Commentary The Hidden Price Tag: Participation Costs and Health Planning TERRY L. COOPER, PHD

Abstract: The citizen participation program of the Los Angeles County Health Systems Agency represents one of the most ambitious efforts at implementing the public involvement provisions of PL 93-641. The first year of this program is discussed and analyzed through a participation costs theoretical framework. Specific costs which are inherent in the organi-

zational design and introduced by the implementation procedures adopted are identified and discussed. Levels of participation after one year of operation are examined and found consistent with the high cost of participation in this program. (Am. J. Public Health 69:368-374, 1979.)

Increased involvement of citizens in the planning of health services is a major goal of the Health Planning and Resources Development Act of 1974 (PL 93-641). The United States is divided into 211 Health Service Areas, each with its own Health Systems Agency (HSA) and a governing board of 10 to 30 members, the majority of whom must be consumers. This provision represents the minimum level of citizen participation allowable under the Act. However, it is possible for individual HSAs to adopt structures and procedures which provide for much greater involvement of the citizenry in the planning and decision-making process. The Los Angeles County HSA has undertaken an ambitious effort to exceed these minimum requirements by establishing local advisory councils and two stages of elected representation. This paper first describes the process of establishing the organization to carry out such an undertaking during 1977. Following a description of the methods and strategies employed in Los Angeles County, a body of literature dealing with a "costs" approach to citizen participation will be discussed in order to illuminate the problems encountered by

programs for public involvement. The geographical scale, the demographic diversity, and the complexity of the design represented by this HSA's efforts provide a very rich and nationally significant case for this kind of analysis.

Address reprint requests to Terry L. Cooper, PhD, Assistant Professor, School of Public Administration, University of Southern California, Bruce Hall 407, Los Angeles, CA 90007. This paper, submitted to the Journal July 28, 1978, was revised and accepted for publication October 24, 1978.

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The Los Angeles County Health Systems Agency The Citizen Participation Plan Under PL 93-641, three kinds of organizations may qualify as a Health Systems Agency: independent, non-

profit, private corporations; public regional planning bodies; and units of local government. In Los Angeles County all three categories were represented. The competing organizations were the Los Angeles County Board of Supervisors, the Comprehensive Health Planning Agency of Los Angeles, and an ad hoc group known as the Steering Committee, which was composed of both health care providers and consumers. ' The Steering Committee was finally selected by the Secretary of the U.S. Department of Health, Education, and Welfare in 1976 as the group to organize the HSA. A 30member Interim Governing Body (IGB) was then constituted from 15 names submitted by this organization, with the remainder designated by the county supervisors. The first task to be addressed by the new IGB was the organizing of five Sub Area Councils (SACs). These councils were intended to AJPH April 1979, Vol. 69, No. 4

COMMENTARY

provide decentralized access to the HSA's decision-making process for the more than seven million widely dispersed citizens of Los Angeles County. Having boundaries coterminus with the five supervisorial districts of the county, each SAC area included approximately one-and-a-half million people. Each of the five SACs was to be governed by a 30-member body consisting of 16 consumers and 14 providers of health care. All 30 members of each council were to be elected by the people residing within the SAC area who had applied for membership and been certified residents. Once established, the five councils were each to elect three representatives to the permanent HSA Governing Body which would include 16 consumers and 14 providers. These elections were to be confirmed by the general membership in each sub area.2 It is quite clear from the Bylaws of the Health Systems Agency for Los Angeles County that, although the primary locus of citizen participation was in the Sub Area Councils, real decision-making authority was to lie with the HSA Governing Board. The members of each SAC were to elect representatives to that body and, thereby, indirectly influence its decisions. However, beyond that annual function they had only an advisory role, as required by PL 93-651. No binding decisions were to be devolved to that level. Nevertheless, the establishment of formal structures with the power to elect one-half of the membership of the county-wide decision-making body, and to provide officially legitimized advice, with at least limited staff support, does represent a potential for significantly increased involvement of citizens in the planning and allocation of health resources. The critical questions for consideration later in the study have to do with the extent to which citizens have perceived and experienced this potential. The Citizens Participate: Implementation of the Plan

