HEALTH Health Policy Advisory Center Volume 14, No. 1

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Reagan's

Health Care m /fii1 Revolution

M aggie Kuhn, Gray Panther P. 19 Brushup on Teeth P.27 Health/PAC Bulletin Peer lanuary-Fcbruory, 1983 Review Board of Editors IAJ Tony Bale Arthur Levin Howard Berliner Steven Meister To the Editor: Carl Blumenthal Patricia Moccia Thanks for the "Profits With­ Pamela Brier Kate Pfordresher out Honor" article (Vol. 13, No. Robb Burlage Marlene Price 4. I think it's greatl That's a Michael E. Clark Virginia Reath gem of a quote by Phar­ Barbara Ehrenreich Hila Richardson maceutical Manufacturers Sally Guttmacher David Rosner Association's Engman at the Louanne Kennedy Hal Strelnick end (and a gem of a re­ David Kotelchuck Sarah Santana sponse!). Ronda Kotelchuck Richard Younge There are a few extremely Richard Zall recent tidbits regarding Bang­ ladesh, just to let you know. Editor: Jon Steinberg For one, there have already Staff: Roxanne Cruiz, Debra De Palma, Loretta Wavra. been measurable effects (compromises) on the original Associates: Des Callan, Madge Cohen, Kathy Conway., Doug Dorman, law, in that: Cindy Driver, Dan Feshbach, Marsha Hurst, Mark Kleiriian, Thomas —the 236 drugs which were to Leventhal, Alan Levine, Joanne Lukomnik, Peter Medoff, Robin Omata, Doreen Rappaport, Susan Reverby, Len Rodberg, Alex Rosen, have been destroyed on 12 Ken Rosenberg, Gel Stevenson, Rick Surpin, Ann Umemoto. September were not, be­ cause MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR AND —export licenses have been SUBSCRIPTION ORDERS should be addressed to Health/PAC, granted for these drugs (and 17 Murray St., New York, N.Y. 10007. Subscription rates are $15 for individuals, $30 for institutions. 233 others), permitting their ISSN0017-9051 shipment to West Africa, other parts of Africa, and 1983 Health/PAC. The Health/PAC Bulletin is published bimonthly. Saudi Arabia; Second class postage paid at New York, N.Y. and at additional mailing —41 drugs originally to be offices. phased out have been rein­ Design: Three to Make Ready Graphics/1983 stated in the national formu­ Cover by Kate Pfordresher. lary; —the original time periods for Articles in the Bulletin are indexed in the Health Planning and Administration data base of the National Library of Medicine and the "phasing out" have been Alternate Press Index. extended. This information comes mainly from "War on Want" in Lon­ Health Action International country. Your publication also don. The last thing is that for­ IOCU Regional Office for Asia reported that certain U.S. drug eign news articles have men­ and the Pacific companies (Merck, Squibb and tioned "hints at reducing the P.O. Box 1045 Pfizer) had sought assistance at annual $160 million in US aid" Penang the American Embassy which, from the US embassy if the Malaysia in turn, had made certain rep­ Drug Reform Law isn't recon­ November 11, 1982 resentations to the Government sidered. Dear Sirs: in support of these multina­ The enclosed letter was sent I read in one of your recent tionals. by someone who wishes to re­ publications that the Govern­ I recently sent to you a copy main anonymous. ment of Bangladesh had of a report on this issue which I banned a large number of received indirectly from a Best Regards, drugs and was in the process of friend who subscribes to the so- Erica Gollub implementing a new policy on called "International Organi­ New York, NY drugs to be available in the zation Monitoring Service.''^

Health/PAC Bulletin Notes & Comment

Huntington Health Services, Inc., is listed doesn't have the resources to audit all such on the American Stock Exchange. It owns four hospitals, but the selective investigations so far acute care hospitals, seven long term care indicate taxpayers are being taken for a facilities, four retirement homes, a pharmacy multimillion-dollar bath. Blue Cross/Blue company, two physical therapy companies, a Shield customers in some states are paying for medical office building, and two real estate similar fraud in higher premiums. holding companies. Federal regulations on reimbursement are According to a report issued by the General too clear to permit the companies involved to Accounting Office (GAO) of Congress this claim errors in judgement with any credibility. January, Huntington also has some very crea­ Because there is no price restraint through tive accountants. Through a series of complex competition when items or services are pur­ entries, they were able to obtain reimburse­ chased from a related company, Medicare and ment overpayments of $215,000 for fiscal years Medicaid reimbusement for such transactions 1979 and 1980 for purchases of intravenous is limited to the lower of (1) the cost to the (IV) solution by Huntington's North Las Vegas related firm or (2) the market value. In every Hospital from a related enterprise. After the case the hospital engaged in fraud attempted to GAO audit the hospital reduced its fiscal 1981 conceal the relationship or the nature of the reimbursement claim by $441,000. The GAO transaction. also found that North Las Vegas had gotten Responsibility for evasions and overcharges $188,000 more than it should have from the lies not only with the hospitals involved, ac­ government by "buying" inhalation therapy cording to the GAO, but with the insurance services from another Huntington company companies which serve as their fiscal interme­ which paid excess salaries to employees diaries. They are supposed to be the govern­ assigned to the hospital. ment's auditors, but under one of the more pe­ The GAO found a similar pattern at Wood­ culiar provisions of Medicare law a hospital ruff Community Hospital in California, a facil­ chooses which insurer it wants to perform the ity owned by two physicians through a holding audit. The hospital is likely to drop a company company. Woodruff got an extra $600,000 in which is too tough, depriving it of a profitable reimbursements by overpaying a related com­ sideline. Presumably the individual account­ pany which has a contract to manage it and ants might be concerned that if their employer juggling the books to obscure transactions with loses the job, they might lose theirs. The GAO other related companies from routine audits. believes a better system could be introduced. Mad River Community Hospital in Califor­ Free copies o f the GAO report, No. HRD-83- nia inflated its operating costs by more than 18, may be obtained by writing to the U.S. $500,000 by a sham sale and leaseback General Accounting Office, Document Hand­ arrangement with a related company. Brook- ling and Information Services Facility, P.O wood Hospital in California ran up excess costs Box 6015, Gaithersburg, MD 20760. of over $450,000 through management con­ Herb Semmel tracts and leases with related organizations. The magnitude of these overcharges is parti­ (Herb Semmel is dean of the Antioch Law cularly impressive because all of the hospitals School and Director of the Consumer Coalition involved are small, under 100 beds. The GAO for Health.) ■

This is apparently an informa­ the "Bangladesh drug issue" will be particularly hurt if the tion organization which keeps and indicated that the multina­ Bangladesh Government does subscribers informed on the ac­ tional drug companies are con­ indeed ban Vibramycin, an ex­ tivities of selected international tinuing their efforts to change traordinarily expensive form of organizations. This particular the new policy. Of course, it is tetracycline. report contained a summary of in their interests to do so. Pfizer continued to p. 4

Health/PAC Bulletin continued from p. 3 about attracting investment? Pfizer Bangladesh, receives It has recently come to my at­ How far can other potential in­ the bulk product, puts it in cap­ tention that another American vestors trust the government to sules or compresses it into consulting organization, Busi­ live up to its initial promises? tablets, and then sells the prod­ ness International, plans to join Of course, Pfizer would not uct locally—realizing yet this debate. Business Interna­ include in this presentation any another profit on the finished tional (BI) has scheduled a so- reference to the total cost to product. called Roundtable Discussion Bangladesh of this particular Now, Vibramycin is a good with the Government of Ban­ drug, Vibramycin. Nor would and useful drug. For those who gladesh, to be held in February they refer to the fact that Vibra­ can afford it, the benefits out­ in Dacca. The conference has mycin is a form of tetracycline, weigh the disadvantages. The the full support of the Chief a well known and established question is whether or not it is Martial Law Administrator, Lt. broad spectrum antibiotic an appropriate drug for Ban­ General H.M. Ershad. which is available from a large gladesh, particularly when Pfizer, the American number of sources around the other, cheaper forms of tetracy­ multinational drug company world at prices as low as 10% of cline are available. with substantial interests in the Vibramycin price. Above This involves a cost/benefit Bangladesh, is conducting an all, Pfizer would not want to in­ judgement. But how can the active campaign to encourage clude in their presentation any Government of Bangladesh other corporations in other in­ information at all about the make such a judgement in the dustries to participate in the BI method by which their Bangla­ absence of all pertinent infor­ program. Pfizer plans to use desh plant acquires the raw ma­ mation. They cannot. this conference as a forum to terials to "manufacture" Vibra­ I guess my main‘'point here is "pressure" the Government to mycin in the country. There are that it appears Bangladesh is depart from its new drug pol­ very good reasons why they being ripped off. Maybe the icy. Pfizer calculates that it can would not want to discuss these country needs this drug, al­ embarrass the Government by issues. though it does not appear on the pointing to this new policy, In the first place, the Pfizer WHO list of Essential Drugs. which of course deprives Pfizer plant in Dacca is required by Maybe it is proper for large vol­ and other drug multinationals Pfizer policy to purchase the umes of foreign exchange to be of significant profits in Bangla­ bulk Vibramycin from Pfizer, allocated toward the purchase desh, as evidence that the Gov­ U.S.A. It must pay for these of Vibramycin. But I wonder if it ernment is not really sincere in purchases in foreign ex­ is proper for a multinational its attempts to attract foreign in­ change—namely in U.S. dol­ drug company to enjoy uncon­ vestors. It hopes that such em­ lars. Pfizer, U.S.A., places a scionable profits (mostly in for­ barrassment would be fanned price on this bulk product eign exchange) from this or, for by questions and comments which permits it, Pfizer U .S.A ., that matter, any other drug. from other multinationals rep­ to realize a healthy profit on the And I do understand that Pfi­ resented at the conference. sale of bulk Vibramycin to its zer's profits from Vibramycin In fact,if Pfizer.plans their ac­ own subsidiary, Pfizer Bangla­ are very substantial. In fact, my tions carefully, they could desh. This "transfer price" friend who works at Pfizer has make a persuasive case. There creates capital flight from Ban­ expressed the opinion that Pfi­ is a lot of good "pr" material in gladesh. It contributes toward zer would probably be forced to the situation. After all, Pfizer the depletion of the country's "close up shop" in Bangladesh could argue, here is a case of an foreign exchange reserves. It if the Government proceeds to honest and sincere foreign in­ jacks up the bill for health care ban Vibramycin. Without vestor coming to Bangladesh, in the country by an unjustifia­ knowing any of the details, I constructing a plant, creating ble factor. The Government of think this one "fact" speaks for jobs etc., and making available Bangladesh does not know, and itself. a modern medicine to cure dis­ Pfizer refuses to provide this in­ There is little doubt that Pfi­ ease. And what happens? After formation, just how much profit zer plans to raise the issue of the the plant is in full operation, the Pfizer makes on this sale from new drug policy during the BI Government tells the investor the parent company to its own meeting in Dacca. They will that it can no longer manufac­ subsidiary. Consequently, Pfi­ probably arrange for someone ture and sell that drug. How sin­ zer pays no taxes to Bangladesh else to ask a pertinent question, cere can the government be on this profit. continued to p. 6

Health/PAC Bulletin Vital Signs

treated in one hospital stay. This tions may be the big gainers ploy is so widely known in the under the new system. industry that it already has a name—"DRG creep." W ash in gto n Whether DRG's curb hospi­ Certified Cash Update tal costs or not, they will surely be a boon to accountants. In response to the clamor for Instead of one national rate for Look up on your doctor's wall cost-cutting, the first major each DRG, there will be nine and you're likely to see a certifi­ change in Medicare reimburse­ regional rates, each with a sep­ cate indicating he or she has ment since the program was es­ arate rate for rural and urban passed an oral and written tablished in 1965 has sailed areas. Since there are 467 exam in a medical specialty. through Congress. Whether it DRG's, there will be a total of Almost three quarters of all will actually cut costs is another 8406 rates nationwide. In addi­ physicians practicing in the matter. tion, reimbursement under U.S. have at least one. Among DRG's will be phased in. Begin­ office-based specialists, the Until now, hospitals have ning this October, 25 percent proportion ranges from 67 per­ been reimbursed on the basis of will be based on DRG's and 75 cent for psychiatrists and 69 "reasonable" costs of providing percent on the old reasonable percent for internists to 100 per­ care, a method which gave cost method. In the second year cent for family physicians. them a free hand in spending the ratio goes to 50-50 and in Board certification has always with virtual assurance of reim­ the third to 75 percent DRG, 25 been regarded as professional­ bursement. Under the new sys­ percent cost. Not until October ly prestigious as well as a testi­ tem, by 1987 hospitals will get 1985 will the changeover be monial of competence to their Medicare money entirely complete, so hospitals will have deliver high quality specialty according to Diagnostic Re­ to keep dual records for three care. lated Groups (DRG's), i.e. a years. It is also, a recent study flat amount for each patient published in Medical Econom­ As if this isn't enough to keep based on the diagnosis, regard­ ics shows, a good indicator of the government computers less of length of stay or utiliza­ prosperity. In 1981 the median busy, the Department of Health tion of services. (For a fuller ex­ annual gross income for uncer- and Human Services is permit­ planation of DRG's, see the pre­ tified specialists was only ted to grant adjustments, vious Bulletin's Report from $112,000 and the net a modest including special allowances Washington.) $70,000. The median certified for sole community hospitals, specialist, however, took in Studies in New Jersey, where public and teaching hospitals, $152,000 gross and $93,000 DRG reimbursement has been and hospitals serving a dispro­ net; almost 30 percent grossed used since 1980, differ on portionate number of low over $200,000. whether it has achieved sav­ income patients and Medicare ings. A leading hospital attor­ beneficiaries. In addition, The 1983 incomes will proba­ ney in Washington predicts off teaching hospitals will continue bly be considerably improved. the record that hospitals will to be reimbursed on a cost basis If America is on the mend, it is adjust to DRG's by upping the for medical education expenses only natural that menders diagnosis to a higher, more such as salaries of residents and should be doing well. Unem­ costly, category or by putting interns. Since residents pro­ ployed steelworkers might con­ through multiple admissions for vide most of the patient care in sider a career in specialty med­ a patient who might have been teaching hospitals, these insitu- icine. ■

