their guild monopoly, shattering, in the process, naive professional prefer- ences for laissez - faire approaches. This is not, of course, a pity the- - poor doctor - story, for the whirlwind of distrust and disdain that my col- leagues are reaping is a result of nothing but the selfishness they have sown since the beginnings of the century. Nevertheless, if we want progressive change, we must recognize new opportunities as they arise and use the new power rela- tionships to formulate whatever strategies might be effective. In search of such change, I have come to believe that important segments of the American medical profession are ready for, maybe seeking, a new alliance to help them address the monstrous dilemmas of medical 34 Health / PAC Bulletin practice. Many physicians, for instance, are genuinely alarmed at the mechan- isms which limit care in managed health systems like HMO's. Others resent the discipline corporate interests impose on the medical workforce - which now includes myriad salaried physicians - as free- market health - care systems expand. Physicians bridle at the mountain of paperwork and miles of bureaucratic maze these systems compel them to deal with; practice is stifled and satisfaction replaced with drudgery. With all this, salaried physicians (including those in training), pri- mary physicians and those in small group practices, and public health doctors are all viewing the world and their work very differently. Hitherto unthinkable possibilities are suddenly credible, perhaps even practical. The time has come for health - care consumers - the elderly, the dis- abled, the handicapped, members of unions and minority groups - to form coalitions, locally and nation- ally, with those physicians'organiza- tions that are ready to deal. Both partners, will, by definition, have to benefit from these agreements. Con- sumers want quality as well as stable and fair costs. This could include mandatory Medicare assignment, capitation, elimination of deduct- ibles and copayments, and in- creased preventive services. The doctors will want more patients, less red tape, and protection from ruth- less market practices and the control of corporations; these aspirations are not inimical to patients'interests. A collaboration between physi- cians and their patients can define the path the United States must travel in order to achieve a humane, affordable health system. The doc- tors know they must either lie with the hounds (the corporations) or run with the hares (the people). Des Callan's warning against writing off our doctors makes even more sense now than it did 20 years ago. OE Winter 1987 Know News 2001: A Health Odyssey Nicholas Freudenberg Nick Freudenberg is director of the Pro- gram in Community Health Education at Hunter College School of Health Sciences / CUNY. 2/15/01: Begin my interviews with health educators on the frontlines for piece in Health / PAC's electronic Bulletin. Two hours late to first meeting couldn't find a jet cabbie who'd take me to Newark. First sub- ject named Thad, 25, works at ITT / Seagram distillery in new subterra- nean work leisur/ es l/e ep zone be- neath city's ruins. Thad's working on campaign to market vitamin - for- tified wine coolers (Fruit Looped) to high schoolers. We preview video featuring Michael Jackson, who's looking younger every year. Video sure to be big hit: MJ shimmies across screen, juggles cans, does the Mars Walk. Thad gives me cup of Fruit Looped. Tastes like melon- flavored freon. Nutri booze - cam- paign perfect for Thad, who shows me copy of his master's thesis from Kaiser University's School of Health Promotion: Changing Nutritional Be- havior Through Tele manipulation - of High visibility - , Pseudo - erotic Role Models. Impressive. 2/17/01: Saw Mini today, on Thad's recommendation. Mini head of health ed. unit of New Orleans health dept. Four hours late - Super- conductor Express hit heavy rail traf- fic outside of Graceland. Mini's responsibilities: awards contracts to private - sector health - ed companies, health - dept. liaison to NO Chamber of Commerce, develops promotional videos for area HMO's. Mini tells me (overjoyed) that Jane Fonda Health Spas recently given major health - ed. franchise: " The Janey - Spas have just launched a campaign to media - ex- pose the benefits of three 20 minute - aerobic cardiovascular jazzercise workouts in the city's Janey Gyms -, " adds (ecstatic), " they have five con- venient locations. " So far, 98% of registrants are white, middle - class women from the condo district, no low income - minorities. Mini's work- ing out arrangement - city will pay Fonda $ 2,000 bounty for every low- income person they recruit. Mini: a real problem - solver. | 2/18/01: Back in New York. Heavily overcast day; Blue Cross / Blue Sieve health - radio put available sunlight level at 35%. Visited Andra in Great Neck, once a patient educator in the old vol hosp - days. Six hours late for appointment when shuttle copter got lost in smog bank. Ended up taking bus from Brooklyn. Andra is Director of Health Education, Public Relations and Utilization at Mega- Humana 743. Business has been white - hot since deregulation of hospital industry. Ask her about proudest achievement. She des- cribes 743's cardiovascular outreach program: " For a modest fee, anyone can sign up for our Happy Heart health program. Members meet weekly at the hospital's penthouse gym. If, at any time, they need cardiac surgery after successfully completing the course, they're en- titled to a 10 percent discount. " Happy Hearts'success has spawned spin - off they're offering to members of 743's local HMO's. Users par- ticipating in Mega Humana's - video home care program and who stay out of mainframe hospital for 12 months get free weekend in Hu- manarest, new hospi - hotel facility. " A lovely place to stay that makes efficient use of the hospital's swing beds, " Andra explained. Good thinking. 