Implementation of the three-tiered organizational plan for public involvement began in early 1977. Ten community education meetings were held from January through March of that year throughout the county.3 In these sessions, members of the HSA staff and the Interim Governing Body met with overflow crowds of 200 to 400 people in school auditoriums, museums, and community centers to provide information and accept membership applications.* Although they were scheduled for approximately two hours in length, most sessions ran longer. The agendas were full, beginning with introductions of staff and dignitaries and proceeding through detailed explanations of PL 93-641, and Los Angeles County HSA organizational structure, the bylaws, the electoral process, and a timeline for the six months following the orientation process. Printed materials were distributed and audio-visual displays were utilized in communicating this information. Typically, the floor was opened for comments and questions from the public at the end of the agenda after *Information for this section not otherwise documented was derived from participant observation at six of the ten community education meetings, including at least one session in each SAC area. AJPH

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an hour-and-a-half of presentations. Fifteen to 30 minutes were allotted for this purpose. Membership applications were accepted in the lobbies of the meeting sites before, during, and after these sessions, as well as at the main HSA headquarters in central Los Angeles during regular business hours. There was no provision for mail-in applications. Any citizen seeking membership either had to attend one of the orientation meetings, or travel personally to the offices of the downtown area of Los Angeles. The reasons given by the HSA staff for these rather restrictive procedures were: 1) their desire to screen out persons who were not sufficiently interested to make the extra effort required; and 2) the importance of being adequately informed before one applied for membership.** The elections to the governing boards of the Sub Area Councils took place on June 21, 1977. Instead of utilizing the regular county election machinery and procedures, an ad hoc system was established under the auspices of the League of Women Voters. Polling places were set up and operated by the League in each of the SAC areas. By election day, 23,495 (0.5 per cent) of Los Angeles County's five million residents and 0.3 percent of its eligible voters had become certified HSA members and were, therefore, eligible to vote. When the votes were finally tallied, 9,058 (39 percent of those who had been certified) had cast ballots.*** Their votes were distributed among 1,439 candidates competing for 150 positions on the five SAC governing bodies.6 Table I compares HSA voting registration and participation with that of recent elections in Los Angeles. The differences are striking. Three weeks after the election a series of legal challenges, initiated by the Los Angeles City Council over alleged balloting irregularities, embroiled the HSA in a struggle to defend the legitimacy of the election and, ultimately, the legality and soundness of its administrative processes. The litigation was settled August 23, but a full investigation of the agency by the United States General Accounting Office continued through December, 1977.6 7-16 The charges involved issues which were serious, but generally tangential, to this citizen participation study. However, Superior Court Judge Robert Weil, in his decision to sustain the election, providing that certain local elected officials were seated on SCA boards, did address two items which are directly relevant. He found that "election registration was unfairly restricted, that the public received inadequate notification of the election, and that instructions to voters-both before the election and on the ballot-wereincomplete." Judge Weil concluded that the HSA violated its own bylaws in its conduct of the election and that the election was not "'substantially rational or procedurally fair." He asserted that one needed "a college degree, a mi-

**Interview with Dr. Albert V. De Leon, Director of the Sub Area Councils, April 1, 1977 at HSA headquarters. See also reference #4. ***The League of Women Voters only staffed the polling sites; the overall management of the election was conducted by the Diamond International Corporation. See also reference #5. 369

COMMENTARY TABLE 1-A Comparison of Los Angeles County Voter Registration and Electoral Participation in Selected Recent Elections Registration Eligible

Adult TYPE

Presidential General Presidential Primary Gubernatorial General Special 1 Proposition HSA

% of Eligible Adult Pop.

