NATIONAL HEALTH PLANNING IN THE UNITED STATES: PROSPECTS AND PORTENTS Leonard S. Rosenfeld and Irene Rosenfeld The National Health Planning and Resources Development Act of 1974 in the United States demonstrates a growing determination in Congress to motivate the system of health services toward greater efficiency in utilization of resources. The Act was designed to overcome some of the weaknesses in earlier planning legislation. More complete coverage and more functional local jurisdictions for planning should result. The Act provides better financial support, and more effective incentives and inducements to assure adherence to plans. Concern is expressed about aspects of the legislation which the authors feel may deserve consideration. The principle of delegating responsibility to voluntary agencies for disbursement of public funds is questioned, and the authors suggest that local public health authorities apply for designation as planning agencies. Reservation is expressed about the adequacy of regional organization as provided by the Act to accomplish its purposes, and the authors recommend demonstrations of regional administrative agencies to implement plans developed by Health Systems Agencies. Failure to incorporate the provision of the House planning bill to set up a national health policy council in the Act is considered unfortunate. Persistence in pursuing the course outlined in the Act is urged.
The signing of the National Health Planning and Resources Development Act of 1974 (P.L. 93-641) on January 4, 1975 represents broad consensus among Congressional leaders and executive agencies on the need for more effective direction of the national health effort. It was the culmination of extended review of experience with earlier national programs of health planning. The scope of consensus is an expression of the pervading sense of urgency surrounding issues of health care. The magnitude of support given to principles of planning and regulation of health services is significant in light of the traditional skepticism, and even hostility, which has, in the past, been accorded t o such governmental intervention in health affairs. The goals of the legislation are clearly expressed: the assurance of adequacy and equity in the availability and access, quality, and efficiency of health services throughout the country. The means for achieving them are set forth more specifically and in greater detail than in any previous legislation in related areas. A framework of cooperation among federal, state, and local agencies for planning, for development, and for regulation is established. The Act represents an increasing recognition that realization of these goals cannot be left for resolution by the “unseen hand” of the marketplace, and that social intervention is necessary if we are t o achieve some reasonable measure of health Protection within constraints imposed by finite resources and a contracting economy.
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The legislation was based on the perspective of 30 years of federal experience with support of programs for health services planning and development at state and local levels. The Hill-Burton Act of 1946 was the earliest such legislation. While it succeeded in expanding the capacity of short-term general hospitals in many communities, it progressed little toward another of its objectives, the establishment of systems based on a functional articulation of facilities and services within hospital service areas. The 1964 Hill-Harris Amendments responded to the demand for more effective control of sharply increasing costs of medical care following World War 11. Although the legislation substantially increased the number of areawide planning agencies in metropolitan communities, its impact on the direction of institutional development was limited. The creation of the Regional Medical Programs ( W s ) in 1965 mobilized substantial national interest in cooperative arrangements among health service organizations, research institutions, and medical schools to facilitate access to advances in diagnosis and therapy. Nevertheless, despite the effort and expenditure of over 500 million dollars, it did not affect the underlying problem of rationalizing services on a regional basis. The Comprehensive Health Planning and Public Health Service Amendments of 1966, were designed to support planning for improvement and maintenance of adequate and efficient community health services. Review of proposals for federal project support has led to greater adaptation to local needs. Funding of training programs did result in substantial expansion of planning manpower resources. There is evidence that some institutional expansion was not pursued because the more critical review by areawide planning agencies shed doubt on the need for increasing capacity. Nevertheless, impact of the program on health services structure and costs fell far short of expectations. APPROACH TO THE 1974 LEGISLATION The 1974 legislation expresses national policy and establishes a framework for its implementation. Nevertheless, in common with any legislation, the structure of the program which it authorized cannot be visualized in precise terms until regulations, guidelines, standards, and other instruments for translating policy into operation have been forged. Some of the following comments, therefore, can only be tentative. Formulation of the legislation and the resulting program involve insights into a wide range of disciplines, methods, and experience, from public administration and the structure of regulation to evaluation and the state of the art of devising social indicators. Experience of modem social planners, and of the utopians before them, permits us to speculate on the desiderata for planning in a more perfect world. Among these are: Broadly accepted community values and goals; Adequate resources for formulation of plans and evaluation of progress, and organizational structure for decision on strategies for arriving at goals; Incentives and inducements, and in simpler terms, the leverage necessary to assure that agencies and organizations in the community move toward implementation of Plans; An organization capable of providing leadership in helping various interested groups
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and agencies in identifying with goals and plans, and in coordinating effort toward their realization. In the discussion that follows, comment is first made concerning certain aspects of the legislation which appear to address, reasonably effectively, problems encountered in earlier health planning efforts. This is followed by discussion of issues and questions that appear not to have been adequately resolved. THE NATIONAL HEALTH PLANNING AND RESOURCES DEVELOPMENT ACT The legislation reflects the experience and disappointments with past efforts in planning. The following comments are directed at aspects of the legislation which appear to make good use of this experience.
Health Service Areas The Act mandates coverage of the entire country by an estimated 160-240 Health Systems Agencies (HSAs), which are accountable to state planning agencies, and in turn to the U.S. Department of Health, Education, and Welfare (HEW). In this way provision is made for complete coverage of the country by planning agencies, within a framework of closely articulated programs and effort at the three levels of government. The new legislation recognizes that many local governmental jurisdictions are not adequate in size to support a critical mass of manpower and facilities for accomplishing its purposes. The minimum population for Health Service Areas, established in Section 151 1 , assures a reasonable base of support for local planning units. Furthermore, the Act requires that Health Service Areas consist of geographically functional units with resources to provide all essential health services. The provision for maintaining the integrity of metropolitan communities is also significant. The components of these communities are local governmental jurisdictions with anachronistic boundaries. They are nevertheless interdependent for human services as well as trade and commerce. Those striving for optimum availability, quality, and efficiency of utilization of resources would not argue with the basic logic of pooling resources of contiguous communities which make up a functional service area, “the community of solution” of the Commission of Community Health Services (1).
Financial Support Federal support authorized in the Act is considerably more generous than that which has been available under the Comprehensive Health Planning (CHP) legislation. Under the latter program, in 1974 some 154 per capita in federal funding was authorized, a ratio of approximately $1 for planning to $2,800 in expenditures for health services. In contrast, the new legislation authorizes basic nonmatching support of 50d per capita (to a maximum of $3,750,000), and up to an additional 256 in matchlng funds. Provision of support on a nonmatching basis is a significant improvement over the Comprehensive Health Planning Program in which matching requirements have contributed to “Onparticipation by some 20 per cent of local jurisdictions.
444 / Rosenfeld and Rosenfeld State planning agencies may receive federal support of up to 75 per cent of operating costs, with authorization of $25 million, $30 million, and $35 million for fiscal years 1975, 1976, and 1977, respectively. Assuming health services expenditures of $1 10 billion in 1975, appropriations at the levels of support authorized would result in a ratio of 62 to 87d per capita and a ratio of $1 for planning to between $598 and 840 for health services expenditures. The more ample federal funding will reduce the need for financial assistance from other sources, and the investment of staff time required to mobilize it. The Act also imposes restrictions on the amount of support that may be accepted by HSAs from individuals and private organizations with interests in health services (Section 1512 b). This should circumvent possibilities for conflict of interest such as those experienced by “B” agencies under the Comprehensive Health Planning Program. In a study of three states by the General Accounting Office, it was found that some donors had stopped or reduced contributions, or threatened t o do so, in an effort to influence positions taken by the planning agency (2).
