iiii iiii i i i 11 11 1 Ii i ! i. I @ill iiiii@! i i I . i , i-I Public Law 93-641, "The National Health Planning and Resources De- velopment Act of 1974," is to be fully implemented by the U.S. Department of Health, Education and Welfare (HEW) within 18 months after January 4, 1975. Essentially the Law does away with the nation's existing Regional Medical Pro- grams, Comprehensive Health Planning Agencies, Hill-Burton Agencies and Ex- perimental Health Service Delivery Systems. Replacing these national programs and discharging their responsibilities as well as new functions will be a network of approximately 200 Health Systems Agencies (HSAS) within the 50 States, Puerto Rico and the U.S. mandated territories in the Pacific. Each'State will have a state Health Coordinating Council and an Advisory Council with a consumer majority, and each of the States' HSAs will operate under a Governing Body with a consumer majority. The Secretary of HEW is named as the federal official responsible for administering the Law, and he in turn will be subject to a National Advisory Council with a consumer majority. Participants The Honorable George Elusbee A. R. Jablonowski Earl Wright Governor of Georgia Assistant Executive Director Director o' Health Facilities and Planning Med ca Malpractice DHEW Reg@on V The Honorable Daniel J. Flood, M.C. Med cal Association of Georgia Wash ngton Robert T. Jones W. Daniel Barker Executive Director The Honorable James F Hastings, M.C. Board Member New Crleans Area Healtri Planning Counc I Washington American Hospital Association Gordon R. Engebretson, Ph.D. The Honorable Ted Stevens George Pickett, M.D. D rector United States Senate Execut ve Board Member Florida RMP Washington American Public Health Associat on George Rosemond, M.D. Henry E. Simmons, M.D. Karen 1. Shanor, Ph.D. President Deputy Assistant Secretary for Health National Center for Cornmun ty Action American Cancer Soc@ety DHEW, Washington Edward Mearns, J.D. Elliot Rapaport, M.D. Paul D. Ward, Executive Director Professor of Law President Californ a RMP Case Western Reserve Univers ty American Heart Assoc ation Walter Branch, Ph.D. Richard Shoemaker Joseph B. Stocklen, M.D. Assistant Director for Assistant Director Pres dent lntergovernmenta Relation,@; AFL-CIO Department of Socia Secur ty Amer can Lung Association DHEW Reg on IV Daniel 1. Zwick Colon R. Wilson Jr., M.D. Eugene Fowinkle, M.D. Associate Administrator for Planning Nationa Art@ir tis Foundat on President-Elect Evaluation and Leg station Associat on of State and DHEW, Washington James C. Hunt, M.D. Territorial Health Officers Pres dent Gerald T. Gardell Nat ona K dney Foundat on Michael K. Gemell Act ng D rector Nationa Assoc ation of Counties Division of Regional Medical Programs The National Association of Regional Medical Programs, 2929 Main St. Buffalo, N.Y. 14214 Foreword On the last day of the second session of the 93rd Congress the Health Planning and Re- sources Development Act of 1974 was passed in the waning hours. The late December recess in governmental functions followed immediately. Perhaps this is why so little publicity was given to the new Public Law 93-641 from Congressional Offices, from the White House, or from the Department of Health, Education and Welfare. It became obvious during the first quarter of 1975 that there was a widespread lack of knowledge, familiarity, or understanding of the sweeping new health services law among the many health service leaders and administrators who normally should have been the most con- cerned with its implications for the future delivery of health services and with the requirements for implementation of the statute. In March it was announced that the Health Resources Administration was planning a series of multi-state informational conferences during the month of April. No similar plans were an- nounced for other governmental agencies or public organizations. Perceiving the urgent need for early dissemination of pertinent information about the new law, the Program Committee of the National Association of Regional Medical Programs decided on very short notice to change the program for its spring educational meeting to develop a National Conference for Health Service Leaders and to devote the entire session to a detailed examination of the Health Planning and Resources Development Act of 1974 and potential prob- lems in its implementation. The meeting was designed to be open to the public with all interested leaders and officials in voluntary health agencies invited to attend. Despite a severely limited length of time for national advertising, 350 registrants attended the meeting. The Program Committee is most sincerely grateful to the program participants and to the various agencies that sponsored and supported their appearance. There was a remarkable and uniform spirit of cooperation among all those involved. Several of the speakers, especially those from the Congress, accepted personal inconveniences in order to contribute to our enlighten - ment. All of us are indebted to them for their compelling sense of public responsibility. JAMES W. CULBERTSON, M.D. Chairman, Program Committee Health Service leaders from across the Nation gathered in Atlanta in late Spring