Changing U.S. Health Care: A Study of Four Metropolitan Areas (review)

59 Review CHANGING U.S. HEALTH CARE: A STUDY OF FOUR METROPOLITAN AREAS By Eli Ginzberg, Howard Berliner, and Miriam Ostow. 221 pp. Boulder, CO: Westview Press, 1993, hardcover, $52.50 (cloth). IN 1987, Columbia University's Eisenhower Center for the Conservation of Human Resources received a three-year grant from the Robert Wood Johnson Foundation to analyze changes in the United States health-care system during the 1980s. The assumption was that the Reagan Administration's decision to privatize health care would result in a void in policy that would be filled by state and local governments, insurers, and health-care providers. The Eisenhower Center examined how this policy void was filled in Chicago, Houston, Los Angeles, and New York City. They hoped to identify "new and emerging trends and distinguish priorities and effective interventions." [p. ix]. The book is divided into six chapters. Eli Ginzberg, the Director of the Eisenhower Center, wrote the first and last, which summarize national changes in health care and the parallels, differences, and prospects among the four large metropolises. The case studies were written by local experts: 1) Howard Berliner, Chair of the Department of Health Services Management and Policy at the New School for Social Research (New York); 2) J. Warren Salmon, Professor of Health Resources and Management, School of Public Health, University of Illinois at Chicago (Chicago); 3) E. Richard Brown, Professor of Public Health at UCLA; and Géraldine Dallek, Executive Director of the Medicare Advocacy Project in Los Angeles (Los Angeles); and 4) Hardy Loe, Virginia Kennedy, and Frank Moore, Professors, School of Public Health, University of Texas Health Science Center at Houston (Houston). The authors follow a standard format. Each chapter describes a city's demographic and economic bases, acute- and long-term health-care systems, supply and demand for medical personnel, and public-health issues. The casestudy chapters vary in length and depth, but adequately describe health care during the 1980s. The descriptions of each health-care system are a significant contribution. The book emphasizes differences among the four metropolises. For example, New York City started the 1980s with a large and comprehensive public-sector Journal of Health Care for the Poor and Underserved · Vol. 5, No. 1 · 1994 60___________________________________________________________ system (ambulatory and chronic-care facilities, clinics, and municipal hospitals ). Chicago did not. Los Angeles's system was closer to New York's and Houston's to Chicago's. The authors' second major contribution is descriptions of how the medical establishment in each metropolis thwarted or captured attempts to change health-care delivery in order to maintain their status and control. Third, the authors show that demographic and economic trends drove policy. All four cities experienced substantial increases in poor and minority Americans and decreases in the ability of businesses and tax bases to support health care. All, especially New York and Los Angeles, faced AIDS, drug abuse, and other drug-related illness and disease that were costly to manage. After reading this book, I conclude that poor and uninsured Americans in these four areas have less access to medical care in the 1990s than in the 1980s, despite an increase in the sophistication of medical personnel and equipment. New York and Los Angeles had more municipal health services than did Chicago and Houston, but also much more demand for these services. In short, by following the path of the four large metropolises, this book comes to the same depressing conclusions about growing inequity in health care as do national studies. The book has three notable omissions. Public-health practitioners recognize that prevention is cost-effective in the long run. Since only about three to five cents of every health dollar is spent on prevention, it would have been useful to see if any of the four metropolises had defended these programs against cuts. Similarly, nothing is said about environmental and occupational health programs. Third, I was disappointed to see no mention of health-services priorities and how they were decided. I assume that this omission is implicit testimony to the reality that public-health priorities have been replaced by economic and political ones. The authors promise to identify policy innovations that improved health care. I will...