Staff Of critical importance to the effectiveness of planning is the adequacy and quality of staff. Staff should bring to the process understanding and competence in accordance with the state of the art in various fields. Among these are: methods of assessing community need and resources; current concepts and methods of intervention; and understanding of experience in this country and abroad regarding the effectiveness of various strategies of intervention. Knowledge of data sources and competence in selecting, accumulating, and analyzing data are basic. Inadequacies in staff resources imposed serious limitations in earlier programs. For example, under Comprehensive Health Planning, a combination of factors, including the narrow population base of many “B” agencies, the restricted financial support, and the paucity of professionally qualified personnel, combined to produce marginal to inadequate staff among these agencies. The planning process was therefore impeded. Because of inadequacy of the data base, there has often been insufficient exploration of social, economic, organizational, geographic, and other implications of proposals and projects. The important functions of review and comment and of review and approval of CHP agencies have often been less effective than they should be. There has been, in general, a lack of criteria for assessing proposals, and often little in the way of critical analysis by staff as a basis for committee and board action. In order to meet matching requirements, and to marshall support in an effort to maintain minimally adequate staff, agency directors often spent inordinate amounts of time in fund raising. One agency director claimed that he had spent 50-60 per cent of his time in such activities, an enterprise which represented less than effective use of his planning talents (2). Prospects for more effective performance under the new legislation appear bright. With larger local planning agency staffs, a degree of specialization should be possible. There is now a much more adequate pool of trained and experienced people in the field of health planning than was the case at the time of the institution of the CHP program.
Technical Assistance Under the best of circumstances, any form of social planning-and health planning is no exception-is a difficult and complex process. Even with reasonable levels of staffing
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and support, few local agencies would be in a position t o provide the full range of specialty skills that may be required. Under previous planning legislation, provision for technical assistance has been very modest. HEW provided very limited guidance and technical assistance both because funds available for the purpose were limited and because of the diffidence among federal agencies about interfering with health planning, which was considered to be a state and local responsibility. Until 1974, federal monitoring and evaluation of program progress was not systematic, consistent, or rigorous. Federal staffing at the national and the regional level was inadequate. Relatively recently, in October 1973, performance standards for state and areawide planning agencies were published, and monitoring and evaluation efforts by HEW were subsequently increased significantly. In contrast to the long delay in the development of national guidelines and standards by the CHP program, the 1974 Act establishes dates for completion of preparatory instructions and documents. Section 1501 requires that, within an 18-month period, the Secretary of HEW will issue guidelines on national health planning policy, including standards and national health planning goals. Section 1533 details the forms of technical assistance to be provided to HSAs and state agencies for development of plans, methodologies, and standards. A National Health Planning Information Center is to be established. Time limits are laid down for developing a uniform system for computing costs for the purposes of rate setting and reporting. Funds are authorized for Centers for Health Planning, in part to provide for such technical assistance as HSAs and state agencies may from time to time require. Other sections of the Act delineate procedures for various review and planning functions at local, state, and federal levels. In drafting the legislation, Congress seemed to react t o the obduracy of the system to change and attempted, through prescription, to ensure continuing effort and accountability. The effects of this degree of specificity are already apparent. The nation is mobilizing for a major effort. Recommendations concerning the delineation of health services areas have been submitted to the Secretary of HEW by the various states, and work is going forward in designation of HSAs and State Planning and Development Agencies, and on formulation of the myriad procedures, standards, and criteria which will be required. While experience suggests that the C H P legislation did not go far enough in specifying the nature and schedule of development of methods and organizational procedures, one wonders whether the current legislation may go too far in prescribing the numbers and features of responsibilities and functions to be carried out by officials, staffs, and deliberative bodies at all levels of government. Will it be possible to mobilize the level of effort and investment of time by those serving on the boards, committees, and advisory bodies called for in the Act? Eventually, some scaling down and more decentralization of responsibility may be necessary in order to bring time and effort requirements within feasible limits. Leverage
The Act provides for adoption of a variety of constraints on capital development and costs, and checks on planning which may influence cost commitment. Among these are requirements that states review and approve investment in physical plant and that State Health Coordinating Councils review and approve or modify Health Systems Plans and h n u a l Implementation Plans of HSAs. Availability of development funds for grants by
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HSAs for support of projects which are consistent with plans and priorities provides further motivation for programs to conform to areawide plans. In another effort to control expenditures, section 1526 of the Act provides for grants to six states to demonstrate rate regulation. Congress is keenly aware of the need for inducements and constraints to encourage conformity with plans and control of costs. This is obviously a sensitive area and one on which opinion is sharply divided. Some observations from the debate around these issues would seem appropriate. There seems to be wide agreement with the distribution of responsibility for administration of Certification of Need provisions outlined in the Act. Regulatory power is well placed in the state agency rather than in the HSA. The former is a politically accountable agency, whereas it is likely that most HSAs will be voluntary in nature and not appropriate for exercise of regulatory authority. The state agency would be in a position to weigh HSAs’ advice against other testimony and data, and would exercise discretion rather than serve as a rubber stamp. Havighurst (3) observes that the statute does not allow much selectivity about the kinds of investments which are to be regulated. Nursing homes, Health Maintenance Organizations (HMOs), and ambulatory care facilities are subject to regulation even though it is in the public interest to encourage rather than inhibit their development opportunities. He suggests that the limiting effects of such regulation may be mitigated in the Secretary’s guidelines by appropriate adjustment of dollar thresholds established for various categories of facilities. HMOs might be exempted from regulation up t o a level of capital investment of $250,000, while a low threshold might be established for other facilities such as hospitals. Havighurst and others question the rationale of regulating HMOs and other ambulatory facilities without according similar attention to solo practitioners. Such extension may not be politically popular or even feasible at this point, because of the power wielded by the medical profession. Nevertheless, experience not only in the United States, but in England and other countries throughout the world, would indicate that there may be n o other way to bring the geographic and specialty distribution of physicians into some reasonable balance. Particularly speculative are prospects for rate regulation as provided in Section 1526 of the Act. Although this authority is vested in the state agency responsible for health planning and development, telling arguments have been put forward for allocating it to another agency. Danger of diverting the energies from planning and the need for special skills distinct from those required for planning are among the considerations. Another danger implicit in combining these two functions is that the planning agency which has approved construction of the facility may be reluctant t o apply sanctions which might place the organization at financial risk. Although the record of rate regulation generally has not been impressive, it does offer a means of exercising some restraint. It would appear that the value of the experience in the demonstration states may be enhanced by generous support of research into the behavior of elements of cost among regulated as compared to those among unregulated institutions. SOME ISSUES AND QUESTIONS Some important issues that did not seem to receive the attention they deserve in the formulation of the legislation include the following:
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Accountability The Act provides alternatives for the sponsorship of Health Systems Agencies. They may be nonprofit corporations which meet the criteria established, public regional planning bodies, or single units of general local government, if the area of the jurisdiction is identical to the health service area. This choice constitutes an improvement over the wording of the House Bill (HR 16204), which provided that health systems agencies be only voluntary private corporations. There is a substantial body of opinion which would question, in principle, the desirability of vesting responsibility of public funds in anything other than a public agency, ultimately accountable to the public at large (4, 5). Problems of conflict of interest and of interference or weakening of the authority of the executive in public policy formulation are some of the dangers seen in delegation of significant public responsibility to private agencies; The local public agency which would seem t o be best suited to the task would be the health department. These organizations are concerned with the health of the entire community. Monitoring of health status and need has been an important part of their responsibility from the time they were first constituted during the 19th century. They are staffed by personnel with training and experience in health administration and in preventive health services. The communicable diseases, which in the first part of the century constituted the principal cause of premature death and disability, have largely been brought under control, in no small part, because of the programs of the health departments. The chronic illnesses which replaced communicable disease as the principal causes of morbidity and mortality were not amenable to the types of preventive measures that had been developed early in the public health movement. However, epidemiologic investigation in recent years has resulted in significant progress in understanding the etiology of many of these illnesses and has indicated directions for intervention. Many of these categories of illness, such as hypertension, arteriosclerosis and coronary heart disease, lung cancer, and cirrhosis of the liver, as well as disability due to accident, are amenable to significant control by means of modifications in public policy, community education, and strategies to motivate behavioral change (6). Since World War 11, the health services in this country have been characterized by accelerating increases in investments in medical and institutional care. While few would debate the importance of these forms of health services, growing numbers of people in the United States, Canada, and England are becoming aware of the fact that we may not be realizing maximum returns for investment in community health services by following this direction. The socially prudent position would be to make maximum use of other modalities, preventive and social as well as medical, to assure the health and welfare of the greatest numbers of people for the lowest expenditure. Partly because health departments have been so closely identified with the communicable diseases, their potentiality for substantial contribution to health services in general has been overlooked. As a result, in the past ten years state and local health departments have been circumvented in the allocation of responsibility for developing Programs under the provisions of major pieces of legislation. The Hill-Harris Amendments to the Hill-Burton Act, Medicare and Medicaid, and the Rh4P and CHP legislation have turned to other organizations, principally voluntary agencies, for' their development and administration. Because of the poor support and increasingly limited responsibilities of local health departments, many are falling into disrepair and are having difficulty in
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recruiting the caliber of staff which they should have. The result has been not only the attrition of health departments, but serious fragmentation of the national health strategy. Local health departments should be encouraged to apply for designation as Health Systems Agencies. In order to meet the criteria for Health Service Areas under the provisions of the Act, it would be necessary, in most circumstances, that local health department jurisdictions combine, possibly in the form of public health authorities. In addition to geographic aggregation, boards of health would have to be reconstituted to meet the standards established for governing bodies of Health Systems Agencies. Such a change would be salutary, since many boards of health are not truly representative of the communities they serve because of the dominance of the medical profession in their makeup.
