These two articles were originally published in The Illinois Socialist in March, 1976, and May, 1976, respectively. The Illinois Socialist was the publication of the Chicago Democratic Socialist Organizing Committee, one of the predecessor organizations to Chicago Democratic Socialists of America.
Chicago Health Planning
by Bob Roman
The United States moved one step closer to socialized medicine early in 1975 when President Ford signed the Health Planning and Resources Development Act. This act establishes public planning institutions in the health care industry. Unlike earlier legislation, these new planning bodies have the teeth to enforce their decisions.
The incisors of this act are the 200 local planning bodies known as Health Systems Agencies (HSA). The areas covered by each HSA were mapped out by the Governor of each state within certain demographic and administrative guidelines specified in the legislation. Illinois has eleven HSAs, including two that span state lines to encompass entire metropolitan areas.
HSAs, by law, have the power to: gather and analyze data; establish health system plans and annual implementation plans; provide technical or limited financial assistance to organizations seeking to implement the plans; coordinate activities with Professional Standards Review Organizations and other planning and regulatory bodies; review and approve or disapprove applications for Federal funds for health programs within the health systems area; annually recommend to the state projects for modernizing, constructing and converting health facilities in the area; as well as assisting the state in reviewing proposed capital expenditures and the need for new and existing health services in the area. Obviously this new planning institution will have a major say in the distribution of health care facilities.
An HSA can have one of three possible structures. It may be a public regional planning body. It may be a non-profit corporation. Or it may be a single unit of local government. Regardless of the structure chosen, between 50 and 60 percent of the HSA’s governing board must be consumer representatives. The remainder must be physicians and other health professionals, representatives of health care institutions (including HMOs), insurers, professional schools, and other allied professions.
Thus far the planning process may seem a little remote from the people, but a single paragraph in the law allows, but does not require, HSAs to establish Subarea Councils to advise them on community needs, planning, and the composition of the HSA governing board. These Subarea Councils are potentially a key arena for public participation in health planning.
The act also sets up new structures on a state level. The state is required to have a state planning agency which meets various Federal requirements. This agency more or less serves as the administrative arm of the State Health coordinating Council (SHCC). At least 60% of the SHCC membership is nominated by the HSAs in the state. Planning on the state level is seen mostly as the integration of each HSA’s annual health systems plans. The state planning agency and the SHCC do conduct reviews determining the need for new institutional health services, the need for existing institutional health services, and the need for all major capital expenditures by institutional health services. They are, however, expected to follow the HSAs’ health systems advice and plans in these reviews.
This is by no means a complete description of the new institutions set up by the act and the relations between them. But even from this limited description, it’s quickly apparent that the HSAs are potentially more powerful that the state government in the field of health planning.
The boundaries of the Health Systems area that includes Chicago includes only Chicago. (Do you wonder why?) There are two applications for the status of HSA in metropolitan Chicago. One is from the city itself. The other is a joint application from two groups active in health planning under previous Federal legislation, Comprehensive Health Planning Inc and the Chicago Community Health Planning Coalition (CHP-CCHPC).
Should the City of Chicago become an HSA, the HSA’s governing board would technically be the City Council. The responsibility for health planning, however, would fall on a commission appointed by Mayor Daley: the Commission for Health Planning and Resource Development.
The composition of the commission must follow the same legal requirements for consumer, professional and health care industry representation as other HSA governing bodies. But even within these legal requirements, the appointments to the Commission follow a pattern well established by other Chicago boards and planning commissions, even to the inclusion of the ever present William Lee, President of the CFL. Other interesting appointments include the fast-rising Alderman Bilandic, Alderman Wilson Frost, 1st Ward Committeewoman Lucia Gutierrez, Patrick A. Murphy, Grace Slattery, Alderman Bennet Stewart, and Robert Vanecko.
As might be expected, the City’s proposal is highly centralized. The only provision for public involvement in planning is a vague scheme for the establishment of an “Advisory Council Network” which will participate in “the decision making process through methods being developed by the Commission which may involve task forces, systematic plan hearings and ad hoc committees at such or/and suitable techniques.” The true nature of this “network” is illustrated by its inclusion under the program area “Community Education” in the City’s work program.
