Improving Public Health Care: Lessons on Governance from Five Cities J. Warren Salmon, David G. Whiteis Journal of Health Care for the Poor and Underserved, Volume 3, Number 2, Fall 1992, pp. 285-304 (Article) Published by Johns Hopkins University Press DOI: https://doi.org/10.1353/hpu.2010.0314

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Original paper IMPROVING PUBLIC HEALTH CARE: LESSONS ON GOVERNANCE FROM FIVE CITIES J. WARREN SALMON, Ph.D. DAVID G. WHITEIS, Ph.D. University of Illinois at Chicago Department of Pharmacy Administration 833 South Wood Street (M/C 871)

Chicago, IL 60612

Abstract:Policy-orientedinvestigationsintopublichealthcaredelivery have been limited, especially during the Reagan era of competition and profitbased health care, when the inner city was essentially forgotten. In this study, policymakers toured five urban public health care systems in different parts of the country to promote consideration of a new governance for Chicago and Cook County's complicated and uncoordinated care for themedicallyindigent. A comparison of patterns of governance revealed strengths and weaknesses of each model. Local leadership and the political will to evolve a system of care, with clear connections between the public and private sectors, account for each city's relativesuccess in addressingmountingneeds of inner-city populations. Key words: Urban health, public health care, governance From 1988 το 1990, Chicago-area policymakers concerned about the inadequacies and unresponsiveness of public health care for the city's underserved, embarked on cross-country tours, sponsored by Chicago's Health and Medicine Policy Research Group, the Metropolitan Planning Council, and the Community Renewal Society. These unprecedented tours enabled dozens of Chicago's most influential public health officials and elected representatives to visit health care systems whose reputations suggested the opportunity for valuable information sharing. Public health care systems are the collective groups of providers owned, operated, or coordinated by local municipal Journal of Health Care for the Poor and Underserved, Vol. 3, No. 2, Fall 1992

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governments. While these are normally quite unlike privately owned systems (whether for profit or so-called "not-for-profit") that mark urban America, the concept moves toward a systematic effort to more effectively serve indigent populations. The five cities selected for this project—Boston, Dallas, Denver, Milwaukee, and Seattle—are regarded as places where public-sector health care enjoys success.1 They represent a variety of modern U.S. cities, from industrial "rust belt" areas to urban centers whose economies have adapted to demands of a modern information-driven, primarily white-collar economy. Their smaller size provides a more reasonable scale with which to understand the implementation of public health care strategies than does a New York, Los Angeles, or Chicago.2 Policy-oriented investigations of urban health care delivery, particularly related to the public sector, have been quite limited.3 This has been especially true throughout the 1980s, when the inner city was forgotten in the onslaught of the Reagan Administration's health policies, which were based on competition and the profit motive.4 These policies diverted attention from underserved populations within which incentives for profit are usually not found. Earlier in the decade, Miller and Moos completed the most extensive investigation of public health care.5 Since then, documentation in the scholarly press by local public health officials themselves has been generally scant; descriptive or evaluative accounts of categorical public health programs predominate. The Public Health Briefs section in the American Journal of Public Health is one source of such presentations. The JournalofPublicHealth Po/icy has published only a few articles related to the overall development of local health care systems, as the Journal of Health Care for the Poor and Underserved now devotes space to the subject.

Now with rising momentum toward universal access to care6, the structural incapacities of urban health care delivery are being highlighted again. It is time to return to both conceptual and critical accounts of public health care delivery in the scholarly literature to stimulate policy discussion and change. Much can be gleaned from the effective implementation of primary care strategies, examples of coordination and integrated services, and cooperative patterns between private- and public-sector health care entities in cities across America. These developments must be seen as building blocks toward national health reform beyond a mere financial fix. Chicago and Cook County: A portrait of crisis.

Health care delivery in Chicago reflects a nationwide contradiction between conditions in the private and public health care sectors.7 In recent years, Chicago has seen a vast increase in the number of physicians, nurses, pharmacists, dentists, administrative staff, and other health workers; private academic medical centers and teaching hospitals have grown in size and influence. However, since 1980,16 community hospitals have closed. Most of

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these closures occurred in poor minority neighborhoods, resulting in the loss of over 14,000 jobs and a serious diminution in neighborhood health care. An estimated 1.6 million Cook County residents either receive Medicaid,

have inadequate private health insurance, or are uninsured.8-9 Cook County Hospital (CCH), the metropolitan area's only public acute-care facility, serves most of these poor and indigent patients; others navigate through private

hospitals that shun the financial losses that these patients represent. CCH is governed by the County Board of Commissioners, an elected body with little expertise in health care and a track record of unresponsiveness to the crisis in community health. The Chicago Department of Health, despite operating a number of community health centers, historically has had few connections to CCH or other county-run programs. This cumbersome administrative relationship has led to near total lack of continuity between the city and county. For example, the former county administration never coordinated even its basic programs—in chronic disease, prisoner health, or ambulatory care— with CCH. This awkward arrangement was remedied only recently.