to weigh the implications of a new law that may have more profound effects on the health of Americans than any- thing seen in a decade. It was the first national meeting on the subject of the Health Planning and Resources Development Act of 1974 (Public Law 93-641) since the law was signed by President Ford in January. Richly varied concerns, praise and skepticism threaded through the talks given by Congressional and Administration lead- ers, health care providers, planners, governmental officials, profes- sional and voluntary health agency leaders and consumers. The Atlanta meeting, said John R. F. Ingall, M.D., Chairman of the National Association of Regional Medical Programs, would ex- plore all aspects of the law with the "fundamental objective to make this law work." "The number one thing we're interested in in the Congress of the United States, as I'm sure you are," said Congressman James L. Hastings (Rep., N.Y.) of the House Subcommittee on Public Health and Environment and a co-sponsor of the bill, "is the development of some sort of a rational national health policy, something this coun- try in my judgment totally lacks." One A succinct assessment of the new law from Georgia's Governor George Busbee set the tone for the meeting called by the National Association of Regional Medical Programs: The Law's Import "I don't know of any act passed by Congress since 1965 that will have more impact on health in this country," he said. Others agreed. Hastings urged the delegates "to devote the best of your ability to try to make this what I think it really is-probably the most impor- tant piece of health legislation that hit the floor of the Congress, and most people don't know it." The law, said Senator Ted Stevens (Rep., Alaska) of the Senate Subcommittee on Labor and Health, Education and Welfare, "is conceived as a preparatory measure to national health insurance, and establishes an elaborate system of federal standards and regu- lations covering the state and local health planning agencies and endowing them with strong power to ensure that institutions abide by the planning decisions on the delivery of services." "While it is too early to tell how 93-641 is going to work," said Daniel J. Flood, (Dem., PA) Chairman of the House Appropriations Subcommittee on Labor-Health, Education and Welfare, "it is not too early to say that we must preserve what good relationships exist in the health community now." An administration view came from Henry E. Simmons, M.D., Deputy Assistant Secretary for Health and Director of the Office of Professional Standards Review. "We now understand, I think, that something more than the fragmented, unemployed efforts of the past will be required if this country is to secure a right to quality health care for all citizens at a price that society can afford." American Heart Association President Elliot Rapaport, M.D., Chief of Cardiology at San Francisco General Hospital, declared that the AHA "considers that Public Law 93-641 has the potential of "The aim really is to avoid profoundly affecting the fate of quality health care throughout the waste and duplication. " country." - Stevens And from American Hospital Association Trustee W. Daniel Barker came this view: "Although it is not the only way to approach planning, it is the law of the land at this time and we have to rededi- cate our efforts to make sure that it works, that it brings together some pretty difficult functions of the regulator, of the planner, of the provider, all in one agency. This, in itself, is a tremendous Herculean task. Two A highly condensed review of the major priorities in P.L. 93-641 was offered by George Pickett, M.D., Director of Public Health and Welfare for California's San Mateo County and Executive Board Member of the American Public Health Association. These priorities include 1) making primary care services avail- able to underserved populations; 2) development of comprehensive health systems to include sharing among institutions and facilities, formation of group medical practice as parts of the systems and consolidation of high cost, low-volume services; 3) training and use of more physician assistants; 4) improved quality of care; 5) com- parison and containment of health care costs, and 6) more em- phasis on disease and cost prevention through nutritional and en- vironmental programs and better education of consumers concern- ing the appropriate use of available health services. "There are a number of potential value conflicts inherent in these priorities," Pickett said. "On the whole they point clearly to- wards the need for a total governmental control of the health indus- try in the United States. Those goals, if priorities do reflect goals, cannot, I think otherwise be achieved. That may not be what Con- gressmen voted for and it may not be widely popular. In fact, impor- tant goals are rarely achieved without offending someone's values, but the basic American ambivalence towards health and welfare is moving painfully towards some conclusion." Five Although feeling the need to get on with implementation, many speakers voiced concerns with the new law and with the potential for problems in developing Health Systems Agencies on local levels and