HEALTH * PAC HEALTH POLICY ADVISORY CENTER Bulletin April 1969
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HEALTH * PAC HEALTH POLICY ADVISORY CENTER Bulletin April 1969 Editorial... THE TROUBLE WITH EMPIRES SHOTS RINGING OUT IN THE STRUGGLE OVER A SOUTH BRONX COMMUNITY MENTAL HEALTH CENTER ARE BEING HEARD AROUND THE MEDICAL WORLD. COMMUNITY-WORKER FORCES ARE BEGINNING TO GIVE "THE BOOT" TO THE ARBITRARY RULE OF AUTOCRATIC GRANTSMEN AND HIERARCHICAL PROFESSIONALS. It's being called an "Ocean Hill-Brownsville" of health and mental health—only the "insiders" are both community and workers. The "outsiders" are the medical empire-promoters themselves. Those who care about an effective recon struction of the health services system must understand the national meaning, particular "imperial" context, and im mense new insurgent social energy contained in such a situation. The striking new challenge being made by community and workers' forces, allied with progressive students and professionals, not only poses new questions, but offers the only real potential for new answers—the basis for a new kind of public service sector of health. The Nixon Administration, like its Democratic predecessor, shows an increasing nervousness about the unfettered free enterprise system of health care and its financing. Despite the 30-years-late "Health New Deal" of Medicare and Medi caid, the nation faces a catastrophic breakdown of its health delivery and financing "nonsystem." In fact, Medicaid and Medicare have accelerated the escalation of medical costs—while barely beginning to fill widening gaps in service. In a nutshell, the financing, organization, and delivery of medical care, as centered in existing institutions for insurance, patient care, and education, are totally out of control. The national establishment has begun a determined search for new "enlightened trustees" to pull some of the scattered pieces together into a more manageably competitive system. Recent national programs such as the Comprehensive Health Planning Act and the Regional Medical Programs are frail beginnings on this course. More dramatically, Governor Rockefeller has called for some kind of national insurance package, presumably Blue Cross-controlled (and Nixon's new HEW chief Robert Finch seems to be listening). In NYC we first had the affiliation program to turn the Promoters' Special MEDICAL EMPIRES are in the news. They are increas City hospitals over to private "leadership," and we now have ingly the target of accelerating community-worker the plan for a Health and Hospitals Corporation to inject private sector "efficiency" into the public hospitals [See movements for decentralized public control of health BULLETIN Special Issue, Winter 1969]. The rallying cry for and mental health services and institutions. [See fea such programs is to encourage "regionalized," rational ture on the Lincoln Community Mental Health Center ized" and integrated hospital and health services plan take-over, Page 13.] The November-December issue ning and development, "centered" in medical schools and [BULLETIN No. 6] described, mapped and assessed major voluntary hospitals. , the rising importance of such publicly unaccountable empires in New York City. In our first medical empire These would-be saviors of the health system, the med case study, we analyzed the patrician and conservative ical schools and major voluntaries, are facing serious domain of Columbia P & S: its internal power forces internal problems: underfinancing (particularly with Viet Nam bleeding research and education budgets), under- and struggles, its external community challenges, and staffing, more restricted access to interesting "teach its rejection of a "promotional" approach to empire ing material," and the resultant institutional competition. development. Also, while national leaders look to them for long-term Einstein-Montefiore's more "promotional" medical policy guidance, local communities are demanding that empire, encompassing the entire borough of the Bronx they do something immediately to get services out to and its 1.5 million inhabitants, is the case study focus people. of this April 1969 issue. The challenge to the promoters of the major medical centers is then to use the growing demand for "trustee shambles of most public health administration, have ship," rationalization," etc., to enhance their own institu chosen a high-handed path. As the Einstein-Montefiore tional and personal positions—and to do it before the Empire case study in this issue shows, they have tended to initiative passes to angry consumers and workers. direct their energies for "reform" in the most arrogant, The promoters of such large institutional complexes, dogmatic and unaccountable fashion. Even while rhetorically given a tangled internal elitist