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HEALTH / PAC BULLETIN Policy HeaAdlvitsohry Center No. 1976 70 May / June 1 HSAS: IF AT FIRST YOU DON'T SUCCEED... The National Health Planning and Resources De- velopment Act of 1974 tries to plan for na- tional health insurance, but falls victim to special interests. 16 Media Scan: Health Care Politics: Ideological and Interest Group Barriers to Reform, by Robert R. Alford 22 Peer Review 24 Vital Signs NHI HSAs AT FIRSTI F If the early days of Medicare and Medicaid YOU DON'T represented the honeymoon period in the SUCCEED... marriage between the federal government and health - care providers, particularly hos- pitals, the current period represents a mid- life crisis, in which the terms of the marriage contract are up for grabs and the future na- ture of the relationship is in doubt. One im- portant reflection of that shift can be seen in the politics of the enactment and implementa- tion of the new federal health planning - legis- lation, formally titled the National Health Planning and Resources Development Act of 1974, more commonly known as PL 93-641. Passed during the closing days of the 93rd Congress and signed into law January 4, 1975, during the early months of the Ford Administration, PL 93-641 represents an at- tempt by federal policymakers to create a health planning - mechanism capable of con- taining health - care costs before national health insurance becomes a reality. The law HSAST Bill Plymo replaced the comprehensive health planning program (CHP), which had expired, un- mourned, six months earlier. It also revamped the Hill Burton - program for medical facilities construction and killed off the regional medi- cal program (RMP). (See BULLETINS, May 1973, May / June 1975, p. 23.) The complexity of the Act's provisions - it takes 33 pages to set forth what the CHP law had covered in five - has been the de- spair of many observers and has led to wide- ly varied interpretations of its meaning. The niceties of its language, however, are appre- ciably less important than the legislative and bureaucratic happenings it has inspired, which are indices of the dynamic of forces working to shape the future of the health- care system. And the legislative language is, in critical instances, sufficiently ambigu- ous to permit widely differing effects, de- pending on political realities at a given time and place. The legislative process saw the cost - cut- ting, rationalizing interests of the federal gov- ernment being confronted, not surprisingly, by the interests of the hospital lobby. The hospital lobby supported a health planning - process which buttressed existing institutions and it otherwise sought to minimize govern- mental interference with hospitals'freedom of action. (The AMA persisted in seeing fed- eral health legislation as an unmitigated evil and thereby continued to make an ass of it- self; see box page 2.) The planning legisla- tion also brought to the halls of Congress an- other complex of interests not typically con- cerned with health legislation, namely state and local governments, which came out of the woodwork to maximize control over what they saw as the present and potential pork barrel of federal health resources. The interests of monopoly capital have been aligned with federal bureaucratic inter- ests in seeking to contain the costs of health care. Health - care costs, after all, are subsi- dized to a large extent by taxes and fringe benefits which, directly or indirectly, are costs of doing business. This sector also sees cost containment as necessary to ward off a crisis which might lead to nationalization of the health system. The interest of health - care consumers in accessible, comprehensive health care at a reasonable cost has not in itself been of con- cern to these appreciably more powerful 2 forces. At best, consumers have been the in- AMA Strikes Out The lobbying strategy of the American Medical Association (AMA) vis vis - a - the health planning - legislation was totally de- termined by its fear that the law might en- croach on the domain of its private - practi- tioner constituency. As a result, the AMA's approach to the legislative and administra- tive process can best described as ineffectual political action followed by ineffectual legal action. The AMA credits its lobbying with winning deletion from the House bill of any reference to rate regulation, but others say it bargained away most of its chips on that ef- fort and that a faux pas by its Illinois affiliate created momentum that defeated a number of diluting amendments offered in committee. The executive director of the Illinois State Medical Society sent a memo to 14 other state societies observing that " if we get lucky, we may create sufficient disarray within the [House Commerce] Committee to delay the whole bill. " The memo somehow got to Com- cidental beneficiaries of the federal bureau- crats'efforts to undermine the power of health - care providers to break the federal bank. In summary, the legislative process that coughed up PL 93-641 saw Congress and the White House become the battleground for a complex struggle with many combatants, in which shifting alliances developed around particular issues. What got coughed up was a description of a monumentally complicated structure, in which planning and _ limited forms of regulation are to take place at three levels local, state and federal - and in which the relations among the respective functions of the three levels are simultaneously tangled and ambiguous. At the local level about 200 health systems agencies (HSAs) will spin out health plans of various descriptions, review and approve or disapprove applications by local provid- ers for federal funding and take part in cer- tificate - of - need programs applying to insti- tutional health services. At the state level state health planning and development agen- cies and statewide health coordinating coun- mittee Chairman Harley Staggers, who was not amused. As the legislative process progressed, the AMA tried to get the entire bill scuttled in favor of a simple one year - extension of the comprehensive health planning (CHP) pro- gram and, failing that, urged President Ford to veto the legislation. After enactment, the AMA took a hands - off position - issuing pot- shots (the " single, most potentially destruc- tive piece of medical legislation ever en- acted, " said Dr. James H. Sammons, AMA ex- ecutive president vice - ) but not even bothering to assign a staff person to keep track of the Act's implementation. In line with its newly militant posture, how- ever, the AMA did threaten a lawsuit. It started threatening a lawsuit in January, 1975, shortly after the law was signed, when its Executive Committee directed its legal staff to draw up the papers. (The " courts are our last resourt to prevent saddling the nation's patients and physicians with this bad legisla- tion, " declared Board Chairman Dr. Richard E. Palmer.) It continued to threaten a lawsuit - in June, 1975, when the House of Delegates voted its support of legal action. By the fall, trade press reports of an " imminent lawsuit " had yielded to press speculation that the AMA had decided to concentrate its energies on getting rid of then HEW - planning chief Eu- gene J. Rubel (see text) rather than file a suit that appeared to have little prospect of suc- cess. In February, 1976 the rumor mill reported that imminent HEW regulations on the certifi- cate need - of - provision of the legislation would " exclude from that program's purview or- ganized ambulatory health care facilities; " that exclusion was intended as a means of warding off an AMA lawsuit. Sure enough, the proposed regulations appeared March 19 with that exclusion. (Ambulatory surgical fa- cilities were included, but with the explanation that that term " does not include the offices of private physicians or dentists, whether for in- dividual or group practice. ") In April, how- ever, it was rumored that the AMA would join the state of North Carolina in a suit against the law, presumably as a means of maintain- ing some credibility without risking failure alone. cils, not to mention governors, will jointly develop guidelines governing national health- planning policy and further plan and admin- ister the certificate - of - need program. HEW has broad supervisory functions over every- thing in the structure below it and serves as an appeals agency for the review - and - ap- proval process. A national council on health planning and development gives advice to HEW. Notice To Subscribers Health / PAC has successfully held down its publication costs over the years. As a result general subscription rates for the BULLETIN have not changed since its inception eight years ago. But rising costs have finally caught up with us. Beginning October 1, 1976, therefore, subscription rates will go up. The new rates will be $ 8 Student sub- scription, 10 $ Regular subscription, and $ 20 Institutional subscription. Sub- scribers will continue to receive occasional special reports at no extra cost. Published by the Health Policy Advisory Center, 17 Murray Street, New York, N.Y. 10007. Telephone (212) 267-8890. The Health / PAC BULLETIN is published 6 times per year: Jan./Feb., Mar./Apr., May June /, July Aug /., Sept./Oct. and Nov./Dec. Special reports are issued during the year. Yearly subscriptions: $ 5 students, $ 7 other individuals, $ 15 institutions. Second - class postage paid at New York, N.Y. Subscriptions, changes of address and other correspondence should be mailed to the above address. New York staff: Barbara Caress, Oliver Fein, David Kotelchuck, Ronda Kotelchuck, Louise Lander, Steven London and Ken Rosen- berg. San Francisco staff: Robin Baker, Elinor Blake, Thomas Bodenheimer, Dan Feshbach, David Landau, Eugene Lacaric, Ellen Shaffer. S.F. office: 558 Capp Street, San Francisco, Cal. 94110. Telephone (415) 282-3896. Associates: Robb Burlage, Morgantown, W.Va.; Constance Bloomfield, Desmond Callan, Nancy Jervis, Kimmerling Kenneth , Howard Levy, Marsha Love, New York City: Vicki Cooper, Chicago; Barbara Ehrenreich, John Ehrenreich, Long Island; Judy Carnoy, Carol Mermey, San Francisco; Susan Reverby, Boston, Mass. BULLETIN illustrated by Bill Plympton. Health Policy Advisory Center, Inc. 1976. 3 This grossly oversimplified version of the statute is fleshed out somewhat in the box appearing on page 8. Any description of the legislative program based solely on the lan- guage of the law, however, bears roughly the same relation to the emerging reality as a pattern bears to the finished garment. CHP: Rejecting the Past The new planning legislation grew out of a widely shared consensus that CHP had been an abysmal failure at rationalizing the health - care system and that it was unthink- able to unleash the inflationary imperatives of national health insurance without creat- ing a new planning mechanism capable of bringing health - care cost inflation under con- trol. The comprehensive health planning legis- lation had been enacted in an offhanded way in 1966 by the same Congress that gave us Medicare and Medicaid and was amended three times thereafter to patch up some of the holes. It spawned a network of state CHP agencies (A agencies), which were units of state government, and areawide agencies (B agencies), which were mostly private, non- profit corporations. The (letter designations of the agencies came from their having been authorized by subsections (a) and (b) of the legislation.) The A and B agencies were given a vague mandate to develop state and areawide com- prehensive health plans, which they were given inadequate resources to develop (the average size of the B agencies'staff was three) and, in any event, no authority to im- plement. The closest thing to a sanction exist- ing in the program was the power given the B agencies to review and comment on appli- cations for federal categorical health grants filed by providers in their area. The problem was that these comments could be disre- garded by the federal granting agency, not to mention the underlying problem that this function was limited to that narrow range of provider activity represented by such federal grants. The B agencies were required to match their own federal operating grants with local funds, funds that frequently turned out to be contributions from provider groups. That fact, needless to say, made it awkward at best for the B agencies to take a hard line against the 4 institutional plans of local providers. A significant structural feature of the pro- gram, reflecting its genesis in the era of " max- imum feasible participation, " was its require- ment that areawide agencies be governed by councils with a majority of health - care con- sumers. The result was an inordinate preoc- cupation with the niceties of the consumer- provider distinction. That preoccupation in turn disguised two underlying problems: first, the federal definition of " provider " was so narrow that a hospital trustee or a doctor's wife would be classified as a consumer; sec- ond, even an individual who was a consumer in the strictest sense was not necessarily an advocate for consumer interests (or, even if such an advocate, did not necessarily rep- resent a constituency that would require such advocacy to be taken seriously). The net ef- fect, as explained to those who read Health Care