COMPREHENSIVE HEALTH PLANNING IN THE UNITED
STATES: A REVIEW OF PUBLIC LAW 89-749

Thesis for the Degree of M. U. P.
MICHIGAN STATE UNIVERSITY
CAMILLA I. KARI
1976

COMP]

In rec«
in health conc
asElects rangin
has also exter
itself, where
tion of these
aCkn0W1<9d9ned I

Passage of Pu]

In or.
its ordained

health! and t

resources , ar

elements of h

iRed.

ABSTRACT

COMPREHENSIVE HEALTH PLANNING IN THE
UNITED STATES: A REVIEW
OF PUBLIC LAW 89-749

BY

Camilla J. Kari

In recent years, there has been a growing interest
in health concerns by Americans, an interest expressed in
aspects ranging from fad diets to air pollution. Interest
has also extended to the health care delivery system
itself, where the supply rarely matches the need. Recogni-
tion of these two important facets of health was
acknowledged by the federal government in 1966, with the
passage of Public Law 89-749, Comprehensive Health Planning.

In order to properly appreciate the difficulty of
its ordained tasks--to develop a holistic context for
health, and to coordinate public and private health
Iresources, are tasks which had never been undertaken before,
elements of health planning as a discipline must be exam-
ined. All of the parameters of the health care delivery
system are mentioned in order to highlight the magnitude of

P.L. 89-749'5 mission.

The law is
showing the gradua
led to its develop

Comprehensi
implementation is t
government offers v
conflict and cooper
Federal level, and
all three shifting
in which the health
the various means c

The total C
is evaluated in the
against the backdrc
comParative means t

indications of f uti

to them, can be 1m

Stand the nature 0

love
mment's I‘Ole ‘.

in the Coming Year:

I
u fii'.‘
: i)

715...?

“g‘."

r“

Camilla J. Kari

The law is then set in historical perspective,
showing the gradual awakening of social consciousness which
led to its development.

Comprehensive Health Planning's actual experience in
implementation is then examined. The concept of health in
government offers valuable lessons in terms of bureaucratic
conflict and c00peration. CHP was instituted from the
Federal level, and implemented at state and local levels,
all three shifting into novel interrelationships. The ways
in which the health planning process was implemented, and
the various means of enforcement used are then described.

The total Comprehensive Health Planning experience
is evaluated in the last chapter. This evaluation occurs
against the backdrop of successor, P.L. 93-641, offering a
comparative means to assess progress. In this manner, some
indications of future trends, and the government‘s reaction
to them, can be interpolated. Since health is a national
priority, and some feel it is a right, the need to under—
stand the nature of comprehensive health planning and the
government's role in it will assume increasing prOportions
in the coming years.

In conclusion, I would like to thank all of the
members of the faculty of the Department in Urban Planning,
but particularly Dr. Carl Goldschmidt, for his time and
effort with the draft, and Dr. Thomas Tenbrunsel of the
College of Urban Development, for his help in developing the

original topic.

COMP REH'

 

1“ partia

 

Sr

COMPREHENSIVE HEALTH PLANNING IN THE
UNITED STATES: A REVIEW

OF PUBLIC LAW 89-749

BY

Camilla J. Kari

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF URBAN PLANNING

School of Urban Planning and
Landscape Architecture

1976

LIST OF TABLES

Chapter

I. HEALTH CARE PI

The State of
The Problem

II. ELEMENTS AND r

Health Deter
Health Actix
Health Resor
Health Goal:

The Partici]
Health Plan]

III. THE HISTORICA;
LEGISLATION

Local Quara;
Federal Int

e TWentie
The First H

The Hill-Bu
The 89th CO

IV. p.11. 89-749:

The State A

Functions
mlnistr

TABLE OF CONTENTS

Page
LIST OF TABLES ,, iv
<211£1§>tner
I 0 HEALTH CARE PLANNING. O O O O O O O O O 1
The State of Health Care Today. . . . . . 2
The Problem Rationale. . . . . . . . . 5
III. ELEMENTS AND PARAMETERS OF HEALTH PLANNING . . 10
Health Determinants . . . . . . . . . 10
Health Activity Types. . . . . . . . . 14
Health Resources . . . . . . . . . . 17
Health Goals. . . . . . . . . . . . 17
The Participants . . . . . . . . . . 20
Health Planning in Context . . . . . . . 21
III ~ THE HISTORICAL BACKGROUND OF HEALTH
LE GI SLATI ON 0 O O O O O O O O O O O 2 7
Local Quarantine Activities. . . . . . . 28
Federal Intervention . . . . . . . . . 30
The Twentieth Century. . . . . . . . . 32
The First Health Grants . . . . . . . . 32
The Hill-Burton Act . . . . . . . . . 34
The 89th Congress . . . . . . . . . . 36
:t:Ԥr. P.L. 89-749: ADMINISTRATION OF THE LAW. . . . 43
The State Agency . . . . . . . . . . 46
Functions . . . . . . . . . . . . 48
Administrative Locations . . . . . . . 50

ii

Chapter

The Areawi

Selectic
Functior

The Advisc
V. THE HEALTH I

The Planni
Coordinati
Policy Vei
Resource 1

VI. POSTSCRIPT

Assessment
Recent De‘
Summary .

BIBLIOGRAPHY .

chapter

The Areawide Agency. .

Selections
Functions

The Advisory Council .

“]’- THE HEALTH PLANNING PROCESS. .
The Planning Process . . .
Coordination . . . . . .
Policy Versus Program Planning
Resource Allocation. . . .

\II.. POSTSCRIPT . . . . . . .
Assessment of P.L. 89-749. .

Recent Developments. . . .

Summary. . . . . . . .
BIBLIOGRAPHY. . . . . . . . .

iii

Page
56

57
59

64
70

71
73

78
84
85
89
96

100

Table
l. Determin.
2. Health A

3. Health R

LIST OF TABLES

Table Page
1. - Determinants of Health. . . . , . . . . . 12
2 - Health Activity Types . . . . . . . . . 15

3- Health Resources. . . . . . . . .

iv

"The h
upon which all
state depend. "

Good h
characteristic
it becomes a m
makes the diff
fulfillment an
0f health affe
cAlpiitrities, ' h i
relc'Itions, with
3There of life
granted; when

CHAPTER I

HEALTH CARE PLANNING

"The health of the peOple is really the foundation
upon which all their happiness and all their powers as a

state depend."--Disraeli.
Good health is probably the single most valued
c211aizcacteristic that an individual can possess. Ultimately
it becomes a matter of life and death. In the interim, it
makes the difference between comfort and suffering, self-
fulfillment and self-limitation. The presence or absence

of health affects not only a man's body but his mental

ca~Pacities, his disposition, his work, his recreation, his

relations with others. It insinuates itself into every
SIpl'lere of life. When present, good health is taken for

gIll‘anted; when not, almost everything else recedes in

3‘ mportance .
The importance of health on a national level is

re_adily acknowledged. Private citizens, philanthropic

3 rganizations and government combine to make health care a

II"l-llti-billion dollar industry. But for all of these huge

e3'tpenditures, health care is still not easily obtainable

for many Americans. A myriad of problems blocks the

 

 

consumer fro:
noting and a
for every pe

positively t

Alth
the realm of
to be mainly
general publ
nature, fede
services to
health indus
far ”Y from
Sweden, It'
is third in
being the le
is not in di
innovative t
eItcellenCe i
entry into t

The

based 0n thr

organiZation

c(91—1sumer from attaining the national goal of ". . . pro-

Ir,‘¢;-.«¢:;:i.ng and assuring the highest level of health attainable
fo 1:: every person, in an environment which contributes

positively to healthful individual and family living."1
The State of Health Care Today

Although most other social services have moved into

the realm of government intervention, health has continued

to be mainly a private enterprise system. Aside from
general public health measures, which are preventive in
nature, federally—sponsored medical research, and limited
Services to special population groups such as veterans, the
health industries have operated virtually undisturbed. This

Laissez-faire attitude is unique to health and certainly a

far cry from the nationalized systems of Great Britain and

SWeden. It may also be the reason that the United States

is third in terms of international health status instead of

being the leader. The quality of American medical practice

is not in dispute here. Medical education, research, and
innovative techniques are excellent in this country. But
ekcellence in theory does not benefit those who have no

entry into the health care system in the first place.
The inadequacies of current health services are
based on three major aspects--accessibility, availability,
and cost. Accessibility is composed of a variety of

1'E'Elfitors: geographical location, inadequate facilities,

organizational gaps in service and administrative

 

restrictions.
prime medical
but cannot ga
ties or unfan
The number 01
their caseloe
Avail
facilities or
as experienci
also encompas
of secondary-
in terms of j
mdical offir
coincide Wit}
These
care. Those.
eliIlible for
However! Sub:
tatiOn and C:
lives 0n the
Medi
find HOVanme
vices, beCau
hQCEsSary.
elastic and
contin“Um fr

Ce strictions. Inner city residents may have a panoply of
prime medical facilities available to them across the city,
but cannot gain access because of transportation difficul-
ties or unfamiliarity with administrative complexities.
The number of physicians in such localities is small and
their caseloads heavy.

Availability is based on the absence of medical
facilities or manpower. Rural areas are most often cited
as experiencing this problem. However, availability is
also encompassed in more subtle terms. There is a dearth
of secondary-care alternatives. Care may be available only
in terms of lengthy expensive bus rides. The schedules of
medical offices and outpatient departments do not usually
c=<32incide with the needs of the working poor.

These factors also affect the financing of medical
care. Those who cannot afford fee—for-service may be
e:l-Ji-gible for government subsidies, free or low cost care.

'However, subsidiary costs in terms of wages lost, transpor-
tation and child care may prove a heavy burden to one who
1 5— Ves on the edge of his income.

Medical care, through the combination of the private
and government systems, .13 available. However, these ser-
vices, because of extraneous factors, are not used until

I‘eCessary. Studies2 show that medical care is income—
e1astic and that preventive care, on the Opposite end of the

continuum from emergency treatment, is underutilized, even

by those who can afford it.

Part
public. The
tion of vari«
However, the
been disease
has been tre
phenomenon 0
hospital and
not health.
achieved wit

What
turbidity, a
State of phy
latter p05 it
f" the broa
°0n3idered a
being result
emmnment.
Called heah
happens tra]

HEM} In ‘

abOVe’ hedl'

non‘h‘ealth
The

.he current

Bffi .
Clem3y.

Part of the problem lies in proper education of the
public. The plethora of recent advertisements for preven-
ti on of various diseases is attempting to alleviate this.
However, the basic concept of medical care in the past has
been disease care, not health care. The basic philosophy
has been treatment, not prevention. Aside from the recent
phenomenon of health maintenance organizations, medical,
hospital and insurance institutions have emphasized illness,

not health. A satisfactory state of health cannot be
achieved without change in the basic health concept.

What is health? Some would say it is the absence of
Inorbidity, ailments, or defects. Others would call it a
State of physical or mental well-being. Certainly the
latter positive definition is preferable. It allows room
fot the broader concept of health, one that is not generally
considered at first association. A positive state of well-
be ing results from a benevolent physical and mental
eth‘Iironment. H. L. Mencken put it thus, "What is the thing

Qalled health? Simply a state in which the individual

happens transiently to be perfectly adapted to his environ-

It"el'lt." In order to achieve the national health goal cited
a‘bcéve, health systems must be correlated with those insalu-
bZt‘ities that exist in society which create a state of
IIICDIl-health.

These two thrusts, administrative reorganization of

the current health system to increase accessibility and

efficiency, and the interrelationship of health with

1E\C,1—1—--1'1ealth factors are mutually beneficial. An increasingly
healthful environment reduces the need for curative medicine

leaves room for preventive medicine. Preventive care,

and
in turn, creates an efficient system for ensuring a health-
fu 1 environment .

Problem Rationale

An attempt to introduce this broader concept of

health into the current system was instituted by the federal

government in 1966. P.L. 89—749, Comprehensive Health

Planning, was an innovative step designed to perform two

functions: to coordinate health services in order to

increase efficiency of resource allocation, and to expand

the basis of health by coordinating it comprehensively with

other social services. Thus, planning was to take place on

dual planes, vertical coordination of health organizations
and horizontal c00peration with other forms of planning.
In order to arrive at an assessment of this law
3 ihce it was adopted, several factors had to be considered.
330 properly appreciate the difficulties facing such an
L11iciertaking, the complexities of the health system are out-
1 ihed in Chapter II. Here, the elements of health are

de‘Vided into those factors which determine a state of well-

1being. Aspects which constitute the health care delivery

System also comprise a part of the total health picture.

Health activity types describe the variety of services

whiCh a health system provides. Health resources are the

 

 

 

basic mat
describe
strator a
health ma
scrutiniz
S
governmen
it would
led to it
legislati
decisions
role in h
the Const
Such a St
Changing
and POint
desCribg,
henSiVe 1
explaine.
confrOnt
fLmetiOn

V .
Ides Sl

ChaptEr
“ignes'

4:

basic materials which produce health care. Health goals

describe the dual nature of the health system as admini-

51:. rator and producer. The decision makers involved in

he alth make up the audience by whom each program is

s c r utinized.

Since P.L. 89-749 was an innovation in terms of

government entry into the health administrative function,

it would be valid to examine the historical trends which

Led to its development. The importance of the law in

legislative history rests on the legal bases of past

decisions and an expansion of the concept of the federal

role in health. Equally important is an understanding of

the Constitutional limitations of government intervention.
Such a survey in Chapter III serves to indicate the

changing ways of thought that brought us to the present,

and points an arrow to future directions.

The actual implementation of P.L. 89-749 is

described in Chapter IV. The forms and functions of Compre-

hensive Health Planning in all of its components are
el’ilbilained, as well as the administrative problems which

con fronted health planners in attempting to organize such a

function. The difference between theory and practice pro-

Vides significant guidelines for future experiences.

The planning aspect of the law is discussed in

Chapter V. With a dearth of specific health planning tech-

niques, the methods and forms of health planning as derived

from the Comprehensive Health Planning experience form an

11
L

 

 

important f<
Comprehensi‘
cooperation
in order to
arrangement.
Chaj
places P.L.
of the bill
background
National He
which attem
The
With a mini
had been in
still in t1“.
Closed Only
While Cone:
agencies.
legal mate]
”Orking d0(
these, Sim
Minimum.
Be.
“me as w
wished fr.

Q'

important foundation for future progress. The ways in which

Comprehensive Health Planning performs its horizontal

cooperation with other forms of planning is also considered,
in. order to assess the practicality of such cooperative

a1:- rangements .

Chapter VI concludes with recent developments and

places P.L. 89-749 in current perspective. An examination

of the bill's strengths and weaknesses provides a necessary

background for assessing its successor, P.L. 93-641, the E
«i

National Health Planning and Resources Deve10pment Act,

which attempts to rectify discovered inadequacies.