Organizational Adequacy The aspirations of Congress in adopting the legislation are expressed in the listing of priorities in Section 1502 of the Act. They include support for: 0 Primary care services for medically underserved populations; Multi-institutional systems for coordination or consolidation of health services, and for sharing of support services; Medical group practices, health maintenance organizations, and other health care organizations; Training and increased utilization of physician assistants, especially nurse practitioners; Activities for the improvement of quality of care; Health service institutions capable of providing different levels of care on a geographically integrated basis; 0 Activities for disease prevention, including studies of nutrition and environmental factors affecting health and the provision of preventive care services; Uniform cost accounting, simplified reimbursement and utilization reporting systems, and improved management procedures for health service institutions; 0 Effective methods for educating the general public about proper personal (including preventive) health care and optimal use of available health services. It is questionable whether the provisions of the Act for establishment of organizational structures to realize these goals are adequate. It would appear that the framers of the legislation either underestimate the magnitude of the administrative task entailed, or mean to stage the development, intending to extend the provisions of the Act and the scope of support as the plans evolve. In either case, comment seems appropriate. The line between planning and organization is often difficult to draw. At best, the two constitute parts of a continuum. Sustained and effective performance of functions of any complexity requires the closest relationship and interchange between the planning and organizational responsibilities. Planning constitutes one aspect of the profile of concerns of those responsible for formulating and administering programs in both industrial and voluntary organizations. In the development of regional organization of health services for which P.L. 93-641 establishes a framework, incorporation of the dual responsibilities of planning and administration within a single agency would not appear to offer the optimal solution,
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although the two functions must, of course, be closely coordinated. Two arguments may be advanced to support this contention. First is the magnitude of tasks assigned to Health Systems Agencies. Considering the state of the art and the complexity of the health services system, the work of planning alone is rigorous. It entails the systematic accumulation of information on needs, resources, utilization, and costs. It requires the formulation of alternative strategies in meeting needs, and the exploration of social, economic, and geographic implications. It presumes exploration of opinion and attitude. Criteria must be devised to provide a framework for interpretation of observations and their translation into program strategies. These efforts must be followed by steps toward implementation and, ultimately, evaluation of progress in the light of enunciated goals. m e delivery of service is the role of providers, the Act gives HSAs the means and responsibility for motivating conformity with plans promulgated by the agencies. HSAs will administer development funds and review and make recommendations concerning federal grant projects and capital investment proposals. HSAs will also be responsible for assessment of effectiveness and continuing need for existing progress and services. It is estimated that about 100,000 project proposals falling within the purview of HSAs are submitted annually (7). This d l mean an average of approximately 500 proposals for review by each HSA per year, a substantial task in itself. This range of planning activities is impressive, and it would appear doubtful that the HSAs would have the additional capacity to carry a parallel range of responsibilities for adapting services to new configurations as delineated in the planning process. The danger of overloading planning agencies and of diverting their energies from their primary task is real. In Puerto Rico, it was found that regulatory functions assigned to the Planning Board seriously impeded planning and policy making (8). Recently, regulatory responsibilities were transferred to another agency. A second reason for questioning the appropriateness of HSAs as the administrators of regional organization is their identification with regulatory functions. It seems unlikely that an agency responsible for the several normative functions assigned to it would be accepted by provider agencies to give leadership in organization of services, in coordination of functions, and in development and administration of joint services. The organization of services in each Health Service Area entails the forging of a system of relationships among medical care and public health facilities and services within a “medical trading area” surrounding a medical center. Its goals are similar to those set forth in the Act: improving and maintaining availability, quality, and efficiency of services throughout the geographic area by means of cooperative effort. Once established, the organization may be adapted to assuring continuity of medical service to the individual through various levels of specialization; to provision of clinical and administrative consultation; to organization of education and training in the several health disciplines; and to the development of central services which may lend themselves to more economical delivery in this manner. Among these are the design and operation of uniform statistical and accounting systems and regional data processing on central computers, laboratory services, pathology services for hospitals too small to maintain their own, blood and tissue banking, and central purchasing. Further, such organizations could sponsor programs of research and development including industrial engineering, a capability of increasing value for achieving maximum efficiency in utilization of manpower and other resources. These are not merely theoretical Possibilities. They have been demonstrated in a number of programs.
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The concept of regional organization has been the subject of wide discussion among bodies concerned with the health services, but it has been applied much more extensively abroad than in the United States. It is basic to the structure of service in Sweden and other Scandinavian countries. It was incorporated in the design of the British National Health Service in 1948. It was provided for in legislation in Saskatchewan, Canada in 1945, and more recently in the legislation of Quebec. It has a long history in other countries and has been an integral part of the structure of health services in the Soviet Union (9). Although aspects of regional organization have been adopted by a number of institutions and programs in the United States, most of these have been limited and ad hoc in nature. Full exploitation of its possibilities has been restricted to certain federal programs and to a number of programs supported principally by foundations as demonstration projects. Two of the latter, the Bingham Associates Fund program, administered by Tufts Medical Center, and the Rochester Regional Hospital Council, have survived. The reasons why the United States has provided barren soil for the growth of regional organization cannot be explored within the scope of this discussion. The new legislation, however, provides a framework and a new opportunity to explore more fully the potential of this form of organization. Within the context of social and political values in the United States, strong motivation is needed to secure the degree of cooperation among institutions and agencies in a service area essential to achieve goals such as those set forth in the Act. Without very strong incentives, powerful centripetal forces within institutions seem to seek self-contained balance in the form of institutional autonomy. Consideration should be given by states and by the federal government to devising such incentives. Reimbursement for services represents one such possibility. With payments from numerous public sources now making up over 50 per cent of hospital revenue, and a higher proportion of nursing home revenue, this should be feasible. Consideration should also be given to providing federal support for demonstrations of regional organizations as administrative counterparts of planning agencies. This could stimulate development and focus attention of providers, payment agencies, and the public at large on the potential values of this form of organization. National Health Policy
In recognition of the need for more effective articulation and coordination of national health policy, the House Bill (HR 16204) required the Secretary of HEW to establish a National Council for Health Policy. The report of the Committee on Interstate and Foreign Commerce (1 0) observes: The establishment of a new Council to recommend a national health policy responds to one of the most frequent criticisms of our federal health effort heard before the Committee. This criticism asserts that the lack of a coherent statement of national health policy with clearly defined goals and priorities leads to fragmentation and inappropriate use of scarce resources at all levels of our country’s health system.