Votes Cast

Participation % of %of Registered Eligible Adult Voters Population

Year

Pop.*

Registered Voters

1976

4,888,405

3,138,209

64

2,549,733

81

52

1976

4,888,405

2,787,431

57

4,985,851

71

41

1974

4,829,130

3,286,898

68

2,057,734

63

41

1973 1977

4,829,130 4,888,405

3,086,664 23,495

64 0.5

1,441,867 9,058

47 39

43 0.2

*Estimated adult population 18 years or older eligible to vote.

croscope, and a divining rod" to understand the election.17 By December 21, 1977, four months behind the original schedule, the HSA organizational structure had been established and was ready to address the tasks for which it was intended.'6 However, the outcome of this lengthy and complicated attempt at creating a democratic, highly participatory organization has produced very limited participation. From the hundreds of citizens who crowded into the orientation meetings and Interim Governing Body sessions during the first three months of 1977, attendance has fallen sharply. Special community education efforts have been initiated in an attempt to increase participation by the public beyond the handful of regular attenders.t18 Why has this occurred after large investments of staff time and money? The easiest answer is that the public is apathetic. Those who have been observers of major citizen participation programs since the "War on Poverty" of the 1960s may simply conclude that the Los Angeles County HSA is another piece of evidence for the futility of efforts to involve the public. However, one ought to wonder whether such facile explanations are adequate. Why would thousands of citizens attend orientation meetings and bother to fill out application forms, only to lose interest within months? Why do people lose interest in significant public policy problems anyway? The following section proposes a heuristic theoretical framework which may help to direct our attention toward more fruitful answers to such questions.

The Costs of Participation A body of literature has emerged over the last 20 years which focuses less on the concept of power (a dominant theme in one stream of thought about citizen particiption during the 1960s,19-25) and more on the calculus of costs and benefits employed by citizens to assess the extent to which a tThe agency came under fire in July 1978 from DHEW for not having demographically representative boards and for inadequate responses to the GAO's report. 370

particular participation opportunity is likely to be worth the required effort.tt Participation by citizens in the public policy process is too often assumed to be a cost-free process to which all citizens have access.29-30 In actual fact, participation requires an expenditure of time, effort, and money in order to attend hearings, become involved in planning workshops, respond to questionnaires, be interviewed, write letters to officials, secure information about the issues, and take part in advisory committees.3' As these necessary expenditures of resources increase for any particular public decision, an increasing number of citizens are excluded from participation. They are priced out of the public decision-making process either because they are unable to afford the time, effort, and money, or because such expenditures cannot be justified in terms of the benefits they perceive will accrue from the participation. If a participation opportunity is perceived to be tangential to a citizen's core interests, he or she will probably conclude that the travel time, parking fees, and psychic stress experienced in a tension-filled public hearing amount to a cost which is too great for the probable benefits. If the matter under consideration is of intense concern, and the anticipated benefits from a participation opportunity are great, but the time, money, and energy are simply not available (i.e., the poor, elderly, handicapped, etc.), there will also be no participation.31-32 The level of participation cost and its perception by the citizenry can be raised or lowered, and it can be transferred from groups that have few resources in time, effort, and money to those who have many. With forethought and analysis, a more equitable distribution of impediments to partici-

ttA cogent normative perspective, relating participation costs to the rights of citizenship has been developed in an unpublished paper, i.e., Warren R and Weschler L: Governing Urban Space, available through L. Weschler, Sacramento Public Affairs Center of the School of Public Administration, University of Southern California, Suite 800, Sacramento, CA. See also references #26-30.

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pation can be achieved through the design of citizen participation programs.32 This amounts to a "fine tuning" of the democratic process which will result in greater opportunities for participation by those with a small resource base. Without a systematic process for managing these costs it is reasonable to believe that administrators will continue to be concerned with production efficiency at the expense of citizen

involvement.28' 30

32

Although considerable attention has been devoted to the theoretical aspects of participation costs,26' 27 there is a paucity of substantive data on these costs. There are also few operational techniques and instruments for use by practitioners.32-34 However, it is possible to suggest how the "costs" approach to public participation would inform and give direction to such an analysis of public programs-in this instance the Los Angeles County Health Systems Agency. In the section which follows the categories of cost to participants will be outlined and discussed as an initial effort along these lines.