The evaluation of Public Law 89-749 was accomplished

with a minimum of direct secondary sources. Since the law

had been implemented fairly recently, some agencies were

st ill in the organizational stages. Most research dis-

closed only rhetorical debate on the merits of the Act,

While concrete materials were available only from working

agencies. Thus, emphasis was placed on primary sources:

legal materials, speeches, unpublished guidelines, and

woI‘lfiing documents. Journal articles were used to supplement

these, since texts on health planning are still at a
mil'Iimum.
Because comprehensive health planning is a disci-
Pline as well as a legal mandate, the latter is distin-
guished from the former by the use of capital letters.

Since the federal programs have unwieldy titles, they are

will be adhe

 

cormnonly referred to by their initials and this practice

wi J. 1 be adhered to within the text.

 

lo

Health Pla
W
Frill-ting 0

2A
CE (Amer
Klarman, T
versity PE

REFERENCES TO CHAPTER I

1

U.S. Congress, Public Law 89-749: Comprehensive
Health Planning and Public HealtFServiEes Amendments of
1.9 6 6 .

89th Congress (Washington, D.C.: U.S. Government
Printing Office, 1966), p. 1.

American Medical Association, The Cost of Medical
Care (American Medical Association, 1963) and Herbert

Klarman, The Economics of Health (New York: Columbia Uni-
versity Press, 1963) .

 

CHAPTER II

ELEMENTS AND PARAMETERS OF

HEALTH PLANNING

 

he

The need to define comprehensive health planning 1
arises from the relative novelty of the concept. Although i

rah

problem-specific planning had previously occurred, it was 1

not seen in a system context. Planning was disease-

oriented for the most part, with occasional forays into the

dell. ivery of services, i.e., as performed by health and wel-

fare councils. But comprehensive health planning was to

encompass problem-specific action, systems administration,

accessibility, availability and delivery of services, and is

now encouraged to look into alternate payment mechanisms.

All the threads of the health network are within the loom of
col“EDrehensive health planning and health, in turn, is inter-

W0V"en throughout the fabric of modern society.

Therefore,
the

sc0pe of chp has a theoretical field of involvement

that ranges from housing standards to multiple sclerosis.
Health Determinants

By consensus of the various agencies,1 the deter-

minants of health were seen to be four: properties of the

10

 

 

11

environment, prOperties of the health care delivery system,

properties of behavior, and prOperties of heredity. In

order to recognize fully the sc0pe of dealing with such a
large problem area, the components of each of these deter-
min ants will be briefly listed in Table l.

Pr0perties of

the environment have long been included as part of the

health problem, particularly in terms of sanitation. Local

public health departments have always been concerned with

environmental quality on a limited scale. The 1970 Census

rated environmental conditions for the first time, an
expansion from the assessment of conditions only within the

four walls of a structure. General environmental determin-

ants of health are composed of nutrition and food quality,

waste systems management and vectors of disease such as

insects and rodents. Housing involves structural safety,

ventilation and efficiency, while crowding deals not only
W11:11 unit density, but privacy on a neighborhood scale.
Pol lutants of land consist of litter and erosion, pollutants

of Water are composed of effluents and run-off, and emis-

sions and noise pollute the air. Mental health, often

environmentally related, is concomitant with physical

health in these factors.

Properties of the health care delivery system are

based on qualities necessary to the effective functioning of

any societal system. Its basic components are accessibility

nOt only in terms of geographic location but transportation

and entry into the system through administrative procedure.

 

 

DEVe lc

12

Table l

Determinants of Health

 

Properties of health care
delivery system:

9.

accessibility
availability

affordability

 

continuity fiJ
' |

comprehensiveness

quality

humaneness

Properties of behavior

a.
b.

C.

abusive habits
personal hygiene

use of delivery system

Properties of heredity

a.

b.

congenital defects

tendencies towards
certain diseases

 

Source: Adapted from "Guide to Plan Document

L - Properties of the 2.
env1ronment:
a. nutrition
b. sanitation
c. vectors
d. housing
e. crowding
f. work place
9. education
i. pollutants in: 3.
i. land
ii. water
iii. air
4.
\
Development," Community Health, Incorporated.

13

Availability is another component, in terms of medical care
for population groups, ethnic or socioeconomic, and in
terms of time, since health is a twenty-four hour affair.
cost is measured not only in terms of physician fee or

hospital stay, but other peripheral expenses, such as medi-

cation. Continuity of care involves follow-up or

preventive treatment, and is related to education, accessi-

bi l ity and affordability. There is also a need for

comprehensiveness of care, a systems approach not only

administratively but medically, since the practice of
re ferral is not practical for all population groups.
Quality is an aspect only now concerning consumers, the
quality of practitioner standards as well as quality con-

trol of medical care; and finally, humaneness, long

discussed, little practiced, where the emphasis on techno-
logical efficiency can contradict the problem itself, a

human being in need of help.

The properties of behavior involve both old and new

p1'3‘C>blems. Abusive habits, such as alcohol and tobacco,

have been on the scene for years, but the widespread abuse

of drugs in this country is relatively recent. Personal

hSigiene and nutrition habits are still a cause for

re~education, since common-sense health seems to have little

Popular appeal (witness the need for accident prevention

Commercials). The use of the delivery system is a preven-

tive type of health behavior, which also requires education,

since the majority of the population sees health care as

primarilY t
for a PlEth
medical use

Prc
and tendenc
in the post
are emphasi
research ar

is a major

l4

primarily treatment care. "Get a check-up" advertisements
for a plethora of ills are attempting to combat this kind of
medical use.

PrOperties of heredity such as congenital defects
and tendencies towards certain diseases are primarily seen
in the postnatal context. Here again, preventive measures
are emphasized since the only other alternative is extensive
research and treatment. Public education and fund-raising

is a major function of voluntary groups.

Health Activity Types

 

The properties which determine the relative health
of a population are spread over a broad spectrum. Health
activity types, while not so far-ranging, are also involved
in a variety of areas as shown in Table 2.

The first type, preventive medicine, apart from
quarantine measures, is a fairly recent phenomenon, and
ranges from vaccinations, environmental controls and family
planning to televised warnings about the dangers of high
blood pressure.

Diagnostic activities are those traditionally con-
ceived of as health care. Treatment can be divided into
those which occur by place: at home, ambulatory locations
or in-patient facilities. Treatment can also be divided by
specialty--medica1, dental and psychological, and further

subdivided by level of specialization—-primary, secondary

15

Table 2

Health Activity Types

 

1. Preventive activities 3. Rehabilitation activities:

a. environmental con— a. by specialty:

trol and services . .
i. phySical

b. education, communi- therapy
cation .. .
11. occupational
c. counselling therapy
d. prophylactic b. by place (see 2a)
procedures

4. Custodial activities:

2. Diagnostic and treatment a home care
activities: °

a. by place: b. domiCiliary care

. c. nursin homes
1. home 9

5. Transportation activi-
ties (getting patients
to services):

ii. ambulatory
locations

iii. in-patient

. . . a. er nc
faCilities em ge Y

b. public

6. Communication activities:

b. by specialty:

i. medical
ii. dental a. between patient and

system
111' psychological b. between components
c. by level of speciali- of system

zation 7. Quality improvement:

1' primary a. licensing of man-
ii. secondary power, facilities
iii. tertiary b. continuing education
d. by intensity of care:
i. emergency
ii. acute

iii. chronic

 

Source: Adapted from "Guide to Plan Document
Development," Community Health, Incorporated.

16

and tertiary. Related to the level of care is intensity:
emergency, acute, chronic, and ambulatory.

Rehabilitation is often a forgotten part of medi-
cine. Not only are the physically handicapped included
here, but the mentally ill and those recuperating from
addiction to abusive substances. Rehabilitation in a
criminal/medical sense is also involved in the psychiatric
treatment of prisoners.

Custodial care usually engenders visions of a state
mental hospital, but also includes care of the physically
and mentally handicapped, and the aged.

Transportation is a neglected part of health.
Although ambulances traditionally brought the patient to
trained care, the paramedic concept is bringing emergency
care to the patient. Non-emergency transportation is being
initiated for the elderly and some experiments are being
made to provide such service to low-income groups.

Communication may seem odd as a health activity, but
it warranted a special television program on the difficul-
ties patients have in talking to and understanding medical
staff. As well as educating the consumer into the health
system, communication activities involve components between
the system and constitute the mainspring of health planning.

Quality control has been a health activity type
practiced by professionals. Now this activity, like others,
is moving into the consumer participation arena. Besides

the initial licensing of manpower and facilities, continuing

education 1

standard of

One
affects pla
major func1
Table 3 sh<
posed of.
resources.
2“lanpower,
that the 11
since the

Fe
Pitals to
health 5y
PurchaSe'
role in IT
kEpt in l:
an effici

derind

17

education is an essential element in maintaining a high

standard of quality care.

Health Resources

 

One of the elements of health that most closely
affects planning is health resources, since one of the
major functions of any planning is resource allocation.
Table 3 shows the contents that health resources are com-
posed of. Knowledge, research and data are all paramount
resources. These can be divided into areas of expertise.
Manpower, in the varying degrees of skill and specialty
that the health field requires is of continual concern,
since the supply does not always match the need.

Facilities of all degrees, from specialized hos-
pitals to neighborhood drug centers all contribute to the
health system directory. Equipment is often expensive to
purchase, staff and Operate but plays an increasingly large
role in modern medical care. This element must also be
kept in balance; its lack or overduplication detracts from
an efficient health system. Funding is a resource that is

derived from a variety of sources.

Health Goals

 

To further complicate matters, health planning, in
line with different approaches, also has different goals.
Health status goals are medical in nature, dealing with

morbidity and mortality rates, infant and maternal deaths,

18

Table 3

Health Resources

 

l. Knowledge/technology: 4. Equipment:
a. environment a. radiation
b. education b. laboratory
c. physical health c. surgical
d. mental health d. pollution control

‘ . devices
e. genetics

e. a 1
2, Manpower mbu ances, buses

- - f. o i a 'o
a. env1ronmentalists c mmun C t1 n systems

- by specialty 5. Money: (Sources of)
b. educators a. individual payer
c. dentists b. third—party payers
d. physicians by i. private
specialty

ii. government

e. nurses c. philanthropy

f. pharmac1sts d. grants

9. veterinarians

h. paramedicals by
type
3. Facilities:
a. schools by type

b. pollution control
plants by type

c. in-patient facili-
ties by level of
care types

d. out-patient
facilities

e. sheltered workshops

f. rehabilitation
centers

Source: Adapted from a "Guide to Plan Document
Development," Community Health, Incorporated.

and other dis
goals 11991135"E
elimination t
of a satisfa:
statements c-
operate in a
future state
These goals
physical anc
healthful l
lOgical or
incidences
Hea
dealing Wit
Philosophy
dealing Wi1
implementa.

fairly Sta

future . T

as Situati
Statements
health 537:
tam; for 1
tion in t]
may“? t:
Conflicts

action

19

and other disease-specific statistics. These aspirational
goals represent the ultimate aims of health planning, the
elimination of morbidity-creating factors and achievement
of a satisfactory national health status. These broad
statements consist of stable policies, a desired end, which
operate in a very long time frame. The emphasis is on the
future state, not necessarily feasible in the present.
These goals can be very phiIOSOphical in nature, i.e., a
physical and social environment conducive to safe and
healthful living; or unattainable due to present techno-
logical or system inadequacies, i.e., elimination of all
incidences of glaucoma.

Health system goals are administrative in nature,
dealing with functional and organizational services.
Philosophy is incorporated here in a more specific manner,
dealing with the agency's approach to planning and its
implementation of plans. Organizational goals are also
fairly stable, but remain in the realm of the foreseeable
future. Therefore, they are flexible and subject to change
as situations prOgress. Health system goals are specific
statements describing the agency's role in the community
health system, i.e., its establishment as the primary con-
tact for provision of health problem and resources informa-
tion in the area; or the changes it hopes to implement by
playing this role; i.e., the resolution of health system
conflicts and issues by public discussion and coordinated

action.

Ano
such a comp
tion called
Participant
and governn
entire pOpL'
zen partici
Providers i
facilities,
Contract fc
government
Perform hm
Planning 51
work withi]
called upo:
elected an.
hint)! of .
these aCto
Part On th
Spectrmn o
organizing
diffiCult

operation

20

The Participants

 

Another of the factors that makes health planning
such a complex endeavor involves the broad range of p0pula-
tion called into play during its various phases.
Participants are basically made up of consumers, providers,
and government officials. Consumers are composed of the
entire population represented by a selected number of citi-
zen participators, who may represent specific interests.
Providers include hospital representatives and other health
facilities, private practioners and third-party payers, who
contract for services. Straddling between providers and
government officials are public health officials, who
perform both provision and regulation of services. Health
planning staffs are funded by government money and generally
work within its administrative network. The legislature is
called upon to enact supportive legal devices and various
elected and appointed public officials have the responsi-
bility of carrying out these directives. Moreover, each of
these actors in the health planning scene has his counter-
part on the local, state and national levels. With a wide
spectrum of participants and a complex hierarchy, merely
organizing a comprehensive health planning schema is a
difficult task, not to mention its smooth and continuous

operation.

Yet an
confronts heal
picture. Sincr
planning must 1
that involve a
far as to state
of resources wi
and suggests ir.
health.2 oeme
is to analyze t
tions, and this
0f Particular d
Planning requir

This in'

rhetorical Vi ew]

21
Health Planning in Context

Yet another aspect in the multi-faceted reality that
confronts health planning is fitting it into the larger
picture. Since health does not exist in a vacuum, health
planning must be compatible with other forms of planning
that involve a variety of social dimensions. Rein goes so
far as to state that the traditional functional allocation
of resources within a single social sector is inefficient
and suggests investment in non-health programs to maximize
health.2 Roemer concurs, "For the very essence of planning
is to analyze the total landscape of health needs in popula-
tions, and this cannot be done along the parochial channels
of particular diseases . . . persons, or . . . agencies.
Planning requires rather the viewpoint of 'community' . . ."3

This interrelationship is reiterated by Kissicks's
rhetorical viewpoint.