As early as the 1930s, CCH was declared physically obsolete. Today, infrastructure problems and the lack of a computerized financial system combine to make the hospital a monument to years of political indifference.10 Although many staff remain dedicated, the ability of the hospital to continue to deliver quality care has been called into question through a series of challenges.1113 Recently, the Joint Commission on the Accreditation of Healthcare Organizations 0CAHO) briefly withdrew accreditation, leaving in doubt the hospital's qualifications for Medicaid and Medicare reimbursement, its dependable sources of revenue besides strapped county property assessments. Although accreditation has been restored, the incident undermined morale and

further weakened the institution's already declining reputation.14 Even with Medicaid funding, the hospital's financial viability remains in jeopardy. Under the state Medicaid program, the Illinois Department of Public Aid pays far less than the cost of providing care.15 Medicaid payments to all providers have become seriously backlogged, for up to 90 to 120 days; the last fiscal year brought a Medicaid shortfall of around $750 million. This further discourages private providers from treating Medicaid recipients, thereby increasing the number of "unsponsored" patients that the private sector triages to CCH. Cook County Hospital, physically obsolete and financially strapped, is the provider of last resort.16 The University of Illinois (U of I) operates a second "public hospital" in Chicago—one which has undergone its own series of organizational and financial mishaps over the last six years. The U of I Health Sciences Center— composed of medical, nursing, pharmacy, dental, allied health, and public

health schools—maintains few formal linkages with either the county or city health services, despite its location adjacent to CCH.

In sum, the metropolitan Chicago area holds the potential for a model public health care system waiting to happen.17-18 This possibility, and the clear

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desire of many parties within and outside of the public health care sector, was the impetus to study urban systems worthy of emulation.1 Methods

This paper describes the administrative and political governance of the various public health care systems. Two characteristics of governance are discussed: the locus of administrative authority in each city, and each system's relationships with other providers in the public or private sectors. The institutional framework for the actual delivery of care is not a primary focus of this paper, although, since it is inextricably connected with governance, it is addressed when relevant.

Administrative authority. A wide variety of factors make health care delivery increasingly complex, especially in the public sector. These include: changing federal payment policies and regulations; state and local fiscal conservatism and the resultant trend to streamline and cut back services; legal, economic, and ethical issues surrounding social epidemics, such as AIDS; and the post-Reagan conservative emphasis on private-sector solutions to public problems, combined with an overall neglect of services to the poor. Thus the challenge in redesigning an administrative structure for a public health care delivery system is to combine efficiency with flexibility. A degree of centralization is necessary to cut down on bureaucratic entanglements and to delineate clear lines of responsibility. Conversely, an openness to new ideas, including the option of implementing structural and administrative changes if necessary, is also essential. The locus and nature of administrative authority— encompassing lines of command, delegation of responsibility, relationship to the local political structure—are thus major factors in the success of a public health care system. The first part of each city description below examines the administrative structure of public health care in the five cities visited. Relationships with other providers. An important element in designing a public health care system that will both serve community needs and remain viable is establishment of sufficient linkage with private-sector providers. Such

relationships buttress a public system in several ways: 1) they provide clinics and neighborhood health centers with needed linkages for referrals; 2) they establish trust between the public and private sector, thus potentially eliminating political and ideological turf battles; 3) they allow insured patients, treated in private institutions, to be referred to the public system for specialty care, thus adding to revenues and furthering cooperation between public and private providers; 4) institutional relationships with teaching institutions can provide a public system with physicians and other staff, while conversely exposing medical students to the realities of practicing medicine in an urban setting.

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AU of the public health care systems examined here have established important relationships with other local providers. The second part of each city description outlines some of these linkages. Boston

The emphasis of Boston's system of Community Health Centers (CHCs) is community-based, primary care. Appropriately, its governance combines

centralized control and local autonomy. The 25 CHCs comprise the heart of the system. The Boston Department of Health and Hospitals oversees the entire operation. Local officials noted that the department's name reflects their philosophy that hospital care and broader health services are not one and the same. Boston City Hospital provides the anchor for an ambulatory system that is constructed across community settings. Administration of the Department of Health and Hospitals. The Boston Department of Health and Hospitals' role includes traditional public health functions, such as inoculation, prevention, and disease screening. The department has expanded its role, however, to encompass community health programs, occupational and environmental health, and analysis of public health statistics.

The institutional base of the department is comprised of three main facilities: Boston City Hospital (Boston's public general hospital, a 469-bed acute-care facility); Mattapan Hospital (a long-term chronic/rehabilitative hospital with 151 beds, providing care for rehabilitation, oncology, respiratory dysfunction, and in gerontology); and Long Island Hospital (a chronic-care hospital with 193 beds, concentrating on gerontology and care for chronically ill patients, including those with Alzheimer's disease). The department also runs emergency medical services for the city, and a school of practical nursing. The Boston Department of Health and Hospitals was established by city legislation in 1965. A commissioner, appointed by the mayor, oversees the department. The commissioner is also the executive director of all three

hospitals that serve as the department's institutional base. To provide the combination of centralization and flexibility necessary for successful public health care delivery, the department is divided into three major operating divisions. These are: the Boston City Hospital In-Patient Services; the Long-Term Care Division (including both Mattapan and Long Island Hospitals); and the Division of Community Health Services. The Division of Community Health Services supports the city's network of community health centers. AU directors of these divisions are appointed by the commissioner. Since this discussion will focus on the Division of Community Health Services, background information on the CHCs will allow a better understand-

ing of the history and current status of Boston's system. Community health centers. In the mid-1960s, the nation's first commu-

nity health center was established in Boston at Columbia Point, as a component

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of the federal Office of Economic Opportunity's "War on Poverty" program. From this initial CHC evolved the current Boston CHC network which includes