One reason socialists favor planning and control of investment is it allows other values than those of the market place to be considered. But in doing so, it shifts the balance of power in favor of those doing the planning. This is why we insist the planning process be democratic and open to public participation.
The Machine is well aware of this second factor. City, and therefore Machine control of the HSA will firmly cement the health care industry into the corporate structure that supports the Machine. The potential power that the HSA will wield will discourage any nonsupport or opposition, and what corporate institution will want to if the usual state of Chicago nonplanning rules the field.
The CHP-CCHPC application is a complete contrast to the City’s proposal. While the institutional form is a non-profit corporation, the commitment is to public participation in planning. Consequently, the Subarea Councils are given a prominent role.
Chicago is demographically divided up into six Subareas. There are three regional offices serving each two Subareas. The Subarea Councils are given a specific role to play, including the nomination of HSA board members, the review of health systems plans and the formulation of local plans.
The CHP-CCHP application is also more specific and more comprehensive in the range of planning proposed that the City’s. Among the areas to be considered are recreation, population, water supply, housing, sanitation services, and environmental pollution. The HSA will also publish an annual Health Status of Chicagoans report. Considering the scope of the planning, this report has potential for an advocacy role in related but not strictly health care fields.
The whole issue of who will be the HSA will be decided by the Secretary of HEW, David Mathews. In deciding, the Secretary must give major consideration to the opinions of the Governor. The Walker Administration’s response has been to approve neither of the applications and to propose that the decision be put off from April to July while the two parties work out a single compromise application.
The reasons for this move are left to your speculation. The result, however, is to pretty well insure the domination of the planning process by the health care industry and Daley’s political mafia.
Chicago Wins HSA Funds
by Bob Roman
The City of Chicago’s application for the status of Health systems Agency has been given conditional approval over the Chicago Community Health Planning Coalition – Comprehensive health Planning Coalition application. This gives the City, and consequently the Regular Democratic Organization, control over Federal health planning funds and a good deal of influence in the health care industry in Chicago.
The official rationalization is that while both applications were “approvable,” the city’s was clearly superior in fulfilling the requirements of the Federal regulations implementing the National Health Planning and Resource Development Act. The Walker Administration’s recommendation that the decision be postponed while the two applicants combine applications was dismissed as the obvious absurdity it was.
If a rationalization is to be any good, it must have some connection with reality. Filing an application for a Federal grant is a bit like answering a rather long and involved essay question with specific requirements for information. The lower levels of the Federal bureaucracy check (among other things) to see if the required information is present. The City of Chicago paid a top-notch consulting firm an arm and a leg to prepare the application, so it is hardly surprising that City application was “better”.
Even given this, it does not mean that the decision was not political. Regulations can be bent a good deal. They were bent a good deal when the HSA boundaries were drawn for Illinois. All it took was a little pressure from the Chicago Congressional delegation.
But the hot potato has not yet come to rest. There are at least two suits filed in Federal District Court concerning HSA boundaries, particularly concerning the rump status of suburban Cook County. And conservatives in the medical profession are mounting a campaign to abolish the whole HSA system. The issue promises to continue smoldering.
Not too many people remember that the United States actually came fairly close to having a national health insurance system (aka Single-Payer) in the early 1970s. President Richard Nixon had even made a counter proposal of something closely resembling what we now know as “Obamacare”. The irony is monumental from a lefty perspective though I expect conservatives can find plenty of ways to rationalize it. It’s only human.
The lack of consensus on competing proposals, the Watergate scandal and all the usual nonsense meant the moment passed and was forgotten. Except that one aspect of a national health system, public planning, did make it through the U.S. House and Senate and was actually signed by President Ford. I think it’s worth remembering this brief experiment in social democracy.
So these two articles dealt with the competition for just what entity was going to be doing that planning in Chicago. If I were to advise my younger self, I’d suggest easing up on the cheap cynicism regarding the old Democratic Machine, not because it was wrong so much as because it confuses issues regarding making planning to some degree both democratic and transparent.
I don’t know how the national planning mechanism came to an end (Carter killed it, probably), but some of the entities set up by the State of Illinois for health care planning on the state level are still in business. Health Systems Agencies are history, as is the old Democratic Machine.