Health planners must consider the social activities
related to . . . the various health programs, for no
planning can be effective out of context. Health is
a social concern, closely related to a variety of
social concerns, and we return to parochialism if we
consider it as a separate entity.4

There are two major reasons besides fear of
parochialism for considering health in a larger context.
One is that in order for planning to fulfill its dual
purpose of resource allocation and coordination, it must
work with areas of activity which affect health, such as

industrial sanitation, safety, air pollution control and

care of the mentally ill, which present problems of funding,

quality of servi
agency interests
health become in
and various skil
problems differs
ning, these dupl
degree.5
Another
c00peration invc
Elling states,

~- . to ass
health plann
Power have c
Changes: in
SYStem. Th
relations,

cerns gener
Not 0n1
statuskquo, but
refleeting Soci

SOCi n
ety have a

manifestation o
influence in th

fore 31%” be

Plann' 7
lng, " So

thSiCal and m I
e

a

synthetic Envir

 

22

quality of service, establishment of standards and multiple
agency interests. Simultaneously, many agencies other than
health become involved in services with health implications
and various skills from other agencies may approach the same
problems differently. With appropriate interagency plan-
ning, these duplications can be ironed out to a significant
degree.5
Another reason for encouraging interdisciplinary

c00peration involves implementation of health plans. As
Elling states,

. . . to assess the power budget available to the

health planner, one must realize how the bases of

power have come to be distributed through complex

changes, internal and external, to the health

system. These have entailed fluidity in power

relations, a more prominent place for health con-

cerns generally in society . . .5

Not only must society be related to health in the

status quo, but health concerns change with the times,
reflecting social changes. According to Engel, changes in
society "have a specific and dominating influence on the
philosophy of health planning . . . there is hardly any
manifestation of modern social and economic life without
influence in this aspect. Planning for health must there-
fore always be integrated with socioeconomic development
planning."7 Some of the modern social concerns that affect
physical and mental health can be traced to urbanization,

affluence, social services trends, education, ecology,

synthetic environmental factors (toxics), and aging.

Co:
ning, Whic}
aspects, a1
There is 6
fields. U:
invention .-
evaluation
health pla:
come to ov
planning j
urban Cont
Changes in
tion and t
needs and
facility 8

Un
the two di
cites two
Planning m
element 0n.
Operated 11
Clearinghm

health admi

ized field

Planners re

mange de

23

Cooperative efforts between specifically urban plan-
ning, which is comprehensive in touching upon all social
aspects, and health planning, have been largely neglected.
There is a dual cause for a partnership between these two
fields. Urban planning's experience with goal formulation,
invention and testing of alternatives, implementation and
evaluation methods has high potential applicability to
health planning. Moreover, health planning concerns have
come to overlap those of urban planning. An article in one
planning journal states, "Understanding and projecting the
urban context is basic to anticipating future health needs.
Changes in urban development patterns, population distribu-
tion and tranSportation systems influence local health
needs and affect decisions regarding health prOgrams and
facility sites."8

Until now, little correlation has existed between
the two disciplines. The American Institute of Planners
cites two reasons for this. For one thing, the health
planning movement has come to be recognized as a forceful
element only recently. The planning that did take place
Operated in a fragmented manner, offering no central
clearinghouse for urban planners to make contact. There
has also been a hostile atmosphere between the two groups:
health administrators often felt that health was a special-
ized field outside the sc0pe of generalists, and urban
planners rejected entry into health because of narrow,

land-use definitions of planning. Limited resources, lack

of knowledg
planning re
tion.

Wit
comprehensi
cooperatior
can now be
health fac:
Plans, coo;
formal wori
counterpar

Wi
Part of th
Planning t
Pose inhez
truly ’comE
acknow1ed€

24

of knowledge and the discrepancy between urban and health
planning regions all contributed to a spirit Of aliena-
tion.9

With the introduction of a formalized mechanism for
comprehensive health planning, some of these barriers to
cooperation have been removed. The urban planning agency
can now be represented on health councils, share data on
health facilities and services, use such data in community
plans, coordinate zoning variances with need, and maintain
formal working relationships with its health planning
counterparts.

With the emphasis placed by theorists on health as
part of the total environment, the failure of chp and urban
planning to Optimize collaboration negates the basic pur-
pose inherent in both forms of planning, that of being
truly comprehensive. Now that health planning has an
acknowledged place in the government structure, its

acceptance by cohorts should follow swiftly.

lCo

Document De
that "Ba51c
of the effo
from around

pose." n.d

2M5

Encyclopedi
m
pl 14 3 0

3Mi
Stance Vere

4W:
BudQEting :
207-3,

5

H:

lS’tration.
l

6
Health, in R

hissick' e

REFERENCES TO CHAPTER II

1Community Health, Incorporated, Guide to Plan
Document DevelOpment, Draft, The introduction states only
that "Basicaily, the information presented is a composite
of the efforts to comprehensive health planning agencies
from around the country, which were surveyed for this pur-
pose." n.d.

 

 

2Martin Rein, "Welfare Planning," in International
Encyclopedia Of the Social Sciences, David L. Sills, ed.,
vol. 12 (New York: Macmillan CO. and the Free Press, 1968),
p. 143.

 

 

3Milton I. Roemer, "Planning Health Services: Sub-
stance Versus Form," Canadian Journal Of Public Health 59,1
(November 1968):434.

 

4William L. Kissick, "Planning, Programming and
Budgeting in Health," Medical Care 5,4 (July-August 1967):
207-8.

 

5Henrik L. Blum and Alvin R. Leonard, Public Admin-
istration--A Public Health VieWpoint (New York: The
Macmillan Co., 1963). p. 260.

 

 

6Ray H. Elling, "The Shifting Power Structure in
Health," in Milbank Memorial Fund Quarterly, William L.

Kissick, ed., 46,1, p. I35} '

7Arthur Engel, Perspectives in Health Planning
(London: The Athlone Press, UniVersity of LondOn, 1968),
p. l.

 

8Bernard J. Frieden and James Peters, "Urban Plan-
ning and Health Services: Opportunities for Cooperation,"
Journal Of the American Institute Of Planners 36,2 (March
19707:84-85.

 

25

26

9For a detailed discussion of these points, see
American Society Of Planning Officials, The Urban Planner
in Health Planning (Washington, D.C.: U.S. Government
Printing Office, U.S. Department of Health, Education and
Welfare, Public Health Service, 1968).

 

 

The
history of
Changes the
values. (:1
or Sharply
SolutiOn w
brought ab
lems and t
“Story 01
POlitical
Synopsis ;
health 1e
surViVal

T
the fledg
succeSSiv
at that t
enfochd'

of Prob 1e

CHAPTER III

THE HISTORICAL BACKGROUND OF

HEALTH LEGISLATION

The Span Of two hundred years that encompasses the
history Of the American states saw technological and social
changes that became reflected in novel needs, concepts and
values. Changing ways of life brought new health problems
or sharply focused on Old insoluble ones. GrOping toward a
solution was an evolutionary process, as each century
brought about an expansion of the concepts Of health prob-
lems and the government's role in dealing with them. The
history of health legislation parallels the dawning
political and social consciousness of the nation. A brief
synopsis is sufficient to indicate the depth of change that
health legislation has passed through, from rudimentary
survival measures to sophisticated programming techniques.

The great bulk of precautionary health measures in
the fledgling United States arose as a response to the
vsuccessive waves of epidemiological diseases that were rife
at that time. These measures were locally produced and
enforced, reflecting the particular medical type and scope

of problem afflicting an area. The original regulations

27

were also dis
maintenance:
it had begun
in effect on

As a
legislation
Virginia in
could not r
ability to
regulated “
indicate t}

quarantine

28

were also disease-specific, coping not with general health
maintenance, but aimed only at containing an epidemic once
it had begun. Moreover, this type of law was temporary,
in effect only until the crisis passed.

As a point of fact, the first medical-related
legislation within the American Colonies occurred in
Virginia in 1639. The Assembly ruled that a physician
could not refuse treatment of patients who lacked the
ability to pay his fee. Most Of the other colonies also
regulated "chirugeons and physicians."1 However, records
indicate that most early medical legislation dealt with

quarantine against contagious diseases.
Lgcal Quarantine Activities

With the tremendous amount of exploration, immigra-
tion and merchant shipping occurring during the seventeenth
and eighteenth centuries, isolated populations were
especially susceptible to the infectious diseases that were
carried aboard sailing vessels. Diseases with high mor-
tality rates, such as smallpox, cholera, and yellow fever
were especially feared. Therefore, quarantine regulations
were established in Boston as early as 1647 when the
Massachusetts General Court ordered a quarantine of all
ships coming from the West Indies. By 1790, rudimentary
regulations existed in almost all American ports.2

In order to enforce these quarantine regulations,

local boards of health were instituted. Petersburg,

Virginia, 58‘
in 1780, and
Baltimore, a:
of these age:
Orleans, har«
enforced rigi
a result of .
However, cha:
quarantine e
ity of the h
nineteenth c
anticontagio
tagiOl‘iiSt pr
aPplied "loc
gnarantine l
the BOStOn B
ProcedUres’

Prompt 1y rel

29

Virginia, set up what was probably the first board Of health
in 1780, and by the turn Of the century, New York, Boston,
Baltimore, and New Orleans followed suit. The effectiveness
of these agencies varied with the sc0pe of the problem. New
Orleans, hardest hit with wave after wave of yellow fever,
enforced rigorous standards. New York responded in kind as
a result Of a particularly virulent epidemic in 1819-22.
However, changing medical Opinion regarding the efficacy of
quarantine exerted political pressure to weaken the author-
ity of the health boards. By the second decade of the
nineteenth century the great majority of physicians were
anticontagionist and antiquarantine. In 1820, an anticon-
tagionist president on the Philadelphia Board of Health
applied "localist principles" and virtually ignored the
quarantine laws still on the books. Around the same time,
the Boston Board of Health, under attack for its quarantine
procedures, was abolished by a new city government, which
promptly relaxed quarantine regulations.3

However ineffectual, the concept lingered, and by
1873 there was some form of health board in 124 cities in
the United States. This local action preceded state-wide
programs. Public health measures were instituted only to
'meet local situations. State authorities took cognizance
of health problems only when pressured by a large number of
localities or a major city. The type of problem which
precipitated action was still the yellow fever epidemic rife

in New Orleans, which resulted in the first state board of

health in L<
Massachuseti
California

state board:
were include

organizatiOJ

On
in the form
on April 3,
allow the c
the capital
members.5

Twc
VerSus. Stat
d(abate gem
and life We
assigned (1‘

central 90*

30

health in Louisiana in 1855. From then until 1872, only
Massachusetts (1869), the District of Columbia (1870),
California (1871), and Virginia (1871) had established

state boards Of health.4 After this, state boards of health
were included as part Of the regular state administrative

organization.

Federal Intervention

 

On a federal level, the first federal health law was
in the form of a request from George Washington to Congress
on April 3, 1794, for passage Of a measure which would
allow the Chief Executive to convene the Congress outside
the capital if epidemic disease should threaten its
members.5

Two years later, the question Of central government
versus states' rights arose in a federal proposal. The
debate concluded that the states' right to preserve health
and life was inalienable. "The law that finally passed
assigned quarantine authority to the states and placed the
central government in a permissive supporting role."6

Public health services had their beginnings in
1798, when John Adams signed an act on July 16, estab-
lishing the Marine HOSpital Service for the relief of sick
and disabled seamen. Hospitals were erected in port cities
and twenty cents a month was deducted from the sailors'

wages toward their upkeep. This constituted what is

31

probably the first prepaid medical plan in the United
States.

Other population groups under the direct jurisdic-
tion of the federal government also benefited from medical
services. From a post-Revolutionary roster of one surgeon
and four surgeon's mates for the Army of 700 men, the War
Department by 1812 had a delineated corps of army medical
Officers. Eventually, there successively evolved the
national medical care of Indians, Of territorials and of
federal employees.7

Another attempt by the Congress to intercede in
health matters occurred with the Act of February 27, 1813,
requiring the federal government to guarantee and distribute
effective cowpox vaccine to any citizen who requested it.
Its repeal nine years later was followed by a ruling by
Supreme Court Justice John Marshall in 1824, stating that
health matters were not specifically assigned and therefore
belonged to the states under the 10th Amendment.8 This had
long been the contention Of the states' righters. "In the
establishment of the Constitution of the United States, the
individual states did not cede to the Federal government
the responsibility and authority for the preservation of
health within their respective borders. They . . .
retained this function and . . . have theoretically
remained responsible for all health activities."9

After the yellow fever scare of 1878 resulted in

the establishment of a National Board of Health Act of

32

March 3, 1879, ensuing Opposition by the states rendered the
agency ineffective and it was allowed to pass out of exis-
tence four years later. After yet another impending
epidemic in 1892, the Act of February 15, 1893, finally put
quarantine authority, which had been bandied about for over

a century, firmly into the hands Of the federal government.10

The Twentieth Century

 

The beginnings of the twentieth century witnessed
little progress in health legislation, with the exception
of two portent trends. In 1906, the Pure Food and Drug
Act was passed. Its sphere was restricted to the prOper
labeling Of containers; not until 1938 was the regulation
of advertising and the inclusion Of cosmetics brought into
its sc0pe. However, this was the first attempt by the
government to legislate peripheral medical concerns: here-
tofore the focus had been on specialized, immediate
problems, such as the control Of communicable diseases.

Also in 1906, there occurred a portent in terms of
health administration. J. P. Norton, professor of economics
at Yale, introduced a bill into Congress calling for the
establishment of a national department of health having

Cabinet status. The bill died without passage in 1912.11

 

The First Health Grants

From this rag-bag of events, one trend was to become

firmly established, the health grant system. In 1918, the.

33

Chamberlain-Kuhn Act authorized the first program of federal
health grants, thereby instituting what was to become the
major role of the federal government in health concerns-—
spending money.

The Constitutional basis for national health
activity is not found in any specific grant of power but in
the federal powers authorized by the courts as connected
with the exercise of the enumerated powers. The principal
foundation for federal intervention in health lies in its
power to regulate interstate and foreign commerce, the power
of taxation and the power to spend money raised by taxation
for the common defense and public welfare. The reservation
by states over health rights and the spending power of the
federal government was to form a peculiar detente over
ensuing years.

Following the conservation Of World War I, the
governments from Harding to Hoover showed little interest
in health except that of veterans. An exception was the
Sheppard-Towner Act, providing grants to states "for the
promotion Of the welfare and hygiene of maternity and
infancy” in 1921.12

The modern era in federal-state relations regarding
public health began in 1935 with Title VI of the Social
Security Act, which authorized $8 million annually for
training and technical assistance to states and local
health work. As Chapman states, "Health had become a

respectable political tOpic, and . . . no political party

34

dared ignore it altogether . . . it was unquestionably a
major watershed in the evaluation of federal health
policy."13
The federal grant system, particularly for physical

facilities, sanctioned by the constitutional basis Of
expending tax monies for the common welfare, continued to
be the main means of federal intervention, but it was an
increasingly powerful intervention, signaled by the phrase
"annual authorization." Smith explains its significance.