Management Review, is that: "... in business, a 51 percent majority means full control.... However, this is not so in the health planning business. " (1) The CHP program had no sig- nificant effect on the behavior of health - care providers. Constrained by its lack of resources, lack of power and the ineffectuality of its con- sumer input, the CHP program had no signifi- cant effect on the behavior of health - care providers. This worried federal policymak- ers. The Senate Committee Report on PL 93- 641, after noting that CHP has been " only marginally successful, " opines in the next paragraph that " effective comprehensive health planning activities are an absolute prerequisite to the successful implementa- tion of a national health insurance pro- gram. " " (2) NHI: Postponing the Future This statement reflects a concern engen- dered by the roaring inflation in health - care costs that came in the wake of the enactment of Medicare and Medicaid. In particular, a significant part of the increase in expendi- tures on Medicare and Medicaid since their inception in 1966 represents the increase in the cost of a day of inpatient hospital care- an increase from an average of $ 49.22 in fiscal 1967 to 110.77 $ in fiscal 1974. (3) In turn, many in both the legislative and executive branches came to perceive that an excess of hospital beds had developed, spurred by the availability of Medicare and Medicaid reim- bursements, and had created an incentive to overutilize this inordinately expensive form of health care. (The Senate Committee Re- port cites estimates of unnecessary beds ranging from 67,000 to 110,000, or 5 to 7 per- cent of the US total; then HEW - Secretary Caspar Weinberger threw around the figure of 70,000.) Thus effective health planning, as a means of reining in and rationalizing a system dan- gerously out of control, came to be seen by federal health managerial types as an es- sential prerequisite to any expansion of Medicare and Medicaid in the direction of national health insurance. One month after the enactment of PL 93-641, in February, 1975, the then director - of health planning at HEW, Eugene J. Rubel said: " This law is attempt- ing to provide a better management focus for the health industry. It is clearly a step in the direction of national health insurance, and it is an attempt to avoid the mistakes made with Medicare and Medicaid. " (4) Back in November, 1974, when neither house of Congress had acted on the legislation, HEW Undersecretary Frank C. Carlucci had spoken of the Administration's intention " to work very hard to enact legislation this year. It's a high priority. It's important that we have a planning structure in place before the enact- ment of a national health insurance pro- gram. " (5) An early attempt to rationalize the health system was a federal certificate - of - need law, known in the trade as section 1122 (of the 1972 Social Security Amendments). It pro- vided that the depreciation and interest portion of Medicare and Medicaid reimburse- ments to institutions would be disallowed if the capital expenditures in question had not received prior review and approval by a designated state agency, usually the CHP A agency. (Implementation of the provision in a particular state, however, was subject to its governor's willingness to designate a state agency and enter into an agreement with HEW. It should be noted that depreciation and interest comprise but a small percentage A HSA B. Plympton CHP 510 of a hospital's reimbursement rate and that the appropriateness of recognizing such items as costs of operation for nonprofit entities has been frequently questioned.) Both the applicability and the sanction of section 1122 were severely limited. Nonethe- less, HEW saw the provision as an important precedent in linking planning and regulation and as the first stage in a strategy of con- trolling hospital costs by boosting state au- thority to halt overbedding. The next stage of that strategy was to be the projected overhaul of the CHP legislation. That overhaul, spurred on by the lapse of the CHP legislation on June 30, 1974, took over a year's worth of the legislative process and became part of PL 93-641. Much of what resulted has more to do with form than sub- stance, in particular with correcting some of the formal deficiencies of the CHP program. On matters of substance, the managerial inclinations of federal bureaucrats have been distorted by hospitals and state and local politicos. Thus the legislators'concern with the in- adequate resources available to CHP B agen- cies is reflected in provisions prescribing minimal staffing standards for their succes- sors, the HSAs, and requiring HEW to pro- vide HSAs with various forms of technical assistance. Their concern with lackadaisical HEW administration of the CHP program is seen in exhaustive provisions for HEW over- sight of the HSAs and the state health plan- ning and development agencies. Their con- cern with provider domination of the B agen- cies is translated into an excruciatingly com- plex definition of " provider " and a prohibi- tion against HSAs receiving money from pro- 6 vider sources. However, on matters of substance, and, to some extent, structure, the managerial incli- nations of federal bureaucrats have been dis- torted by special interest - lobbying by the hospitals and state and local politicos. While the hospitals were determined to protect their position of control over the health - care sys- tem, the politicos were seeking to gain lever- age over what they saw as a source of pa- tronage and local power. The County Commissioners Muscle In One expects to find lobbyists for the Amer- ican Hospital Association (AHA) on the scene when Congress is making moves in the di- rection of enacting health legislation. What is less expected but what was very much in evidence as the health planning - legislation struggled through the legislative mill was the vocal presence of a complex of interests not identified with the health - care system, rep- resented by the National Association of Coun- ties (NACO) and the National Governors ' Conference. Supporters of the legislation first collided with these narrow political interests over the issue of the proposed structure of the HSAs. NACO was determined that local govern- ment would control the HSAs. It wanted HSAs to cover more territory, have larger budgets and be granted more power than their predecessors. It also expected the HSAs eventually to allocate federal health re- sources including national health insurance funds. (Back in 1967, city and county govern- ments had staged a forerunner of this strug- gle when they had lobbied successfully for an amendment to the CHP legislation requir- ing representation of local government on the governing boards of B agencies, most of which were private nonprofit corporations rather than governmental entities.) NACO's position was diametrically op- posed by the Health Subcommittee of the House Commerce Committee, which had drafted a bill requiring that HSAs be private nonprofit corporations. This requirement largely reflected a fear that the purpose of curbing unnecessary hospital construction would be thwarted if politicians took over the health planning - business. In the words of Rep. William Roy (D., Kan.), then an influ- ential member of the Health Subcommittee, " It's almost impossible for a local govern- ment unit to be a health service agency with- out becoming a total advocate for additional services. It's extremely important that we separate health planning from local govern- ment, so we don't get right back into the soup of'anything that's bigger is better.'" (6) The House Subcommittee's stance was also a measure of deference to the hospital lobby: it represented a view of health, in the words of the Committee's report on the bill, as " basically a private industry " in which " there are some private providers of health care who are reluctant to submit to planning done by public government. " (7) Of course neither the pork barreling - inter- ests of the local politicos nor the cost contain- - ment interests of the government had any- thing to do with decent health care per se. Consumers might plausibly feel that their voices as voters would count for more with a government agency like an HSA than with a private corporation. But the staff of such an agency might well be loaded with recipients of patronage or civil servants who are not the most effective advocates for a patient- centered health - care system. But despite the House Committee's position and HEW's support of that position, NACO's lobbyists rounded up enough votes to pass an amendment in the House permitting HSAs to be private nonprofit corporations, public benefit corporations, public regional plan- ning bodies or single units of local govern- ment. The provision survived the House - Sen- ate Conference Committee (the Senate bill had permitted HSAs to be either private or public), albeit with a provision taken from the Senate bill requiring public HSAs to have a separate governing body for health plan- ning. If the meantime, the National Governors ' Conference focused on the precise division of functions among the governors, the HSAs beneath them and HEW above them. (The statute assigns certain functions to governors, as distinct from the state health planning agencies and the statewide health coordina- ting councils (see box page 8).) It succeeded in nudging the House Health Subcommittee to increase the governors'power in the de- lineation of the boundaries of health service areas and in persuading the Senate Labor and Public Welfare Committee to increase their power to determine the composition of the statewide health coordinating councils. Ultimately, however, the legislators rebuffed the gubernatorial onslaught by leaving in place provisions that would enable HEW to play a strong, presumably nonpolitical, su- pervisory role, supervising both state plan- ning functions themselves and the functions of the HSAs. Whether the federal administra- tors will choose to exercise their managerial prerogatives is of course another question. Watering Down: The Hospital Lobby While governors and county commission- ers expressed their concern over who would control the planning structures, the hospital lobby concerned itself with the far more com- pelling issue of what sanctions were avail- able as forms of control. Neither the pork barreling - interests of the local politicos nor the cost containment - inter- ests of the government had anything to do with decent health care per se. One weak sanction that survived the legis- lative process is the power of HSAs to " re- view and approve or disapprove " funding proposals. This escalates the previous powers of CHP B agencies to " review and comment " on providers'applications for categorical health grants, for example, under the Public Health Service Act or the Community Mental Health Centers Act. The catch, however, is that, in the event of an HSA disapproval, the provider in question may appeal to HEW, which may fund the application despite HSA disapproval. Of more interest than the review - and - com- ment or review approval - and - function, fed- eral policymakers projected a scenario for locating at the state level a complex of reg- ulatory, as opposed to planning, functions aimed at containing the quantity and cost of institutional health services. This on the the- ory that while private bodies may engage in planning (private, nonprofit corporations usually comprise local planning structures), regulation is properly a function of govern- ment. (Continued on page 10) 7 All You Ever Wanted To Know About PL 93-641 Perhaps the most striking feature of PL 93- 641 is the complex hierarchy it creates. From bottom to top, the structure and functions of the various layers of that hierarchy, as set forth in the statute, look like this: OE HEALTH SYSTEMS AGENCY HSA (). Structure: May be either private nonprofit or public benefit corporation, public regional planning body or single unit of general local government. In any case the HSA must have a governing body of 10 or more members with an executive committee of no more than 25. The governing body must include 51 to 60 percent health - care consumers who are not providers and who represent the social, eco- nomic, linguistic and racial populations and geographical areas of the health service area and major health - care purchasers. Of pro- vider members at least one third - must be di- rect, as opposed to indirect, providers. (Defi- nition of " provider " in the statute is worthy of the Internal Revenue Code and is designed to prevent, e.g., the wife of a hospital trustee from being classified as a consumer.) Repre- sentatives of local government must be on the governing body, either as consumers or pro- viders. If the area includes a Veterans'Ad- ministration facility or a federally recognized Health Maintenance Organization, they must be represented on the governing body. Functions: Establish, review annually and amend as necessary a long range - health sys- tems plan. Establish, review annually and amend as necessary an annual implementa- tion plan. Once an HSA has developed these plans it is eligible to receive from HEW, sub- ject to congressional appropriations, a grant to establish an Area Health Services Devel- opment Fund. It may use this money to make grants and enter into