environment and the (Continued Page 2) Editorial. espousing "progressive" principles of medical system re integrated and distributed to contribute to the maximum pub organization, they have engaged in wasteful inter-institutional lic welfare? competition, hustling scarce manpower on a fee-basis, and New Directions: First Things First The present plans, pri scrapping over "teaching material." What truly progressive orities and organization of the Einstein-Montefiore Medical projects they have sponsored have often been promoted Empire, as outlined in this issue, must almost literally be on an opportunistic and fragmented basis without sufficiently "turned on their head" to achieve the kind of change needed balanced concern for the people whose lives hang in the and demanded by the people of the Bronx. The untrusted balance. The irony is that these corporate liberals of the "central powers"—both the downtown health bureaucracy medical establishment have begun to imitate the competi and private medical baronies—must be cracked. Rigid and tiveness and self-interest of the solo, fee-for-service systems short-sighted "affiliation" and "corporation" approaches to of which they are often so critical. City health policy must be blocked. Grant-hustling "experi Thus, there is a growing resistance among those whose mentation" and "demonstration" with people's lives, as a lives are most directly affected—as workers and as citizens— substitute for comprehensive programs for people's needs, against the top-down approach to health services in the must be curbed. Profit-motivated insurance-market selectivity, Bronx. This is happening despite the seductive "logic" of unaccountable elite philanthropic and academic granting me regionalism under major medical centers; despite some posi chanisms must be eliminated. Rigidly exclusive academic tive pioneering achievements of certain Einstein-Montefiore hierarchies—the source of the manpower shortage—must be Empire programs; despite the desperate need for any action, flattened. from any source, to give disaster relief for the Bronx's health Alternative Directions: Towards a Public, Community- crisis. Worker-Based Health and Mental Health System for the Clearly, the solution does not lie simply in the re-ordering Bronx. of a thing called the "Bronx health services system." On this • Neighborhood Services: The immediate development both the "corporate liberals" and the "radical insurgents" of neighborhood health and mental health services for all agree—there is no such thing. The real question is where to citizens, regardless of ability or inability to pay, must take begin to challenge the existing national non-system of medical first priority. There must be public support of emergency mismanagement, professional privilege, and narrow "academic "store-front" services. Funds and staff for more "multi medicine," rather than primary care priorities. service centers," patterned after the community-controlled Still, the Bronx is a crucial arena for deciding the shape Hunts Point Center, should be mobilized immediately. of a new health system, not only in New York but nationally. • Community and Worker Control of Health Services: Exist The Bronx provides a dramatic microcosm of the nation's ing health services institutions in the Bronx are due for a health crisis: the South Bronx, like ghetto and poor rural thorough shake-up. Reorganization along the lines of com areas everywhere, is a health disaster area that will require prehensive, continuous and personalized service is not a massive public intervention to meet the crisis. Throughout the "frill," but a life-saving necessity. Since such reorganization Bronx, geographical imbalances in medical resources, disor challenges the profitable academic fiefdoms of the profes ganization and fragmentation of care are perhaps greater sional elitists, workers and community people will have to than in any other borough. And for the Bronx, as is increas lead the way. Within each institution, care must be re ingly true for the nation, there is no going back to a free structured on a team basis, with all health workers (pro enterprise, solo-practice-dominated model of services distri fessionals and others) cooperating around the common goals bution. The question posed by this borough is how can of community service. institutionally based and controlled resources be expanded, • Community and Worker Control of Health Planning: WE APOLOGIZE for the brief BULLETIN As the City-wide Health and Mental Health Council has pro black-out: HEALTH-PAC was growing. As posed, funds and planning power under the Comprehensive of 1969, HEALTH-PAC has tripled in size, Health Planning Act should be delegated to neighborhood boards, to which the City Health Services Administration adding to its full-time staff a physician, an%