Unfortunately, even this limited effort to address a major weakness in the structure of national health services did not survive the process of legislative review. The final Act includes a greatly narrowed provision for a National Council on Health Planning and Development. Terms of reference for the body are restricted to the scope of the Act.
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Removed is any mandate for greater breadth of responsibility, including that of “. . . recommending to the Department of Health, Education, and Welfare, the President and the Congress a national health policy . . . based on priorities which are specified in the legislation,” and that the Council should “. . . review legislative proposals and other federal initiatives which are not directly concerned with the provision of medical care but which the Council can show will have an impact upon people’s health . . .” (10). Nevertheless, provision to coordinate national health policy and focus it on priority goals would be of vital importance to the success of health programs. Even cursory examination of the vast array of health legislation reveals many points at which programs not only do not complement each other but actually duplicate prior efforts or work at cross purposes. RMP and CHP programs were designed t o achieve similar purposes, with little coordination. Areas of jurisdiction of Community Mental Health Centers were created with virtually no reference to the structures of health services or to medical trading areas. A vast and confusing array of grants and other forms of subvention are administered by an equally confusing panoply of agencies, many of which are subjected to frequent reorganization. The result is an interesting, colorful kaleidoscope, responsive to turns in the wheel of political fortune, but with little discernible relationship to changing health needs. Generous support is given in some areas, while incalculable waste results from oversight of others of equal or greater importance. One example may be sufficient to illustrate the point. While shortage of physicians in primary care has reached critical proportions, there is at present no systematic effort to review training needs in the various specialties, and to attempt to adjust investment in training to future requirements. Neither the medical profession nor the federal government has as yet addressed this issue, although it has been evident in trends for many years. A provision of the National Health Manpower Bill of 1974, which was not enacted, would have initiated regulation in this area. Strong leadership and an authoritative voice are required for formulating policy proposals and directing national effort in the health field. Though the proposal for a National Council for Health Policy acknowledged the problem, it is doubtful whether such a body, buried in the vast complex of the Department of HEW, would be adequate to meet the requirements. Many persons who testified before the House Committee recommended that such a Council be placed outside the Department of HEW to give it more visibility and impact. For many years, the possibility of organizing a Council of Health Advisors equivalent to the Council of Economic Advisors, in the Executive Office of the President, has been proposed. Thoughtful people, both in and out of Congress, have long held the conviction expressed by Edwards (ll), until recently Assistant Secretary for Health, that “. . . a Department of Health must be established in the Executive Branch . . .” in place of the current arrangement in which health is represented by one of more than a half dozen Assistant Secretaries of Health, Education, and Welfare. The prospect of national health insurance only lends urgency to this need. COMMENT While carefully formulated public policy with clearly defined goals and programs appropriately designed and adequately supported to achieve these gods are essential to success, national commitment to these goals and efforts is equally important. That this
452 / Rosenfeld and Rosenfeld country is capable of unswerving dedication and of extending prodigious effort in time of crisis was amply demonstrated in World War 11. It was a cause which the government and the American people understood and accepted. Although the health crisis does not pose the same immediate threat to national security, the long-term contingencies are real and ominous. With the new legislation, the federal government has launched on a constructive course designed to integrate efforts relating to important areas of health planning and development. Difficulties in implementing these policies can be predicted. The best strategy would be to hold tenaciously to principles embodied in the legislation, while making such adaptations as appear to be justified on the basis of careful evaluation. Public apathy and even’ cynicism concerning public programs is widespread. Often, failure of programs may be attributed to the fact that issues are not sufficiently clear to the people to get their support for major reforms. Competition for public attention amid the clamor of problems in an unstable world, urgent issues of recession, inflation, and unemployment, as well as the strident voice of commercial enterprise, all add to difficulties in focusing public attention on matters such as health planning. Nevertheless, the public has demonstrated a high level of interest and concern for the health services. Health leaders should make a strong effort to broaden the public’s perception of issues, contingencies, and programs in health planning in order to establish a constituency for a program which represents a substantial increase in public responsibility. The high value placed on pluralism in this country may be traced to the very origins of the Republic and the aura of distrust of central authority which culminated in the Declaration of Independence. Although acceptance of the principle persists, fundamental changes have occurred in the country’s social and economic structure. Small enterprises have been replaced by mammoth corporations. Small institutions have grown, merged, and aggregated into powerful associations. Society has become lumpy, and power is now disseminated to a greatly reduced number of loci. Our image of pluralism as representing broad dissemination of power has coagulated into a system of “oligo-pluralism.” Edwards (1 1) observes, “What passes for leadership from the medical profession, from the academic community, from the hospital field and from the pharmaceutical and other health industries is, I think, likely to be seen as self serving protection of turf,” and he adds, “. . . I am convinced that the pluralistic health care system as we know it in the United States is moving steadily toward its own destruction, not by design, but by default.” Still, Americans are ambivalent toward planning, even though society no longer conforms to their ideal of freedom and opportunity. National choices must be made clear. If, within the hierarchy of public values, past concepts of the place of pluralism and private enterprise in the health services are to continue to dominate, many of the goals of the national health program and of the National Health Planning and Resources Development Act will probably remain beyond reach. These are alternatives and contingencies which should be understood by the public if we are to arrive at informed national choices rather than decision by default. Acknowledgment-The authors wish to acknowledge the helpful comments and suggestions on an earlier draft of this paper by Dr. Harry T. Phillips, professor of health administration at the University of North Carolina School of Public Health.
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REFERENCES 1. National Commission on Community Health Services. Health Is a Community Affair. Harvard University Press, Cambridge, 1967. 2. Comptroller General. Comprehensive Health Planning as Gzrried Out by State and Areawide Agencies in Three. States, pp. 24,79.U.S. Accounting Office, Washington, D. C., April 19, 1974. 3. Havighurst, C. Implications and Operational Problems of the Legislation. Paper presented a t the National Conference on Health Planning, University of North Carolina, Chapel Hill, North Carolina, April 25, 1975. 4. Terris, M. The Future of Health Departments: Medical Care. New York Medical College, New York, April 1975. 5. Reizin, M. S., President of Association of State and Territorial Health Officials. Statement before Subcommittee on Public Health and Environment of the Committee on Public Health and Environment, May 8, 1975. In National Health Policy and Health Resources Development. Serial 93-91.U.S. Government Printing Office, Washington, D. C., 1974. 6. Terris, M. The Future of Health Departments: Prevention. New York Medical College, New York, April 1975. 7. Farag, E. Remarks in panel discussion, National Conference on Health Planning, University of North Carolina, Chapel Hill, North Carolina, April 26,1975. 8. American Society of Planning Officials. Planning for Puerto Rico. The Society, Chicago, December 1968. 9. Rosenfeld, L. S. Regional Organization of Health Services in the United States: An International Perspective. Department of Health Administration, University of North Carolina School of Public Health, Chapel Hill, North Carolina, 1974. 10. House of Representatives. Report of the Committee on Interstate and Foreign Commerce. Report No. 93-138L,pp. 39, 47. U.S. Government Printing Office, Washington, D. C., September 26,
1974. 11. Edwards, C. C. The federal involvement in health: A personal view of current problems and future needs.New Engl. J. Med. 292(10): 559-562,1975.
