HEALTH PLANNING: A CONSUMER VIEW
CCAHS building on its strength undertook a topic that had major political, economic and quality components. Planning is in America a private sector ‘thing’ with a few exceptions. We plan for war and on occasion we seek cures of major diseases which require planning. We can plan for a major event in sports, holidays and national days of remembrance. But planning for the more effective delivery of medical services and products to many is considered socialist or worse, communistic.
But a then $120 billion price tag (today over $1.4 trillion) for medical care services put the need to plan in the forefront. But planning by whom and for what purpose became serious considerations. Voluntary and private sector planning was not working; that is if you wanted to see a national plan that rationalized the dysfunctional system. Because the government paid over 42% of the total expenses it seemed logical that either the government directly plan for medical care delivery or oversee and fund private sector planning. This issue of Health Perspectives described state and federal efforts to plan.
The keystone was the National Health Planning and Resources Development Act of 1974. This Nixon era legislation followed after the Johnson ‘Great Society’ programs based on the premise that government had a role to improve the lives of the masses. The Health Systems Agency (HSA) formed by combining previous legislation became the backbone of health planning for a decade when as with other progressive government programs they were quietly put to sleep.
The HSA portion of the 1974 Act is described. The answer to the question “Will it work?” could only be surmised. But the long history of bias against government involvement in the personal lives of Americans existed then and persists today. The main problem with planning as it developed under this legislation was the same as for all other areas of health care delivery, cost and quality: consumers were left out of the process or could play only a marginal role when invited to participate. This limitation is a result of prior exclusion from meaningful participation and a lack of information and resources to develop a plan from the point of view of consumers who were independent of the providers. In fact the whole model was doomed because there were no concerns, efforts, actions or programs to place wellness and primary prevention first.
Today, we live with the legacy and bias of the past: let the market determine what is needed, how often and by whom. And leave the government out of the discussion (but not the payment). This issue of Health Perspectives would be the first of many on health planning; a subject still not fully addressed today.
It is difficult to imagine that back in 1976 the total amount spent for medical care of just $120,000,000,000 (billion) represented a problem. Today the amount is over one trillion and probably closer to two. But the same terms of endearment about the delivery of medical care and related activities as research would include non-functional, redundant, at cross purposes with the needs of Americans. But that is how with some foresight, the writers and editors of this issue of Health Perspectives saw the coming storm.
This issue recounted some of the pertinent history leading to the mess. And all roads crossed at the triple intersection of profits, politics and planning (actually the lack of the latter). The 1960’s and early 1970’s had a background of political, racial and gender movements to change the staid rationale to keep the poor, the people of color and women in their respective places as defined by the still white and privileged upper classes. Despite these definitions and the controls they once effectively placed on a very significant proportion of the population, change was blowing in the wind. It was so strong that federal legislation shepherded and supported President Johnson and the alliances he put together created an array of legislation that had two goals: (1) to include consumers in the process of planning of health services and (2) to rationalize health planning.
And while the goals were admirable, the seeds of self-destruction lied within these Acts of Congress and within the legislation within many states and local government entities. The issue pointed towards these issues, the conflicts, the lack of skilled planners and the roadblocks that had been laid by confusing legislation often in conflict with others Acts and local legislation. The new legislation often undermined the provider planning organizations but the providers sought to ensure continued control. They had the experience, resources, history, credentials and single focus needed to dominate the planning process but not entirely control it.
The CCAHS publications as this one sought to empower consumers appointed, selected or elected to serve on the new planning bodies. These bodies soon gained recognition by their contribution to the alphabet soup of RMP,’s, CHPA’s, HAS’s, PSRO’s and others. Often when these organizations worked and especially when they didn’t to the liking of the providers a crisis was defined, a committee set to explore the problem, a resolution was proposed and a new name assigned to the replacement agency. An example is the Professional Standard Review Organization[s] (PSRO) which amazing although heavily tilted to control by providers created problems for hospitals. The PSRO’s had been a function of the left, the idealists and the Democratic Party apparatus and were mainly non-profit in though word and deed.
Under President Nixon the scenario of crisis, committee and replacement legislation (creating new organizations) was commonplace reflecting dwindling interest in the poor, blacks and women and as a subsidiary, empowering poor blacks and women in health planning. The new organizations would be named IPRO’s (Independent Professional Review Organizations) and be more compliant with the rising capitalization and free market introductions in medical care planning (left to the market) and delivery (through for-profit corporations). This process would be memorialized in the federal HMO legislation that appeared radical but was just another transitional mechanism of define a crisis, create a committee and rename the problem and solution. But that story is treated in a future issue.