contracts with public and private nonprofit entities for planning and development projects, but not to cover the cost of delivering health services or con- structing or modernizing health facilities. The HSA is also mandated to review and approve or disapprove applications for various federal health grants, not including Medicare and Medicaid (subject to reversal by HEW in the 8 case of a disapproval). At least every five years it must review institutional health serv- ices in its area for continued " appropriate- ness " and make recommendations to the state health planning and development agency. As part of the state certificate - of - need pro- grams, the HSA reviews and makes recom- mendations to the state agency concerning the need for any proposed new institutional health services. @ STATEWIDE HEALTH COORDINATING COUNCIL (SHCC). Structure: At least 16 representatives of HSAs within the state, appointed by the gov- ernor from lists of at least five nominees each, of which at least one half - are to be health- care consumers. These plus other guberna- torial appointments may not exceed 40 per- cent of the total SHCC membership, of which a majority must be consumers. At least one- third of all providers must be direct providers. Functions: Annually reviews and coordi- nates the plans of each HSA and sends their comments to HEW. At least annually pre- pares state health plans made up of the HSAs ' health systems plans, based on preliminary plans submitted by the State Health Planning and Development Agency (with revisions as necessary to achieve coordination or meet statewide needs). Reviews and sends com- ments to HEW on each HSA's annual budget and applications for development fund grants. Reviews and approves or disapproves appli- cations submitted by the state for funds under various federal health programs, not includ- ing Medicaid also (subject to reversal by HEW in the case of a disapproval). OE STATE HEALTH PLANNING AND DE- VELOPMENT AGENCY. Structure: An agency of state government designated by governor; any of its functions may be performed by another state agency at the governor's initiative and with HEW's approval. Functions: Prepares a preliminary state health plan for submission to the SHCC. Ad- ministers a state certificate - of - need program applicable to proposed new institutional health services. At least every five years re- views institutional health services in the state and, after considering the recommendations of the relevant HSA, makes public its findings as to their continued " appropriateness. " OE GOVERNOR. Designates the boundaries of health serv- ice areas within the state, subject to revision by HEW. Is consulted by HEW about the HSA applicant. Selects an agency of state govern- ment to serve as the State Health Planning and Development Agency. Appoints the members of the SHCC. OE HEW. Issues and periodically revises guidelines concerning national health planning policy, including standards of " the appropriate sup- ply, distribution, and organization of health resources " and a statement of health plan- ning goals developed from the priorities spe- cified in the statute, after considering com- ments from all other levels of the structure and from provider organizations. Designates health service area boundaries, based on gubernatorial designations unless they fail to meet the requirements of the statute. Desig- nates HSAs, after consultation with gover- nors. Makes operating grants to HSAs and state agencies, and health services develop- ment grants to HSAs that have a health sys- tems plan and an annual implementation plan and are performing satisfactorily. Pro- vides technical assistance to HSAs and state agencies. Establishes a national health plan- ning information center and grants federal funds for the establishment of at least five cen- ters for health planning. Establishes a uni- form system for calculating the aggregate cost and aggregate volume of institutional health services, a uniform cost accounting system for health services institutions, a uni- form system for calculating reimbursement rates for health institutions, and a classifica- tion system for services health - institutions. Annually reviews and approves or disap- proves the budget of each HSA and state agency. At least every three years reviews in detail the structure, operation and perform- ance of the functions of each HSA and state agency. Prescribes performance standards for each HSA and state agency and estab- lishes a reporting system to permit continuous review of their structure, operation and per- B. Plympton formance. Reviews funding applications dis- approved by local HSAs upon request of the applicant and may make federal funds avail- able notwithstanding HSA disapproval, giv- ing a statement of reasons to the HSA and state agency. Reviews disapprovals of state applications for federal funds by SHCCs at the governor's request and may make federal funds available, giving a statement of rea- sons to the SHCC. Makes grants for demon- stration programs of rate regulation - to no more than six state agencies. Appoints mem- bers of the National Council on Health Plan- ning and Development, except for the three ex officio members. OE NATIONAL COUNCIL ON HEALTH PLANNING AND DEVELOPMENT. Structure: Fifteen members, of which three are nonvoting ex officio - members (the Veter- ans Administration's Chief Medical Officer, the Assistant Secretary of Defense for Health and Environment and the Assistant HEW Sec- retary for Health). The remaining members are appointed by the HEW Secretary for six- year terms. At least five of them are not pro- viders of health services, three are members of HSA governing bodies, more than three are federal officers or employees and three are members of SHCCs. The two major politi- cal parties are to have equal representation. Functions: Advises and makes recommen- dations to the HEW Secretary concerning the development of national health planning guidelines, the implementation of the law and the implications of new medical technology for health - care organization and delivery. HSAs (Continued from page 7) Of the three state regulatory mechanisms considered, the only one to emerge without maiming from the legislative process is a re- quirement that state agencies administer a certificate - of - need program applying to pro- posed new institutional health services, that is, a program prohibiting the construction or expansion of health - care institutions without prior approval of the state agency. The stat- ute gives HEW approval power over the de- tails of the state program and requires that recommendations of the relevant HSAs be considered in administering it. The reason for the smooth legislative sail- ing of the certificate - of - need provision is sim- ply that the AHA and its state affiliates have since 1968 been supporters of state certificate- need of - legislation. Prior to 1968 only one state, New York, had such legislation on its books; by January, 1975, when PL 93-641 was enacted, 29 states and the District of Colum- bia had passed certificate - of - need laws. Many state laws hooked up with the federal CHP legislation by designating the CHP A agency as the administering agency of the certifi- cate need - of - mechanism. The AHA position reflects the realization that a franchise to exist in perpetuity is ulti- mately a protection against competition. In other words, an existing hospital, by virtue either of having a certificate or being ex- empted from the need for one because of its prior existence, is at least to some extent pro- tected against the danger of a competing hos- pital opening nearby and stealing its pa- tients. As observed by the authors of a sur- vey of state certificate - of - need laws, " Con- trol of facilities expansion is currently in ac- cordance with the goal of both the health planners and the dominant, established health care institutions in most states and communities. " (8) HEW has touted the certificate - of - need pro- vision of PL 93-641 as an enormous improve- ment over the earlier version contained in section 1122 of the 1972 Social Security Amendments since preventing unnecessary facilities construction is preferable to apply- ing a financial sanction to such construction after it's taken place. Still, the device re- mains a reactive mechanism - the regulatory 10 agency may only bring its planning function to bear in the context of scrutinizing someone else's proposal to create new facilities or services. Its planning function remains unim- plementable to the extent that it either iden- tifies areas of need that no provider desires to fill or identifies already existing services or facilities that should be eliminated. The problem of superfluous real estate or services (whether reflecting initial overbed- ding or subsequent population shifts) could logically be met by a regulatory mechanism if existing facilities were subject to periodic reexamination of their continued usefulness, and provision made for their being phased out if they were judged no longer needed. Such recertification, however, would under- mine the hospital lobby's rationale for sup- porting certificate - of - need programs, namely their assurance of monopoly status to ap- proved institutions. Thus in the context of the legislative proc- ess, the recertification - of - need idea was no match for the organized onslaughts of an en- trenched interest group. Both Senate and House bills began the process with a provi- sion for periodic review by state planning The AHA realizes that a fran- chise to exist in perpetuity is ultimately a protection against competition. agencies (with HSA input) of the continued need for institutional services and facilities and for their improvement, restructuring or elimination if not needed. The AHA's predic- table attack on those provisions was couched not in terms of hospitals'fears of losing their monopoly status but in terms of the difficulty of borrowing for capital construction in the private money market if one's lenders could not be assured of one's continued existence. In the Senate the AHA onslaught won a floor amendment shooting the recertification provision full of holes in the form of major exceptions to its applicability. In the House, AHA allies secured passage of a two part - floor amendment: the first part substituted " appropriateness " for " need " as the standard against which facilities and services would be reviewed, and the second eliminated any sanction for " inappropriateness " and _ re- duced the state agency merely to making public its findings. The House provision emerged from Conference Committee, and the Conference report went so far as to note the conferees'desire " to stress that the pur- pose of the findings by the State Agency is to inform the public and providers of health services as to the appropriateness of particu- lar services and what, if any, voluntary reme- dial actions are advisable. " (9) The AHA then announced that the House passed - provision had been its preference (10), probably be- cause it eliminated any possibility of a mean- ingful sanction. Of course even the combination of certifi- cation and recertification of need would at best be an indirect strategy for bringing health - care costs under control - which is, in the end, what most legislators and bureau- crats see as the point of the whole exercise. Regulation of institutional reimbursement rates would presumably be a lot more direct as a cost controlling - strategy. The AHA cal- culated that its constituents would benefit in some states and suffer in others at the hands of rate setting - agencies and was thus un- happy at the prospect of their creation nation- wide. It proposed that rate regulation should not be included in federal legislation unless that legislation also provided for comprehen- sive health - care financing (i.e., was national health insurance). In its opposition to a rate- setting provision in the planning law the AHA was joined by the Blue Cross Associa- tion, but for the opposite reason. Blue Cross plans in many localities pay hospitals at dis- counted reimbursement rates justified - on the theory that Blue Cross pays more promptly than commercial insurers and government agencies and BCA feared that rate setting - agencies would establish a single reimburse- ment rate for all third party - payers. After much wavering, the House Health Subcommittee caved in and deleted any reference to rate regulation in its bill. The strongest position on rate regulation taken at any point in the legislative process was a provision reported out by the Senate Labor and Public Welfare Committee, with HEW support, and passed by the Senate. It would have made federal grants available to states that chose to establish programs regulating reimbursement rates. After much wavering during the drafting and redrafting process, the House Health Subcommittee caved in and deleted any reference to rate regulation in its bill, including even a com- promise that would have required publica- tion of reimbursement rates by state planning agencies. The Senate House - Conference Com- mittee took the Senate's provision for optional rate setting - and the House's lack of any pro- vision for rate setting - and came up with a provision for HEW to award grants for dem- onstration programs of rate setting - in no more than six states. Managing Thin