Manuscript submitted for publication, May 27,1975 Direct reprint requests to: Dr. Leonard S. Rosenfeld Department of Health Administration School of Public Health University of North Carolina Chapel Hill,North Carolina 27514
The signing of the National Health Planning and Resources Development Act of 1974 (P.L. 93-641) on January 4, 1975 represents broad consensus among Congressional leaders and executive agencies on the need for more effective direction of the national health effort. It was the culmination of extended review of experience with earlier national programs of health planning. The scope of consensus is an expression of the pervading sense of urgency surrounding issues of health care. The magnitude of support given to principles of planning and regulation of health services is significant in light of the traditional skepticism, and even hostility, which has, in the past, been accorded t o such governmental intervention in health affairs. The goals of the legislation are clearly expressed: the assurance of adequacy and equity in the availability and access, quality, and efficiency of health services throughout the country. The means for achieving them are set forth more specifically and in greater detail than in any previous legislation in related areas. A framework of cooperation among federal, state, and local agencies for planning, for development, and for regulation is established. The Act represents an increasing recognition that realization of these goals cannot be left for resolution by the “unseen hand” of the marketplace, and that social intervention is necessary if we are t o achieve some reasonable measure of health Protection within constraints imposed by finite resources and a contracting economy.
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The legislation was based on the perspective of 30 years of federal experience with support of programs for health services planning and development at state and local levels. The Hill-Burton Act of 1946 was the earliest such legislation. While it succeeded in expanding the capacity of short-term general hospitals in many communities, it progressed little toward another of its objectives, the establishment of systems based on a functional articulation of facilities and services within hospital service areas. The 1964 Hill-Harris Amendments responded to the demand for more effective control of sharply increasing costs of medical care following World War 11. Although the legislation substantially increased the number of areawide planning agencies in metropolitan communities, its impact on the direction of institutional development was limited. The creation of the Regional Medical Programs ( W s ) in 1965 mobilized substantial national interest in cooperative arrangements among health service organizations, research institutions, and medical schools to facilitate access to advances in diagnosis and therapy. Nevertheless, despite the effort and expenditure of over 500 million dollars, it did not affect the underlying problem of rationalizing services on a regional basis. The Comprehensive Health Planning and Public Health Service Amendments of 1966, were designed to support planning for improvement and maintenance of adequate and efficient community health services. Review of proposals for federal project support has led to greater adaptation to local needs. Funding of training programs did result in substantial expansion of planning manpower resources. There is evidence that some institutional expansion was not pursued because the more critical review by areawide planning agencies shed doubt on the need for increasing capacity. Nevertheless, impact of the program on health services structure and costs fell far short of expectations. APPROACH TO THE 1974 LEGISLATION The 1974 legislation expresses national policy and establishes a framework for its implementation. Nevertheless, in common with any legislation, the structure of the program which it authorized cannot be visualized in precise terms until regulations, guidelines, standards, and other instruments for translating policy into operation have been forged. Some of the following comments, therefore, can only be tentative. Formulation of the legislation and the resulting program involve insights into a wide range of disciplines, methods, and experience, from public administration and the structure of regulation to evaluation and the state of the art of devising social indicators. Experience of modem social planners, and of the utopians before them, permits us to speculate on the desiderata for planning in a more perfect world. Among these are: Broadly accepted community values and goals; Adequate resources for formulation of plans and evaluation of progress, and organizational structure for decision on strategies for arriving at goals; Incentives and inducements, and in simpler terms, the leverage necessary to assure that agencies and organizations in the community move toward implementation of Plans; An organization capable of providing leadership in helping various interested groups
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and agencies in identifying with goals and plans, and in coordinating effort toward their realization. In the discussion that follows, comment is first made concerning certain aspects of the legislation which appear to address, reasonably effectively, problems encountered in earlier health planning efforts. This is followed by discussion of issues and questions that appear not to have been adequately resolved. THE NATIONAL HEALTH PLANNING AND RESOURCES DEVELOPMENT ACT The legislation reflects the experience and disappointments with past efforts in planning. The following comments are directed at aspects of the legislation which appear to make good use of this experience.
Health Service Areas The Act mandates coverage of the entire country by an estimated 160-240 Health Systems Agencies (HSAs), which are accountable to state planning agencies, and in turn to the U.S. Department of Health, Education, and Welfare (HEW). In this way provision is made for complete coverage of the country by planning agencies, within a framework of closely articulated programs and effort at the three levels of government. The new legislation recognizes that many local governmental jurisdictions are not adequate in size to support a critical mass of manpower and facilities for accomplishing its purposes. The minimum population for Health Service Areas, established in Section 151 1 , assures a reasonable base of support for local planning units. Furthermore, the Act requires that Health Service Areas consist of geographically functional units with resources to provide all essential health services. The provision for maintaining the integrity of metropolitan communities is also significant. The components of these communities are local governmental jurisdictions with anachronistic boundaries. They are nevertheless interdependent for human services as well as trade and commerce. Those striving for optimum availability, quality, and efficiency of utilization of resources would not argue with the basic logic of pooling resources of contiguous communities which make up a functional service area, “the community of solution” of the Commission of Community Health Services (1).
Financial Support Federal support authorized in the Act is considerably more generous than that which has been available under the Comprehensive Health Planning (CHP) legislation. Under the latter program, in 1974 some 154 per capita in federal funding was authorized, a ratio of approximately $1 for planning to $2,800 in expenditures for health services. In contrast, the new legislation authorizes basic nonmatching support of 50d per capita (to a maximum of $3,750,000), and up to an additional 256 in matchlng funds. Provision of support on a nonmatching basis is a significant improvement over the Comprehensive Health Planning Program in which matching requirements have contributed to “Onparticipation by some 20 per cent of local jurisdictions.
444 / Rosenfeld and Rosenfeld State planning agencies may receive federal support of up to 75 per cent of operating costs, with authorization of $25 million, $30 million, and $35 million for fiscal years 1975, 1976, and 1977, respectively. Assuming health services expenditures of $1 10 billion in 1975, appropriations at the levels of support authorized would result in a ratio of 62 to 87d per capita and a ratio of $1 for planning to between $598 and 840 for health services expenditures. The more ample federal funding will reduce the need for financial assistance from other sources, and the investment of staff time required to mobilize it. The Act also imposes restrictions on the amount of support that may be accepted by HSAs from individuals and private organizations with interests in health services (Section 1512 b). This should circumvent possibilities for conflict of interest such as those experienced by “B” agencies under the Comprehensive Health Planning Program. In a study of three states by the General Accounting Office, it was found that some donors had stopped or reduced contributions, or threatened t o do so, in an effort to influence positions taken by the planning agency (2).