State Health Planning and Development Agencies and State Health Coordinating Councils on the higher level. Boundary designation-establishing the geographic areas for the developing HSAs-drew much comment. The law requires that HSA areas conform as nearly as possible to several existing bound- aries. "I have been through one session in the Professional Standards Review Organization Program in which we had to divide up the United States. Let me tell you something: it can't be done without being crucified in the process. There is no way to satisfy every- body's desire to divide up this country," said Simmons. "Geographic and population boundaries may be considerably different from those in current use in health Programs. State lines may be crossed and interstate Standard Metropolitan Statistical Areas will be involved," said Walter Branch, Ph.D., DHEW Region IV Assistant Director for Intergovernmental Relations. "Trying to line up the functional regions of the health care field with geographical regions is a difficult if not an impossible thing to do. We have hundreds of 'regions' in the health care industry," said Daniel 1. Zwick, Associate HEW Administrator for Planning, Evalua- tion and Legislation. Six Simmons listed the area designation process as the first poten- tial pitfall in implementing the law-"How well we carry that on and how intelligently we can meld those areas into area designations for other programs the government has to have. If that should be fouled Concerns up it would be terrible because that would make integration so much more difficult and integration is necessary across the Nation." Simmons listed as other pitfalls to be avoided the possibility that some particular interest group could capture the process of building effective HSAs and health programs, weakened consumer partnerships because of inadequate public involvement, and lack of adequate and pertinent data required to make the tough decisions about costs and services so that "everybody in fact doesn't get everything they want." Hastings had additional concerns, as did James C. Hunt, M.D., President of the National Kidney Foundation and Chairman of the Department of Medicine at Mayo Medical School. "A lot of my medical friends differ with me on this, but I think it's disastrous what we're doing in the Federal allocation of Federal resources as they relate to manpower, because in the Manpower Act we seemingly are just going to try to put more money into a system that has not solved the problem-that primary problem that I'm concerned about-of maldistribution, both geographically and in the specialties. We're not addressing that question effectively at all," Hastings said. "'The problem I had was Said Hunt: "The thing I guess that concerns me more than .anything else is that there is no provision for health manpower train- with the scrapping of ing in this legislation. And we are going to build a system in terms of everything that had just planning and resources without training of health manpower? That is begun to work." impossible." -Stevens Still other concerns were voiced. "The states should make a strong commitment in terms of polit- ical attention, manpower allocation, appropriation of dollars, organi- zational prominence and so forth, to assure that the law from the State's perspective works and works well," said Eugene W. Fow- inkle, M.D., Tennessee Health Commissioner and President-elect of the Association of State and Territorial Health Officers. Eight The State Health Planning and Development Agency, he said, should be an already established agency with strong demonstrated administrative and other skills; the State Health Coordinating Coun- cil should have highly committed individuals; enabling state legisla- tion is needed. Hunt noted that consumers and providers who have worked together well in voluntary health agencies "are now being pitted against one another in the new legislation, or at least the possibility of that battle for domination of the governing bodies of HSAs cer- tainly exists, so we are going to have to walk a tight rope there ... There are going to have to be a number of compromises and trade-offs between the private sector and government." Without strong early involvement of voluntary organizations, said George Rosemond, M.D., President of the American Cancer Society, "no government sponsored or supported health planning program is going to reach its potential. Our political system seems to require a strong committed private constituency to make gov- ernment programs in professional and public health education meet their objective." "Regional Medical Programs will be gone soon," said Flood. We're not going to sit down and bawl about it. I am convinced that no greater cadre of health systems development professionals ex- ists than the one right here in this room. Rather than cry, you are going to do something constructive, If I know you. You are going to do your best to make Public Law 93-641 work." ""it is going to be a rather startling revelation when we discover that the machinery for improvement and development has been dismantled." -Ward Transition The transitional period from the old laws to the single new one, said Stevens, "is really the problem area as I