Health/PAC Bulletin continued from p. 4 tially more useful that other priate behavior by a multina­ so that Pfizer is not singled out forms of tetracycline and it is far tional drug company. Pfizer as the "troublemaker." It seems too expensive for Bangladesh. does a lot of good things, no to me that it would be relatively And perhaps the telling point is doubt. This isn't one of them! easy to expose Pfizer's strategy that bulk Vibramycin (generic You could be helpful in discre­ and to discredit it. All it would doxycycline) is available from a diting the move to cause the take is for someone with stature number of non-Pfizer sources at Government of Bangladesh to and the appropriate credentials substantially cheaper prices!! abandon their new policy to guide the discussion toward I apologize for this lengthy which does appear to be benefi­ transfer prices and then raise epistle; however I thought you cial for the country. Best re­ the point that, while no one ar­ might be interested in this case gards. gues that Vibramycin is not a in Bangladesh. To me, it is a X good drug, it is not substan­ classic examples of inappro­ H ong Kong ■ WANT THE BEST FILMS ON REPRODUCTIVE RIGHTS?

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Health/PAC Bulletin Who Cares for Health Care? The First Two Years of Reagan Administration Health Policy

by Geraldine Dallek

HV In this present crisis," President Reagan percent or more reduction in funding for a declared in his Inaugural Address, "govern­ number of other health and social programs; ment is not the solution to our problem; gov­ and trims of several billion dollars in appro­ ernment is the problem." The solution he has priations for food stamps, welfare, energy, and proposed is to free American enterprise and housing programs. the American spirit by cutting Federal domes­ "Safety net" programs—those which serve tic spending; shifting powers to the states; and the "truly needy"—would be spared, Inexpli­ easing Federal tax and regulatory burdens. cably, however, programs such as Medicaid, As a primary area of Federal activity, health food stamps, welfare, maternal and child care has been a major target of this effort from health, and community health centers, all pro­ the beginning. The Reagan Administration has grams that provide care only to the poor, were moved on several fronts, attempting to slash its excluded from this category. On the other Federal funding, shift responsibility for the hand, Medicare, the Veterans Administration, poor and the elderly to the states and the volun­ and Social Security programs serving many tary sector, and promote competition through non-poor individuals were included among the deregulation and a change in tax and insur­ inviolable. ance policies. This revolution was to be blood­ According to one study, 60 percent of Ameri­ less, causing no harm to those dependent on cans below the poverty line received either no Federal assistance. "We can continue to meet benefits at all from the Administration-defined our responsibility to those who through no fault safety net programs or only free school of their own need our help," the President lunches.3 promised.1 In 1982, the Administration once again pro­ At the halfway point in the Reagan Presi­ posed drastic cuts, but shuffled the safety net dency, it seems appropriate to assess how far definition. Medicare and Social Security were this revolution has gone, the changes it has tossed out with Medicaid, food stamps, wrought, and its future prospects. welfare, and maternal and child health. Although Congress balked at giving the Federal Budget Cuts President all he requested, programs for the In 1981 and again in 1982, the Reagan poor were slashed severely, especially the first Administration proposed massive cuts in Fed­ year. The 1981 Omnibus Budget Reconcilia­ eral health and social programs. In his Febru­ tion Act (OBRA) trimmed or totally eliminated ary 19, 1981, address to Congress, the Presi­ outlays for approximately 200 programs. dent asked for a five percent cap on increases Health care was a prime OBRA victim. Medi­ in the Federal contribution to Medicaid; a 25 caid matching funds were cut three percent for 1982, four percent for 1983, and four and a half Geraldine Dallek is a health policy analyst in percent for 1984. States were given increased Los Angeles. flexibility to cut their Medicaid programs—

Health/PAC Bulletin which they promptly did, by approximately and social programs to a far greater degree $300 million for Fiscal Year 1982 and then $250 than the Federal cuts in themselves required. million more for FY 1983. In addition, a California, for example, lost $60 million in squeeze on welfare shrank Aid for Dependent Washington but slashed its own programs in Children (AFDC) rolls by ten percent, and this area by $200 million in FY 1981 and $500 those excluded lost their Medicaid coverage as million in FY 1982. well. Categorical health programs—Federally ♦ funded and administered programs targeted to serve specific low income populations or attack Despite all these cutbacks, no basic revolu­ specific health problems—suffered the tion has transformed health care funding. The greatest proportional loss in 1981. Twenty-two Federal government is still in the health care programs were combined into four block business, shouldering the major financial grants, and their total funding was slashed 25 responsibility for meeting the health needs of percent. the poor and the elderly. After performing this radical surgery on ca­ The perceived Reagan mandate to reduce tegorical health programs in 1981, as well as Federal domestic spending notwithstanding, gutting health education and school nutrition the rush to cut was braked by two important and sharply reducing funding for other pro­ factors. First and most obviously, by the worst grams such as food stamps, welfare, and hous­ recession since the 1930's. By the end of 1982, ing, Congress lost much of its taste for going 10.8 percent of the workforce was unem­ after domestic spending. In 1982the legislators ployed, and over 14 percent of Americans ignored an Administration proposal to take were living below the poverty' line. As more away 22 percent of the funding for the Wo­ and more of their constituents suffered drastic men's and Infant Care (WIC) program and fold reductions in income and lost their private it into the Maternal and Child Health Block health insurance, the need for government Grant. Some funds—not much—were restored health programs grew dramatically, and mem­ to the MCH and Primary Care (community bers of Congress were reluctant to continue health centers) block grants. The President seeking "savings" in health programs for the called for an additional $1.9 billion slice out of poor and elderly. Medicaid; he got only $256 million removed. Second, this congressional resolve was Only Medicare, relatively untouched by cuts strengthened by broad and increasing public in 1982, was hard hit, suffering cutbacks total­ support for Federally funded health programs. ling $13 billion for the fiscal years 1983 to 1985. Over the decade and a half since their incep­ (See Report from Washington in the previous tion, Medicare and Medicaid have enjoyed Bulletin). consistent backing in opinion polls, along with This year President Reagan is once again the precept that no one should be denied proposing massive cuts in domestic spending, health care for lack of money. Generally, the but even Republican leaders say there is little public did support the first round of Reagan chance they will make it through Congress. cuts, but not, as political columnist William Paul Laxalt (R-NV), the President's closest Schneider put it, because they felt that "social friend in the Senate, admits that domestic pro­ welfare should be curtailed as a legitimate gov­ grams have already been cut to “the bone." ernment function." Analyzing two polls taken There is no doubt reaching the bone has early in the Reagan presidency, Schneider hurt. But perhaps even more suffering has concluded that, "people want to cut spending resulted from the Reagan tax cuts and other on social programs, but they do not want to cut fiscal policies. They played a key role in creat­ services to the poor, the elderly, the unemploy­ ing the worst economic downturn since the ed, and the disadvantaged."2 Rather, the public Great Depression and lowered the revenues of was persuaded both that the early Reagan cuts state governments while increasing state were needed to curb inflation, considered the expenditures for interest payments, unemploy­ number one priority in 1981, and that by ment compensation, and other uncontrollable eliminating waste and inefficiency these items. Coupled with the Federal cutbacks, the reductions could be made without harming result was enormous gaps between projected those in need. revenues and expenditures. To balance their Convinced that the "fat" had been taken out budgets states were forced to squeeze health of government health programs, the vast ma­

Health/PAC Bulletin KatePfoi jority now opposed further reductions. A re­ Shortly after taking office, the President pro­ cent Harris poll found that 62 percent of Ameri­ posed combining 40 categorical items for cans would rather cut the military budget be­ health and social services into four block fore touching health care outlays in general, grants to the states—with a 25 percent funding while only 34 percent hold the opposite view. cut. The health proposal entailed consolidat­ The sentiment for going after Pentagon fund­ ing 26 programs into two massive block grants. ing first jumps to three to one for Medicaid and Even apart from the budget reductions, com­ an overwhelming four to one for Medicare. munity groups strenuously opposed the con­ "There is something sacred about Federal cept of block granting, fearing that valuable health programs to the American people," programs without a powerful local constitu­ concluded Harris, ''the public gets 'fighting ency would get shortchanged. Nevertheless, mad' when it seems that America could well be the President, strongly backed by the National systematically stripped of all its compassion for Governors Association, got much of what he decency and humanity."3 asked for. Congress gave him the full 25 per­ cent cut and combined most of the targeted Shedding Federal Responsibility programs into seven block grants. Four of them As part of his campaign against the Federal combined 22 health programs. However the government, which he attacked as a bloated legislation did attach strings. State discretion monster depriving states and localities of "dis­ in block grant funding was restricted. Use of cretion," "flexibility," and ''decision-making" one health block grant was limited in such a authority, President Reagan proposed a shift in way that few states were likely to assume responsibility for health and social programs. responsibility over it. Several health programs "Now we know, of course," he declared, were kept out of the blocks, including health "that categorical grant programs burden local planning, migrant clinics, and family plan­ and state governments with a mass of Federal ning. regulations and Federal paperwork. Ineffec­ Despite these setbacks, the Administration tive targeting, wasteful administrative over­ was riding high from its triumphs and set to head—all can be eliminated by shifting the re­ work developing the most radical reordering of sources and decision-making authority to local Federal-state responsibility since the 1930's. and state government." This shift, he prom­ Yet when President Reagan unveiled the "New ised, would bring "government closer to the Federalism" in early 1982, his proposal fell flat. people" and save "$33.9 billion over the next Why the abrupt reversal? State and local five years."4 lobbies, most notably the National Governors

Health/PAC Bulletin the Administration proposal to eliminate Fed­ eral funding for National Health Service hospi­ tals and turn them over to community control. When Congress attempted to appropriate tran­ sition money for these hospitals, the Adminis­ tration tried to block the transfers, preferring to close the facilities instead. "The Administra­ tion did not support the transfer to community control," a study of the transfer of the Seattle Public Health Service Hospital bitterly con­ cluded, "instead it acted repeatedly to prevent the possibility the hospital would continue under local control. From February 1981, when the President's budget was presented to Congress, until November 1981, when the transfer actually took place, representatives of the Reagan Administration used a variety of political, legislative, and bureaucratic maneuvers to close the hospital, effectively Association (NGA), had lost their enthusiasm refuting the New Federalism."7 for the entire concept. Shocked by the magni­ The Administration's New Federalism pro­ tude of the 1981 cuts and the proposals for gram was certainly bold: a $20 billion swap, more, the governors had learned that devolu­ with the Federal government assuming respon­ tion of Federal responsibility to the states came sibility for Medicaid and the states taking over with a very hefty price tag. As early as August welfare and food stamps and accepting a "turn­ of 1981, Georgia governor George Busbee, back" of 43 other Federal programs. The Presi­ the departing NGA chairman, and a strong dent and his officials maintained that the swap supporter of the President's program only a few was basically even since it included a $28 bil­ months earlier, responded to the New Feder­ lion trust fund financed by excise and oil wind­ alism agenda with an acid prediction that "I fall profits taxes to pay for the turnback pro­ fear that it's only a matter of months before grams and make up any difference to states some of our friends in OMB [the Office of which lost money in the swap. Management and Budget- e d ., ] attempt to im­ The balance sheet, however, was bogus. pose their own brand of sorting-out States already had use of revenues from the . . .guided by one sole criterion: What makes excise tax. The oil revenues would be unequal­ it easiest to balance the Federal budget? From ly distributed to a few oil-rich states. The costs the point of view of budgetary tunnel vision, to the states of assuming AFDC and food Federalism becomes an easy matter—pick out stamps had been grossly underestimated and the most expensive, the most difficult to the Federal burden in taking over Medicaid manage, the most politically controversial had been exaggerated. The Congressional Federal programs and hand them over to the Budget Office estimated that the swap would states and localities with a heartfelt sigh of re­ cost the states $1.5 billion and the turnback lief."5 program $13.4 billion during the first year.8 Opposition also hardened at the predomi­ The American Federation of State, County, nantly Democratic grouping of large cities, the and Municipal Employees (AFSCME) warned U.S. Conference of Mayors, following a survey that the states would be out $17 billion in FY of 100 cities in November 1981. "Recently- 1984 and a total of $86 billion by FY 1991, when enacted Federal budget cuts are imposing most states would be left high and dry by the immense burdens on city budgets, resulting in phase-out of the trust fund.9 massive layoffs, service reductions, tax After a year of tough bargaining between the increases, and postponement of needed capital National Governors Association and the investments," the Conference statement com­ Administration, in December 1982 the gov­ plained.6 ernors proposed the Federalization of Medi­ Suspicions that the rhetoric of bringing con­ caid (including funding of long-term care costs trol closer to the people was a cover for budget- and assumption of medically needy programs, cutting and nothing more were heightened by which the Reagan team had wanted to leave