CHCs in neighborhoods throughout the Boston area. Boston is unique in that it utilized the OEO program asa prototype for an ongoing city-wide network of clinics, rather than allow the idea to die when federal funding ended. The CHCs are unique in other ways, as well. They are unusually autonomous. Boston's CHCs enjoy a wide variety of structural arrangements with local hospitals and other sources of support. Four CHCs are licensed satellite clinics of Boston City Hospital; these, plus two others, are also members of the Affiliated Neighborhood Health Center Obstetric Group. Doctors and nurse practitioners provide obstetric services in these six centers. Every CHC has some affiliation with at least one hospital. The four satellite facilities of Boston City Hospital have already been noted; seven others are licensed facilities of private hospitals. Each of the remaining centers is linked to a local hospital, known as a back-up district hospital, for staffing and referrals. These remaining CHCs are not licensed hospital facilities, but are licensed separately by the Massachusetts Department of Public Health. Governance of most of the CHCs comes from independent boards. Community residents as well as health professionals sit on these boards, which are linked financially to the Department of Health and Hospitals. The department provides annual funding to help the CHCs support deficits they may run by serving the poor. It also serves as a conduit for federal funding. As mentioned above, the CHCs are autonomous; few formal structures

link them. CHCs have established informal relationships in some cases, when CHCs have shared goals (such as serving a common patient base) or have received funding from common sources. In recent years, CHCs have used their collective numbers to acquire the most reasonable rates under Massachusetts' aggregate rate-setting mechanism for Medicaid. This linkage has been largely facilitated by the League of Community Health Centers, a private not-for-profit professional organization formed by the CHCs themselves. Relationship with other providers. Most of Boston's community health

centers draw their staff from the house staff at their back-up hospital. If a center is not licensed as a hospital facility, it either recruits staff from the back-up hospital, or recruits on its own from outside of the hospital. Center physicians have admitting privileges at the back-up hospitals. The Boston Department of Health and Hospitals has no legislated power or authority over private health care in Boston, aside from its relationship with the private, not-for-profit CHCs. The department does exercise informal influence that has encouraged private providers to become more aggressive in such issues as AIDS, perinatal care, infant mortality, and substance abuse. Several private-sector group practices also contract with community health centers to provide services. Affiliations between the Boston CHCs and local medical schools have

evolved despite an early history of mistrust. At the time of their establishment,

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many centers' boards resisted establishing such relationships; neighborhood advocates felt that Boston's teaching institutions had a history of unfair dominance in the city's health care system. Largely at the initiation of the teaching institutions themselves, some medical schools began to negotiate with some centers to establish ambulatory medical residency programs. At present, it appears likely that these linkages will be established, paving the way for growing relationships between Boston-area medical schools and at least some of the community health centers. It is notable that Boston's system links closely the provision of health care and governance. Policy decisions tend not to be made by political operatives remote from day-to-day operations; rather, political relationships and medical relationships are intertwined. The clash between politics and health care that might be present in other places is thus less prevalent in Boston. Summary. Boston's network of CHCs is continually evolving to meet the challenges of a rapidly changing health care environment.19 Despite their history of autonomy, CHCs have become increasingly linked in recentyears, out of fiscal and political necessity. The Department of Health and Hospitals, meanwhile, has demonstrated an admirable willingness to accept change, and to support the evolution of the CHCs from an independent cluster of clinics into a more closely coordinated system. The challenge in the future will be to maintain the balance of autonomy and coordination that has come to characterize the CHC network, and Boston's system as a whole. Dallas

Public health care delivery in Dallas is based primarily at Parkland Memorial Hospital. Dallas has the most centralized of all the systems visited for this study. Parkland has a history of innovation and a proactive approach toward public health care. The hospital has aggressively sought to expand public-sector care beyond the stereotypical provider of last resort for the poor and uninsured. It is operated by the Dallas County Hospital District and is the primary teaching hospital of the University of Texas Southwestern Medical Center. It is a unique public provider, given its ideological and programmatic concern for "Patient-Centered Patient-Valued Care."20

Administration of Parkland Memorial Hospital. Parkland is not a hospital, but rather a hospital district. This gives it unusual autonomy in county political affairs. ParklancTs seven-member board of managers, drawn from the fields of business and politics, is appointed by the five elected county commis-

sioners. The board of managers is an independent body whose members are responsible for governance in all but three areas. The county is responsible for: appointment of the board; setting the property tax levy, from which Parkland derives approximately 50 percent of its revenue; and acquisition (purchase and lease) of land for expansion. The board of managers controls all other opera-

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rions, including budget, recommendations for changes in the tax levy, policy requirements as required by JCAHO, and all health care policy. Parkland Memorial Hospital recently launched an agenda of decentralization. The strategy will lessen the hospital's emphasis on high-cost primary care. It includes acquisition of a community hospital in which most of this lower-intensity care will take place. This will allow Parkland, a large tertiary care institution, to do what it does best: focus on high-intensity, specialized care as the back-up center for referrals from the smaller hospital and as a regional academic center.

Parkland has also begun to implement a system of Community-Oriented Primary Care (COPC) clinics.21 Eventually these will be located in eight health centers throughout Dallas. Three COPCs will have contracts with Dallas's two existing federally-funded private not-for-profit health centers. The COPCs will be designed to complement the care being given at the private facilities. Five other COPCs will be owned and operated by Parkland. Parkland has also taken steps to achieve the hospital's long-time goal of expanding its services to privately sponsored patients. A major purpose of this expansion is to subsidize its continued service to the poor. Like the COPCs, these services will focus on areas that complement the private sector. In a

conservative city such as Dallas, where a corporate agenda largely sets the political and cultural tone, this is a pragmatic approach toward diminishing mistrust of public-sector "takeover" or bureaucratic imposition on private initiative.

