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Houvenagle is a 2008 graduate of the University of Louisville. His doctorate is in Urban and Public affairs. He is a supervising clinician at Our Lady of Peace Hospital in Louisville, KY. His research interests are local healthcare politics, grassroots politics, and community power. Full Mailing Address: 3103 Commander Drive, Louisville, KY 40220-1723.
This article explores the local politics of healthcare in one United States venue. It contributes to our understanding by examining who is in charge of healthcare at the local level, their agenda, and how they operate. This article offers a foundation for further study. The local aspect of healthcare politics has seldom been studied. Lennarson-Greer (1997) notes in her article about urban health politics while health and health care are local responsibilities in the United States; little has been expressed in terms of social or governmental theory (p.356). 1 A few scholars in the 1960’s and early 1970’s identified elite hegemony in local health and hospital governance, but did not identify agendas or modus operandi. The early studies were limited due to: 1) the pluralist (Dahl, 1961) versus elitist (Hunter, 1953) stand off in community power research, and 2) technological limitations. The arrival of school of urban political economy opened up an ability to account for divergent elite and pluralist findings in urban settings and thus assisted in moving beyond the standoff (Vogel, 1992, p.13). Molotch’s (1976) “growth machine thesis” is one of these urban political economy theories that offer a plausible, holistic description of both local political structure and the political action within that structure. Molotch’s (1976) theory offers a “both and” sense of the local political situation as opposed to only identifying a political structure. In Molotch’s thesis a central, elite set of local business interests called the growth coalition dominates local political decisions for the purpose of growth. The pluralist and elitist views only identified structure and could not answer the “for what” question that dogged community power studies (Clark, 1968, p.1-21).
For Lennarson-Greer, “Urban health politics and policies attempt to define and fulfill the responsibilities of cities for the health of their population, especially in regard to the hazards and dangers of urban life and the uneven concentration of disease in cities (p.356).
This article examines the growth machine thesis as beginning point to understand local healthcare politics using Louisville Kentucky as the object of study. It is based on earlier research using social network analysis and elite interviewing to answer the following questions: • • • Who are the controlling actors in local healthcare? What is their agenda? How do they act? This article is ordered as follows. The previous relevant literature on local healthcare politics is reviewed. The growth machine thesis is explained. The social network (SNA)
findings and the pertinent interview results are presented. Conclusions are presented. Past Research Sociology and health policy researchers provided two early sets of research on local healthcare politics. Urban studies contributed later. Overall, the previous research suggests elite hegemony but otherwise is a patchwork and does not contain a consistent thread of citation. Sociological research The sociological studies suggested elite hegemony. Belknap and Steinle (1963) found local business interests dominated the hospital board memberships2 in two communities (pp.123124) and that facility development and improvement processes required “a reasonable unity between formal governmental leadership and community leadership in major civic, economic, social, and cultural groups” (p.89). Elling co-authored a series of studies suggesting that economic elites were central in local healthcare governance.3 Starr (1982) concluded that
Belknap and Steinle list board memberships in tabular form along with the professions of the members (p.123). The following are the salient studies. Elling and Blankeship (1962) studied an unnamed community in upstate New York demonstrating hegemony of community leaders on hospital boards. Elling and Lee (1966) studied Pittsburgh (which is of fascination to urban scholars on account of nonprofit dominance in that city) and found hegemony of community economic leadership on hospital boards that was detached from the local health department. , Elling and Blankeship (1971) in another study found the hospital closet to the community power structure fared the best in getting community support.
physicians were historically dependent upon the capital and philanthropy of influential business elites to establish hospitals (pp.152-153). Morone (1982) found that local politicians undermined the local planning bodies of average citizens established by the National Health Planning and Resource Development Act of 1974 because the Health Systems Agencies (HSA’s) were threats to local power bases. The elite dominated the three areas of healthcare governance, facility development and facility expansion. Health Policy Research Public health findings suggested a mix of views. Wilson (1968) found that economic leaders had more informal influence in health planning than political leaders and professionals. Ginzburg (1977) noted that the typical nonprofit community hospital was controlled by elites in alliance with the medical profession (p.3). Litman and Robins (1984) present a divergent pluralist view: Historically, participation of the public in the making of health policy decisions was subsumed in the involvement of the community power structure in institutional governance—a pluralistic, class-based system (p.20). 4 While Litman and Robins use pluralism to describe their view their citations are anything but about pluralism as understood in community power research. Pluralism within the healthcare literature appeared to indicate autonomy of doctors, while it indicates popular or democratic control in urban affairs. A number of international public health authors are worth noting. Tulchinsky and Varavikova (2000) discussed the local level of healthcare decision-making in bureaucratic, but not political, terms as part of the federal system (pp.530-532). Bodenheimer and Grumbach’s
Vogel (1992) summarizes that “Pluralists contended that government dominates the community’s decision-making processes” (p.12). Given Litman and Robins’ limited context and lack of term definition, their use of “pluralistic” and “class-based” is somewhat confusing.