Health/PAC Bulletin with the states) in return for a state takeover of a Although a Private Sector Initiative Task Force limited number of relatively small health pro­ to encourage community effort was established grams. AFDC and foodstamps were not men­ and, in his second State of the Union Address, tioned. The Administration decided to drop the President declared, "The volunteer spirit is swap idea entirely. It is now proposing a large still alive and well in America," even maintain­ block grant for 22 health and social programs ing past levels of aid in real dollars is proving with guaranteed funding for five years. How­ difficult. As one study noted, "Government has ever, with seven new Democratic governors in historically used the non-profit sector as the formerly Republican state houses, the likeli­ conduit through which it delivers services, hood of any New Federalism transfers during with the result that government cutbacks are the rest of the Reagan years appears slim. also private cutbacks!"16 Furthermore, accord­ The block grant strategy may not be so ing to an Urban Institute analysis, a private successful either, since those already in effect sector giving would have to be up 26 percent in have not fulfilled the President's promise that 1982, 39 percent in 1983, and 44 percent in the needy would be protected. Lead poisoning 1984 to make up for Federal cuts passed in the programs within the Maternal and Child Omnibus Budget Reconciliation Act of 1981 Health grant, for example, have not fared well alone.17 In addition, the President's Economic under state control. Distressed by the esti­ Recovery Tax Act of 1981 reduced financial mated sharp 42-55 percent drop in the number incentives to donate for both corporations and of children who will be screened from FY 1981 individuals—at a time when high unemploy­ to FY 1983," supporters of the program are ment, business failures, and economic hard asking Congress to restore Federal responsi­ times leave them less able to give. Even if these bility for it. Representative Henry Waxman (D- hurdles were overcome, any conceivable CA), Chairman of the House Subcommittee on increase would be woefully inadequate to cov­ Health and the Environment, hopes to intro­ er the gap torn by Federal cutbacks. The fol­ duce legislation on their behalf. lowing discussion explains why. Similar outcries are coming from those Health Care for the "Truly Needy" involved in other block granted programs. The increased efficiency and support at the state The Reagan Administration has steadfastly level which was supposed to mitigate the maintained that its budget will not and has not impact of the 25 percent funding reduction harmed those truly in need. Shortly after tak­ have not materialized. Instead, states have ing office, the President stated that "our spend­ passed the cuts on to grant recipients. One ing cuts will not be at the expense of the truly 1982 50-state block grant survey found that a needy."18 A year later, in his 1982 State of the majority of respondents felt that "there had Union Address, Reagan again reiterated his been a decline in the quality of services pro­ Administration's commitment to the impov­ vided in the last year."12 erished: "Contrary to some of the wild charges Neither did public accountability increase you may have heard, this Administration has as had been promised. In fact, as a study by the not and will not turn its back on America's Center for Law and Social Policy noted, "the elderly or America's poor."19 entire block grant implementation process Unfortunately, the reality is quite different. largely took place in the absence of meaningful Cuts in health care programs during the past public comment."13 Several mayors also com­ two years have inflicted great harm on these plained that states "had not consulted with groups. them or offered an opportunity to participate in In the Medicaid program, what began as the state's decision-making process."14 deep cuts in Washington became worse in The President also assured the public that an states. Frantically looking-for ways to adjust to outpouring of good will and money from a Federal reductions and shrink their recession- mobilized private sector would reduce the starved budgets, some states went on a Medi­ impact of Federal reductions. "How can we caid rampage, slashing their programs to love our country and not love our country- pieces. During 1981 and 1982, Medicaid pro­ ment? And, loving them, reach out a hand grams were severely cut in 35 states; dental when they fall, heal them when they're sick, services in 22; funding for drugs, prosthetic and provide opportunity to make them self- devices, or medical supplies and equipment in suffieient?" he asked rhetorically.15 31; emergency hospital services in five; in­ Apparently, Reagan's "we" found a way. patient hospital services in 17; optometrist

Health/PAC Bulletin services and eyeglasses in 17; outpatient serv­ single parent families with incomes slightly ices in nine; rehabilitation and physical thera­ above Social Security and AFDC eligibility, py services in ten; physician services in nine; will illustrate the tragedies inflicted: psychiatric care in 15.20 Some of the cutbacks were drastic. For "A middle-aged woman from Moore County, example, South Carolina, New Hampshire, who supplements her $3000 a year farm and New Jersey imposed a 12 day ceiling on income by cleaning other people's homes, Medicaid hospital coverage. The case of South required two operations for cancer within a Carolina indicates what this can mean: In period of six months. She exhausted her life 1979, 23 percent of hospitalized Medicaid savings during the first surgery and became recipients there required more than 12 hospital eligible for the Medically Needy Medicaid days. South Carolina has also limited any com­ program. But the hospital refused to perform bination of emergency room visits, outpatient the second operation because of the restric­ tions on her Medicaid coverage, even after hospital visits, and physician visits to 18 a she borrowed $1000 from her teenage daugh­ year—far fewer than the chronically ill and ter who had earned the money to try to put children often need. In addition, South Caroli­ herself through college. nians on Medicaid are now reimbursed for only three prescriptions a month. There are no "A carpenter from Morgan County was dis­ abled after being bitten by a brown recluse exceptions. spider and started losing his vision in both Unfortunately, these punishing cutbacks are eyes. When he presented his Medically not atypical. Pennsylvania eliminated eye care Needy Medicaid card, the hospital refused to altogether. West Virginia now covers emer­ perform the surgery necessary to save his gency care only for accidents, injuries, and vision, because the cutbacks had already trauma. Missouri limits prescriptions to two a taken effect. month except for emergencies. "A resident of Clay County with a crushed From early 1981 to the end of 1982 unem­ foot and degeneration of the spine qualified ployment soared from 7.4 percent to 10.8 per­ for a Medically Needy Medicaid card, but cent. Yet, while millions of Americans were when the hospital realized that his card would losing their health insurance along with their not cover hospital services, his scheduled sur­ jobs and the number of people living below the gery was cancelled."22 poverty line was climbing precipitously, Medi­ caid rolls did not increase. This apparent para­ California hopes to save almost $400 million dox is a consequence of tighter Federal and in FY 1983 through Medicaid cuts in physician state welfare and Medicaid eligibility rules. and hospital reimbursement, stricter eligibility During 1981 and 1982 nineteen states have requirements, and reductions in eligibles and already reduced the number of persons eligi­ services. For a 16 year old boy with muscular ble for Medicaid. California alone, under dystrophy this will mean the once a week 40 Democratic Governor Jerry Brown dropped minutes of physical therapy is gone; he must 270,000 Medically Indigent Adults from the make do with 30 minutes twice a month. Medi­ program. Washington, Kansas, Pennsylvania, caid will stop paying $216 a month for medi­ and South Carolina also reduced or eliminated cines needed by a severely disabled 11 year care for adults living on general assistance. old girl. A 75 year old man suffering from Tennessee virtually eliminated its Medically diabetes, bladder problems, high blood pres­ Needy program. Six states terminated Medi­ sure, and arthritis, with $30 left each month af­ caid coverage for families with unemployed ter paying rent at a board and care facility, will parents, and ten for all or some recipients have to pay $ 181 a month before he qualifies for between the ages of 18 and 21.21 Medicaid. A recently unemployed 27 year old In 1981 AFDC changes cut Medicaid eligi­ diabetic suffering from a myriad of disease bility for women and children by ten percent. complications will have to spend half of her In 1982 almost 700,000 more children lost their $524 income on medical care each month be­ coverage. fore becoming eligible for Medicaid. There is no question that these cutbacks These are not isolated cases. Thirty-four mil­ harmed the "truly needy." A few specific cases lion Americans are uninsured at least part of from Tennessee, which in 1981 virtually elimi­ the year.24 Over one half of the nation's poor nated its Medically Needy Medicaid program cannot get Medicaid; in Texas and Mississippi covering the aged, the blind, and disabled only a quarter are covered. Denied Medicaid,

Health/PAC Bulletin the uninsured poor must depend on other Fed­ eral, state, and local health programs—all of which have been slashed in the past two years. During 1982, 725,000 people lost services in funding cuts which hit 239 community health centers (28 percent of the total) and 47 states reduced their Title V Maternal and Child Health block grant programs.25 A recent sur­ vey of 55 American cities found that during 1982 health programs serving indigents have been cut 42 percent.26 Some hospitals and doctors have increased their efforts to provide charity care, but for the most part the private medical sector has made

little or no attempt to cover the widening holes Mike Peters/Dayton Daily News in the safety net. "Current economic con­ straints are forcing providers to ration more them their health benefits," explained one and more," concluded a special committee of Cook County physician, "People who never the American Hospital Association, "Patients thoughtthey would wind up being shoved off to who can afford to pay or who have insurance County."32 coverage will receive care, while other may be The first broad signs that these cutbacks and denied."27 similar ones in food programs are damaging Hospitals in many communities have health have already emerged. Reports of increased rather than decreased pre-admis- increased malnutrition among children, indi­ sion deposits required for treatment. A few gents delaying medical care because of inabil­ documented cases, again from Tennessee, will ity to pay, and doctors and hospitals unwilling demonstrate the consequences: During 1982 a to care for the uninsured poor indicate we are young wife and mother was denied cervical in the opening acts of what could become a cancer surgery when she and her husband, a national disaster. construction worker, could not raise $3,200; a . "There is increasing evidence that both three year old boy's eyesight deteriorated for inpatients and outpatients in public and volun­ lack of hospital care; a 49 year old woman who tary hospitals are now presenting themselves had worked as a tobacco stripped was denied, with more serious disease states," declared the an operation for her stomach cancer because American Hospital Association study on the she did not have a $700 cash deposit.28 impact of the health cuts. "This manifestation These cases also are far from unique. seems to indicate that many patients have Children's Hospital in Washington instituted delayed seeking treatment. The committee pre-admission cash requirements in 1982.29 A concluded that "cuts have triggered a much hospital in Kentucky coerced patients into more rapid deterioration in health status than signing postdated checks and borrowing from most officials responsible for the cuts are now the bank; in at least one case, this institution willing to acknowledge."33 threatened to hold a newborn hostage until the Reductions in maternity care services have bills for the delivery were paid.30 In central been particularly tragic. Cuts at the county Georgia, a public hospital administrator asked and city health department level, in the MCH county commissioners to direct their health block grant, and in Medicaid, coupled with the departments to stop sending poor women in unwillingness of many obstetricians to accept labor to his hospital, recommending that they Medicaid reimbursement, have created a crisis be shunted to the state hospital 120 miles in pregnancy care. The consequences are no away.31 Chicago's Cook County Hospital less distressing for being predictable. reports that since July 1981 the number of Poor women are not getting the pregnancy Medicaid and uninsured patients dumped on care they need. A September 1982 Oregon its doorstep by local private institutions has survey of 1,458 pregnant women in the WIC quadrupled. Many of those dumped are program found that 10.2 percent were receiv­ doubly devastated because they aren't used to ing no prenatal care, 13.3 percent didn't know being treated as the poor often are. "The trans­ what to do about or hadn't made plans for fers affect people losing their jobs and with delivery; 9.3 percent were planning to show up