Parkland is well-equipped for such a move. It has the only inpatient epilepsy unit in the Dallas-Fort Worth metropolitan area, and several other

programs already attract privately insured patients. These programs include any thmia management, dermatology, a private diabetes center, and a continu-

ation of Parkland's kidney transplant facilities, which performed the first kidney transplants in the Southwest. These endeavors have realized sufficient profits to allow Parkland to provide to the uninsured services that are not paid for by county funds. Relationship with other providers. Virtually all indigent care in Dallas is provided by Parkland Memorial Hospital, although, as noted above, significant changes will distribute much of the higher-cost primary care elsewhere. Texas's Medicaid structure is sufficiently prohibitive that few private physi-

cians are willing to care for the indigent. Thus Parkland Hospital's viability virtually determines the state of health care for Dallas's poor. Parkland's affiliation with the University of Texas Southwestern Medical

Center allows only physicians who are members of the U.T. Southwestern faculty to attend at Parkland. Parkland thus has an adequate supply of quality physicians. The medical center, meanwhile, is supplied with a source of stimulating cases for teaching and research. The reputations of both Parkland

and the medical center make recruiting able personnel relatively easy. A new private hospital, Zale-Lipshy University Hospital, recently opened on the

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campus of the medical center. This will further increase the ratio of private-pay patients at the University, and it may also serve to enhance Parkland's referral base of privately insured patients. Dallas has effectively and efficiently merged the responsibilities of providing quality public care with managing a hospital. The hospital administration and the Board of Managers have adopted a business-like attitude that is

somewhat unusual within the public sector. As mentioned, Parkland's strategy avoids threatening private providers, while establishing a viable alternative to existing private health care services.

Summary. Parkland Hospital is an example of the adaptability to local conditions, economics, and culture that we feel is essential for the survival of a

public health care system. Given Dallas's historic conservatism, it is essential that its public sector be vigilant about efficiency and sound fiscal management, and not pose an apparent threat to powerful private-sector interests. Through a well-planned program that private hospitals perceive as an ally rather than an adversary, Parkland has managed to expand despite the present era of retrenchment and privatization. Denver

Denver's network of community-based ambulatory care providers is unlike Boston's or Seattle's (as we shall see later) in that it is directly controlled by the city. The system is administered under the same authority as is the public hospital, Denver General Hospital, and is governed by the Denver City Department of Health and Hospitals. Denver General Hospital anchors the system. Despite this higher degree of centralization of authority, however, there are similarities between Denver's system and the more free-wheeling Boston model. Denver's community health centers are quite independent from Denver General Hospital in day-to-day operations, finance, and goals-setting. Administration of Denver's public health care system. The Denver

Department of Health and Hospitals oversees public health for the entire city. The legislation that established the department designates its broad responsi-

bilities as

the administrative functions of the city and county of Denver pertaining to the physical and mental health of the people, investigation and control of communicable disease, operation of municipally-owned institutions maintained for the care of the sick, aged, injured or mentally ill, and regulation of privately- and publicly-owned institutions for the purposes of sanitation and public health.

In addition to operating Denver General Hospital, the Department of Health and Hospitals is also responsible for a neighborhood health program; an alcoholism treatment program known as Denver C.A.R.E.S.; the Division of

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Public Health; and the Rocky Mountain Poison and Drug Center. It coordinates Denver's EMS trauma system as well. The Department of Health and Hospitals falls under the jurisdiction of Denver's city and county government. The department is administered by a manager and three deputy managers: the Deputy Manager for Community Services (responsible for the city's Neighborhood Health Program, the Community Mental Health Program, and the Program Evaluation Division); the Deputy Manager for Medical Affairs (responsible for Denver General Hospital, county emergency services, and public health initiatives such as in environmental health and health education); and the Deputy Manager for Operations and Finance (budget, personnel, and facility maintenance.) These deputy managers report regularly to the manager.

The manager is appointed by the mayor, who also appoints the three deputies pending approval of the city's Board of Health. The Board of Health's seven members are also appointed by the mayor, who has the power to hire and fire these officials at any time during his or her four-year term. Like Boston, Denver has developed a system of community-based primary care clinics. Also like Boston, Denver's clinics are affiliated with local private hospitals for back-up, and are quite autonomous from the city's Department of Health and Hospitals. However, the city's public hospital has a much greater role in the community health center network of Denver than it does in Boston. Again, we will look at this system in more depth to gain a better understanding of its structure and functions. Neighborhood Health Program. Like Boston's system of CHCs, Denver's Neighborhood Health Program (NHP) is in many ways a legacy of federal support. Monies from the Office of Economic Opportunity (OEO) and a Department of Health, Education, and Welfare Maternal and Infant Care grant helped establish Denver's first satellite clinic in 1966. AU eight clinic facilities were in place by 1969. In the early 1970s, the flow of federal dollars slowed. The city administration recognized the positive impact of the clinics, and made general revenue-sharing funds available to continue and develop the clinics, and to supplement federal grants. The clinics currently operate under a combination of federal and local revenue sources.