Air In the end, the hospital lobby's focus on the issue of sanctions and its relative uncon- cern with the issue of structure paid off: who- ever is warming the chairs in the confer- ence rooms under the new law, their power to encroach on institutional interests is se- verely limited. Not that the hospital lobby plans to stay away from those deliberations; one of the AHA's publications has advised its constituents that " If the HSAs are to be re- sponsive to local needs, local hospitals must play a major role in the selection of the HSA board, in the formation of the HSA itself, and in the development of adequate HSA staff- ing. " (11) The managerial, cost containment - thrust that provided the original impetus for the legislation ended up being reflected in pro- visions that appear to be wholly symbolic. Many commentators have made much of the unprecedented mandate to establish a set of national health priorities to be considered in the formulation of national health planning policy guidelines, a task another provision assigns to HEW. Of the ten priorities enu- merated, however, seven concern themselves with cost containment - and / or efficiency - in- cluding the development of health mainte- nance organizations (HMOs), the increased utilization of physician assistants, the sharing of institutional support services and the edu- cation of the public in personal preventive health care. In part this provision reflects 11 congressional dissatisfaction with HEW's limited policy making - role in the past; the report of the House Commerce Committee ac- companying the planning bill noted that the Committee " has often felt the lack of a single coherent statement of national health policy and a concrete plan by the Department [of HEW] for achieving that policy. Thus, the proposed legislation specifies national health priorities... " (12) Cost accounting based on " true cost " may ultimately prove to be the sleeper of the statute. Another such managerial, but apparently only symbolic, provision, sandwiched in the middle of a section on technical assistance to state and local agencies, instructs HEW to develop a uniform system of cost account- ing for health - care institutions and a uniform system for calculating reimbursement rates, to be based on the true " cost " of services to a particular category of patients. This pro- vision is a survivor of the Senate bill's pro- vision for optional state rate regulation - pro- grams. It has no apparent purpose in the legislation as enacted, but some commenta- tors claim it will ultimately prove to be the sleeper of the statute and some hospital ad- ministrators have expressed anxiety that someone might try to do something with that cost information. Guerrilla Warfare in the Bureaucracy The federal health planning - bureaucracy, where one might expect a managerial ap- proach to the law's implementation, instead has been a battleground where state and lo- cal politicos have taken up arms, with con- siderable success, against federal managers. The leader of the managerial side and arch- enemy of the politicos has been Eugene J. Rubel, who was named acting director of HEW's Bureau of Health Planning and Re- source Development when the bureau was 12 created in May, 1975. Rubel is a Harvard MBA in his 30s who used to enjoy giving out statements about the landmark significance of the new planning legislation (We " are now very definitely intervening in the private practice of medicine and in the organization and operation of health care institutions. " (13)) and who has always been an advocate of the private nonprofit form of local plan- ning agency. Rubel's brash, full ahead - steam - approach to the law's implementation made him a tar- get of many governors, who were unhappy with how their interests emerged from the legislative process and were looking to the implementation process to improve their standing. A letter in August from the Human Resources Committee of the National Gov- ernors'Conference to Rubel's boss, Dr. Ken- neth M. Endicott, Administrator of HEW's Health Resources Administration, forecast " little hope of any cooperation between the Governors and the department in implement- ing this law " if Rubel retained his post. (14) Rubel declined to go quietly, and the bat- tleground then shifted to a search committee created by Endicott to come up with a per- manent health planning chief. An unnamed member of the search committee was quoted as explaining: " Two thirds of the anti Rubel - sentiment is anti the law. Those interests who resist the development of a coherent national health strategy are also anti Rubel -. " (15) As one might expect, Rubel's backers included Chairpersons Kennedy of the Senate Health Subcommittee and Rogers of the House Health Subcommittee. The search committee submitted the names of four candidates for Rubel's job including - Rubel himself to Endicott in December. The impasse continued, however, until March, when Rubel finally threw in the towel and informed Dr. Theodore Cooper, HEW Assist- ant Secretary for Health, that he was bow- ing out. Cooper made Rubel a special assist- ant and gave Rubel's post to Harry P. Cain II, PhD, director of the Office of Policy De- velopment and Planning. In the meantime, another victory for state and local politicos emerged in the very fine print of the Federal Register, when the first proposed regulations implementing the stat- ute were published on October 1, 1975 (three months late). These reflected the lob- bying efforts of NACO, the National Gover- nors'Conference and the National Associa- tion of Regional Councils (NARC), efforts fo- cussed on the interpretation of the statutory provision permitting HSAs to be public re- gional planning bodies or units of local gov- ernment. HEW required public HSAs to sep- arate the governing body for health plan- ning from its regular governing body (the latter being a county board of supervisors, for example, or a regional council of gov- ernments). The health planning - board was re- quired to have the same composition as pri- vate, nonprofit HSAs, a delicately balanced mix of consumers (between 51 and 60 per- cent), direct providers and indirect provid- ers. (The mix is also supposed to represent elected public officials, residents of nonmet- ropolitan areas and the social, economic, lin- guistic and racial populations of the health service area.) The more powers given the governing body for health planning, the less influential would be the regular governing body. As helpfully explained in the preamble (its language being the product of negotia- tions between Endicott and a governors'dele- gation), the proposed regulation would " per- mit (but not require) the regular public gov- erning board of a public health systems agency to exercise considerable authority over its health planning and resources de- velopment program. " (16) That " considerable authority " would include selecting and re- moving members of the health planning - board, establishing the agency's personnel policies, budget and operating procedures and reviewing and commenting on proposed agency actions. Both the AHA and members of the House Health Subcommittee made loud noises about the disparity between the proposed regulatory language and the statutory lan- guage. A " briefing " on the proposed regula- tions held later in October by HEW and the National Health Council was the scene of a heated argument between the representa- tives of the AHA and NACO. Five months later, when its second set of proposed regu- lations appeared on March 19, the most HEW could announce was that comments received on the proposed October regulations, which reportedly numbered about 700, " are cur- rently being evaluated within the Depart- ment. " (17) Boundary Disputes: Carving up the Cities Washington, DC has not been the only set- ting for the expression of conflict between national planners and parochial politicos. One decentralized manifestation of that con- flict has been the struggle around setting the boundaries over which HSAs will have juris- diction - the issue being whether those areas will conform to relatively smaller political jurisdictions or to broader economic regions. The boundary designation - function is shared between governors and HEW. Here as else- where, parochial political interests have been scoring over regional economic interests. In the Philadelphia area, for example, the issue was whether there would be one health service area encompassing the five county - Philadelphia area or whether those five coun- CONGRESS COUNTIES PL93.681 B. Plympton AHA 13 ties would be split up into three HSAs, one of which would limit itself to the city of Phil- adelphia. The larger area was favored by such regional economic interests as the Sun Oil Company and Rohm and Haas Corpora- tion, joined by the area's medical schools and their medical empires. The smaller was backed by Philadelphia Mayor Frank Rizzo, the county governments and the county med- ical societies. After originally designating the five counties as one area, HEW yielded to local political pressure and changed the des- ignation to three. A comparable scenario was enacted in Chicago. Mayor Richard Daley, via Illinois Representative Dan Rostenkowski, chairman of the Health Subcommittee of the House Ways and Means Committee, got the city rather than the metropolitan area designated as a health service area, despite a contrary recommendation by an HEW area designa- - tion task force. In the San Francisco Bay Area, pressure from county governments on Governor Edmund Brown Jr. persuaded him to recommend to HEW that the nine county - Bay Area be carved up into four health serv- ice areas. Sabotage from Above All these skirmishes of course have been motivated by the assumption that federal support for the health planning - process, financial and otherwise, would make control of that process worth fighting over. Evidence that this logical assumption might in the short run, at least, prove unwarranted first surfaced last December when HEW lost a budget bat- tle with the White House. HEW had asked for about $ 140 million for health planning - ac- tivities in fiscal 1977 (the law authorizes $ 176 million), which the Office of Management and Budget (OMB) had recommended cutting to $ 66 million. At a meeting with the Presi- dent, HEW's advocacy of speedy implemen- tation of the law lost out to OMB's go slow - approach at a reduced funding level. President Ford added insult to injury in January, when he included the health - plan- Ford is emerging as the superpolitico of them all. 14 ning program as one of many federal health programs to be consolidated into a health revenue - sharing scheme (see BULLETINS, March April 1976, May 1973). This maneuver was bound to slow down its implementation even if the revenue - sharing proposal was ul- timately rejected by Congress. Both the con- solidation and the reduced funding were pre- dictably attacked by the AHA and NACO, which on this issue found their interests to be congruent. By March, Dr. Paul Ellwood, one of the health scene's major market - re- formers and cost containment - strategists, was citing, as an example of the Ford Administra- tion's lack of a strategy to contain medical inflation, the fact that " Its proposals on the administration and financing of health plan- ning are effectively destroying that pro- gram. " (18) (Ellwood is best known as the originator of the Nixon HMO strategy, see BULLETIN, July August / 1972.) Ford's dilemma of course is that the tradi- tional Republican alliance with small - town and small business - interests has him calling in this election year both for reduced govern- ment intervention in the private sector and reduced government spending. But the only way to slow the growth of government spend- ing on health care, most of which goes to the private sector via Medicare and Medicaid reimbursements, is to increase government intervention, which would at least involve funding of a health planning structure that might eventually develop into a cost con- - tainment mechanism. Because Ford is ap- parently unwilling to acknowledge the pos- sibility of additional but cost effective - gov- ernment expenditures, he is emerging as the superpolitico of them all. Regulation As a Last Ditch - Rescue The supermanager of them all then be- comes a progressive, monopolist Republican expatriate from the Nixon Administration, former Assistant HEW Secretary for Health Dr. Charles Edwards. Currently senior vice- president of Becton, Dickinson and Company, a major manufacturer of hospital supplies, Edwards presented his scenario for " Rational Change in the Health Care System " (19) at a forum sponsored by Arthur D. Little, Inc. in March. After arguing that the cost of health care " is becoming prohibitive " and that that fact made inevitable the occurrence of " funda- mental change in the structure and regula- tion of the health care system, " Edwards laid out what he sees as the only two options for national health policy. One is to let the health - care system remain on its current ec- onomic course, which he predicted would lead to its collapse and subsequent nation- alization. The other is to impose strong cen- tral regulation, which he advocated take the form of a national health authority, compa- rable to the Federal Reserve Board. That au- thority would be empowered by Congress " to