see it. I think there is no question about the necessity to establish the new program as it's outlined in the Act eventually. The problem I had was with the scrapping of everything that had just begun to work, in my opinion, and turning to a new concept which requires the implementation of a total program . .. and in the meantime to attempt to phase out all of these existing programs." "We must remain about the business of RMPs in order to pro- vide continuity during the so-called transition period," said Gordon R. Engebretson, Ph.D., Director of the Florida Regional Medical Program. "Just because a new piece of legislation has been enacted today the health problems of yesterday do not disappear only to await re-discovery and application of the resources of tomorrow's newly-created agencies." He suggested that RMPs or- ganize seminars to help in the development of HSA staff and board capabilities, and use their established public information network to develop effective public education programs. He also urged that Ten Comprehensive Health Planning (b) agencies be assured neces- sary interim support to allow them to continue health planning ac- tivities. "RMPS, like CHPS, are storehouses of information, data, re- ports, recommendations, findings, plans and so on. These should not become lost to the planners and resource developers of the future," said Engebretson. "We really want to make this program work," said Paul D. Ward, Executive Director of the California Regional Medical Program. "It is the law of the land; it is going to need amendments, but I hope that we advance amendments and changes on the basis of improving the situation ... I don't believe that any of us want to see a further deterioration of the health field. I think, too, that we've got to convey our hope for an orderly uninterrupted transition." "This law will not work by itself," said Stevens. "Its success or failure will rest on those people administering and implementing it ' " He urged the delegates to "help meet the objectives of the new law, in spite of my questioning of it. Then, perhaps, the Congressional oversight committees will be able to conclude that the medical needs of all our citizens are being met in a most effective and efficient manner, and we will stop this biennial amendment, change and consolidation of national legislation in the health field and let some continuity seep into the planning and the program of our health care delivery systems. I don't think that's an unattainable goal, but I do think it will take everyone working together to make it achievable. I would hope that all of you will be prepared to critically appraise the efforts that can be made under this new law and to advise us what changes you feel are necessary to achieve this goal." "If there is danger that the transition period will run much longer than 93-641 contemplates," said Flood, "then the Congress will surely be pressed for some legislative relief ... It would be bad judgment, unmitigated stupidity to stop health resources develop- ment in this country just because our administrative restructuring is moving slowly." Eleven Accompanying the concerns about the transition period were equally serious comments about funding support. "Everybody has this idea that there's a windfall of money," said Earl Wright, DHEW Region IV Director of Health Facilities and Plan- ning. "But if we conceive of full coverage of our 50 states with the HSAs and everybody gets 50 cents per capita, you can easily see that $60 million doesn't stretch where 1 05 or 1 1 0 is needed. One of our problems might be some retrenchment in certain areas unless more funds are made available." "We could well end up with less funding under the new leg@sla- tion than we have now," said Robert T. Jones, Executive Director of the New Orleans Area Health Planning Council. "And perhaps, al- though I sincerely hope not, we may see repeated the inequities in the funding of CHP over the past few years." Stevens reminded the conferees that six years ago the Defense Department share of the budget was 48% and that of DHEW 28%: these figures are now almost reversed, with Defense 27% and DHEW 47%. "There is very little room for any more reordering of priorities on a significant scale as we have done in the past six years," he said. I think we have to be patient with the obvious fact that we're at Funding the low end of the roller coaster right now," said Ward. Inflation has hurt all health programs, "but inflation won't be with us forever, and we ve got to be ready-if we really care for the development of a fine health service in America-to run like heck once the question of inflation resolves itself. When the chance comes to really get the push back, then we've got to be prepared to move. And I think that's what we ought to set as our goal in the future." Twelve The Health Planning and Resources Development Act requir that HSA governing boards be made up of a majority of consume a fact that drew thoughtful and provocative comment from ma speakers. "We (the New Orleans CHP agency) supported the legislate we believe it to be good legislation," said Jones. "It places maj responsibilities at the local area and that's where we believe should be. It maintains the