The "new federalism" created by the Social Security

Act was characterized by the redistribution Of

responsibilities for programs to the federal and

state governments--from what was formerly a state-

local responsibility; by the shift of fiscal balance

whereby federal grants become more a necessity than
a supplement . . .14

The Hill-Burton Act

 

In 1946, Congress enacted the Hospital Survey and
Construction Act to provide federal aid to states for
surveying needs and developing state plans for hospital
construction and financially assisting in such construction.
Public Law 79-725, or as it is more familiarly known, the
Hill-Burton Act, created hospital planning councils whose
major task involved statewide identification of bed
shortage areas and the equitable distribution of facilities.
According to Hilleboe and Barkhus this act was to become
significant for future legislation for several reasons. It
was the first time that any systematic statewide planning,

albeit in a limited aspect, was required for the expenditures

35

of federal grants. Secondly, the institution of active
local planning bodies, with health provider representatives,
was to furnish good experience for a more encompassing pro-
gram. It was this piece of legislation which provided the
impetus for a federal—state partnership. For the first
time, there was coordination of facilities planning and
standards were set up for health facilities construction
and distribution. This thrust toward regulative planning
was a forerunner of the Community Health Services and
Facilities Act of 1961. Since facilities planning is an
integral part of general health planning, some excellent
patterns of planning were established, especially in the
area Of community participation.15

Besides physical facilities, Congress undertook a
sustained investment in medical research. Through a series
Of National Institutes Of Health, beginning with cancer in
1938, heart, mental health, arthritis, child health and so
forth, a sum in excess Of $14 billion has been spent over
the past twenty years.

The third resource of health manpower was geared
into federal aid programs by a series Of training acts:
mental health manpower in 1948, public-health specialists
Lin 1956 and broad subsidies for health professions education
in 1963. These were expanded by the Nurse Training Act of
1964, the Health Professions Educational Assistance Amend—
ments of 1965, and the Allied Health Professions Personnel

Training Act of 1966.16

36

Norton's idea became reality and health was given
administrative acknowledgment when it achieved cabinet
status in 1953 with the creation of the Department Of
Health, Education and Welfare. This created better control
of the thrust of federal programs but not the unmanageable

proliferation of categorical grants.

The 89th Congress

 

The period of the sixties was a golden age in terms
Of health legislation. Faced with the knowledge that
despite tremendous expenditures Of health resources, health
care in the United States did not compare favorably to
international standards, Congress and the Johnson adminis-
tration addressed themselves to the organization, delivery
and payment of health services. Two major thrusts charac-
terized the health policy of the mid-sixties: efforts to
guarantee the consumers' capacity to purchase health care,
and institutionalization of health services. To quote
Kissick, "Attention to the financing mechanisms and patterns
of organization that shape health-care delivery systems was
added to the existing responsibilities of the federal
government for categorical grants-in-aid and development of
resources."17

The initiating effort to provide payment mechanisms
in the United States was P.L. 89-97, the Social Security

amendments of 1965. Medicare and Medicaid specified three

means of meeting health care costs: compulsory social

37

insurance, third party coverage and grants to states for
public purchase of medical care. It was assumed that pri—
vate services could assure adequate health care if payment
was provided to certain user groups.

However, a series of bills also focused on the
patterns of organization and utilization. Community Mental
Health Centers, Office Of Economic Opportunity Neighborhood
Health Centers, Regional Medical Programs and Comprehensive
Health Planning, a total Of twenty-seven pieces of major
health legislation were passed by the 89th Congress, mostly
in the first session.

Regional Medical Programs and Comprehensive Health
Planning were both planning-oriented prOgrams rather than
direct service projects. Public Law 89-239, the Heart
Disease, Cancer and Stroke Amendments of 1965 instituted
the Regional Medical PrOgrams (RMP) as an attempt to
coordinate local research efforts among medical schools,
research institutions and hospitals and to disseminate new
knowledge in the local health field. Aside from dealing
with medical data systems, RMP were awarded planning grants
to support surveys of needs and resources, feasibility
studies and the organization of planning staffs. However,
these tasks were to be accomplished without interference in
the patterns and methods of financing patient care or the
administration of hospitals, a mandate clearly stated in ’

the Opening clauses of the act.

38

The bill did incorporate health care providers into
its schema. As one textbook put it, "Local participation,
especially Of health care providers, in planning is a . . .
basic feature of the Regional Medical Programs . . .
(another) feature Of the RMP is the dual nature Of the
funding mechanism-~namely, a planning phase and an Opera—
tional phase."18

The Comprehensive Health Planning and Public Health
Service Amendments Of 1966 (P.L. 89-749) were also charac-
terized by these features. Although differing in terms Of
both organization and intent, RMP and CHP have certain
similarities which are indicative Of practically all health
planning efforts. One analysis found that the legislation
for both programs requires that (l) a planning agency be
advised by a citizen's council, (2) that the agency work
toward regionalizing institutions, (3) that grant money be
available for planning activities, demonstrations and
ongoing projects, and that (4) the agency refrain from
interfering with the existing patterns of health delivery.
This last point is clearly set forth at the onset of each
bill.19

Although it was not to interfere, CHP was mandated
to coordinate private efforts. But even more, CHP was
geared toward government. Its intrinsic innovation was a
"Partnership for Health" concept, the first time regional,

state, and federal agencies would coordinate health

planning efforts. A text on health planning puts it so:

39

. . . the emphasis on the direct federal-regional
relationship means that RMP projects have not easily
been incorporated into . . . existing federal or
state programs. . . . One contribution that (CHP
makes) . . . to health planning in the United States
. . . is to function as a means for the various
federal, state and regional programs to be brought
together in a more coordinated health care system.2

The need for this type of coordination did not dawn
suddenly in 1966. As far back as 1932, a report on Medical

Care for the American PeOple perspicaciously pointed out

 

this need. To quote from this far-seeing document,

Even when each individual hospital is efficiently

administered, wastes . . . often exist in the hos-

pital system . . . as a whole. These are largely

due to the failure to coordinate institutions and

to the lack of any planned development. . . . There

should, therefore, be an agency in each community,

through which the lay and professional groups

. . . could consult, plan and act . . . 1
The report goes on to state that coordination is needed in
metropolitan areas, where inconvenience of location makes
medical care inaccessible although there is no lack of
facilities in the locality as a whole. It is perceptively
pointed out that the major problem is functional, not
geographical, so that the sectionalism of institutions
simultaneously leaves gaps and duplicates services. The
report includes the need for coordination in rural areas,
which could be performed by regional planning agencies and
supervised by the state. State agencies, the book con-
tinues, would need legislative and financial authority and
should foster a broad plan, whereas local bodies would work

under persuasive auspices, through systematic conferences

based on local data. These local agencies would strive for

40

cooperation between the professional groups that furnish
service and the lay groups that receive and finance it.22
The recommendations of this amazing document were
not to be heeded for thirty-four years, when the National
Commission on Community Health Services recommended that
community health services required greater federal partici—
pation and that comprehensive health planning must take

23

place on a continuing basis. After four years of study,

P.L. 89-749 was passed in 1966.

REFERENCES FOR CHAPTER III

1Francis Randolph Packard, The History of Medicine
in the United States (Philadelphia: 31 B. Lippincott,

 

 

2Geoffrey Marks and William K. Beatty, The Story of
Medicine in America (New York: Charles Scribner's Sonsfr—
1973i} P. 262.

 

 

3Ibid., p. 236.

41bid., p. 266.

SCarleton B. Chapman and John B. Talmadge, "His-
torical and Political Background of Federal Health Care
Legislation," in Health Care, Clark C. Havighurst, ed.
(Dobbs Ferry, New York: Oceana Publications, Inc., 1972),
p. 102.

 

61bid., p. 103.

7Robert D. Leigh, Federal Health Administration in
the United States (New York: Harper Brothers, 1927),
pp. 81—248.

 

8Chapman, "Federal Health Care Legislation," p. 104.

9Harry S. Mustard, Government in Public Health
(New York: The Commonwealth Fund, 1945), p. 90.

lochapman, "Federal Health Care Legislation,"
pp. 105-107.

llLeigh, Federal Health Administration, pp. 485-86.

12Chapman, "Federal Health Care Legislation," p. 109.

41

42

l31bid., pp. 111-13.

14David G. Smith, "Emerging Patterns of Federalism:
The Case of Public Health," in Administering Health
Systems: Issues and Perspectives, Mary Arnold, L. Vaughn
Blankenship and Johh M. Hess, eds. (Chicago: Aldine-
Atherton, 1971), p. 131.

 

15H. E. Hilleboe and A. Barkhus, "Health Planning in

the United States: Some Categorical and General Approaches,"
International Journal of Health Services 1,2 (May 1971):
136-37.

16William L. Kissick, "Health Policy Directions for
the 19705," New England Journal of Medicine 282,24 (June 11,
1970):1346. 'i

 

l7Ibid.

18Ernest L. Stebbins and Kathleen N. Williams,

"History and Background of Health Planning in the United
States," in Health Planning: Qualitative Aspects and Quan-
tative Techniques, William A. Reinke, ed.*(§altimore,
Maryland: The Johns Hopkins University School of Hygiene
and Public Health, Department of International Health,
1972), P. 9.

 

 

19Michigan, Department of Social Services, Risin
Medical Costs in Michigan: The SOOpe of the Problem and
the EffEEtiveness‘Of:Eurrent ControIs (Lansing? Michigan:
JfiIy 1973), p. 316.

 

 

20Stebbins, Health Planning, p. 10.

 

21The Committee on the Costs of Medical Care, Medi-
cal Care for the American PeOple (Chicago: University of
Chicago Press, 1932): p. 53.

 

22Ibid., pp. 54-55.

23The National Commission on Community Health
Services, Health is a Community Affair (Cambridge, Massachu-
setts: Harvard University Press, 1967).

 

CHAPTER IV

P.L. 89-749: ADMINISTRATION OF THE LAW

The passage of P.L. 89-749, the "Comprehensive

Health Planning and Public Health Service Amendments of
1966," was greeted with enthusiastic plaudits from the
health fields and the law-makers. Between 1966 and 1967,
the bill was almost universally endorsed with great
Optimism as a progressive innovation. Cavanaugh praised,

The legislation develops a base for a vital step

forward in comprehensive health planning, not as

an end in itself, or as a new and different pro-

gram, but as a dynamic process and means for

identifying and delineating courses Of action.

In contrast to many previous health planning

efforts, the planning elements of P.L. 89-749

are not limited in time, or to a collection of
programs, or to a segment of the population . . .

1

The central concept intrinsic to the legislation was
phrased by William H. Stewart, Surgeon General at the time
of the bill's passage. "In sum, the comprehensive health

planning envisioned in P.L. 89-749 extends laterally across

 

all health activities--those which are strictly medical in
nature and those which relate to health in its broadest
sense. It seeks to assure that the whole is greater than

2

the sum of its parts." The bill became colloquially known

as the "Partnership for Health"--a vertical form of

43

44

"creative federalism," forging a partnership not only
between the federal government and its state and local
counterparts, but among all health resources, public and
private, individual and institutional, all directing their
efforts to a common goal. The bill also provided for the
first time, for consolidation Of nine categorical programs
into a single block grant which state authorities could use
in accordance with their individual priorities.

The law that inspired such rhetoric was quite
simple--both in its language and in its content. Its
purpose was to achieve

. . . close intergovernmental collaboration, Official
and voluntary efforts, and participation Of indivi-
duals and organizations . . . to support the marshaling
of all health resources--nationa1, state and local--

to assure comprehensive health services Of high

quality for every person, but without interference

with existing patterns Of private professional

practice . . .

P.L. 89-749 was an amendment to Section 314 of the
omnibus Public Health Service Act. Seven programs were
provided with grants in five major sections of the bill.
Section 314 (a) provided for state level planning for
health services, manpower and facilities. It required the
creation of a single state agency, advised by a lay council.

Section 314 (b) authorized project grants for the
establishment Of areawide health planning agencies within
the state. Section (c) involved project grants for

training, studies, and demonstrations, while (d) freed the

state health agencies from the old system of categorical

45

grants, allowing greater discretion at the state level
regarding expenditure of funds. Sections (e) and (f)
provided for project grants for health services development
and interchange Of personnel with states, respectively.
Section 314 (g) amended the authority of the Surgeon General
to comply with the preceding sections. The remaining
sections authorized the continuation of previous public
health grants.
The major thrust of the law is stated in the

Declaration of Purpose.

. . . the Congress finds that comprehensive planning

for health services, health manpower and health

facilities is essential at every level Of government;

that desirable administration requires strengthening

the leadership and capacities Of State health

agencies . . .4

The grants to states were based on the submission

and approval of state plans for comprehensive state health
planning. This state plan was required to fulfill several
functions. First, it was to designate or establish a
"single State agency, which may be an interdepartmental
agency, as the sole agency for administering . . . the
State's health planning functions . . .5 Secondly, the law
called for the establishment Of a state health planning
council, to include representatives Of state and local
agencies, private organizations and consumers to advise the

state agency. An interesting departure from previous

participatory councils, which had emphasized the presence

46

of health providers, this council was to consist Of a
majority Of consumers of health services.

The state plan was also called to explicate proce-
dures for the expenditure of funds; to encourage cooperation
between and among government and private groups and similar
agencies in related fields such as education, welfare, and
rehabilitation; to provide methods of administration; to
report to the Surgeon General; and to review annually the
state plan.

Aside from these general mandates, the actual
methods and scope of Operations were left to the discretion
of the individual states. Stewart touted this as the
flexibility aspect Of the bill. "P.L. 89-749 is a genuine
expression Of faith in a process of planning to meet
different priority needs in different ways. It is an
invitation to initiative from states and communities."6
The states' reactions over the ensuing years have been

predictably varied.

The State Agency

 

The state Comprehensive Health Planning agency
became known as the "a" agency because it was cited in
Section 314 (a) to distinguish it from its regional counter-
part, which became the "b" agency. According to various
Senate committee reports, the "a" agency was to provide the
mechanism through which individual specialized planning

efforts could be coordinated to each other. It was to

47

serve as the focal point for relating comprehensive health
plans to planning outside the field of health, such as urban
development and public housing. It was to provide for the
first time, resources tO measure the special health needs
of each state. And it was to extend horizontally through
all health activities from medicine to the environment.7
State planning for health had existed previously
under the aegis of state health departments, whose functions,
described by Mustard, included the study of specific state
health problems such as high neo-natal mortality rates or
disease vector control (vermin), and planning for their
solutions. The state health department also undertook the
coordination and technical supervision of local health
activities and financial aid to local public health depart-
ments. The enactment of regulations which have the force
of law in dealing with sanitation, disease and other public
health controls was largely the work of the state agencies.
Finally, state public health departments had the regulatory
function of establishing and enforcing minimum standards of
performance.8
Although planning pg£_§e_was not a novel phenomenon

to state agencies, the Special qualities called for in
Comprehensive Health Planning presented a challenge. Roemer
relates,

Planning of certain sectors Of personal medical care

or environmental health service has, Of course, been

carried out for years. State health departments have

devoted a good share of their energies to planning
and promoting various preventive prOgrams. . . . The

48

special feature of the CHP program, however, is its

breadth of sc0pe, intended to encompass all aSpects

of health services, in both public and private

sectors . . .9

COping with these new responsibilities placed quite

a heavy burden on states unused to such administrative
planning. Since relatively little research had been devoted
to systems methods Of health planning and there was a
paucity of experienced professional health planners, states
were left to make the rules as they went along. The lack
Of organizational principles in the law or in any textbook

created identity problems as to what the "a" agency should

be doing or where it should be located.