establish rate and fee schedules on a re- gional basis, to approve or reject regional plans for the allocation of health resources, to determine health manpower requirements and see that they are being met, to regulate all public and private health insurance pro- grams, and to advise the Congress and the Executive Branch on budget and policy is- sues. " Such an apparently comprehensive regu- latory scheme would not represent a federal takeover of the health - care system, Edwards reassured his audience, but rather was a means for preventing such a takeover. Nor would it necessarily represent an economic threat to the system: " Some of the best ex- amples of highly successful and profitable segments of American industry are to be found among those subject to federal regu- lation. " Conversely, he argued, " without reg- ulation the health care system and the in- dustrial groups that serve it will shortly see the end of profitability because the US econ- omy will not be able to sustain them. " And strong central regulation is an absolute pre- requisite to the enactment of national health insurance; otherwise, he predicted, " the adoption of national health insurance would hasten, rather than prevent, the collapse of the system. " The Republican monopolist Edwards may find a growing natural alliance among those liberal Democrats who are learning mana- gerial techniques under the aegis of the Con- gressional Budget and Impoundment Control Act of 1974. That experience is apparently providing a sober antidote to their bigger - is- better inclinations and making liberals such as Senator Edmund Muskie, chairman of the new Senate Budget Committee, sound like fiscal conservatives. Thus Muskie criticized Ford's block - grant proposal because it did not inspire " confidence that the government can hold down spiraling health care costs " and would " simply shift the cost of federal programs to the states and cities. " On the House side, liberal Budget Com- mittee Chairman Brock Adams, in an address to an AHA seminar on federal relations, re- cently warned that " We must be realistic and admit we cannot enact a new and compre- hensive national health insurance program unless and until we also enact successful measures to bring in new budget revenues or to attain significant savings. " The Con- gressional Budget Office, a new economic think tank, recently reported to Congress that primarily because of medical inflation, cur- rent federal health programs will increase in cost from about $ 33 billion in fiscal 1976 to about $ 38 billion during fiscal 1977 and $ 58 billion in fiscal 1981. " Only government regulation of the health industry, " the report observed, " would seem to permit improving individual protection without adding signifi- cantly to inflation. " Whatever the short - term vagaries of elec- tion year - politics, the national government and monopoly capital agree that aggressive health - care regulation is necessary to their own preservation. While such regulation may have some beneficial effects for those who use or work in the health - care delivery sys- tem, these effects will be purely coincidental. -Louise Lander References 1. William J. Curran, " Present at the Creation: Health Planning and the Inevitable Reorganization, " Health Care Management Review, I (Winter 1976), 33-34 at p. 38. 2. 2. Senate Report No. 93-1285 of the Committee on Labor and Public Welfare, 93d Cong., 2d Sess., pp. 39-40. 3. Louise Lander, National Health Insurance; He Who Pays the Piper Lets the Piper Call the Tune, Health / PAC, 1975, Table 1, p. 24. (Available from Health / PAC for $ 1.00 plus 21c postage.) 4. Gregg W. Downey, " Healthcare Planning Gets Muscles, " Modern Healthcare, March 1975, pp. 32-40 at p. 32. 5. John K. Iglehart, " Health Report Regulation / Bills Face " Challenge from Doctors and Governors, National Journal Reports, VI (November 23, 1974), 1768-71 at p. 1771. 6. Victor Cohn, " US Health Network Bill Gains, " Washing- ton Post, September 13, 1974. 7. House of Representatives Report No. 93-1382 of the Com- mittee on and Foreign Commerce, 93d Cong., 2d Sess., Interstate p. 40. 8. 8. William J. Curran, Richard J. Steele, and Ellen W. Ober, " Government Intervention on Increase, " Hospitals, 49 (May 16, 1975), 57-61 at p. 61. 9. House of Representatives Report No. 93-1640, 93d Cong., 2d Sess., p. 77. 10. Washington Developments, III (December 27, 1974), 1. 11. Symond R. Gottlieb, " What Trustees Should Know About the Planning Law. " Trustee, July, 1975, pp. 12-16 at p. 12. 12. House of Representatives Report, op. cit., p. 34. 13. Downey, op. cit., p. 32. 14. John K. Iglehart, " Health Report / State, County Govern- ments Win Key Roles in New Program, " National Journal, VII (November 8, 1975), 1533-39 at p. 1536. 15. Ibid. 16. Federal Register, 40 (October 17, 1975), 48802-812 at p. 48802. 17. F11e6d8e8.r al Register, 41 March ( 19, 1976), 11688-711 at p. 18. John K. Iglehart, " Health Focus Dividing / Up the Medical Pie, National Journal, VIII (March 20, 1976), 380. 19. " Rational Change in the Health Care System, " _Remarks by Charles C. Edwards, M.D., Arthur D. Little Executive Forum, Washington, D.C., March 9, 1976, supplied by Becton, Dickinson and Company, East Rutherford, New Jersey. 15  Media Scan HEALTH CARE POLITICS: IDEOLOGICAL AND INTEREST GROUP BARRIERS TO REFORM By Robert R. Alford (New York: Pantheon, 1976) Until the late 1960s the major criticism of American health care was that it was not available to enough people. Among a pre- cocious few the private practicing medical profession and the drug industry were seen as self serving - mercenaries who dominated the politics. For academic social scientists medical care was merely one more instance of the natural social harmony inherent in pluralist, free enterprise society. (1) By the late 1960s, however, that facade of harmony began to crumble throughout American and Western society. The critique of medical care in the US, transcending that of organized medicine and the drug industry, and moving on to a rec- ognition of the imperial designs of the medi- cal schools, the technological expansionism of the voluntary hospitals and the complicity of the Blues, developed first out of a report on the municipal hospitals of New York City by Robb Burlage, appearing in 1967. This critique, dubbed the " empire model, " de- veloped, notably, outside the university, became the basis for the formation of Health / PAC, and was followed quickly by the de- velopment of several academic critiques of American medical care. This review is an interpretation and evaluation of one of those -the work of Robert Alford. The Intellectual Location of Health Care Politics To his credit Alford's earlier versions of the argument under review, appearing in 1971 and 1972, were among the first substantial 16 academic broadsides leveled at the medical care system and developed at a time when virtually all health care academics were still engaged either in apologetics or profession- ally sanitary tests of statistical significance. At the time his work had a substantial im- pact in challenging many more timid social scientists in the health field to face some of the larger issues. The present volume is a further elaboration of those articles with two intensive case stud- ies of aspects of the New York City health care system. Briefly, his argument is that the (change - free) health care dynamics can best be understood by focussing on the mutual relationships among three unequal categor- ies of interest groups formulated as structural interests: professional monopolists (doctors and voluntary hospitals) who dominate the decision making and are thus labelled the " dominant structural interests "; market and bureaucratic reformers who challenge the hegemony of the previous group, but whose challenge and proposals for reform never alter the structural nature of the interests which the former seek to preserve; and the community - oriented, equal health - advocates who are generally marginal to the outcome of the political dynamics over the struggle for control of health care. In his own words: The proposals for change... do not chal- lenge any of the institutional roots from which the power of structural interests derives. None of the decisions called for by the market reformers... or... by the bureaucratic reformers... will challenge the effective institutionalized and legal control of the system as a whole by the dominant structural interests which ben- efit from its continuance in its present form. (page 6) The bulk of the empirical analysis focuses on the use by the dominant structural inter- ests of political mirrors and shadows (Edel- man's symbolic political action (2)) to deflect from themselves the potentially undesirable effects of the proposed market and bureau- cratic reforms. This brings us a long way beyond the standard academic fare of the 1960s: the in- terest group pluralism of the political scien- tists, the consumer sovereignty of economists, and the functionalism, sick role, and patient- doctor relationship of the sociologists - each suggesting in positivist fashion that what was observed was merely the acting out of uni- versal and harmonious patterns of human so- cial behavior. By focusing instead on the warts of the health care system Alford helped bring to the attention of the health care aca- demic world not only their importance and, perhaps, their centrality, but also that their existence may be rooted in the very structure of organization, rather than merely historical oddities to be relegated to footnotes. In short, power and conflict substitute for order and harmony as the lenses through which health care is thus viewed. Still, despite the advances which Alford's analysis provided, it suffers from many of the same defects of other analyses of the same period and genre. Mills (3), Marcuse (4), and Baran and Sweezy (5) represent the forward wing of the rude break with the smug social science which developed in the Post- War period. Though the above represent an important shift in the perceptions and uses of social science, they do not represent a noticeable shift in method: they remain me- chanistic, but progressive, versions of the re- spective extant disciplinary methods; they use the existing methods to challenge the metaphysically derived, normative conclu- sions of their consensus colleagues. Mills analyzes interest group dynamics to dispell the dominant normative perception of pluralism; Baran and Sweezy use an essen- tially Keynesian analysis to suggest that ad- vanced capitalist societies are those of re- current waste and underconsumption rather than the Samuelsonian view of a " grand neo- classical synthetic " image of full employ- - ment and consumer sovereignty; and Mar- cuse intellectually transforms Rostow's ideal of the mass consumption - society into one of commodity fetishism serving to secure ruling- class hegemony through repressive toler- ance. What is progressive about these shifts is that they indicate the possibility of anti- podal conclusions derived from pre existing - methods, with only modest alterations in the behavioral and empirical assumptions. In each case, and this is also true for Al- ford, the organizational structure of what is being analyzed is viewed as both perverse -generally stacked in the direction of the wealthy and powerful - and unchanging. This is debilitating both intellectually and politi- cally: intellectually because it lacks any his- torical sensitivity and politically because it can never lead to a strategy for change. Significantly, Mills and Baran and Sweezy during the 1960s see the only possibilities for progress in the United States growing out of Third World revolution, whereas Marcuse, prior to 1968, sees the developed social sys- tems as totally locked up and incapable of significant change. This is not to minimize or condemn their contribution. Their work provided, if not the appropriate method, at least the appropriate lenses through which to view the social land- scape. To the extent that the social analysis of the 1970s mid - transcends their work it is, no doubt, because of them, not despite them. Similarly, but later, Alford, rather than sur- passing them methodologically, merely re- produced their analytical metaphor and em- broiders in Edelman's symbolic politics for the case of health care. In the end, Health Care Politics must be seen as a " period piece. " In the end, Health Care Politics must be seen as a " period piece. " Dynamics of the Structural Interests The twenty - year period from 1950 to 1970, in which Alford claims to see " dynamics without change, " is actually bounded at both ends by programs, policies, and events which distinguish that period from what precedes it and what will follow it. As a result, the health care behavior which Alford depicts as historically invariant turns out to be his- torically specific. (And this argument could be made for the empire model of Health / PAC, as well.) The period in question is, if nothing else, precisely the period in which the United States is economically unrivalled in the West- ern world. Whereas in the immediate post- War period the European and Japanese eco- nomies are preoccupied with industrial re- construction, the United States is preoccu- pied with the avoidance of possibly endemic 17 depression, specifically, how to absorb enough