Denver's NHP is financed largely through the efforts of NHP, an independent, not-for-profit community-based corporation formed by Denver Health and Hospitals to apply for grants to run the program. The program sees patients at two comprehensive neighborhood health centers (one serving the city's Eastside Health District, one serving the Westside) and eight satellite health stations (four on the Eastside, four on the Westside).

Historically, NHP has operated 10 well-child clinics, each one integrated into the overall system. However, in recent years these clinics have been deemphasized, as their function has been largely taken over by the comprehensive health centers. Outpatient services are available at Denver General Hospital, to which patients are referred for more intensive or specialized care. Anyone who

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lives within the city can use any of the facilities, and privately insured patients are encouraged to do so. Administration of the overall NHP lies in the hands of the Deputy Manager for Community Health Services. Each district has a good deal of autonomy, including its own medical director and administrative officer. These officers oversee professional and staff support of the health center and satellite stations. The centers hire their own physicians and personnel; Denver General Hospital's house staff provides no primary care at the centers. In fact, the hospital has little authority over the centers' policy and management decisions. Extensive use is made of nurse practitioners, who are given substantial responsibility and freedom. Relationship with other providers. Denver's public health care system does not share governance with the city's private health care institutions. Nonetheless, public and private sectors do share linkages. Although Denver General Hospital is not a major affiliate of the University of Colorado Medical School, the hospital serves as an important training center for the city's physicians.

Denver physicians have traditionally been strong supporters of the city's public health care system. In the 1960s, this relationship was threatened by physicians' opposition to a community-based ambulatory care system. Plentiful federal dollars enabled the system to progress despite doctors' protests. Since then, there has been a notable improvement in the relationship between

the Neighborhood Health Program and private practitioners. As in Dallas, physicians have realized that the Neighborhood Health Program complements, rather than threatens, their own efforts.

Denver's system has enjoyed some success in attracting private-pay patients, particularly at Denver General Hospital; approximately 25 percent of Denver General Hospital's patients are privately sponsored. The reputation and newness of the hospital and its medical staff's faculty appointments with the University of Colorado may account for this. In addition, Denver General has established a plan whereby doctors may supplement their salaries by 20 percent from private patients' fees. Thus, though private patients comprise less

than 10 percent of the patients at the neighborhood health centers, Denver General serves more privately insured patients than are seen at most public hospitals. Denver General and other local hospitals have evolved an informal relationship regarding emergency services. To ensure efficiency and ease of monitoring, Denver's EMS dispatching system is centralized at Denver General Hospital, and nearly all ambulance service is comprised of city ambulance and

paramedic teams. Emergency patients are routed to the nearest hospital. Certain other services, such as obstetrics, are provided by area private hospitals when the demand on Denver General exceeds capacity. Thus Denver's public and private health care sectors have established linkages on their own initiative, while the public system continues to operate autonomously.

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autonomous public-sector system that has forged cooperation with private caregivers. Denver General's role as a primary site of training for the city's physicians, despite the lack of major institutional affiliation with the University, is another example of such linkages. Relationships between physicians and the hospital are facilitated : the hospital's quality is made evident to the doctors, who may then obtain staff positions at other Denver institutions and continue their good working relationship with Denver General. Finally, Denver's incentives to encourage the treatment of privately sponsored patients in the city hospital is another example of a policy to avoid "ghettoization" of the public sector. This will strengthen the public sector's financial viability, as well as improve its reputation among the general popula-

tion. Thus the commitment to providing care for those who cannot pay remains strong, even as the system attempts to broaden its scope and establish further credibility among privately insured patients. This may be the most effective public/private partnership that Denver can establish. Summary. The city and county of Denver have taken an unusually aggressive role in shaping the city's community-based public health care system. Although initiated by federal monies, the clinics were recognized early by the city as an important component of public health care delivery, rather than as competition. The active role of the city has made this a more centralized system than exists in either Boston or Seattle, the other cities in this report with extensive community-based primary care delivery networks. The municipal hospital also takes a more dominant role in Denver than in Boston; there are also voluntary associations between private hospitals and CHCs similar to those in Boston. However, the autonomy and freedom to implement their own designs enjoyed by all of the community-based primary care clinic systems in this study is a vital component of the Denver system as well. Again, balance between centralized authority and local control emerges as indispensable. Milwaukee

In terms of its relationship with the private sector, Milwaukee's public system might be characterized as almost a mixed-governance model. The

county's public system has important relationships with private providers but remains publicly administered and funded. Not only local funds contribute; the state of Wisconsin offers significant financial backing, to complement the

revenue garnered from the local property tax. The Milwaukee County Health Plan. Unlike Dallas, Milwaukee County has adopted a pragmatic, fiscally conservative approach toward public-sector health care. Recipients are enrolled in a PPO, the Milwaukee County Health Care Plan (MCHCP), which was established in 1988. MCHCP is actually a

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continuation of an earlier model, the Medical Assistance Program (MAP), which was initiated in 1982 as a county nondepartmental organizational unit to deliver care to Milwaukee County clients receiving general assistance, as well as to those defined as "medically needy"—uninsured without means to pay for care. AU providers of nonemergency care who participate in the MCHCP are located on the grounds of the Milwaukee County Regional Medical Center. The Medical Center consists of the Blood Center of Southeastern Wisconsin, Children's