Functions

 

Four points were specified in the act itself. Each
state would designate the single health agency, would
appoint an advisory council, would complete a state plan,
and would coordinate other local planning efforts. Beyond
these points, no specification was made for the mechanisms
or standards Of coordination.

The American Public Health Association then devised
a statement, ”Guidelines for Organizing State and Areawide
Community Health Planning," which suggested Objectives such
as improving organizational patterns for health services,
discouraging unnecessary programs, identifying health needs
and improving the quality for health care through better

10

coordination. With such vague rhetoric as their only

49

guidelines, it is understandable that most states were still
in the throes of organizational disarray by 1968. By 1970,
enough experience had been gained to sprout more SOphis-
ticated theories, as with Colt's discussion of the "levers
of influence" which could be used by the "a" agency.
According to Colt, primary function is the comple-
tion of a state plan--the articulation of a broad-gauge,
long-range public policy of health efforts for the state.
This would include the development of generalized goals for
the health system and the preparation of guidelines for
planning, program administration and evaluation. Secondly,
through their review and approval function, the state
agency acts as the funnel for government funds, giving it
considerable leverage for influencing the decision making
process. Thirdly, the function of assembling and analyzing
the hard data needed to base decisions on is preeminently
the state's role. "Moreover, as the source of reliable
data . . . the state . . . agency will also achieve a
certain degree of influence over the way this data is used,
and thus in the decision making process itself."11 Related
'to this would be the state's role to supply the traditional
ruealth providers, who lack the resources to maintain a
«continuing planning and evaluation function on their own,
tvith.financial and technical assistance. This would create
nmmre specific planning at smaller scales, at the same time

strengthening the role of the state in the private and

public health fields .

50

Administrative Location

 

A source Of contention was not only the role Of the
"a" agency, but its location within the administrative
framework of the state governmental organization. The
establishment or designation of the agency was left up to
the states, the law specifying only that it be a single
state agency.

The role of state planning in general has been a
complex enough debate without the insertion of the delicate
web of interrelationships that characterizes health plan-
ning. The functions of general state planning are:
provision of generalized intelligence to the executive and
the legislature; coordination Of the planning of departments
and agencies; and the development of plans and programs.
Close cooperation must exist between the planning staff and
those responsible for planning within the individual
operating departments. John Dyckman iterates,

This cooperation is at the heart of comprehensive
planning. The idea of "comprehensiveness" is
hierarchical. Planning, as an activity, becomes
more comprehensive as it cuts across or embraces
more departments Of government and its ability to
be truly comprehensive increases as it moves up
the ladder of authority.12

The same reasoning held true for the location of the
"a" agency. Four Options were immediately Open to the
states at the time of the bill's passage. They could

designate the state health or health and welfare department

as the state Comprehensive Health Planning agency. The "a"

51

agency could also be established as a unit in the executive
office of the governor. The law also allowed the single
state agency to be an interdepartmental commission. The
final Option was the establishment of an independent agency.
John Gardner, then Secretary of Health, Education and Wel-
fare, requested each governor to perform the designation,
the initial step in the organizational process. The
choices that resulted were dependent on parameters such as
the previous existence of a state planning agency and the
level of fragmentation of the states' health programs.
Where a state planning agency existed, the health planning
function was generally placed there, whereas the public
health department was chosen when it administered the
majority Of public programs.

During the first two years of the Partnership for
Health, state CHP agencies were designated in all fifty
states, the District of Columbia, American Samoa, Guam and
Puerto Rico. In twenty-nine of the states and the District
Of Columbia, governors placed the Comprehensive Health
Planning function in their state health departments. In
sixteen states, it became a division in the governor's
office--generally in the state planning agency, the
department of administration or the budget office. In five
states, the interdepartmental commission was chosen.

TO assist them in their decision making, the Council
of State Governments forwarded a letter to the Governors,

discussing some of the aspects of agency placement. It was

52

stated that the organization and location of the Comprehen—
sive Health Planning agency in state government must be
conducive to effective Operation. At a minimum, this must
include representation and inputs from all relevant
interests in the health system and the establishment Of
close relationships to federal and other state agencies
and regional organizations. The necessary ingredients for
an effective planning process include: prestige and
prominence through close alignment with the governor's
Office; the authority to surmount interdepartmental
barriers; planning knowledge and capability; and an
inherent mechanism for implementation of recommendations.13

The placement of the "a" agency in an Operating
department such as the state health department, has the
obvious advantage of a built-in knowledge of medical
affairs. However, a conflict Of interest, competing for
resources and time, between the planning process and the
daily provision of services which an Operating department
must supply can easily be envisioned. Moreover, the role
of CHP involves both public and private spheres of
influence. Traditionally, operating departments, such as
health have dealt with public affairs, and due to their
regulatory function, may have strained relations with the
private sector.

An interdepartmental commission, composed of the

directors of several departments and divisions, although it

53

may provide the comprehensive viewpoint, simultaneously
lacks the cohesive unity necessary for implementation.

Placement in a state planning agency can narrow the
sc0pe Of the "a" agency. Although its function is policy
planning, contact with the daily problems is essential in
policy formulation. Moreover, the large staff needed to
provide expertise in all state planning aspects would make
it difficult to aggregate that number of skilled
specialists.

The placement of the "a" agency in the executive
Office of the governor has many obvious advantages. Pres-
tige and public interest would result. State monetary
budget allocations are made in the executive office,
enabling health affairs to be closer tO-the resource alloca-
tion source. Interaction of CHP with other types Of
planning is made possible by its central location and
neutral ties to any particular department. Finally, loca-
tion in the executive unit enables a close symbiosis to
exist between the governor and the "a" agency. The former
would have immediately at hand all the pertinent information
needed for efficient decision making and the latter would be
in a position of power regarding implementation of their
policies through the governor's influence with the
legislature, executive orders, etc.

As always, there is another side to the coin.
Location in the executive office can also be too flexible,

too independent. It would be easy for the "a" agency to

54

virtually ignore the other agencies with which it must work
and which are crucial in implementation procedures. More-
over, close ties to the governor can place the CHP agency
tOO much in the political spotlight. Since the chief
executive may change every four years, and directors are
appointed tO represent the views of the governor, the
policies and procedure of the "a" agency could lack essen-
tial continuity and stability. Finally, the location in
the executive Office can be too personality-oriented.
Dependence on the governor's own interest in health and his
relationship to the legislaturecould mean that the "a"
agency would experience some stagnant periods.l4
By 1970, administrative issues had been resolved
enough so that all the eligible jurisdictions except Nevada
had innovated and begun conducting statewide planning
prOgrams. However, the progress from organizational stages
to substantive planning did not prevent continuing shifts
in the administrative location of the "a" agency. Within
two years, the number of planning agencies in health
departments had risen from twenty-nine to thirty-five, the
number in the governor's office had fallen from sixteen to
eleven. Six states located their Comprehensive Health
Planning offices in state planning agencies. The original
five interdepartmental commissions were reduced to one
(Louisiana), and whereas no independent agencies had
initially been established, by 1970 Arizona and Michigan

had chosen this alternative.15

55

One reason for these changes in the administrative
location of the state CHP agency is attributable to the new
wave in state executive reorganization. Twelve states
underwent major or substantial reorganization between 1965
and 1972, due to an expansion of state functions in
response to federal-aid programs and the reappraisal of the

16 As a result of

state role in the "creative federalism."
Michigan's general reorganization limiting the number of
total departments or California's superagency groupings or
the establishment of new departments in many states for
transportation, human resources, environmental quality and
other recent concerns, health planning has reflected these
changing trends. As Hall so aptly states,
Even more than the health administrator, the planner
has sought to insulate himself from the vagaries and
hazards of the political process. To minimize inter-
ference with his work, he has experimented extensively
with the organizational chart to find an administra-
tive location with the utopian combination of
proximity to the source of power as well as indepen-
dence from "politics."17
In order to resolve the debate of location and to
determine the relationship of the quality of planning func—
tions with the location of the health agencies' placements,
a survey under the aegis of the Health Services Research
Center Of the American Rehabilitation Foundation was con-
ducted in 1969. Four variables were analyzed in a chi-
square test of association: relative contribution of

factors to the goal-setting process; the proposed solutions

to health problems which were identified; the factors that

56

demand the greatest staff time; or the problems it antici-
pated could be handled by the 314(b) agencies. The same
responses were most frequently given, regardless of agency
placement. The survey suggested that there appeared to be
no association between agency placement, whether health
department, governor's Office or interdepartmental commis-
sion, and the goal-setting processes or health problems
identified by the states.18
As of July 1, 1972, over one-half Of the states
(26) had placed the "a" agency in the state health depart-
ment, eighteen were in the governor's Office or state
planning agency, eight were in health and welfare or human
resources departments and four were either independent or
interdepartmental. This picture is still changing. Doubt-
1ess, agency placement will continue to be flexible in
order to best serve the needs Of a particular state. This
flexibility is the strength envisioned by the law-makers

in creating the original document.

The Areawide Agency

 

The complexities that arose during the organiza-
tional phases of the "a" agencies also beset the "b"
agencies. There had been previous experiences with local
health planning due to health and welfare councils
instituted by local social work organizations and due to
the administrative type of planning practiced by Hill-Burton

advisory councils. However, planning of the broad,

57

comprehensive sc0pe called for by the bill was outside the
expertise of any of these groups. One of the problems
facing the "b" agencies was the lack of specification as to
what such an agency was. According to the law, "any . . .
public or nonprofit private agency or organization" could
receive project grants of up to 75 percent Of costs. A
glimpse through a directory Of such agencies shows the great
majority of these to be private nonprofit groups. Many Of
these sprung up in response to the law, although some had
existed previously in other guises. Several organizational
alternatives were available to qualify for the "b" grants.
Health planning could be built into the framework of an
existing regional planning agency, a new agency could be
established, or the responsibilities of an existing county
health department, health planning agency or voluntary

organization could be expanded.

Selection

 

The ramifications of alternate selections were
explicated in a health planning manual for local officials.
The most widely chosen alternative, the organization of a
new agency, has the Obvious advantage of being specifically
designed to implement Comprehensive Health Planning Objec-
tives without additional commitments. Its organization can
be geared directly to its regional needs, and its resources

devoted to its sole purpose. The equally obvious

58

disadvantage is the time required to begin establishing such
an agency without a previously existing base.

The second alternative is to designate a council Of
governments, regional planning council or economic develop-
ment district as the "b" agency, by appointing a section as
the health planning division. Such a selection provides an
existing organizational foundation, relates CHP to other
physical, social, and economic development and provides a
quasi-governmental tie to assure funding. However, care
must be taken to avoid inhibition of private participation
in such a governmentally-oriented program. If the existing
agency lacks effectiveness, the CHP function will suffer
equally. And the emphasis on its original planning purpose,
combined with lack of health planning experience, may
belittle the health aspect.

Expansion Of existing health departments have the
same pros and cons as their state counterparts: experience,
personnel, knowledge and coordination versus limited view-
point, service orientation and a government base.

Use of an existing health planning agency provides
the necessary base, but this is Often specific and limited
in sc0pe, and tends to be regulatory and provider-oriented.

The existing framework Of a voluntary agency also
provides a base, but one which tends to concentrate on the
previous area Of expertise.19

All of these alternatives are bounded by the needs,

concerns, and individual situations of a region. The

59

legislators Of P.L. 89-749, realizing that a wide variety of
interests and organizational frameworks characterizes this
large nation, deliberately inserted the flexibility neces-
sary to fit all these circumstances.

By 1966, the year of the bill's passage, there was
a total of 80 agencies around the nation. By 1972, this
figure had more than doubled; from 198 areawide agencies,
69 were in the organizational phase and 129 were already at
the planning stage. Every major metropolitan area had a
"b" agency serving it, and every state except Rhode Island
had at least one such agency. More than half the population
in the United States lives in an area served by a regional
agency. The boundaries circumscribed by an areawide agency
range from one county to thirty-two; most are multi-county

regions.

Functions

 

The stated purpose of the "b" agency, according to
the law, is ". . . developing (and from time to time
revising) comprehensive regional, metrOpOlitan area, or
other local area plans for coordination of existing and
(planned health services, including the facilities and
services required for the provision of such services . . ."20

Like their predecessors, the Hill-Burton councils,
areawide CHP agencies have tended to concentrate on the last

phrase cited above. Substantive planning seems to have

focused on the review and comment responsibilities of the

60

"b" agency. This refutes the purpose of P.L. 89-749 which
was "an attempt to promote positive planning, that is,
planning to meet pe0ple's needs, rather than to put a check

on hospitals' capital decisions."21

CHP aimed at creating
regional agencies concerned with medical services, preven-
tion, environmental health and manpower as well as
construction. Yet, as Stebbins says, "Planning under CHP
auspices has tended to focus on facilities . . . 'a' and
'b' agencies have developed standards and guidelines to be
used in planning new facilities or renovating or relocating
existing facilities."22
With the original passage of P.L. 89-749, CHP
agencies were called upon to comment on proposals for the
expenditure of certain federal funds, but this function was
not viewed as a major responsibility. However, review and
comment activities were expanded with the passage of
P.L. 92-603 (October 1972) which requires review Of capital
expenditures which (1) exceed $100,000, (2) changes the bed
capacity of a facility by such an expenditure, or (3) sub-
stantially changes the services offered by a facility by
such an expenditure. Thus, the review and comment respon-
_sibilities of both "a" and "b" agencies have greatly
expanded, Often to the detriment Of other planning
functions. However, in a number of states, the responsi-

bility devolves especially on the areawide agencies, since

they have the responsibility for undertaking review and

61

comment on numerous federal programs as well as review Of
projects under the above certificate of need legislation.
Federal prOgrams calling for CHP agency review now
include alcoholism, communicable disease control, mental
health centers (staffing and construction), mental retarda-
tion facilities, family planning, health maintenance
organizations (HMOs), Hill-Burton projects, migrant health,
drug abuse, Regional Medical Programs, student loan
forgiveness, venereal disease control, state public and
mental health plans and federal health facilities (VA

3 The recommendation Of the areawide agency

hospitals).2
is passed on to the state for final approval, but such
approval is Often routine, since the "b” agency is the most
closely involved with the local situation and thus must
accept the major portion Of responsibility.