of the surplus generated in produc- tion to keep the labor force " fully " employed. (6) With this as temporary backdrop, then, three immediate postwar health care devel- opments become understandable and sug- gestive of the historical origins of Alford's structural interests. Not in chronological or- der, the establishment of the National Insti- tutes of Health and congressionally - backed increases in bio medical - research step up ex- penditures for research, and especially medi- cal technological - development; the Hill Bur- - ton program provides federal money for the construction of hospitals (rural at first, but later urban as well); and the expansion of voluntary and commercial health insurance through industrial bargained - union - fringe benefits not only substantially increases the access to increasingly costly health care but, equivalently, provides the continuing finan- cial basis for the capital expansion devel- oped in the medical school research centers and promoted by their graduates. Starting from specific (individual) defect, anti epidemiologic - medical theory and fee- for service - provider payment, and unob- structed by any planning or popular control over the delivery system, the super imposi- - tion of these policies and programs merely stepped up the pace of accumulation and simultaneously provided the financial means by which the internally generated techno- logical imperatives could be realized. With the force of law, technological sanctimony, and much public and private money, Al- ford's dominant structural interests are, in the early part of this period, largely as he de- scribes them. Such a structure, however, at the same time contains its own negation. In particular, the uncollectable accounts receivable, un- necessary care and redundant accumulation inherent in this new structure, were to lead to policies which eventually and inevitably would lead to the demise of the dominant structural interests. As the unit expense of health care began to increase in response to the new dynamics set in motion, the uncollectables from the poor and the long and expensive stays of the old brought the private hospitals and insur- ance plans together, in opposition to the AMA, to champion the passage of some fed- eral program to pick up the medical expen- 18 ses of these two groups. And this alliance B. Plympton began quite some time before the arrival of the Kennedy administration in Washington (1957). (7) In response to the social dynamics set in motion within the medical profession, hospi- tals felt increasingly compelled to accumu- late expensive service units even if they could be expected to be used rarely: the penalty for not so doing was (and is) the fear of losing members of the medical staff, the marketing officers of the nation's hospitals. And given the fee service - for - (piecework) mode of reimbursing providers, much care was provided because it was revenue - gen- erating, rather than clinically justifiable. A recent public estimate of the extent of wasteful expenditures in health care put the figure conservatively at $ 20 billion in 1974 or roughly 25% of personal health care ex- penditures for that year. The principal com- ponents of that estimate include unnecessary hospital construction, unnecessary hospitali- zation, and unnecessary surgery (8) all, for the most part, a consequence of the structure laid in place by the early 1950s. In response to the first contradiction came the Medicare and Medicaid laws over the strident objections of the granddaddy of all the dominant structural interests - the AMA. And in response to the latter two contradic- tions have come a series of planning and regulatory acts, which despite their severe cooptation in early stages, have had their effect in curtailing the autonomy of the pre- viously unbridled interests. Among these are Comprehensive Health Planning, Regional Medical Programs, Peer and Utilization Re- view (enacted through the Medicare law), Prospective Reimbursement, Certificate of Need, and the yet tested - to - be - Professional Standards Review Organizations, Health Maintenance Organizations, and Health Sys- tems Agencies. The extent to which (or whether or not) these have been or will be progressively ef- fective is not the main issue. For, to return to the opening of this review, in the end Al- ford's structural interests all reside within the petit bourgeois - (middle class) layer of the society (9); their ability to control their own territory rests ultimately on the continued satisfaction or lack of political interest of the other major groups in the political economy -the corporate bourgeoisie and organized labor. Yet, the former have since 1970 strong- ly indicated in many different media and study reports (Forbes, Fortune, Business Week, the U.S. Chamber of Commerce, Com- mittee on Economic Development, Confer- ence Board, and all three Nixon administra- tion Secretaries of Health, Education and Wel- fare in congressional testimony (10)) the con- clusion that the fee service - for - system is no longer effective in rationally delivering health care and recommended the reconsti- tution of the system on a prepayment, HMO basis. Many explicitly corporate models are already in the process of software develop- ment or actual formation. (10) The latter, la- bor, will either respond in kind or suffer the consequences of corporate dominated - health care, and social democrats will likely move for the adoption of a National Health Service, one version of which is already close to Con- gressional introduction. (The " National Com- munity Health Services (Dellums) Bill, " Com- munity Health Alternatives Project, Institute for Policy Studies, Washington, D.C.) Still, the present context is not simply one of interest group politics writ large, for the situation of the American economy is now quite different from what it was at the be- ginning of this period. The American econ- omy is now challenged from several of its " trading partners " and, domestically, chronic stagnation is the general condition. The cor- porate view of the crisis argues that it has resulted from the diversion of too much of the social surplus from direct private invest- ment to (productive non - ) social and public ex- penditures. This, it is argued, has resulted in the lowered competitive edge of the Ameri- can economy internationally, and the low- ered rate of return to capital investment, since, it is argued, taxes, capital costs (in- terest rates), wages (including fringes) and the debt (asset -to - ) structure are so high. The Alford's structural interests all reside within the petit- bourgeoisie; their ability to control their own territory rests ultimately on the continued satisfaction or lack of political interest of the... corporate bourgeoisie and organized labor. strategy for recovery as enunciated by both the Republicans and the Democrats (the lat- ter represented by a recent Brookings Insti- tute statement) is a tight fiscal and loose mon- etary policy, which, in effect, translates into the reallocation of public expenditures back toward direct private investment while main- taining a high level of unemployment con- tinuously into the 1980s. For health care the implication of these statements is the marked reduction in expenditures based on the wide- ly held belief that the current level is un- justifiable. Irrespective of the validity of this view, it appears clear that the swashbuck- ling days of the dominant structural interests are over. Either strong bureaucratic controls will be imposed on the providers or the sys- tem will be reconstituted on a prepayment 19 basis. In either case " the effective institution- alized and legal control of the system as a whole by the dominant structural interests which benefit from its continuance in its pres- ent form " will be broken. And this without to any significant degree altering the larger political economic - system of power and wealth. There is no apparent recogni- tion of the pathogenic effects of a society based on accumu- lation through insecurity (competition). One can see these shifting sands today in the medical care politics of New York City, the empirical basis of the studies of both Al- ford and Health / PAC. With hospital utiliza- tion rates declining, the voluntary hospitals are now more interested in closing, rather than exploiting, the municipals. Indeed, there is now substantial pressure coming from within their own trade association, the Health and Hospitals Planning Council, to close some voluntary hospitals. Even the medical schools are on the defensive, unable to maintain the levels of activity made possible by funding no longer available. Beyond the Health Care System But even this is only to argue with Alford on his own terms: the political sociology of health care organization, broadly conceived. A major limitation of this approach is the corollary implicit in Health Care Politics that all that stands between universal access to quality health care and the present circum- stances is the retrograde, dominant structural interests. There is no apparent recognition of the pathogenic effects of a society based on accumulation through insecurity (competi- iton), resulting directly in pollution and stress and ultimately in heart disease, stroke, kid- ney damage, mental disorders, drug addic- tion, cirrhosis, cancer, and other pulmonary 20 disorders. There is a further oversight implicit in the book its assumption that there is nothing awry with medical science, if only it were not applied under such mercenary circum- stances. Yet we are now beginning to find how inaccurate that assumption has been. The sociology of knowledge in (the ideologi- cal nature of) medical science is quickly be- coming a fruitful area of intellectual inves- tigation, particularly in the specialty areas of obstetrics, hypertension, oncology, and psychiatry. Naturally it would be too much to expect these last two issues to be systematically dealt with in a single book which also inves- tigates the political sociology of health care organization to the length which this one does. Yet it is rather late in the day to let such fundamental issues go unmentioned in a book entitled Health Care Politics. Moreover, to the extent that these two defects are em- pirically significant, the analysis of health care providers becomes that much less cru- cial. Beyond Analysis Finally, though it is not incumbent upon intellectuals in bourgeois society to root their investigations in strategic considerations, crit- icism of Health Care Politics along these lines would seem in order, given its polemical thrust. As stated toward the beginning of this re- view, a static and mechanistic model of social behavior has, at best, no strategic implica- tions, since, by inference, nothing can be done. The present distribution of power, ac- cording to such theories, does not rest on some delicate equilibrium of social contra- dictions, but rather on " the effective insti- tutionalized and legal control of the system as a whole... " The historical origins and spe- cificity of that control are never investigated, and, as a consequence, cynicism substitutes for program in the politics of the reader. Surely, this is not Alford's end and, in fair- ness, it should be pointed out that in the final paragraphs of the book he suggests that a class or institutional perspective may be su- perior to the pluralist or bureaucratic. Ac- cording to that perspective health care is but a metaphor of the larger society and can only be significantly altered through a social movement, yet invisible, capable of reconsti- tuting our entire present society on a new basis. However hortatory the intent, it still leaves us with nothing. It does not point out the contradictions of the present, both in the health care system and out, which portend the possibilities of the future - both progres- sive and retrograde - on the knowledge of which we can begin to build a program - both in the health care system and out. We must move beyond the nihilism of Ivan Illich (11), the victim blaming - of Victor Fuchs (12), and yes, the cynicism of Health Care Politics. " Philosophers have only interpreted the world in various ways; the point, however, is to change it. " (13) -Sander Kelman (The author teaches in the Sloan School of Hospital Hospital Administration Administration Administration at Cornell Univer- Univer- sity sity. This This review review was adapted from an article article appearing appearing in in the Journal of Health Politics Politics, Policy Policy and Law, Vol. 1, No. 1.) Footnotes and References 1. Arnold Rose, The Power Structure, (New York: Oxford Univ. Press, 1967) Chapter XII, and, for example, Paul J. Feldstein, " The Demand for Medical Care, " Milbank Me- morial Fund Quarterly. 2. 2. Murray Edelman, The Symbolic Uses of Politics (Ur- bana, Ill. Univ of Illinois Press, 1967). 3. C. Wright Mills, The Power Elite (New York: Oxford University Press, 1956). 4. 4. Herbert Marcuse, Dimensional One - Man (Boston: Beac- on Press, 1964). 5. 5. Paul Baran and Paul Sweezy, Monopoly Capital; An Essay on the American Economic and Social Order (New York: Monthly Review Press, 1966). 6. Ironically, this is also the precise period and the sense in which the conclusions of Baran and Sweezy are ac- curate but also historically specific. 