Health/PAC Bulletin at a hospital in labor; and 4.5 percent (66 bureaucracy. The other is to carve additional women) reported they will be having home pieces from programs when Congress refuses births because they had no money for hospital to go along. care.34 In 11 poor communities in New York In fairness, it must be said that the Reagan City, 20 percent of women delivering babies deregulatory fervor is not blind. Some new had late or no prenatal care.38 regulations are favored, such as the notorious Between 1980 and 1981, 15 states reported a "squeal rule," which would require family rise in infant mortality rates. Eleven other planning services to notify the parents of a states reported a rise during 1982.36 It is too teenage who came to them for assistance, and early to know whether these increases are the other regulations which would require the beginning of a trend or a reflection of the nor­ physical separation (including separate mal cyclical changes in infant mortality rates. entrances) of abortion services from Federally Yet, it appears certain that in poverty areas with financed family planning activities. Aside from rampant unemployment a crisis exists. The being burdensome, such regulations, particu­ Michigan Department of Public Health reports larly the latter, would substantially increase that "Neighborhoods in Detroit are experienc­ costs for hospitals and other abortion pro­ ing an epidemic in infant deaths" reaching 33 viders. per 1000 live births, a rate comparable to that Nevertheless, the President was able to pro­ of Honduras.37 claim in his 1982 State of the Union Address Because the absence of preventive or pri­ that "Together we have cut the growth of new mary care increases long term and even life­ Federal regulations nearly in half. In 1981, time deterioration in health, the failure to care there were 23,000 fewer pages in the F ed eral for the truly needy will weigh on the nation as Register, which lists new regulations, than well as the individuals concerned for a long there were in 1980." time. Over the past two years his Department of Health and Human Services has done its part, Deregulation and Competition consistently trying to fashion the regulatory The effects of the budget cuts were exacer­ process to the Administration model. It has bated by continued cost inflation in medical issued regulations which do little more than services. Although the recession did brake the parrot vague statutory language, thus leaving overall inflation rate, it seemed to have much massive loopholes; reinterpreted old regula­ less impact on health care. In 1981, hospital tions to eliminate health program recipients costs jumped 19 percent while the overall rate and agencies; and substantially weakened was climbing 8.9 percent. In 1982, hospital Federal enforcement of existing regulations. In costs were up 12.6 percent when the general one of the more egregious efforts to promote rate slowed to 3.9 percent. this strategy, 318 pages of categorical program The Reagan Administration answer to this regulations were replaced with six pages of problem was to promote competition by free­ block grant regulations which left states free to ing states and private health care providers spend the funds in almost any manner they from "excessive" regulation and promoting a wished. In the words of the preamble to the "competitive" health plan. block grant regulations, “to the extent possi­ The assault on the "virtual explosion of gov­ ble, we will not burden the state administration ernment regulations" was announced by Presi­ of the programs with definitions of permissible dent Reagan in his February 1981 State of the and prohibited activities, procedural rules, Union Address. He pledged to ''come to grips paperwork and recordkeeping requirements, with inefficiency and burdensome regula­ or other regulatory provisions."38 In addition, tions—eliminate those we can and reform the without statutory authority, HHS has added others." His appointees have tried hard to keep new Medicaid regulations allowing states to this promise in health care as in environmen­ restrict the number of persons eligible. tal, health and safety, and other areas where More action is planned on the regulatory the Federal government exercises oversight. front in 1983, including proposals to eliminate Health care "regulatory reform" has two critical Hill-Burton Act requirements that com­ purposes from the Administration's perspec­ pel hospitals which have received capital fund­ tive. One is to free hospitals, nursing homes, ing through the act to provide some services for and other health care providers from the ex­ the poor and regulations which weaken stand­ pensive and wasteful demands of an overblown ards which must be met by hospitals and nurs­

Health/PAC Bulletin ing homes wishing to obtain Medicaid and ney generals, and others opposed the regula­ Medicare reimbursement. tions. Despite all this activity, on balance the As this storm of protest indicates, resistance Administration's regulatory crusade has met to the Reagan regulatory reform attempts has with more failure than success. Congressional been widespread. Americans may question opposition, public outcry, and court decisions why so many regulations are needed, but they have thwarted its efforts time and again. generally believe government rules protect One major defeat came in the Primary Care them. A majority of those surveyed in an block grant. In the October 18, 1981 F ed eral August 1979 Gallup poll declared that Register, HHS published a list of 1,500 places although government health regulation may no longer considered a medically underserved boost the cost of health care, "the benefits of area (MUA). Because the funding for a com­ regulations outweigh the drawbacks."39 Ameri­ munity health center (CHC) is predicated on cans want their government to set nursing its MUA service, the ''dedesignations" would home standards, protect them from harmful have terminated Federal funding of approxi­ drugs, and ensure that tax money is spent on mately 85 CHC's. HHS based its decision on programs which meet government purposes. faulty analysis of old census data; according to The Administration asserts that a competi­ its calculations, parts of Harlem in New York tive health system would obviate the need for and Watts and East Oakland in California—im­ oversight such as health planning and PSRO's, poverished communities with high infant mor­ as well as reduce costs by making even the tality rates and few physicians—were no longer poorest more aware of what their health ser­ medically underserved. Congressional com­ vices cost. Currently, the argument goes, com­ plaints and appeals from affected community prehensive first dollar health insurarice cov­ health centers and the threatened communities erage insulates patients from the economic themselves compelled HHS to back off. Of the consequences of their decision to seek medical 77 CHC's which appealed and submitted their care since they don't pay a penny for it outside own census data, 71 won their cases, only three of premiums. If they become more price con­ lost, and the remainder are still under review. scious, says the pro-competition logic, con­ HHS lost another round in its efforts to sumers will shop around for the best, most undermine CHC's last December when a Fed­ economical insurance plan or service to meet eral Court in the District of Columbia prohib­ their needs. Insurance companies, forced to ited it from turning over administration of cen­ compete for enrollees, will in turn pressure ters to two states under the Primary Care block hospitals and physicians to organize and com­ grant. Congress joined in the CHC defense by pete with one another. attaching a rider to the "orphan" drug bill To drop these dominoes into place, the requiring HHS to issue separate regulations for Administration seeks several Federal policy the Primary Care block before putting the changes. First, tax laws must be altered to CHC's in state hands. Congress also, in the Tax require workers to pay income taxes on Equity and Fiscal Responsibility Act of 1982, employer contributions to health insurance nullified HHS's Medically Needy regulations premiums above a specified level. Second, and prohibited it from promulgating changes Medicare recipients should be given the option in nursing home survey and certification of dropping the program in return for a vou­ requirements for several months. cher or credit to buy private health insurance. Such setbacks haven't deterred Health and Third, the spread of Health Maintenance Human Services from its appointed deregula- Organizations (HMO's) and other groups of tory path. In what may be the most audacious physicians and hospitals should be move to date, HHS tried to scrap the rule which encouraged by easing Federal requirements. requires the publication of proposed regula­ As with the Administration's "New Federal­ tions for public comment. The Washington Post ism" and "regulatory reform" efforts, this headlined this initiative "Calls for Comment on "competition" strategy is limited to actions Plans to Shrink Calls for Comments." The which serve ideological goals. For example, public did comment, vehemently and with rare the Administration supports the rapidly unanimity. Every one of the 1,103 responses increasing involvement of large for-profit cor­ received from HHS program beneficiaries, porations in health care even though their advocacy groups, members of Congress, market share in many areas is already sufficient health care providers, labor unions, state attor­ to inhibit competition. Nor has the conserva­

Health/PAC Bulletin tive drive to strip the Federal Trade Commis­ this year. (See Report from Washington in the sion of authority over physicians and dentists, a previous Bulletin for more details- ed.) decidedly anti-competitive move, aroused any Ironically, the Reagan Era may be marked by protests from HHS. Finally, as many health a significant increase in Federal control of the economists have noted, the competitive plans health care industry, the opposite of what the being discussed all involve a degree of regula­ President sought. Moreover, during his first tion of the insurance industry, a project hereto­ two years in office, Federal health programs fore never even envisioned in government cir­ suffered less financially than other programs cles. for the poor such as food stamps, welfare, hous­ The Administration has been singularly ing, and education. There was, it seems, no unsuccessful in promoting its competition way the attempted revolution from above could strategy. During 1982, a proposal in the Senate overcome the deep support for a strong Fed­ to cap tax-free benefits of employer paid health eral role in the financing of health programs— insurance and a Medicare voucher proposal in especially Medicaid and Medicare—among the House went nowhere in the face of biparti­ the American people and their state and local san opposition. This year instead of a gran­ representatives. diose "competitive" plan the Administration Even so, the Reagan Administration has has proposed limiting the tax exemption for weakened the Federal support system. Health employer-paid health insurance and establish­ care funding has been reduced at all levels of ing a voluntary Medicaid voucher system—but government; the nation's impoverished suffer even this slimmed-down initiative is given little the consequences. Under the Administration's chance of passage by most analysts. aegis the for-profit health care sector has con­ These setbacks are hardly surprising given tinued to grow at a phenomenal pace, consum­ that the competition strategy has no support ing an ever-larger piece of the health care pie. from labor, the Chamber of Commerce, the Health care programs will remain vulner­ health insurance lobby, senior citizen groups, able as long as there is no consensus on how to or hospitals and physicians. In addition, even transform our chaotic mishmash of a system supporters of the competition philosophy con­ into a coherent program which guarantees cede that it would be many years before the equal access to quality care for all Americans. Administration plans could curb health care There is little likelihood of advances on the cost inflation significantly. One of them, Sena­ Federal level soon. National health insurance tor Robert Dole (R-KN), spoke for most mem­ seems many years off. bers of Congress last year when he declared, In the intervening years, health advocates “We can't wait for long-term competition might look again at some of the Reagan agen­ plans."'10 da—not the part which says less is better, but The Administration has also been defeated, the part which says that the responsibility for sometimes unexpectedly, in other competition providing health care should be shared by initiatives. Two years ago the demise of health state and local governments and the voluntary planning and PSRO's appeared imminent. sector. In essence, while fighting Federal cuts Although weakened, both may survive. Last we can seize opportunities at the state and year, despite intensive provider lobbying, the county level. Federal Trade Commission retained authority The Federal government assumed the major to oversee (i.e. regulate) physician and dental burden of financing health care because the practices. states and local government were unable and, The only clear Reagan victories were in in many cases, unwilling to do so. Neverthe­ HMO deregulation and in giving the states less, even an activist Federal policy would more freedom to assign Medicaid contracts leave space for important state initiatives. competitively and limit the freedom of Medi­ Existing laws in areas of state and local respon­ caid patients to choose their own doctors and sibility could dramatically improve health care hospitals. if their intent were vigorously pursued and the Instead of competition, Congress turned to relevant agencies adequately funded. For regulations. In passing TEFRA, the Federal example, legislation requiring states or local government for the first time seriously tackled governments to provide medical care for indi­ the issue of rate regulation and controlling hos­ gents is often vague or ignored. New state laws pital Medicare costs. Stricter controls on phy­ requiring employers to provide health insur­ sician Medicare reimbursement may follow ance to all their employees would increase