Other functions which are included in the compendium
of regional agency activities are similar to those of the
state, but on an areawide scale. Provision of assistance
to institutions, agencies and groups in developing planning
mechanisms as individual service providers constitutes the
technical assistance aspect. The areawide agency is also
responsible for collective planning in relating the health
’programs within the regional framework.

Substantive planning involves the formulation Of

goals and policies for improving the existing system in

providing physical, mental, and environmental health

62

services and designing programs on varying time scales to
attain these objectives.

The provision of liason and informational services
to the public and apprOpriate interest parties includes
advising on legal and research topics. Periodic evaluations
are another mandate Of the law. Assistance in the local
implementation of state programs comprise yet another
responsibility. Aside from state-coordinated data systems,
"b" agencies must conduct special studies Of particular
health problems in the area, and determine by surveys,
factors peculiar to the region in terms of environmental
hazards, socioeconomic characteristics, financial, organi-
zational and jurisdictional impediments to effective
resource use. The number and nature of health services,
facilities and manpower available in the area, as well as
potential sharing with adjacent regions is also the respon—
sibility of the regional agency.

The areawide agency is also mandated to involve
public and voluntary health related organizations through
consensus and mutual communication. This communication
extends to its governmental counterparts.

For the first time, there is a direct relationship
not only to the state but to the federal government.
Formerly such a relationship existed only with the state as
intermediary. The direct interaction is symbiotic--the
federal government is relieved of the onerous review tasks

involving its multiplicity of programs, while simultaneously

63

ensuring that regional federal programs are consistent with
the health needs of the locality. The "b" agency, in turn,
receives its financial support from Washington.

The relationship of the areawide agency to its state
counterpart is less succinct. Its foundation lies in
voluntary cooperation, with the state allowing room for the
"b" agency voice in its schema, and the areawide agency
making the effort to become involved in the larger picture.
Activities particularly ripe for OOOperative efforts
include health legislation development. Here the "b"
agency is best suited to judge the influence of state legis-
lation on the total picture. In turn, the "a" agency has
the responsibility for keeping their local counterparts
advised of legal trends, in order that the latter can make
pertinent decisions.

Recruitment and training programs also provide
Opportunities for cooperative endeavors, since manpower can
be trained and facilities shared to provide for the needs
Of both state and regional agencies. Collection and use of
data is another obvious area for mutual cooperation.

Similar data types collected on a broad geographical basis
create a uniform information foundation, from.which particu—
lar statistical requirements can be derived. With the

state directing the type, scope and depth Of data needed,
and the areawide agencies performing the actual compilation,
the former difficulties of mismatched data bases on

incompatible scales can be overcome.

64

The Advisory Council

 

Advisory councils play an important role in both the
state and areawide Comprehensive Health Planning agencies.
P.L. 89-749 calls for the "a" agency to

provide for the establishment of a State health plan-
ning council, which shall include representatives of
State and local agencies and nongovernmental organi-
zations and groups concerned with health, and of
consumers of health services, to advise such State
agency in carrying out its functions . . . and a
majority of the membership of such council shall
consist Of representatives Of consumers of health
services.24

The actual composition of membership is left to the
discretion of the state, but a typical roster might include
commissioners Of public health, mental health, labor,
economics, public education and other related fields.
Physicians, dentists, nurses, pharmacists, hOSpital adminis-
trators, and medical educators would also be appropriately
placed on the board. Representatives of local health
agencies, voluntary organizations and manpower training
would be included. Consumers could be divided by Sphere of
interest in health services to labor, schools, welfare
recipients, mentally retarded, or by type of activity, such
as mental health and environmental hazards. The remainder
needed to fulfill the majority seating could be appointed
at large. Such appointments are generally named by the
state's chief executive for a term of office. Members of

the state CHP council serve without pay and meet at regular

intervals during the year.

65

The council makes its tasks manageable by dividing
into committees and tasks forces. Functional areas
generally include health facilities, manpower, services,
finance and environment.

The Advisory Council of an areawide agency Operates
in much the same manner. Council membership consists Of
similar categories Of representation from government and
consumer interests. However, in addition to functional
representation, regional councils must also reflect repre-
sentation by population distribution. Executive committees
maintain the consumer majority; task forces, subcommittees
and technical advisory committees need not.25

The problem facing both state and areawide advisory
councils is the task of recruiting interested, aware and
knowledgeable representatives. Because health is largely
a technical field and consumers must work with experienced
health professionals, they may Often feel at a disadvantage
regarding expertise. Having majority standing is not
effective if consumers feel inhibited in exercising their
voice. For this reason, some states have initiated orien-
tation programs for consumer members, introducing them to
vocabulary, rules and processes Of health planning. This
may somewhat alleviate the handicap burdening novice
consumer representatives.

Still another detriment tO efficient Operation
involves the time commitment needed by representatives.

Glances at several areawide council rosters shows that a

66

majority of consumer representatives are non-working women,
while most health providers are men. While this may not be
representative of areawide councils at large, it seem safe
to surmise that scheduling creates an imbalance. Holding
meetings outside of working hours should alleviate this
condition.

Combining a population representative with the
necessary functional requirements can also pose difficul-
ties for an areawide council. Care must be taken to create
a council large enough to absorb both representatives by
functional category and at-large consumers to represent
geographical areas.

A review of the literature suggests that the Compre-
hensive Health Planning Councils which consist of an
organized body Of intelligent citizens, laymen, and profes-
sionals, have far-reaching effects on health in their area.
Although the health planning councils are not regulatory or
funding agencies, but are advisory in the real sense, the
inherent power Of a properly constituted and functiOning
group is in little doubt. The intent of the law dictates
that the judgement of the councils is a valued input into
the decision making process. The state council's responsi-
bility lies in designing the overall health plan for the
state. The regional council's duty is to fit the pieces for
its region into the state plan. The cooperative endeavor

called for by CHP must also exist here.

REFERENCES TO CHAPTER IV

1James H. Cavanaugh, Discussion Comment in "Partner-

ship For Planning," by William H. Stewart. Extensions of
Remarks before the National Advisory Health Council,
November 28, 1966. (Mimeographed.)

2Ibid., p. 7.

3U.S. Congress, Public Law 89-749: Comprehensive

Health Planning and Public Health Services Amendments Of
1966, 89th Congress iWashington, D.C.: U.S. Government
Printing Office, 1966), p. l.

 

41bia.

5Ibid., pp. 1—2.

6William H. Stewart, The Report of the House Com-
mittee on Interstate and Foreign Cofihercé (Report NO. 2271
to accompany H.R. 18231), October 133 1966, p. 11.

 

7U.S. Senate Committee on Labor and Public Welfare,
Report No. 1665 to accompany S. 3008, September 29, 1966 and
House Committee on Interstate and Foreign Commerce,
Report of House Committee, p. 11.

 

8Harry S. Mustard, The Government in Public Health
(New York: Commonwealth Fund, 1945)7’p. 103. ”7

 

9Milton I. Roemer, "Controlling and Promoting
Quality in Medical Care," in Health Care, Clark C. Havig-
‘ hurst, ed. (Dobbs Ferry, New Yofk: Oceana Publications,
Inc., 1972), pp. 67-68.

 

10Herman E. Hillboe, "Administrative Requirements for
Comprehensive Health Planning at the State Level," American
Journal of Public Health 58,6 (June 1968):1044.

 

 

67

68

11Avery M. Colt, "Elements of Comprehensive Health
Planning," American Journal Of Public Health 60,7 (July
l970):ll96.'

 

12John W. Dyckman, "State Development Planning:

The California Case," Journal of the American Institute Of
Planners 30,2 (May 1964)?146.

 

 

13Elaboration of points taken from a special letter
to the Governors, discussing the location of the "a" agency,
written by Brevard Crihfield, Executive Director of the
Council of State Governments, n.d. Zerox reproduction.

14Elaboration of points stimulated by Brevard
Crihfield and Jay Endsley Of the Michigan Office of Health
and Medical Affairs.

15The above discussion is summarized from the
results of a survey Of state CHP agencies undertaken by the
ARF and authored by Nancy N. Anderson, Comprehensive Health
Planning in the States: A Study and Critical AnaIysis
(Minneapolis, Minnesota: Institute for Interdiscipiinary
Studies, American Rehabilitation Foundation, December 1968),
pp. 5-8.

 

 

16George Bell, "The New Wave in State Executive
Reorganization," State Planning Issues '72 (Council of State
Governments and CounéilOi'StatefiPlanning Agencies, March
1972). PP. 62-63.

 

17Thomas L. Hall, "The Political ASpects Of Health
Planning," in Health Planning: Qualitative Aspects and
Quantative Techniques, Wi11iam A. Reinke,ed.i§altimore,
Maryland: The JOhns HOpkins University School of Hygiene
and Public Health, Department of International Health,
1972), p. 74.

 

 

18Donna Anderson and Nancy N. Anderson, Comprehen-
sive Health Planningin the States: A Current Status Réport
. iMihneapolis, Minnesota: Institute fofiinterdiscipiihary
Studies, American Rehabilitation Foundation, July 1969),
pp. 9-15.

 

 

19National Association Of Counties Research Founda-
tion, Comprehensive Health Planning: A Manual for Local
Officials IWashington, D.C., an.), pp. 24-26.

 

 

69

20U.S. Congress, P.L. 89-749, p. 3.

 

21Barbara and John Ehrenreich, The American Health
Empire: Profit and Politics (New York: RandOm House, 19707,
pp. 194-95.

 

 

22Ernest L. Stebbins and Kathleen N. Williams,

"History and Background Of Health Planning in the United
States," in Health Planning: Qualitative Aspects and
Quantitative Techniques, William A. Reinke, ed. (Baltimore,
Maryland: The JOhns Hopkins University School of Hygiene
and Public Health, Department of International Health,
1972), p. 12

 

 

23U.S. Department Of Health, Education and Welfare,
Health Services and Mental Health Administration, The Review
and Comment Responsibilities of State and Areawide Compre—
hensive Health Planning Agencies (Washington, D.C.: U.S.
Government Printing Office, May 1973).

 

 

 

240.8. Congress, P.L. 89-749, p. 3.

 

25Extrapolated from the Secretary of State of
Kentucky, Executive Order 68-474, Frankfort, Kentucky,
June 14, 1968, Working Document. (Mimeographed.)

 

CHAPTER V

THE HEALTH PLANNING PROCESS

It would probably be a fair assessment to say that
many Of the health planning techniques used now were for-
mulated as a result of the passage of P.L. 89-749. Because
of the mandate for comprehensive health planning, there
opened a ready market for competent professional health
planners, and schools of public health took up the
challenge of filling the educational void. Previously,
those involved in health planning were largely public
health professionals, whose viewpoint was rather special-
ized, and a sprinkling of public administrators and planners
who extrapolated the general planning process into the
health field. With the advent of comprehensive health
planning legislation and the necessity for its rapid
implementation, researchers went to work to devise some
principles that would aid those involved in such a complex
endeavor.

The few health planning textbooks that exist have
maintained the general planning process phases: identifica—
tion of health needs (study design), inventory of health

resources (data collection), consideration of alternative

70

71

courses of action (analysis), development of recommended
priorities (goal formulation), implementation and evalua-

tion.

The Planning Process

 

The on-going, cyclical aspect of planning has
always been emphasized in theory. Cavanaugh succinctly
states, ". . . it is not with decision making itself that
Comprehensive Health Planning is concerned, but rather with

the process of decision making."1 In A Manual for Health

 

Planning, it is defined as "a dynamic process, a means to

 

an end, which is concerned with identifying problems,
considering alternatives, and making decisions about future
actions . . ."2 Kissick considers this realization to be
of great significance.

. . perhaps the most valuable lesson we have learned
is that it is the planning process that is of para—
mount importance. . . . A rigid, inflexible, "perfect"
planning system§ or a master plan is not what we want
in health . . .

Reinke presents a schematic framework of the plan-
ning process by placing "mission" at the tOp of the chart,
then proceeds downward to goals, objectives, functions,
targets, programs and procedures and instruments, each
being the offshoot Of the phase above it. He explains this
verbally.

Planning initially requires the identification of
health problems as major deviations from broad goals
and Of the causal and contributing factors associated

with the problems. Second, alternative plans of
action are specified in the light of imposed

72

constraints. Particular courses of action are
selected from among the alternatives on as rational
a basis as possible. Objectives are then assigned
to appropriate points in the plan of action along
with the activities (procedures) and resources
(instruments) required . . .

Facets of this health planning process are hardly
original to Comprehensive Health Planning. Planning
elements have been included in health activities for many
years. Program development planning has been a significant
function of public and private Operating agencies. However,
program planning is typically a linear process rather than
cyclical, and has resulted in limited evaluatory feedback.
Resource allocation decisions have traditionally been made
based on budgetary considerations and categorical program-
ming. Baker cites the advent of the planning-programming-
budgeting concept as permitting a new rationality for
allocating resources based on broad, defined and consistent
public policies. Program evaluation, assessed against
health Objectives, has long been a part of traditional
health planning. This evaluation has been on a one-to-One
basis and technical in nature. Only, recently have cost-
benefit analysis and other techniques enabled a more
sophisticated approach.5

Anderson identifies other principal features of
previous planning programs as promotion and education of
health principles, action-planning on a problem-by-problem

basis, coordination and technical advice, including data

collection.6 These tasks are still inherent in

73

Comprehensive Health Planning. However, there has come to
be a redefinition of terms. Coordination is now emphasized,
including citizen participation. Program planning has
shifted to policy planning. Resource allocation continues,
but on a broader, more SOphisticated level. These three

elements Of CHP will be examined separately.