7. Howard Berliner,'The Origins of Health Insurance for the Aged, " International Journal of Health Services, 3 (Summer, 1973). 8. Sidney Wolfe, M.D., " Statement at HEW Conference on Inflation, " September 19, 1974. 9. Elements of the middle class (defined as a class, rather than as a status group) neither own the means of pro- duction nor are directly employed by them. Instead their principal activity, as doctors, lawyers, clergy, teachers, etc., is to reproduce the social relations of the society. 10. J. Warren Salmon, " The Health Maintenance Organiza- tion Strategy: A Corporate Takeover of Health Services , " Journal of Health Services 5 Delivery (Fall, 1975) International. 11. HeHaelatlht hI v(aNn eIwl lYiocrhk,: MPeadnitchaelo nN,em e1s9i7s6:) .T he Expropriation of 12. Viccitoarl F uCchhso iChcoeic e(,N Wehwo NYeow rSkha:l l BYaosrki cLi vBeo Boaksisc,? H1e9al7t5h,) .Ec onomics and So- 13. From a scene in the movie, " Morgan. " FROM HEALTH / PAC'S ILLUSTRATOR \ " Bill Plympton draws beautifully, perceives accurately and is mean TUBE to his subjects to the different | degrees they deserve it. He is one STRIPS of the more solid of the 70s generation of cartoonists. " Jules Feiffer BY BILL PLYMPTON " ?!! I wish that I had done these. " David Levine Bill Plympton's caricatures of film folk such as Monty Python, Godard, and Metz have been a feature of Cineaste for years. His cartoon strip which takes aim on the media is a regular feature of New York's Soho Weekly News. Now, the best of his strips and selected caricatures are available in book form with a delightful forward by playwright Robert Patrick. Be the first intellectual on your block to own a Bill Plympton first edition! Enclosed is $ 2.50 for Bill Plympton's Tube Strips. Name fm Address City State Zip Smyrna Press Box 841 - Stuyvesant Station NYC 10009 } 21 ing its production of " family Peer Review practitioners " practicing in the US today. While these " souped A MALPRACTICE: up GPs " consider themselves specialists in family care, they still are office based and do general care. I do see, how- ever, that in numbers they are small, they don't relate well to IMPACT IN CALIFORNIA _ the old GPs and they adamant- Dear Health / PAC: ly defend problem oriented - medical records, reexamina- I read your malpractice ar- ticle in the January February / BULLETIN. I found it timely and informative. I liked the general setting of the article in that you state that this situ- ation only becomes a crisis when it becomes an economic tion, more licensure and con- tinuing education programs. Thus, they seem to fall in with the primarily office based - spe- cialists. These professionals will not shift the scene from the office to the institution and will supposedly lower malpractice threat to professionals and in- stitutions. Your first section, on rates through more competent practice. These doctors are the triumph of economics, was good but could have been stronger with the addition of specifics regarding insurance company investments and losses. I agree with your analy- sis of the contradictions medi- trained to develop group prac- tice and this perhaps is the key to their institution of the future perhaps they are pawn in an even bigger game. I see the malpractice crisis as a way for the insurance com- cal professionals find them- selves in, for example, com- plaining of insurance compa- nies following free market in- centives while defending them for themselves. I like your development of the internal conflict in medical panies (and behind them or be- side them, who? banks? -but at least corporate powers with an interest in the expanding health market) to raise the ante on health professionals (doctors in this case) to drive them out of their bastion of practice between those who defend no limitation on prac- tice and no reexamination and " control self - and self policing - " and into the modern capitalist market economy. In other those other professionals who words, medical practice, or at want limitation of practice and frequent reexamination. I think that this split does generally break down between office- least the interchange between practitioner and patient, is an area that has not been pene- trated by capitalists in search based generalists and primar- ily hospital - based specialists. I would add that I think that the move toward reexamination and more efficient medical re- of profit. If practitioners can be driven from solo practice to group practice and then out of private practice altogether to some sort of institution (I'm un- cordkeeping came from the so- clear here perhaps - like Kai- called family practice move- ser) then doctors become work- ment, which indeed does have ers, not individual entrepre- its base in institutions (and neurs, and money can be made roots in the liberal wing of in- from their labor. Thus, raise 22 ternal medicine) but is increas- the level of malpractice premi- ums, drive them to group situ- ations where they will receive " free malpractice, " wages and benefits like other workers. The fact that hospitals are becoming legally liable for the practice of those professionals in them fits in here also, in that as institutions (in the future controlled and operated by in- terests wanting only profit) they will try to closely super- vise their workers for maxi- mum efficiency. Your next section on " A Healing Relationship or a Mar- ket Transaction " rings true, es- pecially the conflict between the professions'quest for profit and its supposed altruistic mo- tives. I would like to add the example of fetal monitors as an instance of technology de- veloped basically for profit. They provide some informa- tion to professionals about the status of the fetus during the labor process but may actually create the same problems that they detect. They have added tremendously to the cost of la- bor and delivery. I agree with you that the evasiveness of the malpractice issue is a case of the " foam rubber pillow syndrome. " Here in Chico, California the biggest hue and cry has come from physicians, mostly anesthesi- ologists ologists and and GPs GPs practicing practicing surgery. A neurosurgeon, 3 anesthestists and 5-7 GPs have stopped practice altogether and more have limited their practice. The " crisis " was used as an excuse: 1) by GPs and OB gyns / to restrict their practice to in- clude only private fee paying - patients and to exclude Medi- Cal (welfare) patients. All GPs have dropped OB. 2) by the medical society and hospital accreditation committees to deny hospital privileges for an OB gyn / who had agreed to take welfare pa- tients, worked part time - for the local Feminist Woman's Health Center and was sympathetic to home births. 3) by the medical society to publicly blame insurance com- panies and attorneys for the increased rates. 4) by all local MDs to raise their fees - e.g., from $ 450 to $ 1000 for a normal delivery. I enjoyed your article. I hope that you can use some of these undeveloped ideas to improve your analysis. I imply that cor- porate interests have " motives " in " raising the malpractice ante " against organized medi- cine. Perhaps this is not literal- ly true but I feel that the effect is the same. I would appreci- ate a reply. I work in a neigh- borhood health center in Chi- co, California and information such as the BULLETIN is inval- uable to us. -Mark Murray COMING THIS SUMMER PROGNOSIS NEGATIVE: CRISIS IN THE HEALTH CARE SYSTEM OE A NEW HEALTH / PAC anthology of many of the best recent articles from the Health / PAC BULLETIN, as well as important health policy articles from other publications. Major sections cover Health Care Institutions, Health Workers and Government Intervention in the Health System. OE To be published this summer by Vintage Books (Random House). Price: 2.95 $ per copy (paperback). For bulk orders, order directly from publisher. m@ If you would like to see the table of contents of the book for possible use in courses this fall, write to: Health / PAC 17 Murray Street New York, N.Y. 10007 23 which have been found to be Vital Signs SALARY DISCUSSION A NO NO - Alabama Blue Cross may have been a little overzealous in its attempt to cut costs. Seek- ing to block a union organizing campaign among its employ- ees; it prohibited "... employ- ees from discussing their wages among Blue themselves. " Unmoved by Blue Cross'argu- ment that it did not strongly enforce the measure, a Nation- al Labor Relations Board judge ruled the tactic illegal. (Wall Street Journal, May 25, 1976) carcinogens - for example tri- chloroethylene and polyvinyl chloride.) Copies of the chloro- form report and additional in- formation are available free of charge from the Office of Can- cer Communications, National Cancer Institute, Bethesda, Maryland 20014. BONANZA FOR PUSHERS The ban on TV advertising of cigarettes, enacted in 1970, has proved to be a bonanza for other media. Newspaper and magazine advertising by ciga- rette makers has increased by over 300 percent since 1970. Advertising expenditures by makers of the top 20 brands, which had reached 241 $ mil- CHLOROFORM CAUSES CANCER? Chloroform, long used as an anesthetic in hospital operat- ing rooms, has recently been found by the National Cancer Institute (NCI) to cause liver, kidney and thyroid cancers in mice and rats. In a report re- leased on June 10, 1976, NCI scientists called the findings " definitive for animal studies " and " a warning of possible carcinogenicity in humans. " These results may help ex- plain the unusually high rates of cancer found among operat- ing room workers (see BUL- LETIN, November / December, 1974). Chloroform, also known as trichloromethane, is used in ex- tracting and purifying antibio- tics, in manufacturing dyes, drugs and pesticides, and in some toothpastes, cough medi- cines, liniments and salves. It lion by 1970, dropped for a couple of years after the ban, but overtook the previous high in 1974, totalling $ 243 million. Advertising for 1975, when the totals are calculated, is ex- pected to be even higher. The only major publications which refuse cigarette advertising are the New Yorker and Read- ers Digest. (Health Law Newsletter, March 1976; Washington Monthly, February 1976.) HEALTH COSTS PUT CRUNCH ON EMPLOYERS American industry, which will pay $ 3.18 billion in em- ployee health and safety costs this year, is becoming increas- ingly unhappy with the rising cost of health care. General Motors, which claims it spends far more for Blue Cross - Blue Shield (1,700 $ per employee) than it does for steel (a cost it is a widely - used industrial sol- won't reveal), is calling for vent. These studies are part of workers to pay for their own a continuing NCI screening health insurance in contract program for possible carcino- negotiations with the United gens. (Chloroform is one of a Auto Workers. Increasing num- class of chemicals called chlo- bers of companies are turning 24 rinated hydrocarbons, many of to self insurance - of employees, in house - claims monitoring, and involvement in local health planning in an attempt to control health costs, accord- ing to Business Week. (Trustee, April 1976; Washington Report on Medicine and Health, May 17 and May 31, 1976; Business Week Magazine, May 17, 1976.) DES SIDE EFFECTS: EQUALITY BETWEEN THE SEXES Researchers at the Univer- sity of Chicago recently found sterility among one third - of the sons born of mothers who used the drug diethylstilbestrol (DES) during pregnancy. The finding follows by four years discovery of the occurrence of a rare form of vaginal cancer among daughters whose moth- ers used the drug during preg- nancy. DES was widely used to prevent miscarriages be- tween the 1940s and the early 1970s. More recently it has been used as a " morning after " contraceptive pill. (American Medical News, April 26, 1976.) MARKETING INFANTICIDE Increased reliance on bottle feeding is one of the prime con- tributors to high infant mor- tality rates in developing coun- tries, a recent nutrition study by Cornell University has found. The study adds fuel to a growing controversy. Manufacturers of infant for- mula, facing declining birth rates at home, have stepped up marketing efforts in devel- oping countries where birth rates remain high. These bot- tle fed - infants suffer high rates of malnutrition and diarrhea, particularly among poor fam- ilies who may lack clean water for diluting the pow- dered formula, facilities for sterilization and refrigeration, and / or income to purchase sufficient amounts of formula. Studies in some Caribbean islands found 82 percent of the mothers overdiluting formula, in some cases stretching a four- day supply to make it last as long as three weeks. Use of the formula also deprives infants of the immunological protec- tion of breast milk, making them less able to fight infec- tions. But powerful advertising techniques associate bottle feeding with sophistication and development. In addition for- mula makers employ " milk nurses " who, working out of maternity wards and clinics, give away free samples and encourage mothers to bottle feed. Their identification as medical personnel (most are not) greatly enhances their credibility with poor mothers. Thus mothers are convinced to give up breast feeding, which is free and nutritionally and immunologically ideal for the infant. " In many instances, placing an infant on a bottle is tantamount to signing the death certificate of