Health/PAC Bulletin access to care for millions of low-income and 16. Report of the Special Committee on Federal Funding of marginally-employed workers and their fami­ Mental Health and other Health Services, American lies. Hospital Association, Health Care: What Happens to People When Government Cuts Back, August, 1982, The voluntary sector should also be pushed p. 23. to assume a "fair share" of the responsibility for 17. Salamon, L., and Abramson, J., The Federal Govern­ providing care to the poor. The growing body ment and the Nonprofit Sector: Implications of the of evidence on the brutal consequences of the Reagan Budget Proposals, Washington, D.C.: Urban health cuts must be used in community efforts Institute, 1981, as cited in Report of the Special Com­ mittee, Ibid to increase charity or reduced cost care by 18. President Reagan's Speech on the State of the Nation's hospitals and physicians. Economy, Feb. 18, 1982. Of course, despite Administration claims to 19. President Reagan's State of the Union Address, Jan. 26, the contrary, state and voluntary programs 1982. 20. National Health Law Program, Medicaid Cuts in Serv­ cannot take the place of a strong Federal com­ ices and Eligibility: 1975-1982, November 15, 1982. mitment to ensuring equal access to quality 21. Id. health care. And this is what the American 22. Summary of Testimony and Recommendations of Gor­ people want and have come to expect in time of don Bonnyman, Legal Services of Middle Tennessee, need. Because they do, President Reagan's Inc., Before the Special Joint Committee for the Study of the Tennessee Medicaid Program, Oct. 20, 1982. health care revolution is doomed to fail. The 23. Morrison, P., "The 111 Feel Pain of Cuts in Medi-Cal," challenge is to create a new, rational, and com­ L.A. Times, Dec. 22, 1982. passionate system from the ruins he will leave 24. Davis, K., and Rowland, D., "Uninsured and Under­ behind. served: Inequities of Health Care in the United States," Johns Hopkins University, Sept. 30, 1982. 25. Rosenbaum, S., and Weitz, Jr., Children's Defense 1. President Ronald Reagan's Address on the State of the Fund, Children and Federal Health Care Cuts: A Na­ Nation's Economy, 1981. tional Survey of the Impact of Federal Health Budget 2. The Field Foundation, Project on Food Assistance and Reductions on State Maternal and Child Health Serv­ Poverty, cited in William Schneider, "More Guns, ices During 1982, Jan. 1983. Less Butter: The Working Poor Will Be Hardest Hit by 26. United States Conference of Mayors, Human Services Spending Cuts," Los Angeles Times, March 22, 1981. in FY 82: Shrinking Resources in Troubled Times: A 3. American Public Health Association, Nation's Health, Survey o f Human Services Officials in the Nation's Ci­ July, 1982. ties, Oct. 1982. 4. President Ronald Reagan's State of the Union Message, 27. Report of the Special Committee on Federal Fundings, Feb. 18,1981. op. cit.,p. 26. 5. Hirsch, S., "Governors Gamble for Power—and 28. Testimony of Gordon Bonnyman, op. cit. Lose," People and Taxes, June 1982. 29. Report of the Special Committee, op. cit., p. 30. 6. United States Conference of Mayors, The FY82Budget 30. Winslow, P., “State Investigating Local Medical Cen­ and the Cities: A Hundred City Survey, Ho\. 20, 1981. ter," The Commonwealth Journal, Sept. 3, 1982. 7. Hughes, R., Costa, L., and Tompkins, R., M.D., 31. Upchurch, J ., “Indigents From 2 Area Counties Urged "Health Care and the New Federalism: Reality vs. To Use Hospital in Augusta," Telegraph-News, Macon Rhetoric," Presented Nov. 16, 1982 at the annual meet­ Georgia, May 15, 1982. ing of the American Public Health Association. 32. Heise Kenan, “ 'Dumping' the Poor at County Hospi­ 8. Hirsch, op. cit. tal," Chicago Tribune, Sept. 3, 1982. 9. Mathews, I., "States Unable or Unwilling to Shoulder 33. Report of Special Committee, op. cit., p. 28. 'Federalism' Burden," The Washington Post, Feb. 34. Curry, M., Preliminary Report on A Survey of The Ac­ 1982. cess To Perinatal Care and The Incidence of Perinatal 10. American Federation of State, County and Municipal Morbidity in the State of Oregon, The Oregon Health Employees, AFL-CIO, President Reagan's New Fe­ Sciences University, School of Nursing. deralism: Every State a Loser, Feb. 2, 1982. 35. Public Interest Health Consortium For New York City, 11. National Coalition for Lead Control, Children, Lead Hospital Construction Task Force, Feb. 14, 1983. Poisoning and Block Grants: A Year-End Review of 36. Statement by Edward N. Brandt, Jr., M.D., Assistant How Block Gran ts Have Affected the Na tion's Ten Meat Secretary for Health, Department of Health and Hu­ Crucial Lead Screening Programs; Opening State­ man Services Before the Subcommittee on Rural De­ ment of Henry A. Waxman, Chairman, Subcommittee velopment, Oversight and Investigations Committee on Health and the Environment, Hearing on Lead on Agriculture, Nutrition and Forestry, U.S. Senate, Poisoning of Children, Dec. 2, 1982. March 14, 1983. 12. Roberts, P., New Federalism or Old Hoax? Block 37. Michigan Department of Public Health, Infant Deaths Grants in FY1982, Center for Law and Social Policy, in Michigan: Analysis and Recommendations, 1982. Oct. 31, 1982. 38. 45 CFRParts 16,74,96, Vol. 47, No. 129. Tuesday, July 13. Id. 6, 1982. 14. United States Conference, op. cif. See also United Sta­ 39. Kohut, A., andNygreen, N., American Medical News, tes Conference of Mayors, Human Services in FY 82: Nov. 23, 1979. Shrinking Resources in Troubled Times, Oct. 1982. 40. Nelson, H., “U.S. Deficit Derails Plan to Stimulate 15. President Ronald Reagan's Inaugural Address, “Let Us Health Care Competition," L.A. Times, March 31, Begin an Era of National Renewal," Feb. 6, 1981. 1982. ■

Health/PAC Bulletin Bulletin Boora

left, the best place to find out is the Inventory of. Wanted Progressive Health Organizations. More than Health Law Program is look- 50 organizations which participated in first |f' jpr ^^xperieneied Medicaid/health care national meeting in 1981 are profiled. Copies fitoaftdng reform advocate. Prior employ­ are $6.30 from Health/PAC, 17 Murray St,, ment as an attorney at a local legal services New York, NY 10007. office is preferable but not required. The OjsejiingfeisLos Atiffeies, but applicant pre- Better living Through ferencefor th« D.C. office will be considered. Salary is $25~$40 thousand, commensurate Activism with training and experience. Far further in­ The innovative City of Toronto Department of formation, write Sylvia Drew Ivie, Execu'ive Public Health has just published a 60-page Director, National Health Law Program. 2639 booklet entitled "O u r Chemical Society; A S. La Clenega Blvd., Los Angeles CA 90034. Manual h r Action. The focus is on identifying ways in which individuals and groups can par­ ticipate in efforts to control the use and dis­ Manning Ahead posal of toxic chemicals from cigarettes to PCB's. Copies are $4 (checks payable to the Cornel! University's Department oi City Treasurer, City of Toronto) from the Health Pro­ and Regional Planning will held its fourth motion & Advocacy Section, Toronto Depart­ Progressive Planning Summer Program June ment of Public Health, 7th Floor, East Tower, 6-August S. Most of the academic courses City Hall, Toronto, Ontario, Canada M5H 2N2. and shorter institutes will b e concentrated in June, when there will also be evening lec­ tures and social events. Courses include Ninety Miles To Another National Planning and Industrial Policy (Ho­ W orld ward Wachtel}, Neighborhood Housing The Ministry of Public Health of the Republic Strategies (Chester Hartman), and Rural of Cuba, the World Health Organization, the Planning Issues (Charles Geisler and Mark Pan American Health Organization, and the Lapping). Tuition is $700 for courses, $150- United Nations Childrens Fund are sponsoring $375 tor the institutes. Some partial aid is a major public health and primary care con­ available. For more information, contact ference in Havana, Cuba, beginning July 3, Pierre Clavel or Lynn Coffey, Dept, of City 1983. and Regional Planning, 201 West Sibley Hall, The Conference will focus on developing a Cornell University, Ithaca, NY 14853. multi-disciplinary approach for achieving the WHO goal of "Health for All in the Year 2000;" Creeping Reaganisvn on understanding the development, structure and functioning of the Cuban health care sys­ The National Health Law Program (NHeLP) tem and the health status of the Cuban people; has published a concise summary of the on understanding Cuba's role in contributing Administration's 1984 health budget. It's title is to higher health levels among Third World Hsrcf Facts, an apt description of the contents. peoples; and on exchanging information and A $3 contribution will help defray costs, experiences on the organization and delivery including postage and handling. Write to the of primary care services. Participants are com­ National Health Law Program, 2639 La Ciene- ing from over 100 countries. g& Blvd., Los Angeles, CA 90034. For a full conference brochure or further in­ formation contact: Robert Guild, Program Director, Marazul The In Crowd Tours, 250 West 57th Street, New York, New If you want to know what's left of the health York 10107.

Health/PAC Bulletin Maggie Kuhn: "All of us are in this together."

T h e Polish Veterans Hall is two flights up from question or turn on the microphone. "We have one of downtown Montreal's chic new pedes­ continued it, and we've related it to the interna­ trian malls lined with expensive restaurants tional scene, to the spread of multinational cor­ and boutiques. The hall, however, is a barren porate power to the Third World, to the stage looking out on a worn dance floor and a environmental destruction that has been part balcony scattered with park benches and fold­ of a greedy, profit-centered system, and also ing chairs. the reforms of nursing homes and the organiza­ Filled with some 400 health activists from tion of patients rights committees. Our newest around the United States and Canada gathered priorities are housing and Social Security. We for the American Public Health Association's consider the Number One public health prob­ annual convention, it resembles the Pennsyl­ lem to be the arms race and the real and vania wedding scene in The Deer Hunter. present danger of nuclear destruction. Related Many in the audience comment that such a to that is the prospect of widespread radiation setting is a perfect antidote to the sterility of the damage because of the nuclear weaponry that modern convention halls of the conference. we're building and the way in which we have Attractive or not, its modesty recalls the put our hopes for energy into nuclear power broom-closet beginnings of the Gray Panthers, plants. whose National Convenor and co-founder is "A lot of people criticize us for- not being a this evening's guest of honor. single issue group the way many are," she Maggie Kuhn arrives accompanied by a acknowledged, "That's a hazard, but it also small entourage of younger Gray Panthers, suits our style because we believe in coalitions. who surround her like bodyguards. She climbs We believe in networks. We've chosen the the stairs to the hall carefully, pausing at each Gray Panthers to maximize the network—we step, but in continuous conversation with those call our publication the Network. We call the around her. She graciously accepts the long chairs of our local groups 'convenors.' People stem rose offered her and the other Gray Pan­ will say, 'What's a convenor? Who's in charge?' thers and gives me a kiss and a compliment. And we say, 'The convenor is the person who Her party takes its place in the buffet line and brings people together.' That, in a sense, epito­ then brings dinner up another flight to the mizes what we are trying to do. We believe in balcony, where she asks her younger compan­ getting people together who have been work­ ions to "bring me interesting people to meet." ing independently and fighting turf wars, wast­ For the next hour she holds a salon-like ing a lot of time and energy in those competi­ audience with a stream of old friends and new tive battles. Now is the time to come together. acquaintances. She then joins about 15 other "We've forged a coalition of young people Gray Panthers on stage. and old people because they are caught in the They receive a long standing ovation. She same ageist society. It's just as hard to grow up leads everyone in We Shall O vercom e. The as it is to grow old. What we've identified in audience responds with the Internationale. In many groups are the commonalities that old a brief speech Maggie's crisp, tart voice stirs and young people have. We realize how much the audience until it eagerly accepts her we need each other and how much rigid age instruction in the Gray Panther growl. segregation leads to age alienation. We realize "Health has always been one of the Gray what that has done to the society as a whole— Panther's major issues," she tells me later, divided it and increased the conflict between launching into an interview before I can ask a generations and the fear of old people by the

Health/PAC Bulletin young and the fear of young people by the old." cause she did not want her baby born in the A division, I suggest, which seems to be segregated South. Maggie's aunt, a secretary exploited like those between black and white and suffragette, lived with their family after her and between men and women. husband died; she taught her niece to read and "It is exploited,” she responds energetically. served as a role model. Their household also "It also diminishes the impact and socialization included her younger brother and their great and opportunities that the old and the young and great, great aunts; a four generation fam­ would have to work together if they could get ily. Maggie's father worked his way up from of­ together." fice boy in the Bradstreet Company, a credit Perhaps, I wondered aloud, in part because agency that later merged with its chief com­ of the way our lives have become so mobile. petitor to form Dun and Bradstreet. He People don't live and grow up in the same place managed branch offices in Buffalo, Memphis, with their parents and grandparents. Louisville, and finally Cleveland, where Mag­ “I think it's mobility," she says. "It's super­ gie grew up and graduated from the College technology that has made many of the skills that for Women of Case-Western Reserve. There older people have obsolete and obsolescent. she began writing and helped organize the col­ Even in a relatively short time, it has contrib­ lege chapter of both the League of Women Vo­ uted to the waste and downgrading of historical ters and the Young Socialists League. Her first perspective and of human experience." post-graduation job was with the YWCA, I comment that often my generation doesn't where she found political mentors organizing seem to have much interest in history because young women in poorly paid clerical jobs. it's not seen as relevant to the present or future; "The Young Women's Christian Association certainly many have talked about the Old Left at that time was very radical," she tells me, and the New Left and how they couldn't talk to "much more so than now, always stocked with each other. socialists. It was a very powerful influence in "Well," she answers, "I feel that in forging my life. I had mentors there—some very gifted our coalition between and among different age and courageous women who were doing some groups we put together the New Left and the great things. I was really inspired. I was on the Old Left. There's a difference in life styles. staff of two YWCA's locally and on the interna­ There's a difference in leadership style that tional staff of the YWCA in New York during we're just beginning to perceive and deal with. World War II as head of publications in the A more controlling, autocratic style of leader­ USO division. That made me very sensitive to ship, in many ways, characterized the Old the whole military establishment. I've been Left—but it was necessary, you know, to have blessed that there has been a certain reinforce­ that kind of vigorous, male leadership. But ment in different directions throughout my life. with the women's movement and the large I'm privileged, really, that this happened." numbers of women who are now in the labor From the YWCA she went to Boston to work force and in social groups of different kinds with the Unitarian Church until 1948, when she that have social and political impact, the more began her 25 year association with the national consensus, egalitarian leadership style is just staff of the United Presbyterian Church. This beginning to emerge. was the Church in which she had been raised "I believe that in coalition-building we'll and in which her parents had always been have to come to grips with new styles of leader­ active. ship. It's very hard to bring people together Working out of Philadelphia, she wrote for who have come from different parts of the and edited the church magazine, Social Pro­ human enterprise. But when they are together gress (later the Journal of Church and and have discovered a common goal, a new Society). In the mid-50's she did a study on the kind of humanness enables them to work costs of medical care for older people which together. Most of the older Gray Panthers have stimulated her interest in health care and led to their roots in the Old Left, and in the peace a confrontation with the medical establish­ movement." ment—the American Medical Association, the Margaret E. Kuhn herself is part of that ma­ American Hospital Association, and Blue jority. She was born in 1905 in Buffalo, al­ Cross. In 1961 she helped plan and then though at the time her family was living in chaired the section on national agencies for the Memphis. Her mother delivered Maggie in the first White House Conference on Aging, a con­ front bedroom of her own mother's house be­ vocation which recommended what four years