Coordination

 

Coordination involves the distribution of resources
among a fixed vertical system, national, state, and local
strata. Within each of these is a horizontally organized
system, which Operates by function (health, education,
housing) or by clientele served (age, problem, income).
These complex components are also interrelated, with over-
lapping workloads and a conglomerate of activities relevant
to the solution of a single problem. The purpose of coordi-
nation is to bring these services into better harmony
without reducing autonomy. Thus, the triple thrust of
coordination is to reduce the duplication of agency
activities which perform similar tasks, to enhance inter-
agency communication and to create a central repository
of information.7

Federal guidelines for coordinative activities Of
the CHP agencies specify the identification of health
related organizations and planning bodies and the establish—
ment of COOperative relationships. A strategy for planning

coordination in the state is encouraged, focusing on

74

eliminating duplication of planning effort and filling gaps
in existing activity. The respective roles and responsi-
bilities of the state and areawide health planning agencies
are included in the delineated strategy. Organizational
links and regular channels of communication and mutual
input are major elements in coordinative planning. Recog-
nition of conflicts Of interest in both public and private
spheres and reconciliation of these are equally important.
Coordination within and between subsystems works in two
ways, by agreements and joint planning. Coordination by
agreement, according to Anderson, can accomplish only a
limited degree of change, usually by instituting something
that did not exist before. Since it is based on estab-
lishing consensus among its participants, who are Often
providers, the influence Of such cooperative planning is
limited to what can be accomplished through persuasion and
project funds. Such measures are insufficient to enact
the removal or change of Obsolete or inefficient programs
and facilities. The major advantages of this type of
planning lie in its emphasis on encouraging grass roots
action on cooperative endeavors toward a common goal under-
taken by those who provide services. Disadvantages exist
in terms of its piecemeal approach and its assumption that
existing prOgrams can be maintained without major altera-
tion.8

This lack of power to enforce recommendations which

are Opposed by affected members can also distort joint

75

planning, which operates similarly on the governmental
level. Mary Arnold poses this as a system malfunction.

Coordinative planning . . . implies that there should
be coordination of the action of two or more organi-
zations . . . so as to increase availability of
scarce resources or to enhance the impact of several
organizations' actions. Thus there is an implied
larger system consisting of the input and output
constituencies of the particular set of organizations
concerned with coordination. In this case, however,
the larger system is merely the general arena in
which a particular set of organizations operate and
not the total social environment. This type of
planning generally falls into an information

exchange and mutual adjustment process. The autonomy
of each subunit of these sets Of organizations is

not questioned. . . . Public Law 89-749, the Partner-
ship for Health Program, is an attempt to develop
coordinated community, local and state plans for
allocating resources to meet the health needs of

each area, but there is no plan for the larger system
planning that is tied directly to this.9

The conclusion to be drawn seems to point to the
fact that coordinative planning, pg; fig, is not a sufficient
means of implementing or enforcing effective action.

Relying on common agreement to induce change may result in
nothing more than a harmonious maintenance of the status

quo.

Policy Versus Program Planning

 

There has not been a great controversy over the
question of whether Comprehensive Health Planning should be
problem or long-range planning, policy or program-oriented.
It is generally accepted that its prOper role lies in the
sphere of the continuous and broad, leaving concrete

specifics to the Operating agencies. Moreover, it has

76

generally been agreed that the initiation of such policy
belongs in the hands of the public. As Baker states, "A
citizen participatory planning process is essential to
assist the develOpment Of unified policy."lo An assessment
of societal values and needs serves as the guide to accept-
able statewide policy for both public and private sectors.
Arnold presents this, not only as a question of efficacy,
but of ethics. ". . . the problem of the apprOpriateness
Of goals or Objectives is an ethical or value problem,
which is not amenable to rational analysis. Therefore, the
choice Of goals and Objectives is left to the political
process of obtaining consensus . . ."11
Once policy goals have been formulated, methodol-

ogies for problem-solving in a policy-planning context must
be devised. If the emphasis is away from short-term crisis
conditions, there is danger that a policy would be so
aloof as to be unresponsive to the concrete realities Of
chronic problems, or immediate priority needs. The Work
Program, FY 1973, of the Michigan "a" agency reflects this
concern.

Comprehensive health planning has been viewed as a

dynamic process resulting in a series of problem

specific—ahaiy§es as opposed to static plan docu-

ment. We clearly recognize, however, that the

ultimate success Of these efforts is heavily depen-

dent upon the extent to which . . . crises are

addressed within a rational, overall framework.12
Baker affirms, "If the planning cycle is to . . . respond to

the complexity of our social planning challenge, it must

also accomodate both long and short-range planning efforts

77

. . it must be convertible to both program level and
policy level planning activities."13

Criticism has been leveled at CHP agencies for
dealing with areas which theorists feel are out of bounds.
With the confusion over the definition of CHP, the pressure
for immediate results and public scrutiny, agency directors
have found it easier and more dramatic to neglect long-
range interests for responsive planning. Such activities
are prOper only when carried within recognized parameters
and an acknowledged direction, as the Michigan agency
realized.

The type of planning which deals with policy versus
Operational planning has been termed managerial planning.
In her study of the "a" agencies, Anderson cites management
information systems, priority setting, budgeting processes
and resource distribution as the major functions of this
form of planning. The authority in this type of organiza-
tion is derived from close ties to policy makers and
elected officials, to whom the planning agencies make
recommendations. Using administrative and budget tools
such as information systems, planning-programming-budgeting
techniques and cost effectiveness analysis, management
planning can deal with longer range problems and consider
policy issues on a broader base than can coordinative
planning.

Since managerial planning places more emphasis on

a health systems approach, it attempts to consolidate

78

resource and production units, reducing duplication of
services and covering gaps, particularly in areas where it

exerts funding approval authority.l4

Resource Allocation

 

According to the EncyclOpedia of the Social Sci-

 

ences, allocation is the division of limited resources among
competing claimants. It involves a policy choice of the
same resources among welfare goods, i.e., health, education,
housing. The question of allocation within a single social
sector, such as health has traditionally been dealt with
by functional domain, that is, health has been the concern
only of health programs, and health programs have dealt
only with medical factors.15
According to Baker, the process Of planning-

programming—budgeting has been a major cause for change in
health planning.

Resource allocation decisions, particularly within

the governmental sector, have historically been

based on a line item budget defining categorical

programming needs and expectations . . . the advent

of a planning-programming—budgeting concept . . .

has had a significant impact on the health care

system . . . 6

This radical concept is true not only for planning

within the domain Of P.L. 89-749, but for the passage of the
bill itself. Rethinking the traditional categorical and
project grants resulted in the flexible block grant that

enables each state to use its own PPB formula. The point

of major importance is not only the efficient allocation Of

79

resources within the health planning sector, although this
is a primary function Of CHP. However, the integration of
CHP with other state plans and the efficient use of
resources on a state-wide, multi-function basis is another,
Often neglected aspect. Without such consideration, diffi-
cult as it may be to implement in the bureaucracy of state
government, there is no possibility for fulfillment of the
term "comprehensive" or Arnold's total environment. The

Program Policy Guidelines for FY 1975-76 for Michigan

 

indicated this realization.
A review of the current situation in Michigan indi-
cates that virtually every public and private agency
concerned with health performs health planning . . .
utilizing different data sources, different resource
allocation procedures, and self-maximizing objectives
. . . many of these agencies have conflicting priori-
ties Or are competing for limited resources. The
resulting dilemma is . . . that there are no univer-
sally acknowledged criteria for determining the best
resource allocation . . .17
The supposedly rational process of planning, without
such criteria, can devolve into a strategy of relative
values and self-aggrandizement. One of the major pitfalls
has been the lack of a common data base. Since decisions
are based on information, it is obvious that different
facts will lead to different decisions. Information can
be distorted by being outdated, by a non-cohesive geographi-
cal Or population base or by non-consistent variables.
Areawide agencies have had to begin from scratch to create

a compendium of health statistics based on their own unique

geographical region. It is obvious that resource allocation

80

decisions will become more coherent when supported by a firm
foundation of knowledge, the collection Of which has become
the function of CHP.

Another means for controlling resource allocation
decisions is to put certain decisions directly into the
hands of the agencies. The original passage of the bill
called for a minimum review and comment role, but subse-
quent amendments have greatly expanded it. The most recent
expansion of this activity came with P.L. 92-603, 1972,
which requires review of capital expenditures. Both state
and areawide agencies are called upon to accord approval
or rejection for a wide variety Of other state and federal
projects.18

The major way in which CHP agencies effect their
resource allocation is regulatory planning through review
and comment. This type Of regulatory planning Offers an
administrative mechanism for accomplishing planning controls
with veto power over the constituents. By placing a
boundary on performance standards to ensure minimal compe-
tence or coordination, regulatory planning Opts for a
negative role instead of creative input. The type of
planning also fails to include all but a certain segment of
the private health sector. With such a limited scope and
limited participation, regulatory planning should only be a
partial function of the total CHP picture. Moreover, it
can prove a heavy burden to the limited resources Of the

agencies themselves, draining time and manpower away from

 

81

corallary planning activities. CHP should be more than a
clearinghouse for health facility construction and grant
applications.

With a diversity of roles Open tO them, state and
areawide agencies have been able to Opt for any combination.
In practice, the ARF survey showed that such a combination
of coordinative, managerial and regulative planning
actually did occur. The organization and planning of the
agency seemed to be the primary accomplishment, especially
in terms Of deriving a philOSOphic process for comprehensive
health planning. Establishing a working relationship with
public and private agencies, citizens and professional
groups was also a widespread achievement. The creation of
task forces, preparation of legislation, public education
and information about CHP, staff training, review and
comment were other functions which were seen to be vital
functions by the agencies.

These tasks were able to be realized because of
P.L. 89-749. In the next chapter, those shortcomings Of

the law which inhibited progress will be explored.

 

REFERENCES TO CHAPTER V

1James H. Cavanaugh, "Past, Present and Future
Goals and Philosophy in Comprehensive Health Planning,"
Paper presented at the Conference on Comprehensive Health
Planning, American Hospital Association, Chicago, Illinois,
October, 1968.

2Anna B. Brown and Vlado A. Getting, A Manual for

Health Planning, Michigan Community Health Services Study
NO. 6*(Ann Arbor, Michigan: University of Michigan, School
of Public Health, 1969), p. 1.

 

 

3William L. Kissick, "Planning, Programming and
Budgeting in Health,"-Medical Care 5,4 (July-August 1967):
203.

 

4William A. Reinke, "Overview of the Planning
Process," in Health Planning: Qualitative Aspects and Quan-
titative Techniques, William ATTReinke, ed. (BaItimoré,
MaryIand: The Johns Hopkins School of Hygiene and Public

Health, Department Of International Health, 1972), p. 67.

 

 

5Frank Baker, "Comprehensive Health Planning,"
State Planning Issues (March 1971), p. 78.

 

6Nancy N. Anderson, Comprehensive Health Planning
in the States: A Study_and Critical Analysis TMinneapolis,
Minnesota: Institute for Interdisciplinary Studies, American
Rehabilitation Foundation, December 1968). PP. 17-18.

 

 

7Martin Rein, "Welfare Planning," International
Encyclopedia of the Social Sciences, David L. 81115, ed.
v01: 12 (New York: Macmillan CB. and the Free Press, 1968),
pp. 142-53. ‘

 

8

 

Anderson, Health Planning, pp. 21-22.

82

 

83

9Mary F. Arnold, "Philosophical Dilemmas in Health
Planning," in Administering Health Systems: Issues and
Perspectives, Marth71ArnOld et'a1., eds. TChicago: Aldine-
Atherton, I971). p. 211.

 

 

loBaker, "Health Planning," p. 78.

11Arnold, "Dilemmas in Health Planning," p. 210.

leichigan Department of Management and Budget,
Office of Health and Medical Affairs, Work Program, FY
1973-74.

 

l3Baker, "Health Planning," p. 79.

14Anderson, Health Planning, pp. 22-24.

 

15Rein, "Welfare Planning," pp. 142-53.

16Baker, "Health Planning," p. 78.

17Michigan, Program Policy Guidelines for the Fiscal

 

 

Year 1975-76 (April 1974). PP. 32-33.

 

18For a list of review and comment projects, see
Chapter IV.

CHAPTER VI

POSTSCRIPT

The purpose behind the preceding chapters was to
place comprehensive health planning in a setting, to state
briefly its purpose and need, to place it in historical
perspective, to list its contents and methods, to explicate
its process and techniques and to describe the workings of
P.L. 89-749, the first Comprehensive Health Planning legis-
lation in the United States. The purpose of this chapter
is to provide a critical assessment of CHP as it is cur-
rently practiced.

The purpose Of a critical assessment is not to
belittle the accomplishments of a law that had no precedent,
no previous expertise and no organizational base. That
P.L. 89-749 was ever passed is in itself no mean feat.

Such a passage reflected well on the insight of the legis-
lators and others responsible for its conceptions. Such
insight could not be all encompassing, however, and

P.L. 89-749, faced with high expectations, could not have
hOped to fulfill them.

The final phase Of the planning process is evalua-

tion. The bill itself provides for annual self-review by

84

 

85

the agencies. The federal government is undertaking an
assessment of CHP organizations.l Such evaluation is
particularly necessary for planning programs, where time-
frames are long and results may be nebulous. Accomplish-
ments may not be concrete or dramatic, thus hard to assess.
But the future is built on the past, and progress uses
steps carved out of corrected errors. In retrospect, the
entire Comprehensive Health Planning experience offers

invaluable lessons in the study of government in health.

Assessment of P.L. 89-749

 

The previous description of the organization and
methods of Comprehensive Health Planning has revealed some
Of the anomalies and weaknesses inherent in its current
structure and practice. Some of these were due to the
bill itself; others resulted in the way the law was applied.

One of the structural paradoxes of P.L. 89-749 that
became evident was contained in the Opening phrases of the
act. The mandate to coalesce both private and public
health services was immediately contradicted by the non-
interference proviso. Not only was CHP to refrain from
effective action in the private sphere, it was to coordinate
federal, state, and local public activities without an
administrative structure in which to operate. Although
federal review responsibilities later became expanded,
there was no central clearinghouse or guidelines for

implementing such coordination. Many health-impacting

 

86

federal and state programs contained no requirements for CHP
review. Therefore, all of the "comprehensive" coordination
that was to be exercised by CHP depended solely on volun-
tary cooperation. Without political authority or
enforcement clout, worked into the law itself, the coordina-
tive mandate of CHP has remained relatively ineffectual.
Ironically, an example of such an impediment to CHP is its
predecessor, Regional Medical Programs. Because it is not
state-based but regional, it is not responsible to state
executive Offices, including CHP. Nor is such responsi-
bility legally mandated. With greater funds at its
disposal, and with the corallary power, RMP's independence
from Comprehensive Health Planning restraints poses a

threat to the latter's effective functioning.

Other weaknesses contained within P.L. 89-749
itself involve lack Of definition. Nowhere did the bill
specify what "comprehensive" meant. Nowhere was "planning"
defined. "Health" was considered self-explanatory. As
was discussed in Chapter II, each word of the term
"comprehensive health planning" involves different par-
ameters and policies. Indeed, according to the present
system, the terms "comprehensive” and ”health" are mutually
exclusive; health means medical affairs and comprehensive
involves everything else. Without a redefinition Of the
term "health," the traditional boundaries of medicine

remain the paramount concern.