Hospital of Wisconsin, the Curative Rehabilitation Center, Froedtert Memorial Lutheran Hospital, the Medical College of Wisconsin, as well as the public Milwaukee County Medical Complex (MCMC) and the Milwaukee County Mental Health Complex (MCMHC). MCHCP also operates an adult primary care clinic located in downtown Milwaukee, as well as several community-

based outstations of the Milwaukee County Mental Health Complex. The MCHCP is governed by the Milwaukee County Board, a part of the county's Department of Administration. The Health Care Plan functions as the county's health insurance for the medically indigent. The county public hospital, MCMC, is reimbursed by the MCHCP. As in other locales, the county property tax provides most of the money for this reimbursement, although state revenues offset about 46 percent of these incurred costs. This state support is essential to the ongoing viability of the Plan. The Milwaukee County Medical Complex was recently established, by legislative fiat, as a separate department from other county social services. Administration will be removed from the Milwaukee Department of Health and Human Services, and the administrator of the medical complex will become a member of the county's executive cabinet. This administrator will report to the

county executive instead of to the director of the Department of Health and Human Services. The MCHCP administers most provision of health care for approximately 20,000 "dependent" or "medically needy" Milwaukee residents. MCHCP is the sole provider for Milwaukee's poor, since the city operates no primary care clinics. Criteria for enrollment in the MCHCP are quite strict. Chapter 49 of the Wisconsin State Statutes defines a dependent person thus: ...an individual without the presently available money, income, property, or credit, or

other means by which it can be presently obtained...sufficient to provide the necessary commodities and services specified in sub. (5m) S.49.01(2).

Only those eligible for general relief, who are not insured by Medicaid, Medicare, or any third-party private insurance, are eligible for participation in MCHCP. Medically needy individuals are considered those who do not receive

general relief from the county, but whose medical expenses exceed their ability to pay. Their eligibility depends on a "spend-down"; until they have spent a sufficient amount of their income to be dependent, they do not qualify for MCHCP. In 1990, a family of four could have a net income of no more than $470.00 per month; a family of three, $395.00. These amounts are considerably

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below the federal poverty level for urban families. Approximately 5,000 of the patients in MCHCP are dependent; the remaining 15,000 are medically needy. The city's Department of Health primarily limits its activities to traditional public health activities, i.e., inoculations, disease control, and the like. The

city runs two clinics. These are funded primarily through patient income, and they also receive Medicare waivers and minimal city funding. Relationship with other providers. Both public and private providers on the campus of the Milwaukee Regional Medical Center participate in MCHCP. These include the Milwaukee County Medical Complex, the Milwaukee County Mental Health Complex, the Blood Center of Southeastern Wisconsin, the Medical Collegeof Wisconsin, Froedtert Memorial Lutheran Hospital, Children's Hospital of Wisconsin, and Curative Rehabilitation Center. MCHCP reimburses patients for receiving emergency services at private hospitals only if the hospital has obtained authorization for the care. Authorization is granted on a case-by-case basis, usually for life- or limb-threatening emergencies.

Froedtert Memorial Lutheran Hospital, a private facility located on the grounds of the MCMC, has a direct contract with MCHCP to provide nonemergency and emergency care to any patients referred there through MCHCP's utilization review process. Froedtert is a Preferred Provider under the MCHCP. The Curative Rehabilitation Center, also on the Medical Center

grounds, is the other private Preferred Provider. The Medical Complex and the Medical School of the University of Wisconsin have a strong linkage. The medical school rents research and laboratory space from the MCMC. In return, the medical center staffs the medical complex as well as Froedtert and Children's Hospitals. Faculty from the University of Wisconsin practice at all institutions participating in the MCHCP. This assures a universal standard of care, as well as cooperation.

Although Milwaukee's public health care system is physically centralized, it is also distinguished by its institutional diversity. Rather than emphasize community-based primary care, specialty clinics on the grounds of the MCMC provide comprehensive care with a wide range of services. The preponderance of medical activity under the MCHCP comes under public-sector entities. Thus despite the presence of three private institutions as components of the system, public-sector health care delivery is dominant in the public/private partnership. For the most part, the needs of the population take precedence over private profits, although the strict spend-down requirements of the MCHCP help prevent unmanageable financial losses. This combination of efficiency with a longstanding dedication to providing for the public welfare helps ensure both longevity and continued quality of the system. Summary. Milwaukee's unique alliance of public and private providers, all under the auspices of the MCHCP and all at one location, allows it to be fiscally conservative while still providing quality care. As in Dallas, Milwaukee

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aggressively seeks private-pay patients in both its public institutions and the private institutions affiliated with the MCHCP. However, it should be noted that the requirements for full coverage under the MCHCP are very strict, and during the two-year period we have examined the Plan, the total enrollment has not increased appreciably from what it had been in the mid-1980s. Fiscal conservatism, in this case, may result in difficult access for some poor residents of Milwaukee who have not spent down sufficiently to enroll in the MCHCP. Seattle