Health/PAC Bulletin later became Medicare. Her other work with the Church's national staff included civil rights, sexuality, race relations, women's rights, housing, and the problems of the aged. In 1970, just before the Presbyterian Church applied its mandatory retirement rule to her, Maggie gathered five friends in a similar situa­ tion at the Interfaith Center in New York to found the Consultation of Older and Younger Adults for Social Change. During the weeks before her retirement Maggie took advantage of her secretary, duplicating machine, and basement broom closet-office in the old Witherspoon Building in Philadelphia to organize the group. In 1972 when she was appearing on a New York TV talk show, the producer suggested that her fledgling organization be called the "Gray Panthers."The name stuck. In 1973 the Gray Panthers merged with Ralph Nader's Retired Professional Action Group and added their projects on hearing aids and nursing homes legislation to the Pan­ ther's anti-war effort. Since then the Panthers have mushroomed into a 60,000 member or­ ganization with more than 120 decentralized networks in 40 states. Its concerns range far be­

yond the problems of ageism and aging which Julie Jensen absorb most "senior citizen" groups to peace, housing, health, and Social Security. The Pan­ brother made me very sensitive to the whole ther's major proposal for solving Social Secu­ mental health field," she continued. "My rity's financial deficit, for example, was full brother and my father could never agree, and I employment. To focus on specific issues, the think it damaged my brother emotionally. He Panthers have spawned a number of other was a tragic person—they were both tragic in coalitions and organizations, including the Na­ that my father couldn't appreciate his son. Sam tional Citizens' Coalition for Nursing Home Re­ was institutionalized, and it was most painful to form, the Pension Rights Center, the Older see my father. He went every week to see Sam, Women's League, and the Caucus and Center to try and work it through, until the day Sam for the Black Aged. collapsed. I tried to help, but I couldn't. My I had read a comment of Maggie's that "the feeling has been throughout my life that your nicest thing about growing old is that you can own personal pain has to be put to some social speak your mind." When I tell her this, I add use. We must use our personal pain for that as I was growing up I was often told, organizing. "When you get older you'll outgrow all your "I think that a number of us in the Gray radical ideas, you'll know better"—a common Panthers have had that same drive. It's one of belief in a society where most people portray our distinguishing characteristics. There's a aging as growing more conservative and reluc­ commitment that the Gray Panthers have to tant to face change. social justice and different agendas, but the "There are a lot of very conservative old peo­ product and the goal are a just and peaceful ple who have made it," she responds, "or who society. In our best moments we have felt a have been broken by life and many dis­ movement that epitomizes that. One that appointments and losses and have never been brings together confluent streams of protest." able to regroup on the basis of the larger public The day after the dinner in her honor Maggie interest to transcend their own pain and to see participates in a panel on "Older People as that it's part of the whole human predicament. Actors Rather than Acted Upon". She stands at "The tragedy that I experienced with my the dais commenting on the papers that she has

Health/PAC Bulletin HIGHLIGHTS OF GRAY PANTHER HEALTH ACTIONS: 1971-1983

1971 Gray Panthers in Philadelphia 1974 Maggie Kuhn is keynote participate in an OEO-funded speaker at the Medical University of Pennsylvania Committee for Human Rights Health Law Project nursing annual meeting, and addresses home patient organizing pro­ the American Nurses Associa­ ject. By 1972, the project tion on "Death and Dying— operates in several nursing The Right to Live, The Right to homes, and drafts a nursing Die." home bill of rights. At the AMA meetings in Chi­ cago, 200 Gray Panthers pick­ 1972 Elma Griesel of Ralph Nader's et and stage street theater. Retired Professional Action Maggie Kuhn attempts to read Group (RPAG), begins a study a joint Gray Panther-MCHR of the hearing aid industry, resolution before the AMA with help from Gray Panthers House of Delegates, but the in Baltimore, New York City, microphone is taken from her. and Los Angeles. In 1973, the report Paying Through the Ear 1975 The first issue of the national is released, and Griesel joins Gray Panther newspaper the Gray Panther staff. Network features a story on Rep. Ron Dellums' national 1973 National and New York Gray health service proposal. Panthers sponsor an alterna­ The Gray Panther Long-Term tive health conference during Care Action Project releases the American Medical Asso­ Citizens' Action Guide: Nurs­ ciation meeting in New York ing Home Reform, by Elma City. Health/PAC, the Medical Griesel and Linda Horn. Committee for Human Rights, and several unions take part; 1976 The Berkeley, California, Gray speakers include H. Jack Panthers open the free Over 60 Geiger, Maggie Kuhn, Health Clinic. Marshall England, Elma 1977 The Dellums National Health Griesel, John Ehrenreich, Service Bill is introduced in Judy Wessler, and Lillian Congress. The Gray Panthers Roberts. A Gray Panther pam­ invite Rep. Dellums to address phlet "Toward a National their second convention, and Health Service" is prepared for endorse the bill. the conference. Gray Panther networks around Maggie Kuhn calls for a the country begin to pressure national health service in testi­ for doctors to accept Medicare mony before the Senate Com­ assignment. The Gray Panther mittee on Aging subcommittee convention passes a resolution on health. calling upon the Department of

Health/PAC Bulletin Health, Education and Welfare who accept assignment. to issue local listings of MD's New York Gray Panthers con­ who accept assignment. duct an outreach campaign to The Gray Panthers convene older New Yorkers on prescrip­ the National Citizens' Coali­ tion drug abuse. tion for Nursing Home Reform, 1981 Frances Klafter testifies for the and Elma Griesel becomes Gray Panthers and the Coali­ director. Beacon Press issues tion for a National Health Ser­ Nursing Homes: A Citizens' vice before the House Ways Action Guide by Horn and and Means subcommittee on Griesel. health to oppose Medicare With the National Senior Citi­ vouchers. zen Law Center representing A Gray Panther position paper them, the Gray Panthers bring for the White House Con­ a class action suit against HEW ference on Aging reiterates to allow administrative hear­ support for the Dellums ings for Medicare claims of less National Health Service bill, than $100. calls for continuing protest^ 1978 The San Francisco Gray Pan­ against physician refusal to thers protest the closing of the accept Medicare assignment, Post Street nursing home. demands improved nursing Despite opposition from the home care, and protests the Oregon and American Dental Reagan Medicaid cuts. Associations, an Oregon Gray 1982 San Francisco Gray Panthers Panther statewide ballot provide counseling on Medi­ measure wins permitting pur­ care supplementary insurance chase of dentures from dental plans. technicians. The Gray Panthers endorse the 1979 Rep. Thomas Downey intro­ Health Service Action Council duces a Gray Panther bill to HALT program calling for a halt abuses in medigap (Medi­ price freeze on health services care supplement) insurance. provided by doctors, hospitals and nursing homes. 1980 The Public Citizen Health Research Group publishes The Gray Panther National Health Task Force begins a Your Money or Your Health: A Senior Citizen's Guide to bimonthly newsletter, Health Avoiding High Changing Watch. Medicare Doctors, with a 1983 Gray Panthers locally and in forward by Maggie Kuhn, and Washington DC continue pro­ assistance from Gray Panther tests against proposals to Health Task Force chair restrict access to health care Frances Klafter. Local Gray by cutting Medicare and Medi­ Panther campaigns follow, caid benefits. using the guide's methods for compiling directories of MD's Roger Sanjek

Health/PAC Bulletin heard that afternoon, demonstrating her intel­ "To some degree," she tells me later, "I think ligence, wit, and comfort with detail, drawing there's a very strong thread of interest in out the common threads. ethics—social ethics—that goes back through "We have made a fetish in America of inde­ the Gray Panthers' thinking. We have very dif­ pendence," she tells the audience, "I have sur­ ferent religious persuasions. We have a num­ vived my entire family, and I suffer with ber of people who are Jewish with different arthritis. If I am not interdependent, I'm utterly degrees of commitment to the Jewish commu­ dependent! We must use our personal pain to nity. We have a number of young Jews who are organize." She goes on to a critique of the very much interested in the radical Jewish left. "massively paternalistic" field of gerontology, They're marvelous people; they relate to the complaining of gerontologists who have made old Jewish socialists from Poland and Russia. careers studying aging and the elderly by And we've got a lot of Roman Catholics who are "quite objectively removing themselves from in and out of habit. Then there's some of us who the fact that they themselves are aging." As have had seminary training and long term con­ always, she emphasizes the growing awareness nections with some kinds of liberal Protestant that aging is something that we all have in faiths. But there's this common understanding common, "all of us are in this together." of what the Lord reguires of us. It's that sense of The papers on her panel, she notes, share a justice. . . , 'Thus saith the Lord.'You don't say concern with “community diagnosis." recogni­ it in the meeting, and we never pray, but maybe tion of the "universal needs" of housing and we should." health. She points out that each examined When I ask for an example of how the Gray "gerontophobia—the irrational fear of old peo­ Panthers mesh the Old and New Lefts, she ple and growing old," and recommended grins and says, "We have fun. We have a lot of intergenerational contacts and organizing. arguments—we're very strongminded peo­ She challenges "the pathology of the health ple—but there's a certain kind of exuberance, care system," saying "to a large extent we have too. We're good at guerrilla theatre. We've practiced health as a private, individualized done some great stuff. The Boston and Twin affair—us and our symptoms. The privatizing Cities Gray Panthers and the Gray Panthers in of health care has removed patients from their the greater Chicago area were part of a free societal networks and roles and settings, quite street theatre. This was built out of reminis­ far from where we live and work. Individual­ cences of Old Lefties. The injustices they have ized diagnosis and treatment have obscured worked against and all that stuff. You know, the social conditions and structures in which that's great. There's no substitute for it. And human beings live and die." when you get people together, there's Maggie then describes several examples of exuberance and excitement. There's a lot of successful intergenerational day care centers energy. We've got two men on the Steering in impressive detail. She warns of the potential Committee who were with the Abraham Lin­ hostility and resentment she has observed coln Brigade in Spain fighting fascism. You see between young staff and old clients in pro­ what I mean?" grams for the aging. She insists upon the On the last morning of the convention Mag­ importance of training new leadership among gie Kuhn receives the Presidential Citation older people, who can use the leisure time of from the American Public Health Association. retirement to become "watch dogs and watch The theme of the convention is "Aging and bitches" in monitoring and lobbying public Health: An International Perspective." Stanley bodies around societal issues, not just those of Matek, the APHA president, notes that this the aging. "No one of us can be healthy as a award is presented only in cases of "unusual part of a sick society," she concludes. merit to persons who are not professionally Her comments have been both personal and engaged in public health practice." After list­ political, playful and angry, clever and com- ing her many accomplishments and awards, he monsensical. When she leaves the dias, she is describes her as having "an uncanny ability to again surrounded by her entourage of younger deal with issues and causes which allow her to Gray Panthers, who seem to be protecting their be critical of social injustice while remaining fragile treasure. The lush hotel bears little supportive of people." He attributes the success resemblance to the Polish Veterans Hall, the of the Gray Panthers to this quality. audiences are equally dissimilar, but her mes­ When Maggie accepts her award, she first sage remains the same. asks all the other Gray Panthers in the great