Assessing the Costs to Participants: The First Step The measuring of cost levels goes beyond the limits of this study. However, it is possible here to begin identifying what might be anticipated as costs by various categories, which could then be measured empirically through an instrument with intensity scales for each category. Using the Los Angeles County HSA as an example, participation cost concerns can be grouped into two major categories: those which are inherent in the formal organizational design, and those which are a result of the ways in which the design has been implemented.

Organizational Design Complexity: The Los Angeles HSA, in its very effort to function in a decentralized fashion, reaching down to five sub-areas of the county, presents the citizen with a threetiered organizational structure with elaborate rules and complicated formulae for representation. In order to function effectively within this kind of organization, a participant must, as an absolute minimum, expend considerable time and effort in working through a 13-page set of bylaws, written in language which requires sophistication and a substantial base of organizational knowledge to understand. Comprehension of the bylaws represents a cost to potential participants which varies in level and significance depending upon one's education, intelligence, and prior experience with formal organizations. Scale: The extensive geographic area and large population represented by each SAC seem likely to create significant costs for ongoing and active participation. Districts with more than a million people scattered over areas greater than many large cities present serious impediments for potential participants. Even though the meetings are rotated around the sub-areas, anyone attempting to maintain regular attendance would be faced frequently with travel distances of 10 to 30 miles and driving times by private automobile of 20 to AJPH April 1979, Vol. 69, No. 4

45 minutes. Those who must rely upon public transportation would, for all practical purposes, be excluded, since such service is poor in the Los Angeles region generally, and nonexistent in some of the outlying areas of the county. Also related to scale, is the psychic cost of participating in meetings with unknown persons in areas which are unfamiliar territory. The anonymous impersonal environment which is inherent in constituency gatherings of this scale is likely to be experienced as a psychic cost ranging from mildly dissatisfying for some, to extremely intimidating for others. Implementation Beyond those costs which were built into the design of this HSA, lie those which were added to the price tag of participation by virtue of the ways in which the design was

implemented. * Information: Information concerning the purposes of the HSA, the role of the citizens, and the times and places of the orientation meetings was extremely limited. A brief newspaper article appeared in The Los Angeles Times approximately one year prior to the implementation of the Sub Area Council structure. ' When the orientation meetings were initiated in January 1977 very little additional information had been disseminated to the general public, although organizations directly involved in the health field tended to receive more attention. Only after the series of meetings was well under way did spot announcements begin to appear on the radio-at the usual odd hours reserved for public service announcements-and small advertisements, approximately seven inches by three inches in size, were placed in the local newspaper. The informational content of these announcements and newspaper pieces was not only so scant that it was impossible to determine the importance of either the HSA, or participation in the orientation sessions, but, in at least one instance, there were also serious inaccuracies. Another participation cost related to information was the frustration created by unrealistic expectations. Persons who did receive the brochures prepared by the HSA staff were seriously misled regarding their role in the decisionmaking process. The first paragraph of one of the brochures tells the reader that PL 93-641 "makes it mandatory for citizens like yourself to have the opportunity for intense participation in planning the health needs of your community" (emphasis added).35 Exaggerated claims of this kind tended to generate expectations that all participants, rather than only a few, would be directly involved in making decisions. Citizens who attended the initial SAC meetings soon discovered this was untrue; they were only electors of a SAC board and advisors to the decision-makers. Furthermore, they found themselves in crowded meetings with 300-500 other people, thus making it extremely difficult to obtain time even to voice an opinion, let alone really participate in discussion. Coping with this kind of frustration creates psychic stress that represents a significant participation cost. *Illustrative material in the sections which follow was derived from participant observation at six of the ten community education meetings, unless otherwise documented. 371