Staff Of critical importance to the effectiveness of planning is the adequacy and quality of staff. Staff should bring to the process understanding and competence in accordance with the state of the art in various fields. Among these are: methods of assessing community need and resources; current concepts and methods of intervention; and understanding of experience in this country and abroad regarding the effectiveness of various strategies of intervention. Knowledge of data sources and competence in selecting, accumulating, and analyzing data are basic. Inadequacies in staff resources imposed serious limitations in earlier programs. For example, under Comprehensive Health Planning, a combination of factors, including the narrow population base of many “B” agencies, the restricted financial support, and the paucity of professionally qualified personnel, combined to produce marginal to inadequate staff among these agencies. The planning process was therefore impeded. Because of inadequacy of the data base, there has often been insufficient exploration of social, economic, organizational, geographic, and other implications of proposals and projects. The important functions of review and comment and of review and approval of CHP agencies have often been less effective than they should be. There has been, in general, a lack of criteria for assessing proposals, and often little in the way of critical analysis by staff as a basis for committee and board action. In order to meet matching requirements, and to marshall support in an effort to maintain minimally adequate staff, agency directors often spent inordinate amounts of time in fund raising. One agency director claimed that he had spent 50-60 per cent of his time in such activities, an enterprise which represented less than effective use of his planning talents (2). Prospects for more effective performance under the new legislation appear bright. With larger local planning agency staffs, a degree of specialization should be possible. There is now a much more adequate pool of trained and experienced people in the field of health planning than was the case at the time of the institution of the CHP program.
Technical Assistance Under the best of circumstances, any form of social planning-and health planning is no exception-is a difficult and complex process. Even with reasonable levels of staffing
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and support, few local agencies would be in a position t o provide the full range of specialty skills that may be required. Under previous planning legislation, provision for technical assistance has been very modest. HEW provided very limited guidance and technical assistance both because funds available for the purpose were limited and because of the diffidence among federal agencies about interfering with health planning, which was considered to be a state and local responsibility. Until 1974, federal monitoring and evaluation of program progress was not systematic, consistent, or rigorous. Federal staffing at the national and the regional level was inadequate. Relatively recently, in October 1973, performance standards for state and areawide planning agencies were published, and monitoring and evaluation efforts by HEW were subsequently increased significantly. In contrast to the long delay in the development of national guidelines and standards by the CHP program, the 1974 Act establishes dates for completion of preparatory instructions and documents. Section 1501 requires that, within an 18-month period, the Secretary of HEW will issue guidelines on national health planning policy, including standards and national health planning goals. Section 1533 details the forms of technical assistance to be provided to HSAs and state agencies for development of plans, methodologies, and standards. A National Health Planning Information Center is to be established. Time limits are laid down for developing a uniform system for computing costs for the purposes of rate setting and reporting. Funds are authorized for Centers for Health Planning, in part to provide for such technical assistance as HSAs and state agencies may from time to time require. Other sections of the Act delineate procedures for various review and planning functions at local, state, and federal levels. In drafting the legislation, Congress seemed to react t o the obduracy of the system to change and attempted, through prescription, to ensure continuing effort and accountability. The effects of this degree of specificity are already apparent. The nation is mobilizing for a major effort. Recommendations concerning the delineation of health services areas have been submitted to the Secretary of HEW by the various states, and work is going forward in designation of HSAs and State Planning and Development Agencies, and on formulation of the myriad procedures, standards, and criteria which will be required. While experience suggests that the C H P legislation did not go far enough in specifying the nature and schedule of development of methods and organizational procedures, one wonders whether the current legislation may go too far in prescribing the numbers and features of responsibilities and functions to be carried out by officials, staffs, and deliberative bodies at all levels of government. Will it be possible to mobilize the level of effort and investment of time by those serving on the boards, committees, and advisory bodies called for in the Act? Eventually, some scaling down and more decentralization of responsibility may be necessary in order to bring time and effort requirements within feasible limits. Leverage
The Act provides for adoption of a variety of constraints on capital development and costs, and checks on planning which may influence cost commitment. Among these are requirements that states review and approve investment in physical plant and that State Health Coordinating Councils review and approve or modify Health Systems Plans and h n u a l Implementation Plans of HSAs. Availability of development funds for grants by
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HSAs for support of projects which are consistent with plans and priorities provides further motivation for programs to conform to areawide plans. In another effort to control expenditures, section 1526 of the Act provides for grants to six states to demonstrate rate regulation. Congress is keenly aware of the need for inducements and constraints to encourage conformity with plans and control of costs. This is obviously a sensitive area and one on which opinion is sharply divided. Some observations from the debate around these issues would seem appropriate. There seems to be wide agreement with the distribution of responsibility for administration of Certification of Need provisions outlined in the Act. Regulatory power is well placed in the state agency rather than in the HSA. The former is a politically accountable agency, whereas it is likely that most HSAs will be voluntary in nature and not appropriate for exercise of regulatory authority. The state agency would be in a position to weigh HSAs’ advice against other testimony and data, and would exercise discretion rather than serve as a rubber stamp. Havighurst (3) observes that the statute does not allow much selectivity about the kinds of investments which are to be regulated. Nursing homes, Health Maintenance Organizations (HMOs), and ambulatory care facilities are subject to regulation even though it is in the public interest to encourage rather than inhibit their development opportunities. He suggests that the limiting effects of such regulation may be mitigated in the Secretary’s guidelines by appropriate adjustment of dollar thresholds established for various categories of facilities. HMOs might be exempted from regulation up t o a level of capital investment of $250,000, while a low threshold might be established for other facilities such as hospitals. Havighurst and others question the rationale of regulating HMOs and other ambulatory facilities without according similar attention to solo practitioners. Such extension may not be politically popular or even feasible at this point, because of the power wielded by the medical profession. Nevertheless, experience not only in the United States, but in England and other countries throughout the world, would indicate that there may be n o other way to bring the geographic and specialty distribution of physicians into some reasonable balance. Particularly speculative are prospects for rate regulation as provided in Section 1526 of the Act. Although this authority is vested in the state agency responsible for health planning and development, telling arguments have been put forward for allocating it to another agency. Danger of diverting the energies from planning and the need for special skills distinct from those required for planning are among the considerations. Another danger implicit in combining these two functions is that the planning agency which has approved construction of the facility may be reluctant t o apply sanctions which might place the organization at financial risk. Although the record of rate regulation generally has not been impressive, it does offer a means of exercising some restraint. It would appear that the value of the experience in the demonstration states may be enhanced by generous support of research into the behavior of elements of cost among regulated as compared to those among unregulated institutions. SOME ISSUES AND QUESTIONS Some important issues that did not seem to receive the attention they deserve in the formulation of the legislation include the following:
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Accountability The Act provides alternatives for the sponsorship of Health Systems Agencies. They may be nonprofit corporations which meet the criteria established, public regional planning bodies, or single units of general local government, if the area of the jurisdiction is identical to the health service area. This choice constitutes an improvement over the wording of the House Bill (HR 16204), which provided that health systems agencies be only voluntary private corporations. There is a substantial body of opinion which would question, in principle, the desirability of vesting responsibility of public funds in anything other than a public agency, ultimately accountable to the public at large (4, 5). Problems of conflict of interest and of interference or weakening of the authority of the executive in public policy formulation are some of the dangers seen in delegation of significant public responsibility to private agencies; The local public agency which would seem t o be best suited to the task would be the health department. These organizations are concerned with the health of the entire community. Monitoring of health status and need has been an important part of their responsibility from the time they were first constituted during the 19th century. They are staffed by personnel with training and experience in health administration and in preventive health services. The communicable diseases, which in the first part of the century constituted the principal cause of premature death and disability, have largely been brought under control, in no small part, because of the programs of the health departments. The chronic illnesses which replaced communicable disease as the principal causes of morbidity and mortality were not amenable to the types of preventive measures that had been developed early in the public health movement. However, epidemiologic investigation in recent years has resulted in significant progress in understanding the etiology of many of these illnesses and has indicated directions for intervention. Many of these categories of illness, such as hypertension, arteriosclerosis and coronary heart disease, lung cancer, and cirrhosis of the liver, as well as disability due to accident, are amenable to significant control by means of modifications in public policy, community education, and strategies to motivate behavioral change (6). Since World War 11, the health services in this country have been characterized by accelerating increases in investments in medical and institutional care. While few would debate the importance of these forms of health services, growing numbers of people in the United States, Canada, and England are becoming aware of the fact that we may not be realizing maximum returns for investment in community health services by following this direction. The socially prudent position would be to make maximum use of other modalities, preventive and social as well as medical, to assure the health and welfare of the greatest numbers of people for the lowest expenditure. Partly because health departments have been so closely identified with the communicable diseases, their potentiality for substantial contribution to health services in general has been overlooked. As a result, in the past ten years state and local health departments have been circumvented in the allocation of responsibility for developing Programs under the provisions of major pieces of legislation. The Hill-Harris Amendments to the Hill-Burton Act, Medicare and Medicaid, and the Rh4P and CHP legislation have turned to other organizations, principally voluntary agencies, for' their development and administration. Because of the poor support and increasingly limited responsibilities of local health departments, many are falling into disrepair and are having difficulty in
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recruiting the caliber of staff which they should have. The result has been not only the attrition of health departments, but serious fragmentation of the national health strategy. Local health departments should be encouraged to apply for designation as Health Systems Agencies. In order to meet the criteria for Health Service Areas under the provisions of the Act, it would be necessary, in most circumstances, that local health department jurisdictions combine, possibly in the form of public health authorities. In addition to geographic aggregation, boards of health would have to be reconstituted to meet the standards established for governing bodies of Health Systems Agencies. Such a change would be salutary, since many boards of health are not truly representative of the communities they serve because of the dominance of the medical profession in their makeup.