Like Boston, Seattle has a network of community-based ambulatory care facilities that is difficult to describe summarily. Thanks to a history of local grassroots activism, the city became the fortunate recipient of federal largesse starting in the late 1960s, through the efforts of the late U.S. Senator Warren Magnuson. The city has taken an increasing role in what had formerly been an entirely independent clinic network, making it more of a system than it has historically been. The Department of Public Health, run jointly by the city of Seattle and King County, administers public health in the city.22 This dual arrangement has existed since 1951, when the city and county merged their duplicative health departments. In 1980, administration of the department was transferred from the city to the county as the population shifted to the suburbs. Administration of the Seattle-King County Health Department. The

mayor and the county secretary appoint the director of the Seattle Department of Public Health. The director is usually a physician. The health department is divided into seven divisions. The Seattle Division attends to the public health of the city. King County performs most traditional public health functions, including sanitation, inoculation, disease control, and related necessities. The Seattle Division, in turn, is divided into three district centers, each of

which operates a clinic in a different area of the city. These clinics are quite autonomous, even to the extent that the services they provide are different. The North District center provides a family health program, a maternity program, and special projects such as a youth outreach program. Patients of all ages are treated there. The Central District center, on the other hand, has no onsite child health programs; its patients are primarily adults over 60 years of age. The Columbia center administers only to patients up to age 21, except for pregnant women of all ages. In addition to these facilities, the Seattle-King County Health Department also runs five categorical service clinics and several other "specialty" (tuberculosis, sexually transmitted disease) clinics, all of which serve the general at-risk population. The 13 private not-for-profit community clinics in Seattle contract with the city for some services and also work jointly with the three city clinics. They focus solely on primary care delivery, while the city generally addresses broader public health issues such as immunization and administration of the

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federal Women, Infants, and Children (WIC) Program, in addition to primary health care delivery. The Seattle Community Clinics. Seattle's clinics were not initially part of a municipal plan to deliver community-based care. They arose out of the populist community health movement of the 1960s, and were primarily volunteer-run "free clinics," serving their immediate communities, until the mid1970s. In the 1970s, the clinics began to pool their resources as funds became more scarce. Eight finally came together and formed a consortium, Neighborhood Health Centers of Seattle, in 1972. Other clinics followed suit and in 1976,

one of these clinic consortia received Seattle's first federal funding.

The year 1976 was important for Seattle's clinics. That year, certain Seattle communities were federally designated as Health Manpower Shortage Areas. They were thus able to receive personnel from the National Health Service Corps during the following year. During this time, the independent clinics began to establish formal affiliations with local hospitals. The clinics were provided with specialty backup services for outpatients and inpatients. In addition, they were able to expand into such areas as tertiary care and maternity services. In 1977, Seattle reorganized its health department and created the Seattle Division, which worked to establish a closer relationship with the clinics.

In this way, the city became an increasingly active partner in providing care. Like public service programs across the country, Seattle's community clinic system lost significant amounts of federal support during the Reagan era. Unlike many other municipalities, however, the city of Seattle made a strong effort to compensate for this loss. The Seattle Public Health Service Hospital, threatened with closure, was transformed into a Public Development Authority and renamed Pacific Medical Center. By the 1980s, the state of Washington also increased its support, allowing Seattle's clinics and health department to continue and expand their programs even through this difficult period of national public-sector retrenchment. Seattle plans three additional major health centers, as well as a Southeast Seattle Community Health Center, which will include a pediatric clinic, a community center, and a district office. Seattle's clinics—both the health department clinics and community clinics—are utilized by a notable portion of over 20 percent of the city's residents. Relationship with other providers. As outlined in the previous section, Seattle's health department has developed a strong working relationship with the independent community health centers, which rely on two local private hospitals for backup services. Several other private institutions contribute maternity services to low-income women and families referred to them from the clinics. There are no other formalized linkages; although the community health centers have become integrated into the public sector, they are still autonomous and retain an element of the independent spirit that is a legacy of their community activist origins.

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Unlike other cities examined here, Seattle's public-sector support for private, not-for-profit community health centers was largely unplanned. Disparate forces, working toward similar goals and willing to set aside ideological differences for the sake of the common good, allowed consortia of clinics to come together with a city/county health department that strongly supported community-based primary care. The historical contribution of federal support in Seattle should not be overlooked. The community health centers have thrived and become an attractive adjunct to existing city/county public health services largely due to federal monies in the 1960s and early 1970s. The city and eventually the state stepped in when the federal government abdicated its funding responsibilities. Seattle's history, as well as Boston's and Denver's, demonstrates the necessity for national policy to support local public health care initiatives, in order for the local programs to thrive. Thus pressure at the federal level to return health as a national policy priority must not be overlooked in favor of local programs. Summary. Unlike either Boston or Denver, Seattle has a network of

community-based clinics that were initiated independently of any governmental program, local or federal. However, early on, the importance of public support became clear, and both national and local funds were indispensable in the establishment and development of Seattle's current system. Seattle and King County, like both Boston and Denver and Denver County, have realized both the value of the community clinics and their unique success as independent, autonomous entities. As elsewhere, coming together in consortia and centralizing to a certain extent have come at the clinics' own

initiative. A model of governance that might be described as "distanced nurturance"—financial support and administrative oversight, but allowing as much independence and individual development as possible—is a characteristic of the most successful community-based clinic networks. Discussion

The purpose of this project was to gather data on successful public-sector health care initiatives in urban areas, with the eventual goal of using these findings to encourage discussion of policy options in Cook County and Chicago. A summary report prepared for the Field Foundation of Chicago explicates our overall findings, and provides greater information on other parameters not reported in this paper; the report also contrasts findings from the selected cities with a more thorough reflection upon public health care in Chicago and Cook County.1 We are also hopeful that this project may help policymakers elsewhere improve the quality of pubic health care in their own communities. Each of the five cities witnessed a significant rise in the social epidemics that plague all urban areas. Each experienced overcrowding at most public facilities. And each suffered the effects of federal funding cutbacks and other

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travesties of misguided competitive health policies. Yet success stories are alive in Boston, Dallas, Denver, Milwaukee, and Seattle.