COMMENTARY

Meeting Sites: Most of the orientation meetings were held in community facilities such as schools, community centers, and museums. Very few of these sites were adequately equipped for parking the cars of several hundred persons. This required the expenditure of time and effort in locating a parking place, followed by a walk of several blocks to the site, and might well have been a special deterrent to women traveling alone, elderly persons, and the handicapped; in addition, some meetings were held in the evening when fear of crime is the greatest among those who feel particularly vulnerable. For those who persisted, once inside the door another set of stress-producing costs was encountered. In several of the meetings there was inadequate seating. Participants found it necessary to stand in doorways and crowd into the lobby areas in order to hear what was being presented inside. The acoustics in such rooms were very poor, and in one case there were columns that seriously obstructed the viewing of the speakers and audio-visual materials. Meeting Format and Agenda: Although citizens tended to arrive at the meetings assuming there would be a substantial amount of participation, they found themselves sitting passively through an hour-and-a-half of lengthy introductions of officials and dignitaries, speeches of HSA staff members, explanations of printed materials which had been distributed, and audio-visual presentations. The frustration of expectations for direct participation was quite evident in the number of people who lined up at the floor microphones to speak, even at the late hour reserved for audience response. At times there were between 10 and 20 people lined up at each of the two microphone positions with only 30 minutes of remaining meeting time. After a few minutes, some gave up with obvious expressions of irritation and disgust. Others waited for their turn, and instead of addressing the substantive issues, used the opportunity to ventilate their feelings about tokenism in the HSA's approach to citizen involvement. Meeting Communication Methods: Even if meeting formats had been designed to encourage participation, the communication of clear, concise, and comprehensible information would have been essential for effective participation. To the extent that the methods utilized for communicating failed to do so, citizens were confronted with another set of costs for participation. Although sign language translation was usually available for the deaf, the use of English in oral and written communication in Spanish-speaking communities presented prohibitive costs for many. Also, public address systems were seldom powerful enough for the rooms and numbers in attendance. Furthermore, an overhead projector was used for the display of tables, charts, and graphs; this would have been suitable for much smaller rooms with groups of no more than 100, but was totally inadequate for a gymnasium or auditorium with 300 or 400 persons present. Generally, the information was not discernible beyond the first few rows of seats. Membership Process: As has been indicated previously, only persons who were certified members of an SAC were allowed to vote. Those unable to attend the nearest meeting 372

had to travel to another one, usually miles away, or to the HSA headquarters which would represent a substantial trip for the majority of citizens in sprawling Los Angeles County. Elections: The problems discussed above affected participation in the SAC governing body elections, the only significant binding decision open to the general membership. The conditions faced by a potential voter amounted to what Judge Robert Weil described as unnecessarily rstrictive registration processes and inadequate dissemination of information to the public. Acquiring and evaluating information about the candidates alone was a formidable task. In addition, the special election procedure required extraordinary efforts to simply notify voters of the election date and polling places. Furthermore, driving times of up to one-half hour to the polls were involved. The result was a low voter turnout and considerable confusion among those who felt the unusual time and effort required to vote was worthwhile.

Participation One Year Later As of July 1978, general participation by citizens (those not elected to the governing bodies) was averaging between 25 and 30 for each of the five sub-area meetings.** Most of those attending appeared to be the regular participants in the five standing committees of each SAC. Larger numbers (up to 100 persons) have turned out for particular issues such as critical bylaws changes, or components of the health system plan which were under review during the Spring months of 1978. After one year of effort, then, approximately 150 citizens at large, plus an equal number of SAC board members, have been participating on an ongoing basis in the work of this agency. Three hundred citizens of Los Angeles County's total population have been regularly involved in helping to make decisions that will influence the allocation of the estimated $4.5 billion spent annually on health care in that area.6 The majority of these participants are what one SAC staff member described as "citizen participation veterans." They are either health providers, professionally involved in the HSA planning issues, or "the active consumers with time, education, and economic security." He concluded that, "affluence is the key factor to afford participation," and went on to suggest that those who participate regularly are people who understand the significance of planning. They represent labor unions, medical associations, consumer advocacy groups, the health industry, and government. They have the most resources to invest in the HSA and they stand to reap the greatest benefits. Although no systematic statistical data are available to either confirm or deny this characterization of SAC participants, it is consistent with the reports of other SAC coordinators.