provision for consumer majority in t decision making process, and that's as we believe it should be.' But how consumerism can best contribute to effective heal planning obviously troubled many. Consumers, Engebretson note have to be representative of the ethnic, linguistic and racial norities, the sexual population and special groups such as retire persons, requiring "judicious selection of governing body member Control It may be difficult to recruit a seasonal farm worker to serve on a HSA governing body who would lose pay and may possibly mov from location to location with the harvest. Rather the task should b one of selecting someone who would effectively represent the i terests of this population group." "Many people may say that we've had consumer input in th past and it just hasn't worked. You're right, it hasn't worked, but wh hasn't it worked?," asked Karen I. Shanor, Ph.D., of the Nation Center for Community Action. "Governing boards of local agencies which by law have consumer majorities, all too often fail to reflect th interest of the public. The General Accounting Office has foun professionals such as retired physicians, administrators at home for the aged and directors of social services programs listed a consumers. "Conflicts of interest abound," she said, and consumers are often intimidated by the sophistication of providers. She offered suggestions for improvement under P.L. 93-641: seek consumer representatives through community-based organizations; train them, as well as providers ("because it works both ways"); develop Fourteen par@:c@pa@:on process; hold public meetings in locations to encourage real participation; enlist or-st iiner@i le@ colle:-t needed data; develop sub-area councils; that consumers will be nominated for the state health coor- (-@iri,iting Council; rise consumer input in quality care criteria and at all le,,'EIS of planning and implementation. f:@ii,-hard Shoemaker, Assistant Director of the AFL-CIO Depart- rTienL of Social Se--urity, added further to the consumerism debate. P,I-ost health planning agencies, he said, "are afraid of consum- ers, ,-,ffective consumer representation. Oh yeah, they like to have them on the boards because they are convenient window dressing bul iri terms of developing effective consumer participation into the plani-.rg process I would say it's been a dismal failure. Generally in planrzrg bodies a majority of consumer representatives is like hav- ir,g si),, lambs and four tigers. You know how that's going to turn out. "Further control will b "NDw I don't want to be completely one-sided; I recognize that necessary, possibly in t@,e c(.)rsumer has many handicaps. For the consumer to effectively training, licensing and participate in the planning process takes a great deal of effort away reimbursement from i-ii!; normal activities." Th(@ training of consumers, he said, "is a matter of some mechanisms." - Pickeft utgerc,/. It's completely unrealistic to think that the providers of healt@i (,are, any more than any other group, will willingly acquiesce to wr(.nching change. They won't willingly offer to have their ser- vices eliminated or curtailed or even modified if they are no longer needed or if these services can be performed better at less costs by other ethods, individuals or institutions. Neither will they recognize these facts because they have not generally understood the needs of corislimers." Shoemaker recommended that consumers be provided with their own technical staff, a practice that was adopted in the War Labor Board days of World War 11. But if consumer representatives at the NARMP Atlanta meeting had concerns about the shape of things to come with P. L. 93-641 so too did providers. "I don't believe that the physicians in this state or around the country are very happy about the way the law was finally written, Provider ConcernS passed and signed by the President," said Adam Jablonowski, As- sistant Executive Director of the Medical Association of Georgia and a representative of the American Medical Association. "There is a great deal of concern being expressed by our physician members for the kinds of controls that are envisioned- in the law, certainly for construction and expansion of hospitals," he said. Another fear of physicians is the kind of service controls that the law envisions. It's probably the one area which has the most emotional impact on physicians. They are very concerned that some bureaucrat is going to tell physicians and their hospitals whether or not certain services can be performed in a particular institution. This obviously has a very negative kind of connotation as far as HSA is concerned for physicians. Another concern is the availability of funds for the development of changes in the health care delivery system. "Without individual physicians who are in the active practice of medicine participating on the board of directors, I don't believe the HSA will be able to succeed." "I still have a lot of problems in my mind visualizing how the planner who is an innovator. . . can also be a developer, a practical administrator, a practicing physician, and at the same time be a regulator." - Barker Sixteen "The initial review responsibility will be assigned to the HSA. This