Although critics of the public sector characterize it as resistant to change, we found diverse and flexible models toward implementing public health care systems in urban settings. Keys to advancement are innovation and careful

consideration of local political, social and cultural factors. Though the cities that we visited are neither ideal nor without significant remaining problems, each city has attempted to tailor its health care delivery to meet its particular needs within the context of its historical development. The primary, overriding conclusion drawn by the project participants is that leadership and political will by local governments are essential if structures and governance for decent and humane health care to at-risk populatwns are to be successfully implemented. Also vital to successful development toward a public health care delivery system is coordination among metropolitan, county, and state policymakers and providers. Chicago's cumbersome dual city/county administration has been a major hindrance to breaking the city's current policy logjam. It will be essential to develop mutually supportive relationships, between the city and the county, between these governmental entities and the University of Illinois at Chicago, and among private-sector community-based and hospital providers. Steps in these directions are finally underway this year with a ne w Cook County administration and city health department forming an Ambulatory Care Council for joint planning. In other communities across the country, officials may find that establishing such cooperative relationships is mutually beneficial. Revenues to support a public hospital can be derived from a variety of sources, as demonstrated by innovative programs like those found in Dallas. Creative approaches toward enhancing revenue can buttress added care initiatives. Since it appears that national or state health insurance reform toward universal coverage is far in the future, more immediate financing must be

generated locally. Paying for the delivery of health care to the indigent must primarily become the responsibility of city and county government. However, significant contributions can also be made by community-based not-for-profit health and human services providers, funded by federal, state and philanthropic sources. The essentiality of Medicaid and other state public health support cannot be underestimated. On a programmatic level, several of the cities demonstrate that a decen-

tralized system can improve responsiveness to community health needs. Decentralized systems can also facilitate more efficient reallocation of resources to the neighborhood level. AU efforts of this type should be undertaken with

substantial community participation, which could be enhanced in every city visited. Community participation in designing and planning a health care system can lead to greater public awareness of health as a day-to-day concern; social epidemics, such as AIDS and violence, may be better addressed directly on this level. Prevention and community health promotion may also be more successful in the long term if neighborhood residents are involved in the health

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planning process, and can help identify areas of most concern to those who will be served. Community-based not-for-profit providers seem more eager than others to experiment in these ways. It should be stressed that significant problems and shortcomings remain, even in cities with relatively successful programs. The MCHCP spend-down

requirements that qualify Milwaukee residents for free care are quite strict; enrollment in the MCHCP has not expanded beyond approximately 20,000 residents for several years, indicating that significant numbers of underserved people remain unenrolled. Other attempts, such as Denver's SCOPE, to enroll the uninsured in private insurance have been almost as limited.23 Boston's system of clinics is largely dependent upon state revenues in a state whose economy is in dramatic decline, and continues to struggle to fulfill its promise. Although quality of care in the neighborhood clinics appears universally good, the clinics themselves differ greatly in terms of resources, quality of physical plant, and comprehensiveness of services. The historic tension between the city's academic institutions and established community organizations hinders important linkages among the public sector and both medical schools and their teaching hospitals. However, each of these five municipalities has established health care as an important component of public policy discussion and local action. While officials in the metropolitan Chicago area continue to view health as a subject of political turf battles, leaders in the five cities realize that health care delivery, no less than education or fire control, is a vital public responsibility. This commitment to health care as a social priority, a commitment shared by citizens and public servants alike, is essential to the development of successful public health care delivery systems in American cities. Conclusion

In the midst of continued crisis in urban health care, particularly as the public sector remains the provider of last resort to mounting numbers of the uninsured and underinsured, it is vital to examine experiences of cities that have been able to advance, or at least hold at bay a critical deterioration across the 1980s. As debates over a national health program and state health insurance initiatives intensify, it is crucial to recognize the long, hard challenge of restructuring public health care delivery in local areas. The five cities analyzed here provide a useful foundation with which to reorganize public health care, and for encouraging policymakers to be more responsive to new efforts for financing care to the underserved. For those who seek greater visibility for public-sector health care, it is imperative to note that merely covering greater numbers of our population is woefully insufficient for real, lasting progressive reform. This paper is based on a presentation to the Urban Health Committee, Medical Care Section, American Public Health Association Annual Meeting, November 1991, Atlanta, GA. The authors

wish to thank Maggie Santos for assistance in the preparation of this manuscript, and the Held Foundation of Chicago which provided funding for this comparative analysis.

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KATHERINE MASSEY, dds, ms VERONICA SCOTT, md, mph MARTA SOTOMAYOR, PhD DONNA YEE, PhD

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RICHARD ENOCHS, PhD AMYCATO7PhD

IRENE JILLSON-BOOSTROM, PhD GORDON BONNYMANjD RONALD BRAITHWAITE, PhD ANTHONY CEBRUN,jd JOYCE D. KIRKLAND-ESSIEN, md THERMAN EVANS, md ROBERT HARDY, md VERONICA SCOTT, md BARBARA NABRIT-STEPHENS, md CYNTHIA HODGE, dmd Readers ' Services

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Correction: In "Improving Public Health Care: Lessons on Governance from Five Cities" by J. Warren Salmon, Ph.D. and David G. Whiteis, Ph.D. [Vol. 3, No. 2:285-304], the Medical College of Wisconsin is erroneously referred to as the medical school of the University of Wisconsin. The Medical College of Wisconsin is a private, freestanding medical school that until 1967 was the Marquette University School of Medicine.