**Information in this section was derived from interviews with all five of the SAC coordinators on July 11-12, 1978 and minutes of all five of the SAC governing boards for January-June, 1978. AJPH April 1979, Vol. 69, No. 4

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Conclusions Having looked at the Los Angeles County HSA's approach to citizen participation from a "costs" perspective, it seems appropriate to conclude with the following observations and recommendations: 1. When attempting to evaluate a citizen participation effort of this kind, the "numbers game" should not become the primary consideration, but numbers of participants should not be ignored entirely. Planning, as a citizen participation task, is fraught with problems under any circumstances, since it is extremely difficult for most people to perceive the significant benefits which are to be gained by participation. The payoff is too remote, both temporally and spatially. It should not be surprising that the "'veterans" are the citizens who have sufficient knowledge, experience, and interest to be able to perceive the personal benefits that are at stake in such a complex long-term process. If the development of a health systems plan for Los Angeles County is to adequately reflect the full array of interests in the county, it is important that enough citizens identifying with those interests be present to represent them. What is needed in this and similar cases is a much more systematic analysis of what those interests are before initiating a public participation program, and a monitoring of the extent to which they are represented in the decision-making process at regular intervals after it is underway; 2. Lowering or subsidizing participation costs needs to be taken far more seriously in programs of this kind. If regular participation is desired from those with few resources it will be necessary to create a more favorable cost-benefit ratio for them. This may be accomplished either by re-designing the structures and procedures employed, or by providing supplements of various types which involve the sharing of participation costs with the public, or some segment of it; 3. The unrealistic raising of the public's expectations in attempting to increase participation should be resisted. Citizens should not be led to believe that they will be doing more than providing advice, primarily through committee work and, to a more limited degree, through public hearings. This is not to suggest, however, that the importance of the public's role as advisors and electors of governing body members should be played down. The significance of the health planning process, and the need for an expression of citizen preferences, should be honestly, but vividly presented.32 The use of graphics, film, and other visual media can assist citizens in perceiving the benefits that are likely to accrue to them from participating. In summary, as citizen participation planners consider both the organizational design and the implementation procedures to achieve their goals the following questions should be addressed: * What are the participation costs inherent in the proposed program? * Who is likely to experience these costs as disproportionately burdensome? * Is it desirable and feasible to lower or subsidize these costs? AJPH April 1979, Vol. 69, No. 4

* If so, how much should they be lowered or subsidized? * What techniques should be employed to achieve these cost levels? * What are the benefits which may accrue to citizens as a result of their involvement? * Which of these benefits will be most difficult for the public to perceive? * How can this perception be enhanced? Unless systematic and forthright answers to these questions are prepared, frustration and disappointment for citizens and administrators alike will intensify cynicism on both sides, and an essential opportunity for further democratizing American public life will be lost. The "hidden price tag" will, in effect, disfranchise millions of people who cannot afford to participate in the shaping of public policy.

Post Script Following the preparation of this article, the Health Systems Agency of Los Angeles County failed to receive permanent designation by DHEW as a result of inadequate efforts to respond to the criticisms raised in the report of the General Accounting Office. The agency is being dismantled and the process has been initiated for designating a new organization as the HSA for this area.