provides a major opportunity for local providers to help state government and community leadership to shape a more effective "And we're going to build health care delivery system," said the Hospital Association's Barker. system in terms of plannin "Regulations are just not going to fade away as costs continue and resources withou to escalate, as the demand on our services continues to multiply training of health manpowe and the expectations of our citizens continue to expand. Tha t is impossible. H u n "The main issue is really how all these things that are required by the law are going to fit. Whether we are going to have a non-profit association or governmental mechanism. What does it do with the doctor's office practice, with the institutional services-all these things are still kind of up in the air. "What for example, will happen when a new hospital is needed and one of the requirements is that at least every five years that institution is reviewed to see if it still needs to be in existence? How can you arrange to borrow money when there is no assurance that in five years that institution is going to be needed or even be there?" he asked. "There are large problems ahead of us unless we work together to find alternative uses for structures and for institutions as needs change." "The National Kidney Foundation," said Hunt, "is worried-we are concerned, We are particularly concerned with the concentra- tion of the enormous amount of power in the Secretary of HEW." He recalled that regulations for the end-stage renal disease program authorized by the 1 972 Social Security Amendments are still not in final form. "But that's 2-112 years since the law was passed and these regulations still aren't out, and if you're worried about regulations being out for 93-641 then I think you should be. "I'm concerned," Hunt continued. "Will history repeat itself? RMP, CHIP and Hill-Burton legislation is terminated. It's too bad because these programs, particularly in the last several years, have become extremely effective. The RMP, I think, has served more than anything else to bring the private sector together. The voluntary health agencies have helped bring volunteers together. It's too bad that they didn't put together our expertise earlier." Seventeen Federal Role "I would hope that we had not gotten away from the concept of "We are particularly regional planning," Stevens said, "instead of mandating im- concerned with the mediately the concept of national planning ... Whether or not we concentration of the can truly improve the situation with the authority contained in this new Act to me remains to be seen. The areawide, statewide and enormous amount nationwide agencies could become a bureaucratic nightmare or of power in the they could become the vehicle for developing a comprehensive Secretary of HEW." health care services program through the cooperation of the con- -Hunt sumers, the providers and the government officials." "There is no doubt," said Simmons, "that the Federal govern- ment must assume a larger role in the development of health re- "Government sources and in making certain that those resources effectively re- involvement and spond to the health needs of the American people. With the adop- regulation in the tion of national health insurance even under an essentially private insurance system, the involvement of the Federal government will health care industry be still greater than it is today." will continue "All of us, in government and out, must guard against the ten- to grow. dency for necessary and proper involvement to become unneces- sary encroachment on the practice of medicine and the whole - Barker health care delivery system. Clearly there are things that govern- ment can do best in the health field . . . but individual decisions involving the care of individual patients are best kept out of "'When government bureaucratic hands whenever possible. It would be tragically un- makes a mistake, wise for any of us to assume that policy, good or bad, can be or should be framed by government alone." the whole of "RMP," Simmons said, "did do a good deal of work and it did society suffers, and do a lot of network creating, and it did have innovation, and it had every individual some remarkable effects. Now, I believe that the scope of the prob- lems in the government will require every bit of talent that RMP has and institution in it." left over." -Simmons Nineteen in The costs of medical and health care, a basic consideration ' the new law, caused a great deal of discussion in Atlanta. along with public accountability. Health planning in this country needs public accountability," declared Michael K. Gemell, legislative representative for the Na- tional Association of Counties. In following the legislation as it de- veloped in Congress, he said, "we wanted to stress that governors should be given the option to designate private, non-profit corpora- tions, regional councils of government or a single unit of general purpose government to do the health planning and be designated the HSA." The concept won, Gemell said, but there remain differ- ences in interpretation between Congress and DHEW as to what the law intends. "Who will appoint the governing bodies in