Organizational Adequacy The aspirations of Congress in adopting the legislation are expressed in the listing of priorities in Section 1502 of the Act. They include support for: 0 Primary care services for medically underserved populations; Multi-institutional systems for coordination or consolidation of health services, and for sharing of support services; Medical group practices, health maintenance organizations, and other health care organizations; Training and increased utilization of physician assistants, especially nurse practitioners; Activities for the improvement of quality of care; Health service institutions capable of providing different levels of care on a geographically integrated basis; 0 Activities for disease prevention, including studies of nutrition and environmental factors affecting health and the provision of preventive care services; Uniform cost accounting, simplified reimbursement and utilization reporting systems, and improved management procedures for health service institutions; 0 Effective methods for educating the general public about proper personal (including preventive) health care and optimal use of available health services. It is questionable whether the provisions of the Act for establishment of organizational structures to realize these goals are adequate. It would appear that the framers of the legislation either underestimate the magnitude of the administrative task entailed, or mean to stage the development, intending to extend the provisions of the Act and the scope of support as the plans evolve. In either case, comment seems appropriate. The line between planning and organization is often difficult to draw. At best, the two constitute parts of a continuum. Sustained and effective performance of functions of any complexity requires the closest relationship and interchange between the planning and organizational responsibilities. Planning constitutes one aspect of the profile of concerns of those responsible for formulating and administering programs in both industrial and voluntary organizations. In the development of regional organization of health services for which P.L. 93-641 establishes a framework, incorporation of the dual responsibilities of planning and administration within a single agency would not appear to offer the optimal solution,
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although the two functions must, of course, be closely coordinated. Two arguments may be advanced to support this contention. First is the magnitude of tasks assigned to Health Systems Agencies. Considering the state of the art and the complexity of the health services system, the work of planning alone is rigorous. It entails the systematic accumulation of information on needs, resources, utilization, and costs. It requires the formulation of alternative strategies in meeting needs, and the exploration of social, economic, and geographic implications. It presumes exploration of opinion and attitude. Criteria must be devised to provide a framework for interpretation of observations and their translation into program strategies. These efforts must be followed by steps toward implementation and, ultimately, evaluation of progress in the light of enunciated goals. m e delivery of service is the role of providers, the Act gives HSAs the means and responsibility for motivating conformity with plans promulgated by the agencies. HSAs will administer development funds and review and make recommendations concerning federal grant projects and capital investment proposals. HSAs will also be responsible for assessment of effectiveness and continuing need for existing progress and services. It is estimated that about 100,000 project proposals falling within the purview of HSAs are submitted annually (7). This d l mean an average of approximately 500 proposals for review by each HSA per year, a substantial task in itself. This range of planning activities is impressive, and it would appear doubtful that the HSAs would have the additional capacity to carry a parallel range of responsibilities for adapting services to new configurations as delineated in the planning process. The danger of overloading planning agencies and of diverting their energies from their primary task is real. In Puerto Rico, it was found that regulatory functions assigned to the Planning Board seriously impeded planning and policy making (8). Recently, regulatory responsibilities were transferred to another agency. A second reason for questioning the appropriateness of HSAs as the administrators of regional organization is their identification with regulatory functions. It seems unlikely that an agency responsible for the several normative functions assigned to it would be accepted by provider agencies to give leadership in organization of services, in coordination of functions, and in development and administration of joint services. The organization of services in each Health Service Area entails the forging of a system of relationships among medical care and public health facilities and services within a “medical trading area” surrounding a medical center. Its goals are similar to those set forth in the Act: improving and maintaining availability, quality, and efficiency of services throughout the geographic area by means of cooperative effort. Once established, the organization may be adapted to assuring continuity of medical service to the individual through various levels of specialization; to provision of clinical and administrative consultation; to organization of education and training in the several health disciplines; and to the development of central services which may lend themselves to more economical delivery in this manner. Among these are the design and operation of uniform statistical and accounting systems and regional data processing on central computers, laboratory services, pathology services for hospitals too small to maintain their own, blood and tissue banking, and central purchasing. Further, such organizations could sponsor programs of research and development including industrial engineering, a capability of increasing value for achieving maximum efficiency in utilization of manpower and other resources. These are not merely theoretical Possibilities. They have been demonstrated in a number of programs.
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The concept of regional organization has been the subject of wide discussion among bodies concerned with the health services, but it has been applied much more extensively abroad than in the United States. It is basic to the structure of service in Sweden and other Scandinavian countries. It was incorporated in the design of the British National Health Service in 1948. It was provided for in legislation in Saskatchewan, Canada in 1945, and more recently in the legislation of Quebec. It has a long history in other countries and has been an integral part of the structure of health services in the Soviet Union (9). Although aspects of regional organization have been adopted by a number of institutions and programs in the United States, most of these have been limited and ad hoc in nature. Full exploitation of its possibilities has been restricted to certain federal programs and to a number of programs supported principally by foundations as demonstration projects. Two of the latter, the Bingham Associates Fund program, administered by Tufts Medical Center, and the Rochester Regional Hospital Council, have survived. The reasons why the United States has provided barren soil for the growth of regional organization cannot be explored within the scope of this discussion. The new legislation, however, provides a framework and a new opportunity to explore more fully the potential of this form of organization. Within the context of social and political values in the United States, strong motivation is needed to secure the degree of cooperation among institutions and agencies in a service area essential to achieve goals such as those set forth in the Act. Without very strong incentives, powerful centripetal forces within institutions seem to seek self-contained balance in the form of institutional autonomy. Consideration should be given by states and by the federal government to devising such incentives. Reimbursement for services represents one such possibility. With payments from numerous public sources now making up over 50 per cent of hospital revenue, and a higher proportion of nursing home revenue, this should be feasible. Consideration should also be given to providing federal support for demonstrations of regional organizations as administrative counterparts of planning agencies. This could stimulate development and focus attention of providers, payment agencies, and the public at large on the potential values of this form of organization. National Health Policy
In recognition of the need for more effective articulation and coordination of national health policy, the House Bill (HR 16204) required the Secretary of HEW to establish a National Council for Health Policy. The report of the Committee on Interstate and Foreign Commerce (1 0) observes: The establishment of a new Council to recommend a national health policy responds to one of the most frequent criticisms of our federal health effort heard before the Committee. This criticism asserts that the lack of a coherent statement of national health policy with clearly defined goals and priorities leads to fragmentation and inappropriate use of scarce resources at all levels of our country’s health system.