REFERENCES 1. Nelson H: L.A. County Will Get Health Planning Unit. The Los Angeles Times November 17, 1975. 2. Bylaws of the Health Systems Agency for Los Angeles County, Inc. January 4, 1977. 3. Los Angeles County Health Systems Agency: Who's Planning for Your Health? 4. Staats Elmer: Report of the General Accounting Office February 24, 1978. 5. Nelson H: Independents Lose in Health Care Election, The Los Angeles Times June 29, 1977. 6. Kaye J: Billion Dollar Blackjack: The Politics of HSA, New West October 24, 1977. 7. Paddock RC: Election for Health Agency Challenged, The Los Angeles Times July 13, 1977. _ Illegal Action in Election for Health Agency Alleged, 8. _ The Los Angeles Times July 14, 1977. 9. __ and Keppl B: Health Agency Concern Told, The Los Angeles Times July 20, 1977. 10. Delay Sought in Certification of Winners in Health Unit Election, The Los Angeles Times July 22, 1977. 11. Irregularities in County's New Health Agency Charged. Board Declines to Act. The Los Angeles Times July 25, 1977. 12. __ Court Intervenes in Health Unit Dispute. The Los Angeles Times July 26, 1977. 13. Yaroslavsky Asks Federal Audit of Health Agency. The Los Angeles Times July 27, 1977. 14. __ Bitter Dispute Raging Over Health Agency. The Los Angeles Times August 15, 1977. 15. Luther C: Councilman to Get Seats on Health Agency. The Los Angeles Times August 24, 1977. 16. Interim Governing Body of the Los Angeles County Health Systems Agency: Report of the U.S. General Accounting Office: Response and Recommendations of the Health Systems Agency for Los Angeles County, Inc. Governing Body to the General

Accounting Office Report April, 1978. 373

COMMENTARY 17. Paddock RC: Judge May Nullify Health Unit Election. The Los Angeles Times August 9, 1977. 18. Coates M: Health Group Has Long Way to Go. Northwest Leader July 13, 1978. 19. Bachrach P and Baraty M: Power and Poverty, Theory and Practice. New York: Oxford University Press, 1970. 20. Fredrickson G, Ed: Neighborhood Control in the 1970s: Politics, Administration and Citizen Participation, New York: Chandler Publishing Company, 1973. 21. Alinsky, SD: Rules for Radicals. New York: Vintage Books, 1972. 22. Ruoss, M: Citizen Power and Social Change: The Challenge to the Churches, New York: Seabury Press, Inc., 1968. 23. Arnstein, SR: A Ladder of Citizen Participation. JAIP 35: 216224, 1969. 24. Stenberg, CM: Citizens and the Administrative State: From Participation to Power. PAR: 32: 190-198, 1972. 25. Parenti, Michael: Power and Pluralism: A View from the Bottom. J Pol 32: 5 01-5 30, 1970. 26. Buchanan JM and Tullock G: The Calculus of Consent: Logical Foundations of Constitutional Democracy, Ann Arbor: University of Michigan Press, 1962. 27. Downs A: An Economic Theory of Democracy, New York: Harper and Brothers, 1957.

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28. Ostrom V: The Intellectual Crisis of Public Administration. University of Alabama Press, 1974. 29. __ and Ostrom E: Public Choice: A Different Approach to the Study of Public Administration. PAR 31: 203-216, 1971. 30. Warren R and Weschler L: Consumption Costs and Production Costs in the Provision of Antipoverty Goods. Presented at the sixth annual meeting of the American Political Science Association, Los Angeles, CA, 1970. 31. Verba S: Democratic Participation in Gross B.M: Social Intelligence for America's Future. Boston: Allyn and Bacon, Inc., 1969: 12632. Fagence M: Citizen Participation in Planning. New York: Pergamon Press, 1977. 33. Rosener JB: Citizen Participation: Tying Strategy to Function in Marshall P, Ed: Citizen Participation for Community Development: A Reader on the Citizen Participation Process. Washington, D.C.: National Association of Housing and Redevelopment Officials, 1977. 34. Kelley Jr. S, Ayres R, Gowen WG: Registration and Voting. Am Pol Sci R 61: 359-377, 1967. 35. Los Angeles County Health Systems Agency: Public Participation in Community Health Planning.

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The hidden price tag: participation costs and health planning.

Commentary The Hidden Price Tag: Participation Costs and Health Planning TERRY L. COOPER, PHD Abstract: The citizen participation program of the Los...
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