the HSAS?" he asked. "That's a question not answered in the law. We maintain that local elected officials are the ones best to appoint. Nobody seems to understand that public accountability can only rest, we think, with the local elected officials." Edward Mearns, Professor of Law at Case Western Reserve University, and a legal advocacy representative, offered these comments: "When I say my reasonable expectations are assured access to adequate care on a more equitable basis, I think I recognize that this has to be achieved even at the expense of perhaps offending some of the ideologues who would maintain a present balance of the private and public roles in health care delivery. "At some point the consumers, the non-professionals, the rest of us have to say something about developing the instruments to achieve public accountability. We've got a terrible struggle to get the consumer aware. I think the consumer is only moved to perceive inadequacies from the actual delivery of care, and is not concerned with patiently observing experiments in decision-making or in pro- cedure. Twenty WIL When it comes to making choices on costs, saidA,FF. k- ett, "the provider has a ready and expensive answer: the "ier 'value@ Conflicts really has the responsibility and he will pay for that answei, makes it. To deal with such problems effectively we will ha@,( .i. r n about negotiating quality rather than assuming it simply a We'll have to chance shifting control from providers to cori,, T I r S. The priorities in the new Act, he continued, are "laucl. @l.nd acceptable ... but are in conflict with one another. Betl, i@-i@@)re ti- equal access and higher quality simply cannot be obtaine. "Taken to ether, our new cally at a lower cost, even at the same cost. Something he.@ iD e, 9 some value. national priorities are in "To make any real progress in achieving the goals en@,, -,erGIed d.,.,onflict, with one another. by Congress, a substantial expansion and change in cont. ..@Pickeff be necessary. It's not clear that this would ultimately iE@a@- a government-managed national health insurance but it is cl if all the priorities were to be attained, control of the indus', ,vc-iijld have to be wrested from the providers and transferred to ie con- sumers, who would hopefully combine democratic humanism ",ith managerial rationalism. If this really happened, it is hoped ',,',al cov- ernment will broker the transfer and not assume unto itse the ar- rogance of control. We may not like the results." Twenty Two Timetable The timetable in Public Law 93-641, which has legislative au- thority extending through June 30, 1 977, begins with the area boun- dary designation, a process likely to be largely cortipleted in late @ummer, followed by HSA formation "It will be possible," said Gerald T. Gardell, Acting Director of the Division of Regior,@al Medical Programs, "to establish many @ealth systems agencies by January, principally in homogeneous ,ural areas such as the upper peninsula of Michigan and in those states which will have a statewide HSA, and in those areas where an existing agency-CHP(b) or RMP-transfers itself into the HSA. "Formation of HSAs by January 1 is unlikely in those areas where there are likely to be competing applicants, where there have been major metropolitan areas such as New York, San Francisco, Boston, Chicago and Detroit." Twenty Three wr@@ to contribute sub- Once HSAs are in place they are expected stantially to an effective national health insurance and to the Nation's developing health policy. Flood, listing his own personal priorities, chose first a mech- anism for resources development -"filling gaps, seeing that patients get service where it doesn't exist now"-followed by the national riorities set forth in the new law and national health insurance. p "Congress knows that we need national health insurance. I think it is a plus for the lawmakers, however, that they have debated over several years how to provide that insurance. It is complicated. The infusion of gobs of new money into our health care delivery system could have catastrophic price results. "The real answer, of course, is prevention," he said, adding that he hoped the Public Health Service Commissioned Corps could be put "back at work at prevention of disease." National health insurance, said Hastings, "will come next year cost. in some form." But he, too, expressed concern about Everyone seems to want in it access to everything available, he said. "My friends we'd better understand one thing once we start writing na- tional health insurance: there is not enough money in the whole world to make those kinds of promises and then deliver." "Once we do have a national health insurance program," said Jablonowski, "and all the elements are successfully functioning there obviously will have to be some kind of formulation of national health policy, and I believe that physicians should carve out for themselves a role in the formulation of this national health policy. They must have a strong voice in the development of such policy and its implementation. This obviously means participation on all levels in the development of HSAS, of both providers and consum- ers, and I think they can work together." Twenty Four National Health Insurance Twenty Five "There i sno fir-.