the child, " says Michael Latham, author of the study. Protests against the manu- facturers of infant formula, chief among which are Nestle, Abbott Laboratories, Bristol- Myers and American Home Products, are mounting in Eu- rope and the US. Here they are spearheaded by the Inter- faith Center for Corporate Re- sponsibility (ICCR) which also distributes a widely acclaimed - film entitled, " Bottle Babies. " ICCR may be reached at Room 566, 475 Riverside Drive, New York, New York 10027; phone (212) 870-2294. (New York Times, April 6, 1976; Village Voice, March 22, 1976.) DEPARTMENT OF INTERESTING FACTS OE The health care bill of a person 65 or older averaged $ 1,360 in the fiscal year ending in June 1975, three times that of a person 19 to 64 years old, ac- cording to a recent report is- sued by the Social Security Administration. Not only are their bills large, but they are increasing rapidly - expendi- tures by the elderly rose 18 percent in fiscal 1975 com- pared to 11.4 percent in fiscal 1974. (American Medical News, May 24, 1976) OE The nation's health care bill will reach $ 133 billion for fiscal 1976 double - the amount spent in 1970, according to the Congressional Budget Office (CBO). Under current policies, health care spending will reach $ 252 billion by 1981- a 113.5 percent increase in the next five years, predicts the CBO. OE Family budget estimates show that the amount spent on health care by an urban fam- ily of four is virtually identical for low, intermediate and high budget families. These fami- lies with average budgets of $ 9,588, $ 15,318 and $ 22,294 spent $ 818, $ 822 and $ 857, re- spectively, on health care. In contrast, expenditures for ev- ery other item in the budget were graduated by income level. Estimates of family budgets are conducted annu- ally by the Bureau of Labor Statistics. (Bureau of Labor Statistics release, May 5, 1976) OE Worklife expectancy for men has fallen 1.4 years - from 41.5 years in 1950 to 40.1 years in 1970. In the same period, worklife expectancy of women 25 has increased from 15.1 to 22.9 years. (Monthly Labor Review, February 1976.) @ Women physicians earn a median income of $ 33,000 com- pared to $ 54,000 for all doc- tors, reports a recent survey by Medical Economics. The reasons? Women physicians average only 55 hours a week, compared to 60 for all doctors [a difference which in private practice, at an average of $ 12 per patient visit, translates in- to $ 21.000 per year]. More im- portantly, however, there are relatively few women physi- cians in high paying - surgical specialties. 84 percent of wom- en physicians are in nonsurgi- cal specialties (especially gen- eral practice, anesthesiology and pediatrics) compared to 58 percent of all physicians. (New Physicians, June 1976) BREAKTHROUGH FOR HEART ATTACKS: HOME CARE The British have made a ma- jor breakthrough in the treat- ment of heart attack victims; they have discovered home care. A four year - British study found that the death rate with- in 28 days after the attack was 12 percent for those treated at home and 14 percent for those treated in the hospital. After a year, rates were 20 and 27 per- cent respectively. The subjects were men between the ages of 60 and 70 who had not suf- fered medical complications during the first few hours after the attack. (New York Times, May 18, 1976.) GETTING (LITERALLY) WHAT YOU PAY FOR What should a doctor do when a patient can't pay the 26 bill? Incredible as it may seem, " Take back the services, " was the answer of Dr. Bobby Mer- kle of Uniontown, Alabama, who immediately removed stitches from the arm of 14- year - old Melvin Armstrong upon finding that Armstrong didn't have the full $ 25 fee. Merkle, the only physician in Uniontown, is white. Arm- strong, like 65 percent of the county residents, is Black. The Armstrong family, in a $ 50,000 damage suit, was granted $ 20 by an all white - jury - the cost of having the wound restitched by a physi- cian in a neighboring com- munity. The case is being ap- pealed. Merkle was merely censured by the Alabama State Board of Medical Exam- iners. (New York Times, May 20, 1976.) RULING: HOUSESTAFF ARE STUDENTS Interns and residents are " students rather than employ- ees " according to a March 19, 1976 ruling of the National La- bor Relations Board (NLRB). In a 4-1 decision, the NLRB re- jected the contention of house- staff at Cedars - Sinai Medical Center, Los Angeles, that they are entitled to the protection of the National Labor Relations Act. By its ruling the NLRB threw a monkey wrench into the or- ganizing efforts of the Physi- cians National Housestaff As- sociation (PNHA). Housestaff unions, except in states where existing labor laws cover them, may now be forced to strike for recognition, even if every intern, resident and fel- low at an institution is en- rolled in a collective bargain- ing unit. Housestaff associa- tions are now in the same posi- tion as other hospital workers before federal legal protection was extended to employees of non profit - hospitals in 1974. The Board's ruling was based on its conclusion that housestaff are " primarily en- gaged in graduate education- al training " and thus provide patient care merely as a by- product of the schooling. The single dissenting board member, John Fanning, voci- ferously argued against the majority. " Certainly, " he wrote, " there is a didactic component to the work of any initiate, but simply because an individual is'learning'while performing this service cannot possibly be said to mark that individual as ' primarily a student and there- fore, not an employee'" Fan- ning charged his fellow Board members with using a mean- ingless " semantic distinction. One does not necessarily ex- clude the other. " RULING: PNHA REACTS PNHA President Dr. Robert G. Harmon denounced the NLRB decision: " Saturday night, " Harmon said, " 60,000 doctors went to bed as doctors and Monday morning they woke up to find they were stu- dents. This was brought to you by the same Administration that brought Watergate, Spiro Agnew and the Nixon par- don. " Harmon promised to ap- peal the Board's decision, and, if unsuccessful, to fight for Congressional action explicit- ly including housestaff under the federal labor law. The American Association of Medical Colleges (AAMC), on the other hand, was de- lighted with the decision. Its president, Dr. John A. D. Coo- per, reiterated the AAMC stance in its " friend of the court " brief before the Board, commenting, " This decision will further strengthen the tra- ditional teacher student - rela- tionship, which is largely re- ginia 25301. For a limited time, Bloom, Bernard, Changing Pat- sponsible for the superior train- sets of all three booklets will terns of Psychiatric Care (New ing American physicians re- be available for $ 5 plus $ 1 for York: Human Sciences Press, ceive. " Like many other Washing- postage. * * 1975). $ 15.95. ton actions these days, the NLRB ruling was tinged with a conflict interest - of - . Board mem- ber Peter Walther was, before joining the board, a member of a Philadelphia law firm A Berlitz guide to bureau- cratese spoken in health policy discussions has just been pub- lished by the House Commerce Committee Subcommittee on Health. A Discursive Diction- Burt, Marvin R., Policy Analy- sis: Introduction and Applica- tions to Health Programs (Washington, D.C.: Information Resources Press, 1975). which represents St. Christo- ary of Health Care serves as a Cady, James F., Drugs on the ! pher's Hospital, whose house- handy guide to medical, legal Market: The Impact of Public staff was also petitioning for NLRB recognition. Although and governmental terms and acronyms, providing not only Policy on the Retail Markets for Prescription Drugs (Lexing- Walther did not take part in the decision against the Phila- definitions and explanations, but a touch of whimsy as well. ton; Lexington Books, 1975). $ 13.00. delphia housestaff, he did join National health insurance, for the majority in the landmark Los Angeles case. instance, is defined as " a term not yet defined in the United States. " The Discursive Diction- ary was prepared by Subcom- mittee staff member Lee Hyde and is available for $ 2.40 from the Government Printing Of- fice. Children's Defense Fund, Doc- tors and Dollars are Not Enough: How to Improve Health Services for Children and Their Families (Washing- ton: Washington Research Project, 1976). $ 4.00. ANNOUNCEMENTS A manual on community health organizing, published Books Received in three booklets, has just been completed by Terry Mizrahi Andersen, Ronald; Kravits, Jo- Madison. Booklet I: The Amer- anna and Anderson, Odin ican Health System: A Consu- (eds.), Equity in Health Serv- mer Information and Action ices: Empirical Analysis in So- Guide offers an analysis of cial Policy ( Cambridge: Bal- major actors in the health sys- linger Press, 1975). tem and a guide to help local groups analyze parts of the Berger, Lawrence B. and Sul- system most relevant to them. livan, Paul R., Measuring Hos- Booklet II: The People's Guide pital Inflation: A Composite to Good Health discusses rights Index for the Measurement of consumers not only to get and Determination in the Com- health care, but also to partici- monwealth of Massachusetts pate in making health care (Lexington, Mass.: Lexington policy. Booklet III: Organizing Books, 1975). $ 14.50. for Better Health: Strategies for Consumer Health Groups ana- Brown, R. G. S., The Changing lyzes various community National Health Service (Lon- health struggles and discusses don and Boston: Routledge & different strategies. Kegan Paul, 1973). $ 3.95. The three booklets are avail- able from the Appalachian Re- search and Defense Fund, Inc., 1116 - B Kanawha Boulevard Bernard, Jean, Vital Signs: A Doctor Diagnoses the Medical Revolution (New York: Mac- Day, Lu Ann and Andersen, Ronald, Access to Medical Care (Ann Arbor: Health Ad- ministration Press, 1975). Flook, E. Evelyn and Sanazaro (eds.), Health Services Re- search and Rand D in Perspec- tive (Ann Arbor: Health Ad- ministration Press, 1975). $ 7.50. Fry, John and Farndale, W. A., International Medical Care: A Comparison Throughout the World (Wallingford: Washing- ton Square East, 1972). Hershey, Nathan and Miller, Robert D., Human Experimen- tation and the Law (German- town, Maryland: Aspen Sys- tems Corporation, 1976). Hetherington, Robert, Hopkins, Carl E. and Roemer, Milton I., Health Insurance Plans: Prom- ise and Performance (New East, Charleston, West Vir- millan, 1975). $ 8.95. York: John Wiley, 1975). 27 Hillard, Mildred, Orientation and Evaluation of the Profes- sional Nurse (St. Louis: C. V. Mosby, 1975). $ 6.50. Howard, John and Strauss, An- selm, Humanizing Health Care (New York: John Wiley, 1975). Kane, Robert, Kasteler, Jose- phine M. and Gray, Robert M., The Health Gap: Medical Serv- ices and the Poor (New York: Springer Publishing, 1976). Kosa, John and Zola, Irving Kenneth (eds.), Poverty and Health: A Sociological Analy- sis (Cambridge: Harvard Uni- versity Press, 1975). $ 15.00. Kress, John R. and Singer, James, HMO Handbook: A Guide for Development of Pre- paid Group Practice Health Maintenance Organizations (Germantown, Md.: Aspen Sys- tems Corporation, 1975). Krizary, John and Wilson, An- drew, The Patient as Consum- er: Health Care Financing in the United States (Lexington, Mass.: Lexington Books, 1974). Lane, Marc J., The Doctor's Lawyer: A Legal Handbook for Doctors (Springfield: Charles C. Thomas. 1974). Levin, Arthur, Talk Back to Your Doctor: How to Demand and Recognize High Quality Health Care (Garden City: Doubleday, 1975). $ 7.95. Study Group on the Federal Budget, The Problem of the Federal Budget (Washington, D.C.: Institute for Policy Stud- ies, 1975). Lippard Lippard,, Vernon Vernon W. W.,, A A Half- Half- Century of American Medical Education: 1920-1970 (New York: Josiah Macy Fund, 1974). $ 7.50. ~ Torry, E. Fuller (ed.), Ethical Is- sues in Medicine: The Role of the Physician in Today's So- ciety (Boston: Little, Brown, 1976). $ 9.50. New Human Services Institute, College Programs for Parapro- fessionals: A Directory of De- gree Granting Programs in Hu- man Services (New York: Hu- man Science Press, 1975). $ 9.95. Ristak, Richard, Pre Medicated - Man: Bioethics and the Con- trol of Future Human Life (New York: Viking, 1975). $ 8.95. Rutstein, David, Blueprint for Medical Care (Cambridge: MIT Press, 1974). 8.95 $. Schneeweiss, Stephen M. and Davis, Stanley W. (eds.), Nurs- ing Home Administration (Bal- timore: University Park Press, 1974). 19.50 $. Schechter, Daniel S., Agenda for Continuing Education: A Challenge to Health Care In- stitutions (Chicago: Hospital Research and Educational Trust, 1974). $ 6.00. Verrett, Jacqueline and Caper, Jean, Eating May Be Hazard- ous to Your Health: The Case Against Food Additives (New York: Simon and Schuster, 1974). Wallace, Helen (ed.), Health Care of Mother and Children in National Health Services: Implications for the United States (Cambridge: Ballinger, 1975). Wilson, Florence A., and Neu- hauser, Duncan, Health Serv- ices in the United States (Cam- bridge: Ballinger, 1974). Woolley, F. Ross et. al., Prob- lem Oriented - Nursing (New York: Springer Publishing, 1974). Young, James Harvey, Ameri- can Self Dosage - Medicines: An Historical Perspective (Lawrence: Coronado Press, 1974). 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