Health/PAC Bulletin auditorium to stand and share in the applause. more accurately, she might say, "hope" or a Then she calls upon all the Gray Panthers in radical's faith—is infectious. For a moment her spirit to stand. Soon she has everyone up. vigor and determination make everyone in the Her acceptance speech is punctuated with ballroom feel young. the language of the social gospel and libera­ After the presidential gavel has been passed tion theology, what she has called the "pro­ and the new president officially calls the con­ phetic witness of the Church." She expresses vention to a close, Maggie is surrounded by a both her outrage and her delight. "In truth," crowd of well-wishers and friends. She makes a she tells her audience, "there is an overriding luncheon date and arrangements for returning public health issue before us all—disarmament to her hotel and the airport, while a young in a world just one bomb blast away from anni­ Philadelphia Gray Panther passes the respon­ hilation. Disarmament and ending the arms sibility of her care on to me. race requires the efforts of us all, young and I ask her if there are senior citizen groups old. . As she continues, her voice sharpens, that represent a traditional conservative per­ and the acceptance speech takes on the spective. She nods vigorously. "Yes, there's a character of a sermon, rich in hell-fire and new group that is really dangerous. They are radical faith: Reagan's favorite people, the National Al­ "It is important now to take stock of the his­ liance of Senior Citizens. It was organized by a torical perspective that we all enjoy and give a young, ultraright Republican who Reagan new kind of commitment to whistle-blowing on nominated as one of the delegates to the World that powerful interlock of private interests in Assembly on Aging—Klingscales. He has writ­ health: the private insurance industry, includ­ ten terrible things about the Gray Panthers. He ing the two Blues; the multinational pharma­ published a four page diatribe in their journal ceutical houses, those pushers of Valium and about our 'Communist leanings.' So there are Thorazine; the manufacturers of medical sup­ people on the Right and in the Republican plies and hospital equipment; and the Ameri­ Party, and we just can't be bothered to worry can Medical Association. We spend more than about them. any other Western country for private medi­ "We're not going to be a huge movement," cine, and yet the chronic cripplers that afflict she continued, "I think that it would be coun­ us later-life bloomers have not been attacked terproductive if we had millions and millions. very successfully. Arthritis, gout, lupus, We'd have a hell of a time getting consensus. emphysema still defy even amelioration. Some Our meetings would be spent trying to bring all of the side effects of drugs for arthritis are those people aboard. Our groups have a core almost as bad as the pain. I speak out of expe­ of 20, 30, 40, 50 people who are absolutely of rience." one mind—not in detail but in a general goal. The litany continues: abuse of pesticides, And they don't need persuasion. You don't industrial pollution, the nuclear arms race, need a seminar on Reaganism or Reagon- withdrawals from Social Security, the soaring omics, they know it!" costs and declining service of "our present I comment that there's a certain irony in our competitive profit-centered health system." current president being the oldest we have She calls for a "radical critique of health for ever had. profit" and collaboration between consumers "But it's social class that sets him apart," she and public health professionals, "so that our responds. "He's old and rich!" society, our sick society, might indeed be "Of course," I say, "we don't call heads of healed." For this she prescribes mass educa­ major corporations who are 75 or 80 'senior tion, mobilizing outrage, alternative ap­ citizens.' " proaches, new awareness, applied research— "The class differences are so immense," she the time-honored solutions. She calls upon her adds, "when you look at the people who come audience to join the "International Giraffe to one of the senior centers or the nutrition sites Appreciation Society" which "honors those or who are homebound and on the receiving who stick their necks out." end of different kinds of home services com­ Moments later she teaches the entire APHA pared to the rich and powerful people who are the Gray Panther growl. With this ritual cheer still on boards." she leads an audience of sedate professionals Our talk ends abruptly as we realize that she into their first act of sticking their necks—and is due back at her hotel for her luncheon date. tongues—out. Maggie Kuhn's optimism— She invites me to come along. With six of us in

Health/PAC Bulletin the hotel restaurant, she neither dominates nor why the Canadian health system is superior to withdraws from a conversation that reviews the the American, concluding with a disquisition events of the convention, the plight of nurse on how to extort uppers and downers from your practitioners, the crime of Medigap insurance, local G.P. the ethical dilemmas of grantspersonship, and At the airport we get separated at the ticket the exodus of non-profit employers from the counter. The others disappear through Cus­ Social Security system. Maggie demonstrates a toms without saying goodbye. When I get to the knowledge of detail and curiosity that one does gate, the waiting area is filled with familiar not expect of a public figure and seems to be faces from the convention, all heading back to learning much more than she is teaching. New York. It's standing room only. The flight is After lunch she joins a friend for an after­ called, and a long line forms to board. From noon of shopping before catching her flight behind me someone calls my name. When I back to Philadelphia for a brief stop at home. turn, Maggie Kuhn reaches up to hug me say­ She is especially excited because there is a ing, "I just wanted to say goodbye." Thus my newborn baby there, adding still another three days in Montreal with her ended as they generation to her multi-generational shared had begun, with a kiss and a compliment. living arrangement. We take a taxi with two Hal Strelnick other friends on their way to Philadelphia. They inform the cab driver that his fare (Hal Strelnick teaches in the Social Medicine includes an American celebrity. "I only carry program at Montefiore Hospital in the Bronx winners," rejoins the cabbie. He then explains and is a member of the Health/PAC Board.) ■

Bulletin Board Rx for Change Research is continuing. Funds are still needed for further taping and editing. Inquiries, sug­ Nurses' Network, an independent organiza­ gestions, and contributions may be sent to tion of nurses, and Tamerik Productions need Nurses Network, c/o Health/PAC, 17 Murray help in producing a video documentary on St., New York, NY 10007, or Tamerik Produc­ nursing. tions, 237 Second S t., Jersey City, NJ 07302. Their project: The predicament of nursing today is both a symptom and a part cause of the continuing American health care crisis. Ninety-eight per­ Paper Chase cent of nurses are women; they suffer all the The Association for Faculty in the Medical traditional ills associated with a female occu­ Humanities, a section of the Society for Health pation—chronic underpayment, especially in and Human Values, is planning a conference to proportion to the skills and responsibility be held during the annual meeting of the Asso­ involved; long hours, unhealthy rotations and ciation for American Medical Colleges, working conditions; inadequate child care; November 5 - 7, 1983, in Washington D.C. lack of recognition and input; and a low rate of Papers with a maximum reading time of 20 unionization. Nursing faces many complex minutes on any topic relating health care and issues and challanges, not the least of which is traditional concerns of the Humanities will be motivating nurses themselves both to under­ considered. The papers will receive blind stand the issues affecting them better and to review, so the author's name should appear play a more aggressive role in promoting only on a cover page. The deadline for receipt change. Through the testimony of nurses the of essays is July 1, 1983. Five copies should be documentary will try to further these aims sent to Peter C. Williams, J.D., Ph.D., Depart­ while increasing public awareness of the true ment of Community & Preventive Medicine, nature of nursing and its problems. ..Health Sciences Center, Stony Brook, N.Y., Twenty-five hours of footage have been shot. 11794.

Health/PAC Bulletin Oral Surgery is concerned with extraction. While many Body English generalists do simple extrac­ tion, complicated or extensive surgery will most likely be re­ ferred to a specialist. Oral sur­ within the profession. There is geons have more experience evidence in medical literature with inhaled and intravenous that greater experience and ex­ anesthesia, and therefore are posure to cases and procedures deemed better able to avoid or often produces better results. treat any anesthetic complic- To their credit, dentists have tions. long practiced preventive care Oral Pathology involves A Brush - Up through educating their pa­ diagnosis and treatment of dis­ O n Teeth tients about the dangers of eases of the oral cavity, includ­ by Arthur A. Levin sugar and the need to brush ing malignancies. and floss effectively as well as With the exceptions of oral Periodontics, which con­ by providing dental hygiene pathology work and orthodon­ centrates on treating gum dis­ services. In this respect they tics, most generalists can prob­ ease and related tissue diseases are different from physicians, ably do much of what the spe­ with deep curettage and sur­ who have traditionally been cialist can. Whether they do it gery. less concerned with prevention as well is a matter, of debate Endodontics is treatment of and education than with inva­ within the profession. There is disease affecting the inside of sive, curative approaches. evidence in medical literature the tooth, pulp, and nerves. Dentistry as a profession dif­ that greater experience and ex­ Root canal work is one exam­ fers from medicine in other posure to cases and procedures ple. ways as well, although many often produces better results. Orthodontics takes care of people believe that the educa­ The whole subject of quality teeth that are out of position tional requirements are equally control in dentistry is murky. and other oral defects. rigorous. Unlike medicine, for As many patients will attest, it is Children with braces know example, it remains a general­ difficult to know whether you such specialists all too well. ists' profession, although there are receiving good care or bad Pedodontics is a general has been an increasing trend until you suffer from the latter. dentistry for children. towards specialization over the Because most dentists are in Oral Surgery is concerned past decade. As in medicine, solo practice even if they share with extraction. While many specialists are required to com­ an office, there is little oppor­ generalists do simple extrac­ plete at least two years of train­ tunity for concurrent peer re­ tion, complicated or extensive ing beyond the basic four year view. Judgements on perform­ surgery will most likely be re­ course. The specialty areas in­ ance usually occur only when ferred to a specialist. Oral sur­ clude: the patient becomes dissatis­ geons have more experience Priodontics, which concen­ fied and visits another practi­ with inhaled and intravenous trates on treating gum disease tioner. Any bad-mouthing of a anesthesia, and therefore are and related tissue diseases with predecessor's work at that point deemed better able to avoid or deep curettage and surgery. doesn't improve the physical treat any anesthetic complic- Endodontics is treatment of condition of the patient; in any tions. disease affecting the inside of case the new dentist's bias is Oral Pathology involves the tooth, pulp, and nerves. difficult to measure. diagnosis and treatment of di­ Root canal work is one exam­ There is strong evidence that seases of the oral cavity, in­ ple. dentistry could benefit from cluding malignancies. Orthodontics takes care of quality assessment and assur­ With the exceptions of oral teeth that are out of position ance. A 1974 survey showed pathology work and orthodon­ and other oral defects. that one half of all dental x-rays tics, most generalists can prob­ Children with braces know submitted to Pennsylvania Blue ably do much of what the spe­ such specialists all too well. Shield were unsatisfactory for cialist can. Whether they do it Pedodontics a general den­ diagnostic purposes. Other as well is a matter of debate tistry for children. studies have outlined addi- ►

Health/PAC Bulletin care, particularly brush­ Your ing and flossing tech­ niques. • Does not discuss treatment Freckles plans and fees in advance. Ruin your appearance • Does not use a lead apron Be free this summer from their embarrassment! Don’t when taking x-rays to have freckles all over your nose again. If you do— goodby to shield reproductive or­ good looksl Stillman’s Freckle Cream is gans and does full mouth guaranteed to remove freckles or your money refunded. It x-rays frequently (see the has a double action. Freckles Body English column in are dissolved away by this snowy, fragrant cream. Your the May/June 1982 Bul­ skin is whitened, refined and softened at the same time. letin for a more detailed Guaranteed to remove discussion of this.) •very freckle You simply apply Stillm an's*t • Does not have the neces­ night like any ordinary cold cream. While you sleep Its magical action sary equipment to treat takes place. Gradually the freckles world for this ourpose. All drug­ fade from sight, and your com­ gists carry it in 50c and St sizes. you for an allergic reaction plexion grows clear and milk white, beautiful as a baby’s skin. Write for *4Beauty Parlor to anesthesia. Freckles are caused by sunlight Secrets** — which beats down as fiercely in Send for" Beauty Parlor Secrets" • Does not appear to realize America as in Italy or Africa. Un­ and let us tell you what your par­ less you do something, your skin ticular type needs to look best. will constantly grow worse. The Crammed with make-up hints, Given free it your mind is in the same longer you wait, the harder it will skin and hair treatments. If you you buy 83 be to remove them. So start worth Still­ head as your teeth and buy S3 worth Stillman toilet man toilet now! articles in 1924 we wilt present you a r t i c l e * in Women send for Stillman's with beautiful, large size bottle 1924. mouth. The practitioner Freckle Cream from the four cor­ perfume, free. You need our many ners of the earth. It is the most preparations daily in your home. should answer all your widely used preparation in the Get our booklet. questions, fully describe