Unfortunately, even this limited effort to address a major weakness in the structure of national health services did not survive the process of legislative review. The final Act includes a greatly narrowed provision for a National Council on Health Planning and Development. Terms of reference for the body are restricted to the scope of the Act.
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Removed is any mandate for greater breadth of responsibility, including that of “. . . recommending to the Department of Health, Education, and Welfare, the President and the Congress a national health policy . . . based on priorities which are specified in the legislation,” and that the Council should “. . . review legislative proposals and other federal initiatives which are not directly concerned with the provision of medical care but which the Council can show will have an impact upon people’s health . . .” (10). Nevertheless, provision to coordinate national health policy and focus it on priority goals would be of vital importance to the success of health programs. Even cursory examination of the vast array of health legislation reveals many points at which programs not only do not complement each other but actually duplicate prior efforts or work at cross purposes. RMP and CHP programs were designed t o achieve similar purposes, with little coordination. Areas of jurisdiction of Community Mental Health Centers were created with virtually no reference to the structures of health services or to medical trading areas. A vast and confusing array of grants and other forms of subvention are administered by an equally confusing panoply of agencies, many of which are subjected to frequent reorganization. The result is an interesting, colorful kaleidoscope, responsive to turns in the wheel of political fortune, but with little discernible relationship to changing health needs. Generous support is given in some areas, while incalculable waste results from oversight of others of equal or greater importance. One example may be sufficient to illustrate the point. While shortage of physicians in primary care has reached critical proportions, there is at present no systematic effort to review training needs in the various specialties, and to attempt to adjust investment in training to future requirements. Neither the medical profession nor the federal government has as yet addressed this issue, although it has been evident in trends for many years. A provision of the National Health Manpower Bill of 1974, which was not enacted, would have initiated regulation in this area. Strong leadership and an authoritative voice are required for formulating policy proposals and directing national effort in the health field. Though the proposal for a National Council for Health Policy acknowledged the problem, it is doubtful whether such a body, buried in the vast complex of the Department of HEW, would be adequate to meet the requirements. Many persons who testified before the House Committee recommended that such a Council be placed outside the Department of HEW to give it more visibility and impact. For many years, the possibility of organizing a Council of Health Advisors equivalent to the Council of Economic Advisors, in the Executive Office of the President, has been proposed. Thoughtful people, both in and out of Congress, have long held the conviction expressed by Edwards (ll), until recently Assistant Secretary for Health, that “. . . a Department of Health must be established in the Executive Branch . . .” in place of the current arrangement in which health is represented by one of more than a half dozen Assistant Secretaries of Health, Education, and Welfare. The prospect of national health insurance only lends urgency to this need. COMMENT While carefully formulated public policy with clearly defined goals and programs appropriately designed and adequately supported to achieve these gods are essential to success, national commitment to these goals and efforts is equally important. That this
452 / Rosenfeld and Rosenfeld country is capable of unswerving dedication and of extending prodigious effort in time of crisis was amply demonstrated in World War 11. It was a cause which the government and the American people understood and accepted. Although the health crisis does not pose the same immediate threat to national security, the long-term contingencies are real and ominous. With the new legislation, the federal government has launched on a constructive course designed to integrate efforts relating to important areas of health planning and development. Difficulties in implementing these policies can be predicted. The best strategy would be to hold tenaciously to principles embodied in the legislation, while making such adaptations as appear to be justified on the basis of careful evaluation. Public apathy and even’ cynicism concerning public programs is widespread. Often, failure of programs may be attributed to the fact that issues are not sufficiently clear to the people to get their support for major reforms. Competition for public attention amid the clamor of problems in an unstable world, urgent issues of recession, inflation, and unemployment, as well as the strident voice of commercial enterprise, all add to difficulties in focusing public attention on matters such as health planning. Nevertheless, the public has demonstrated a high level of interest and concern for the health services. Health leaders should make a strong effort to broaden the public’s perception of issues, contingencies, and programs in health planning in order to establish a constituency for a program which represents a substantial increase in public responsibility. The high value placed on pluralism in this country may be traced to the very origins of the Republic and the aura of distrust of central authority which culminated in the Declaration of Independence. Although acceptance of the principle persists, fundamental changes have occurred in the country’s social and economic structure. Small enterprises have been replaced by mammoth corporations. Small institutions have grown, merged, and aggregated into powerful associations. Society has become lumpy, and power is now disseminated to a greatly reduced number of loci. Our image of pluralism as representing broad dissemination of power has coagulated into a system of “oligo-pluralism.” Edwards (1 1) observes, “What passes for leadership from the medical profession, from the academic community, from the hospital field and from the pharmaceutical and other health industries is, I think, likely to be seen as self serving protection of turf,” and he adds, “. . . I am convinced that the pluralistic health care system as we know it in the United States is moving steadily toward its own destruction, not by design, but by default.” Still, Americans are ambivalent toward planning, even though society no longer conforms to their ideal of freedom and opportunity. National choices must be made clear. If, within the hierarchy of public values, past concepts of the place of pluralism and private enterprise in the health services are to continue to dominate, many of the goals of the national health program and of the National Health Planning and Resources Development Act will probably remain beyond reach. These are alternatives and contingencies which should be understood by the public if we are to arrive at informed national choices rather than decision by default. Acknowledgment-The authors wish to acknowledge the helpful comments and suggestions on an earlier draft of this paper by Dr. Harry T. Phillips, professor of health administration at the University of North Carolina School of Public Health.
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REFERENCES 1. National Commission on Community Health Services. Health Is a Community Affair. Harvard University Press, Cambridge, 1967. 2. Comptroller General. Comprehensive Health Planning as Gzrried Out by State and Areawide Agencies in Three. States, pp. 24,79.U.S. Accounting Office, Washington, D. C., April 19, 1974. 3. Havighurst, C. Implications and Operational Problems of the Legislation. Paper presented a t the National Conference on Health Planning, University of North Carolina, Chapel Hill, North Carolina, April 25, 1975. 4. Terris, M. The Future of Health Departments: Medical Care. New York Medical College, New York, April 1975. 5. Reizin, M. S., President of Association of State and Territorial Health Officials. Statement before Subcommittee on Public Health and Environment of the Committee on Public Health and Environment, May 8, 1975. In National Health Policy and Health Resources Development. Serial 93-91.U.S. Government Printing Office, Washington, D. C., 1974. 6. Terris, M. The Future of Health Departments: Prevention. New York Medical College, New York, April 1975. 7. Farag, E. Remarks in panel discussion, National Conference on Health Planning, University of North Carolina, Chapel Hill, North Carolina, April 26,1975. 8. American Society of Planning Officials. Planning for Puerto Rico. The Society, Chicago, December 1968. 9. Rosenfeld, L. S. Regional Organization of Health Services in the United States: An International Perspective. Department of Health Administration, University of North Carolina School of Public Health, Chapel Hill, North Carolina, 1974. 10. House of Representatives. Report of the Committee on Interstate and Foreign Commerce. Report No. 93-138L,pp. 39, 47. U.S. Government Printing Office, Washington, D. C., September 26,
1974. 11. Edwards, C. C. The federal involvement in health: A personal view of current problems and future needs.New Engl. J. Med. 292(10): 559-562,1975.
Manuscript submitted for publication, May 27,1975 Direct reprint requests to: Dr. Leonard S. Rosenfeld Department of Health Administration School of Public Health University of North Carolina Chapel Hill,North Carolina 27514