2/19/01: Last interview: Mull, head of health education department at Columbia Business Sch. (school B - acquired health - ed after Sch. of Pub- lic Health dismantled). Eight hours late - f orgot to set alarm clock. Mull's students take marketing, public relations, accounting, man- agement, video production. Also an elective in public health, two semesters in ethics (instills " profes- sional standards "). Mull worried that tuition, now fifth highest in country (35,000 $) , will keep away low- and middle income - students, but mentions new Marlboro Man Health Promotion scholarship- Reynolds pays 50% of student's tui- tion for five year - commitment after graduation. A real go getter -. 2/21/01: Didn't feel like writing piece today - sharp toothache. Called Gatekeepers'Health Plan, switch- board physician told me wrap string around tooth, other end to door- knob, slam door. Said co payment - bill for consultation would arrive tomorrow. Felt lousy drank - three cans of Fruit Looped. Felt better. Y' Winter 1987 Health / PAC Bulletin 35 Know News 2001: A Health Odyssey Nicholas Freudenberg Nick Freudenberg is director of the Pro- gram in Community Health Education at Hunter College School of Health Sciences / CUNY. 2/15/01: Begin my interviews with health educators on the frontlines for piece in Health / PAC's electronic Bulletin. Two hours late to first meeting couldn't - find a jet cabbie who'd take me to Newark. First sub- ject named Thad, 25, works at ITT / Seagram distillery in new subterra- nean work leisur/e s l/e ep zone be- neath city's ruins. Thad's working on campaign to market vitamin - for- tified wine coolers (Fruit Looped) to high schoolers. We preview video featuring Michael Jackson, who's looking younger every year. Video sure to be big hit: MJ shimmies across screen, juggles cans, does the Mars Walk. Thad gives me cup of Fruit Looped. Tastes like melon- flavored freon. Nutri booze - cam- paign perfect for Thad, who shows me copy of his master's thesis from Kaiser University's School of Health Promotion: Changing Nutritional Be- havior Through Tele manipulation - of High visibility - , Pseudo - erotic Role Models. Impressive. 2/17/01: Saw Mini today, on Thad's recommendation. Mini head of health ed. unit of New Orleans health dept. Four hours late Super- - conductor Express hit heavy rail traf- fic outside of Graceland. Mini's responsibilities: awards contracts to private - sector health - ed companies, health - dept. liaison to NO Chamber of Commerce, develops promotional videos for area HMO's. Mini tells me (overjoyed) that Jane Fonda Health Spas recently given major health - ed. franchise: " The Janey - Spas have just launched a campaign to media - ex- pose the benefits of three 20 minute - aerobic cardiovascular jazzercise workouts in the city's Janey Gyms -, " adds (ecstatic), " they have five con- venient locations. " So far, 98% of registrants are white, middle - class women from the condo district, no low income - minorities. Mini's work- ing out arrangement - city will pay Fonda $ 2,000 bounty for every low- income person they recruit. Mini: a real problem - solver. " 2/18/01: Back in New York. Heavily overcast day; Blue Cross / Blue Sieve health - radio put available sunlight level at 35%. Visited Andra in Great Neck, once a patient educator in the old vol hosp - days. Six hours late for appointment when shuttle copter got lost in smog bank. Ended up taking bus from Brooklyn. Andra is Director of Health Education, Public Relations and Utilization at Mega- Humana 743. Business has been white - hot since deregulation of hospital industry. Ask her about proudest achievement. She des- cribes 743's cardiovascular outreach program: " For a modest fee, anyone can sign up for our Happy Heart health program. Members meet weekly at the hospital's penthouse gym. If, at any time, they need cardiac surgery after successfully completing the course, they're en- titled to a 10 percent discount. " Happy Hearts'success has spawned spin - off they're offering to members of 743's local HMO's. Users par- ticipating in Mega Humana's - video home care program and who stay out of mainframe hospital for 12 months get free weekend in Hu- manarest, new hospi - hotel facility. " A lovely place to stay that makes efficient use of the hospital's swing beds, " Andra explained. Good thinking. 2/19/01: Last interview: Mull, head of health education department at Columbia Business Sch. (school B - acquired health - ed after Sch. of Pub- lic Health dismantled). Eight hours late - f orgot to set alarm clock. Mull's students take marketing, public relations, accounting, man- agement, video production. Also an elective in public health, two semesters in ethics (instills " profes- sional standards "). Mull worried that tuition, now fifth highest in country (35,000 $) , will keep away low- and middle income - students, but mentions new Marlboro Man Health Promotion scholarship - Reynolds pays 50% of student's tui- tion for five year - commitment after graduation. A real go getter - . 2/21/01: Didn't feel like writing piece today - sharp toothache. Called Gatekeepers'Health Plan, switch- board physician told me wrap string around tooth, other end to door- knob, slam door. Said co payment - bill for consultation would arrive tomorrow. Felt lousy drank - three cans of Fruit Looped. Felt better. Y' Winter 1987 Health / PAC Bulletin 35 J Labor's Safety & Health Movement See page 17 WE IBP RING RESCUE OUR RECORDS Inside: The Wall Street crash page 3 Why the Dellums bill still matters page 12 Queries on quackery page 22 2001: A Health Odyssey page 35 America peddles cigarettes in the Far East page 28 Health Policy Advisory Center 17 Murray Street New York, New York 10007 2nd Class Postage Paid at New York, NY. NOTE TO SUBSCRIBERS: If your mailing label says 8611, your subscription expires with this issue.