-al oi-Pcle on national @iealtf-i [)olicy, no highest I I @ officeorcourtof last resort," said 3'mriori@,;. "Wc-,'i the United States have not given tha;' distinction to anyone cr institution. And frankly I hope we nc-2ver do." "We have taken a sif-riDlistic attitu(Je toward @--i..-itional health pol- Health Policl@f icy in the last two dc@@cade We assumed that isolated, fragmented programs at the F(@(ieral world Somehow 3(@lve a multitude of problems," "It didi,,'t work. ['low -AiE,-, feel sense of u,gE@i,-i y. Not only have ied on them, but past efforts proveri jnecl,-,al to hopes we even more to the po nt national h@'.,alth inSL]r-ari(,',E@. Nhen it comes, is sure to impose a st@r@.lin on the he@'Ith care s,yster-ri the likes of which we have never befo!e ex,@erienc(@@I." National healt'ri insurance, sa'd Mearns, "is c (@)ing to come with planning that's prett,,,, primitive. Tf-,e big feai- for rTie is that it comes when we are riot ready, that -we w 11 do again w@,,a' we do so often in this country-proc'Lj(;e the expectation in those dwellers in the inner cities, the expectati,")n of t@ose rural areas where services have been inadequate or i-ion-exi,,:;tent. I do not view wi 'h great calm the creating once again of Iiig@i hopes which are riot met, when the services are not there." "It's time to put behind debate on issues raised in the develop- ment of Public Law 93-641," said Jones. "T@iis may be and quite likely is the last opportunity we have for local decision-making about allocation of our health resources in this country. The continuation of negative rhetoric will not serve our purposes and will not serve the health care consumers of the Nation. It could, however, well serve a strategy which will lead to the complete Federal domination of health planning in this Nation." Twenty Six "We can coordinate, we can pul@ lay and professional volun- teers together, we can do studies, we can define means, particularly in terms of facilities and so on," said Hunt. "Especially we should get back and work together with you, the professionals in administration who have capabilities that we don't have, particularly in this interim period. We must make this legislation work because it probably is the last chance the private sectors are going to have not to be totally controlled by the government." "Unless we want doctors' strikes, staff revolts or hospital ad- ministrators becoming as transient as college presidents," said Flood, "then we'd better not pose radical changes in our health system." "I believe in a patient being allowed to choose his doctor. I believe that for the demonstrably ill as well as for the worried well it is essential that a doctor know the whole patient and that the patient have confidence in his doctor. Those are essential parts of the cure, you know." "America has generally avoided the excess of the right and the left, the over-regimentation some countries have perpetrated. I want her to avoid excessive change in medicine as well. We are experi- menting slowly with Health Maintenance Organizations and other systems. This is an era of world-wide over-rapid and often mis- directed change. If we watch our priorities, attend to highly visible resource development needs, and rebuild our disease prevention army then I think we will be able to afford national health insurance and we'll live to see our medical care system become as good as the best anywhere." Twenty E)even Program Committee James W. Culbertson, M.D., Chairman Memphis Regional Medical Program Harry Auerbach III nois Reg onal Med cal Program Donald G. Brekke National Association South Dakota Regional Med@ca Program Of Regional Medical Programs Evangeline L. Hebbler, M.P.H. Oh o Valley Regional Medical Program Board of Directors Granville Larimore, M.D. Florida Regional Med cal Program John R. F. Ingall, M.D. Chairman Robert Miller Buffalo, New York Northeastern Regional Medical Programs J. Gordon Barrow, M.D. John A. Mitchell, M.D. Atlanta, Georgia California Regional Medical Program Robert W. Brown, M.D. J.S. Reinschmidt, M.D. Kansas City, Kansas Oregon Regional Medical Program Charles W. Caldwell J.A. Sabatier, Jr., M.D. Oakdale, Iowa Louisiana Regional Medical Program James W. Culbertson, M.D. Samuel Sherman, M.D. Memphis, Tennessee California Regional Medical Program Robert P. Lawton Roger J. Warner Cranston, Rhode Island Arkansas Regional Medical Program Benjamin Morgan Charles White, Ph.D. Buffalo, New York California Regional Medical Program Donal R. Sparkman, M.D. Robert A. Younqerman, J.D. Seattle, Washington Southeastern Regional Medical Programs Paul D. Ward Nathaniel Polster, Consultant Oakland, California Government Information Representative Twenty Eight Public Information Committee William Boquist, Chairman Calitorn@a Regiona@ Med cal Program Edna Carroll B -State Regional Medical Program Frederick E. Frazier Missouri Regional Medical Program Gerald N. Gold New Jersey Reg onai Med ca Program Dennis E. McClendon Florida Regiona Medical Program Sylvia Sterne Louisiana Regional Med ca Program Photographs by Steve F McCourtie, Linda R. Johnston and Donald Trantow Sketches by Robert C Hunt, Book Design and production by Pat Cunningha