 

87

Further confusion arose due to the ambiguity of
"comprehensive." Although the law contained the words
"envirOnment," "education, welfare and rehabilitation,"
planners understood these to be examples of, and not
restrictions to health-impacting social functions. But
where did it stop? Interpretations could range from
traffic pollution to physical fitness programs. Without i

parameters to guide them, planners were innundated by a

 

mass Of potential applications Of the term "comprehensive," ' F
all of them needed, all of them feasibly the concern of

chp. Before substantive planning could even begin,

valuable time was spent deciding what the substance of the

planning should include.

"Planning" also posed a problem. The Hill-Burton
and RMP programs had federal planning guidelines delineated;
moreover, their content was defined and limited. Compre-
hensive Health Planning was not so fortunate, creating
further confusion and time lost to devising a sphere Of
operations, methods, and techniques.

The weakness Of P.L. 89-749 was compounded by
attitudinal difficulties arising from the lack of defini-
tion. First of all, the spate of enthusiasm which greeted
CHP was not yet tempered by the difficulties of implementa-
tion. The Optimism engendered by the act created high
expectations of reorganizing public-private health service
relations. Another hope was that of effecting a new

rationale, not only in administration, but of delivery of

88

health services. Without enforcement authority, without a
firm foundation of experience and knowledge, without a
settled administrative structure, and without the ability
to delve into the private sphere, an ambience of disil-
lusionment set in. Anderson makes this quite clear when she
cites "the 31 percent turnover of 314(a) agency directors
since the program's inception . . . (and) the transition in
titles (of articles) . . . from 'potentials of comprehensive
health planning' to 'problems Of comprehensive health
planning.”2
Another weakness confronting CHP involved the type

Of planning that was generally opted for. In Chapter V, it
was reported that the American Rehabilitation Foundation
identified three types of planning--managerial, regulatory
and cooperative, with the last most widely practiced. The
ARF report concluded,

It is unrealistic to expect providers of health ser-

vices to volunteer to close up an unworkable shop,

to give over responsibilities they have long regarded

as their own . . . or to phase out a program in order

that another may initiate it. . . . In summary, (chp)

based on the "cooperative planning" model offers

insufficient assurance that it can effect coordina-

tion, protect consumer interests, be broadly represen-

tative of all health concerns, or directly involve

the government policy makers.3

Yet a further problem resulted from the consumer

participation requirement. Laudable though such participa-
tion may be, those handicaps cited in Chapter IV remain

valid--consumers disadvantaged by lack Of technical

expertise, time for meetings and assessing reams Of data,

 

89

balance of consumer representatives by geography, area Of
interest and population group, and the difficulty of
removing the traditional preconceptions about health care.
These barriers could be removed with education, but the
need for such an orientation was not taken into account in

the law.

Recent Developments

 

Legislative action on comprehensive health planning
has not stood still since the passage of P.L. 89-749 in
1966. Awareness of some of the discrepancies in the law
led to an attempt to rectify these by "The Comprehensive
Health Planning and Service Act of 1970" (H.R. 18110).

The Report of the Committee on Interstate and Foreign
Commerce, the House body assigned to health matters, stated
that the principal purposes Of the proposed bill were to
extend and expand the original authorizations for grants.
The bill also provided the initial authority for the
development Of a cooperative federal, state, and local
statistics and information system to produce comparable
and uniform health data throughout the nation. The bill
further required representation of Regional Medical Pro-
grams on the state health planning advisory council. The
legislators commented,

The committee is aware that the question of the

proper relationship of Comprehensive Health Plan-

ning and other programs is of concern to all persons

engaged in health programs in the States. As the
program of (CHP) achieves greater strength in the

 

90

States, it is intended that closer coordination of

programs will result. For that reason, the commit-

tee will consider, as future legislation, in the

field of health activities . . . the prOper role

Of CHP in the direction of the new legislation.4
The report continued that the existing law did not specify
that state CHP plans provide for environmental health,
"although this was clearly contemplated by the original
legislation." Furthermore, although the state plan for
provision of public health services was required under
Section 314(d) to be in accord with the state CHP plan,
H.R. 18110 would add that the state plan be compatible with
the total health program of the state. The movement toward
a more specific, more powerful comprehensive coordination
was on the way.

This movement was assisted by a series of bills
expanding the basis for the review and comment function of
CHP. P.L. 90-174 created an amendment for state CHP,
requiring the state plan to make provisions for assisting
each health care facility to develOp a program for capital
expenditures for replacement, modernization and expansion
consistent with an overall state level. These review and
comment responsibilities did expand the base of comprehen-
sive health planning authority, although only in a negative
sense, through veto powers. Further attention was awarded
the CHP prOgram with P.L. 92-585 (1972) which mandated the
review and comment by CHP agencies, of Public Health

facilities utilization. Although the progress involved in

this law was minimal, the overt recognition by Congress of

 

91

CHP's role in monitoring health affairs strengthened its
position with related agencies. Another expansion of this
function occurred in 1972, with P.L. 92-603, which provided
for review of facilities requesting a certificate of need.
Subjecting applications to a scrutiny in the light of
regional needs meant that duplication Of services and over-
provision of bed spaces was avoided when a health facility
decided to modernize, expand or rebuild.

The realization that expansion of review and veto i
54-

 

powers was not sufficient to correct the deficiencies of
P.L. 89-749 was evidenced early. An attempt to patch up
the existing law without drastic change was accomplished by
amendment. The modifications made through Public Law
91-515, "The Heart Disease, Cancer, Stroke and Kidney
Disease Amendments of 1970," were disappointingly mild. It
called for a systems analysis of national health care plans
and cost-benefit studies for national health insurance, and
did implement the uniform health information survey for all
levels of government. However, in terms Of extending grant
authorizations for CHP, P.L. 91-515 amended only represen-
tation on the state council and inserted the phrase "and
including environmental considerations as they relate to
public health." The changes in representation did rectify
two anomalies that had occurred in P.L. 89-749. Section
220(b) called for representation of federal agencies, as
well as state and local, including a representative of a

Veterans' Administration hospital. Furthermore, a

92

representative Of RMP was specified to serve along with
"organizations concerned with health." Both of these
amendments were designed to answer charges that the federal
government refused to COOperate in coordinative planning.
Section 316 of the same act called for the estab-

lishment of a National Advisory Council of Comprehensive
Health Planning Programs. Members were to consist of
leaders in the fields of science, medicine, organizational
health care, officials in CHP agencies, state and local
officials in government or health and consumer representa-
tives. The duties of the Council were to

assist . . . in the preparation of general regula-

tions for, and as to policy matters arising with

respect to, the administration Of Section 314 . . .

with increased emphasis on cooperation in the

coordination of programs . . . with the . . .

Regional Medical Programs, with particular attention

to the relationship between the improved organiza-

tion and delivery of health services and the finan-

cing of such services . . .5

The recognition of the need for (1) a central

federal clearinghouse, (2) unified general regulations and
policy clarification, (3) cooperation with RMP and
(4) emphasis on the delivery of health services all indi-
cated that Washington was aware of the lapses of the
previous law. The means of change occurred with the
passage Of Public Law 93-641 on January 4, 1975. Cited as
”The National Health Planning and Resource Development Act

Of 1974" this law set, for the first time, national guide-

lines for health planning, changed "a" and "b" agencies to

 

 

 

93

"health systems agencies," set up a program for state
health planning and encouraged health resources development.

The purpose of this new law was a far cry from the
rhetoric of "assuring the highest level of health." P.L.
93-641 corrected the vagaries of P.L. 89-749 in a reasonably
substantive manner. It stated that the achievement Of equal
access to quality health care at a reasOnable cost was a
federal priority, that the massive infusion Of funds into
the existing system had failed its purpose, and that
previous responses to the problem had not resulted in a
comprehensive approach to the lack of delivery, maldistribu-
tion and excessive cost of health care. It cited overuse
of hospitals, warned providers to become involved in policy
develOpment, and recognized the public lack of knowledge
regarding personal health care and system utilization.

Each of the weaknesses Of the current system that were
pointed out in preceding chapters were acknowledged by
P.L. 93-641.

This amazing document went even further. It called
for national standards for the supply, distribution and
organization of resources, as well as a statement of
national health planning goals to be expressed in quantita-
tive terms. Detailed guidelines replaced Obscure assurances.
Ten priorities listed areas to be of prime concern,
including the develOpment Of group practices and health
maintenance organizations, stress on prevention and general

health education. The mandate of noninterference was

 

94

nowhere in evidence. The National Council no longer speci-
fied consumers, but emphasized multi-level government
participation, including the Department of Defense.

The organization of the planning bodies which were
to act on these concerns was spelled out point by point.
Part B of the law--Hea1th Systems agencies, defined health
service areas in detail. The legal structure of such
agencies was formulated and staff Size, expertise and duties
were specified. The establishment Of an agency's governing
body was spelled out and its responsibilities and functions
listed in detail. Other agencies that it must coordinate
with were designated, as well as review responsibilities.
Several pages were devoted to the designation of such an
agency, whereas the previous bill had devoted one paragraph
to the entire establishment and organization of the "b"
agency.

Part C, dealing with state health planning and
development, called for a state agency to administer a
state program. Two interesting departures from the previous
pattern required the state agency to conduct its business
meetings in public and required "providers of health care
doing business in the State to make statistical and other
reports . . . to the State agency."

The function of the state agency changed from
creating an overall state health plan to preparation of a
state plan “which shall be made up of the HSP's (health

systems plans) of the health systems within the state."

 

95

The state could make the revisions necessary to achieve
appropriate coordination Or to deal more effectively with
statewide health needs.

Further functions included administration of a
certificate of need program, which involved not only ser-
vices and facilities, but new organizations as well. The
state was also to review periodically all institutional
health services being offered in the state.

The new "Statewide Health Coordinating Council"
still had a majority of consumers on its board. However,
each of the regional agencies was now to be represented.
This council was still to act in a review and advisory
capacity.

Part D, General Provisions, detailed procedures and
criteria for reviews of proposed health system changes.
Technical assistance to state and regional agencies was to
be provided by the Secretary of HEW, and would include
planning approaches, methodologies, policies and standards,
guidelines for the organization and operation of the
agencies and establishment of a national health planning
information center to provide uniform systems for cost
accounting and other statistical derivations. Other centers
for health planning would give technical methodological
assistance for multi-disciplinary health develOpment.
Federal review of all health systems agencies would occur
at least every three years. The remainder of the law dealt

with financial aspects of implementation.6

 

96

It is evident that the problems facing P.L. 89-749
were made known to legislators and were of a sufficiently
serious nature to warrant prompt alteration. Only nine
years after P.L. 89-749 was passed, only a part of which
involved substantive planning, it was superseded by P.L.
93-641, which amended, point by point, the inherent flac-

cidity Of its predecessor.
Summary

This ready rectification of the law augurs well for
the future progress of health planning. More of the par-
ameters of health organization and delivery, environment
and prevention are gaining recognition and acceptance and
therefore broadening the sc0pe of health planning to what
it should be. The history of social change in terms of
health legislation reveals a steady advance to fuller
understanding of the inadequacies of the health system.

From an era of laissez-faire, the Sixties created an era of

 

government intervention. It is heartening to see this has
not waned, but seems to be a continuing trend. With the
strictures which bound Comprehensive Health Planning
removed, National Health Planning has sufficient SCOpe to
implement the planning process methods which exist to date,
and to develop further skills.

Whether P.L. 93-641 will face the same pitfalls as
its predecessor remains to be seen. Although its scope is

widened and the noninterference clause removed, its

 

 

97

structure remains a supplement to the current delivery

 

system; it does not supplant it. It may be that, although
the trend is away from a policy of protection of the
health industry to a philosophy Of accountability, law and
medicine is "metaphysical misalliance."7 The health laws
express themselves through government agencies. Much of
health care remains in the private sphere. Springer
queries,

Can the legal system bring about a planned comprehen-

sive health care program that meets the currently

felt and specifically articulated needs for access,

reasonable costs and quality? The answer . . . is

probably not. Our system and our philosophy cannot

tolerate such an intrusion. Moreover, the division

of powers is too complex . . . among executive

agencies and legislative bodies . . . the law can

point to change, but it alone is rarely capable of

transforming entrenched institutions, systems and

mythologies that act as Operational hypotheses for

action.3

Two alternatives remain Open. Legal restraints can

increase and government intervention expand. Many see this
as feasible; witness the present debate about a national-
ized health system. Or the private sector can move to
rectify present inefficiencies. Group practices and health
maintenance organizations, either for profit or not, are
already burgeoning. Many see this as a practical applica-
tion of free enterprise, whereby affordable preventive
medicine will be the attractive, viable alternative. This
has much to be said for it. The public and the medical

establishment could effectively block nationalization for a

long time. Moreover, the American people would be

 

98

reluctant to endorse a closed government system. An effi-
cient delivery system watchdogged by the government would be
an acceptable compromise and in full keeping with past
parallel situations. It is quickly becoming an American
tradition that the free enterprise system Should be pro-
tected, while at the same time, the government is expected

to protect the people from it. It seems likely that

led
government intervention will take the stance of standardi- E
zing, regulating and supporting private health care. That kg

this will continue to be the trend is forecasted by the
mandate in the new bill to foster alternate health care
mechanisms. In the uniquely American spirit of partnership
between government and big business, the health, happiness,

and power of the nation is being advanced.

REFERENCES TO CHAPTER VI

1"Federal Assessment Program of Comprehensive

Health Planning Agencies," undertaken by the Office of Com-
prehensive Health Planning, Public Health Service, 1974.
Results had not yet been analyzed at this time.

2Nancy M. Anderson, Comprehensive Health Planning in
the States: A Current Status Report (Minneapdlis, Minnesota:
Institute for Interdisciplinary Studies, American Rehabili-
tation Foundation, July 1969), p. 21.

 

 

3American Rehabilitation Foundation, Planning for
Better Health: An Experiment in Partnership, 1968, p. X:12.

 

4U.S. House of Representatives, "Comprehensive

Health Planning and Service Act of 1970" (H.R. 18110),
Report of the Committee, July 1970, pp. 3-4.

5U.S. Congress, Public Law 91-515: The Heart Disease,
Cancer, Stroke and Kidney Disease Amendments of 1970,

9lst Congress TWashington, D.C.: U.S. Government Printing
Office, 1970).

 

6U.S. Congress, Public Law 93-641: The National
Health Planning and Resource Development Act of 1974,
93rd Congress (Washington, D.C.: U.S. Government Printing
Office, 1975).

 

7Eric W. Springer, "Law and Medicine: Reflections of
a Metaphysical Misalliance," Milbank Memorial Fund Quar-
terly L,3 (July 1972, Part 1).

 

81bid., p. 282.

99

 

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