I Stillman Co., 20 Roaomary Lana, Aurora, III* | the treatment plan, and Stillmans Freckle | Please send free copy of “Beauty Pallor I cream j Secrets.1' discuss the pros and cons K » U « * d.uih Whitcnt the Skin | N am e... of options based on your individual needs, re­ : J sources, and preferences. tional areas of poor quality den­ Many authors have written No list can be complete, tistry that could benefit from guidelines to help consumers nor can it assure quality quality control. Since dental pick a dentist who offers the ap­ care. Choosing a good den­ care, like medical care, is propriate high quality care. A tist is not an easy task and will largely elective and very list of negative practices may most likely involve some trial seldom life-saving, the poten­ provide the easiest method for and error. Many of the above tial for abuse looms large. Un­ spotting the poor, inappro­ practices can be checked der our current fee-for-service priate dental care which should during a first visit. If your system a dentist's income, like a be a signal to seek another judgement is that the care physician's, is based on the practitioner. The following are you are getting is not what it number of procedures done, so some of the most easily recog­ should be, or unnecessary, there is an incentive to do more nized dental flaws: it's time to change dentists. than is required rather than • Does not provide emer­ Because the number of prac­ less. gency care. titioners is growing much Only a handful of states at­ • Does not take a complete faster than the number of pa­ tempt to compensate for the dental and medical his­ tients, the laws of supply and lack of quality assurance and tory, including medica­ demand work in the con­ peer review opportunities by tions being used, if any. sumer's favor, giving you requiring continuing educa­ • Does not do a complete ex­ some control over both qual­ tion for relicensure. In another amination of the oral cav­ ity and costs. handful of states, dental so­ ity, both visually and with cieties require continuing edu­ fingers. Arthur A. Levin is a member cation as a condition of mem­ • Does not use a probe to ex­ of the Health/PAC Board bership. However this may be plore and examine your and Director of the Center lip service: there is scant evi­ gums. for Medical Consumers, dence that continuing educa­ • Does not provide instruc­ publisher of the newsletter tion alone improves quality. tion in good preventive Healthfacts. ■

Health/PAC Bulletin and its various workplaces and the financial systems for payment. In Part I, physician control is seen as a re­ sponse to ". . .forces that transformed medi­ cine into an authoritative profession [involv­ ing] both its internal development and broader changes in economic life. . .At the same time there were profound changes in Americans' way of life and forms of consciousness that made them more dependent upon professional authority and more willing to accept it as legiti­ mate." (Page 18). . .[It is] authority that in­ heres in the status of physician because it has The Social Transformation of American Medi­ been institutionalized in a system of standard­ cin e by Paul Starr: New York, Basic Books, ized education and licensing." 1983. Starr argues that consumer acceptance of The Social Transformation of American this mode of control is a natural consequence of M edicine has received ecstatic reviews from a the dependency engendered by the develop­ broad spectrum of health academics. Jack ment of scientific medicine, although public Geiger, a noted critic of the health care sys­ perceptions were generally greater than the tem, wrote in the New York Times that if you science available to physicians. read only one book on American medicine it Chapters two through four explain haw this should be this one. control was solidified as American society Such praise is deserved if one reads the book emerged from the Jacksonian era, in which as a factual account of the development of the every individual was assumed to have the abil­ health care system. But Starr has set himself a ity to provide health care, and at the turn of the higher task, that of explaining the reasons for century entered the Progressive era, when spe­ the transformation of medicine from a cottage cialized technical knowledge and authority be­ industry of many healers from different social came linked to a specific group (in this case classes into a system dominated by an elite physicians) identified as expert through group, physicians. shared experience in education, socialization In this latter effort the book is unsatisfactory and membership. Justification for these new and somewhat misleading. Furthermore, Starr professionals was provided by the "Progres­ ignores the consequences of the system of phy­ sives" who believed that "science provided the sician dominance and its impact on quality of means of moral as well as political reform and and access to health care; his concern about who saw in the professions a new and more ad­ the enormous financial cost arises primarily in vanced basis of order." the context of the threat this poses to continued According to Starr, "[T]he growth of medi­ physician control. Indeed, the most negative cal authority was related more to the success of statement in the book about the current health science in revolutionizing other aspects of care system is a quote from Forfune Magazine. medicine and the growing recognition of the On the historical level, the book is almost en­ inadequacy of the unaided and uneducated cyclopedic in its breadth of detail about doc­ senses in understanding the world." In this tors and their rise to power in the United States. context of physician dominance and a per­ Similarly, there is sufficient information about ceived scientism in medicine, hospitals re­ the health care delivery system to recommend placed the home as the focal point of health the volume to novice students of health care care. Public reliance on physicians' services and others interested in learning something increased as physicians became more access- about this service sector that currently con­ sible through developments such as growth of sumes 10% of our GNP. public transportation and private automobiles, The book is divided into two parts (later to be increased urbanization, and geographic mo­ published as two books for the paperback bility. Traditional forms of medical practice, market). The first describes the birth of medi­ including those offered by peddlers of patent cine as a dominant profession; the second ana­ medicines, homeopaths, and lay and faith lyzes emergence of bureaucratic and cor­ healers, lost most of their earlier legitimacy porate structures encompassing both medicine and often even their legal status. ►

Health/PAC Bulletin With physicians in control, the next step was (3)Diversification and corporate restruc­ to minimize the degrees of variance among turing, leading to conglomerates under a M.D.'s. In the 19th century, physician training holding corporation; ranged from education of an elite group in (4) Vertical integration - the shift from the Europe in current scientific knowledge to a ru­ single-level-of-care organization, such as a dimentary formal education obtained primar­ hospital or clinic, to comprehensive care or­ ily in apprenticeships to physicians. Those in ganizations such as health maintenance or­ the latter group might also spend some months ganizations (HMO's); in one of the many hundreds of proprietary (5)Concentration of ownership of health fa­ medical schools. Most of these institutions cilities. lacked even the most rudimentary laboratory In contrast with his excellent historical ac­ equipment; their clinical staffs varied widely in count, Starr's analysis of the rise of physician knowledge, ability, and commitment to educa­ dominance contains substantial weaknesses. tion. Although he expressly recognizes the rele­ Starr's analysis of the educational changes vance of political economy, historical process, runs something like this: a lot of well meaning and institutional development to an under­ people, mostly physicians, had a lot of trouble standing of the particular development of the in the pre-scientific era deciding what good health care system in the United States and of­ medicine was; as the science got better the best fers considerable relevant information, he doctors by sheer force of talent won the right to treats the development of physician hegemony decide that about 10 years after high school as an inevitable historical process even while was a goodly amount of time to complete the acknowledging that it was not. requirements for becoming a doctor; that this For Starr, first and foremost, the rise of the limited the profession to a wealthy strata able to profession was the "outcome of a struggle for afford the direct and indirect financial costs cultural authority as well as for social mobil­ was inevitable but not intentional. ity," an evolutionary process which in his for­ Once physicians established their power mulation implicitly approaches a theory of po­ base as the group who would determine the litical natural selection in which the inherently shape of medical care services, they set out to superior, namely professional groups, prevail. control and limit the influence of public health It seems as if Starr has studied the profession so professionals, pharmaceutical companies, long that he has unconsciously become its hospitals, government agencies, and sup­ champion. porters of health insurance—that is, of any Translated into plain English, the “cultural group or institution that might threaten physi­ authority" of physicians, which Starr defines as cian control and thus income. "the probability that particular definitions of Part II of the book describes the growth of the reality and judgments of meaning and value modern health care system, including major will prevail as valid and true", means that the teaching institutions and hospitals, and the de­ public accepted the adage "Doctor knows velopment of private health insurance and best!" But as even champions of current medi­ governmental programs. In the section entitled cine such as Lewis Thomas admit, in the crucial "The Triumph of Accommodation," the author time period of the rise of physician dominance, describes the uneasy equilibrium between 1900-1924, doctors knew little more about physicians, private insurers, and Social Secur­ healing than in the 19th century. In this stage of ity. "The Liberal Years" details the expansion scientific development, the diagnostic abilities of public programs and their redistributive ef­ of doctors had vastly improved but their ability fect, and is followed by an examination of the to cure had not yet progressed. Starr never ex­ crisis in financing them in "End of a Mandate." plains why the cultural authority of doctors was The book closes with a good account of the rise established at a time when their expertise of profit-making health care enterprises. lagged so far behind public perception. Starr distinguishes five separate dimen­ On the contrary, he argues that the domi­ sions, each of which contributes to corporati­ nance of the profession arose directly from zation of health care in a different degree: scientific developments in medicine and the (1) Change in ownership from public and public's growing faith in the potential of voluntary to profit-making; science. Medical doctors became the high (2) Horizontal integration and the rise of priests of scientific health care just at a time multi-institutional systems; when science and technology were replacing

Health/PAC Bulletin the church and the family as the cultural and ance. Companies paid over $2 million for this social bases of society. privilege." Science did open the way for public accept­ During a two week period in October of that ance of physician authority, but Starr down­ year, wrote Monty Poen as quoted by Starr, plays or ignores political and economic factors "every bona fide weekly and daily newspaper that encouraged scientism and its cultural as­ in the United States (10,033 in all) carried a cendancy. Science and technology were the five-column-wide, fourteen-inch-deep ad from magic path to the new world of industrial capi­ the AMA or from one of its business allies de­ talism the United States was bounding into at crying the enemies of free enterprise, while the beginning of the twentieth century. It is not 1600 radio stations broadcaist spot announce­ surprising that this political economy fostered ments and 35 magazines carried similar adver­ a culture in which medical practitioners with tisements." years of formal training commanded an author­ Starr sees this material advantage as "itself ity not deserved then, if it is now. only a reflection of the ample social founda­ Further, Starr downplays the relationship of tions of the opposition's strength" (emphasis this scientific transformation to the immediate added). Cultural and social organization are interests of capital. He dismisses E. Richard the foundation or substructure; financial and Brown's Rockefeller Medicine Men as simplis­ economic strength are relegated to superstruc­ tic Marxism and factually incorrect in arguing ture. The engine that drives the wheel of social that capitalism encouraged an emphasis on change is cultural hegemony. medical care of the sick rather than public Starr's almost exclusive focus on profes­ health and prevention. sional authority is particularly evident in his Starr is right that the early "philanthropists" last chapter, in which he warns against the contributed to both aspects of health; the ques­ "Coming of the Corporation"—that is, the con­ tion is where they put the major part of their trol of health care by private, profitmaking cor­ contributions. Starr ignores Brown's documen­ porate conglomerates. The entire focus of this tation of the massive absenteeism that plagued chapter, thirty pages in length, is on the impact industry in the early part of this century, but of corporate dominance on physician "auton­ even so ends up affirming Brown's basic thesis, omy." Only one paragraph expresses concern that capitalism supported scientific research, that "a corporate sector in health care is also medical education, and hospital construction likely to aggravate inequalities in access to to create a healthier work force. health care." This is a rare concession. Starr is a firm be­ Starr's vision of the health care system of the liever that cultural authority precedes future is bleak. "Instead of public regulation, economic and political power. In discussing there will be private regulation, and instead of the change in the control of the distribution of public planning there will be corporate plan­ drugs—from manufacturer directly to con­ ning. Instead of public financing for prepaid sumer into manufacturer-doctor-consumer, for plans that will be managed by the subscribers' example, Starr asserts that "Once again, chosen representatives, there will be corporate cultural authority was being converted into financing for private plans controlled by con­ economic power and effective political organi­ glomerates whose interests will be determined zation." by the rate of return on investments." But ever By the postwar era, Starr says, the cultural the optimistic liberal, Starr concludes, authority of medical interest groups had been "Perhaps this picture of the future of medical transformed into a political and economic con­ care will also prove to be a caricature. trol structure in which their wealth and power Whether it does depends on choices that were sufficient to deny any reform movements Americans have still to make." for national health insurance. In material re­ The Social Transformation of American sources alone, the American Medical Associa­ Medicine does not suggest how the American tion spent $2.25 million in 1950 to combat a na­ people will understand they have a choice to tional insurance program; the chief propo­ make, any more than they understood there nent, the Committee for the Nation's Health, were alternatives to physician sovereignty. Nor spent $36,000. "During that period," Starr does it explain how they will be able to exercise notes, "the AMA also offered businessmen the choice in the face of new forms of cultural opportunity to join in sponsoring advertise­ authority, let alone the economic and political ments denouncing compulsory health insur­ power of the corporate sector that Starr docu­

Health/PAC Bulletin ments. Starr's assertion that the choice will be If this were a more traditional sociological made by "Americans" assumes a model of de­ study of the structure of the medical profession, cision-making in which every citizen has an one might not expect so much of its author. But equal voice, a model which has no relation to he has aspired to broader questions, asking the reality of political power. “what explains the forms of medical practice, The beauty of such Panglossian sociology is hospitals, private health plans, and public pro­ that it affirms not only that we live in the best of grams that emerged in America out of the all possible worlds, but that we have chosen to diverse possibilities that were historically do so democratically. It is easy to imagine that available." He has not answered his own ques­ if Paul Starr's disturbing picture of a cor­ tion. The cultural authority of physicians is an poratized health system becomes a reality, he insufficient base on which to build an under­ might add a chapter in thirty years explaining standing of the present system. why this too was inevitable and right. There is a Louanne Kennedy conspicuous failure to suggest what our al­ ternatives to this or the status quo are, or how a (Louanne Kennedy teaches in the Health Care more humane, patient-oriented system provid­ Administration department at Baruch College, ing superior care at reasonable cost might be CUNY, and is a member of the Health/PAC achieved. B oard .) ■

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