(2005) description of local policies also was in national government terms and not local terms (p.60-62). These books were devoid of any discussion of local political structure and agenda. A fourth type of study from public health is Gentile-Donnell (2004). She reviewed the chronology of a Philadelphia public hospital’s closing as it related to the various levels of formal local government. Her political discussion was limited to the legislative activity of formal government and did not present any theory of political activity. Urban Studies There were several pertinent urban studies works reflective of their times. Swanson’s (1972) complex “cybernetic” political model5 allowed for multiple formulations of government involvement in healthcare on any particular level. Schussler (1994) explored American Corporatism (high degree of business and government cooperation) in the building of the new University of Louisville Hospital and the Humana corporation’s landing the management contract to run it. Britton and Ocasio (2007) explored how hospitals and orphanages were located in Chicago between 1848 and 1916 which supported the growth machine thesis as an explanation for locational decisions. The Growth Machine Thesis As noted earlier, the growth machine thesis is an urban political economy theory about how cities are governed that appears to have congruence with the previous findings. Molotch formulated it in 1976 (and revised it with Logan in 1987). Molotch asserts in the growth machine thesis “that the political and economic essence of virtually any given locality in the present American context is growth.” Growth unifies local elites in their quest for constant expansion of the city in the areas of population, land development and commerce. For Molotch, elites are primarily motivated by growth to achieve consensus and that “this growth imperative is
This model seems similar to the model by Clark (1968) on community decision-making (pp.15-21).
the most important constraint upon available options for local initiative in social and economic reform” (1976, pp.309-310). For the elites in the positions to gain economically, the city is a growth machine and the elites informally come together as a growth coalition to make political decisions for the city. The local public only weighs in on local issues when local elites have agreed to disagree on those particular issues (Logan and Molotch, 2007, p.51). Molotch’s growth coalition consists of three categories of local business players who have the most to lose or gain from land-use decision-making (1976, p. 314). The first category consists of parochial/local businessmen (especially property owners) and those in “locallyoriented financial institutions who need local government in their daily money-making routines.” The second category of players includes the lawyers, syndicators and realtors who make their incomes and revenues servicing the property owners and investors. The third category consists of parties whose fortunes are tied to the overall growth of a metropolitan area as a whole such as the daily newspaper, universities and utilities. According to Molotch this group of interests mobilizes, legitimizes and sustains local pride and growth momentum into “particular kinds of policy decisions” (1976, pp.314-316). At the core of the growth machine thesis is local dependence (see Cox and Mair 1988). The three categories of political players are business interests embedded in the local area—not to mention that North American city government is locally dependent on tax revenues it levies within its borders. The growth coalition players have fortunes that are tied to the fortunes of the city and its development as they get their revenues and profits from land use within the city. The salient feature of the 1987 revision is an expanded list of players in Table 1. National or multinational firms with multiple branch plants, back offices, and service centers are not usually part of the growth coalition and thus not involved in local politics. Such a concern is not
Table 1 here locally embedded in any one geographic location and can move its operations wherever economically efficient/in its interest.6 Since the growth machine thesis suggests central or key relationships within a community, testing for its presence is a matter of measuring and evaluating relationships. The growth machine thesis offers a set of nominal variables for social network analysis (SNA) by which relationships in a local network can be interpreted. Method The two-step research method for answering the research questions used SNA7 and elite interviewing of individuals. The UCINET8 software package identified pertinent informants. The pertinent SNA analyses were 1) clique analysis (several values of N) on a dataset of 4438 cases,9 2) Bonacich centrality of organizations and individuals on the dataset of 4438 cases, and 3) Multi-dimensional scaling (MDS) (Non-Metric) of the relationships amongst the different growth coalition interest groups. Graphical analyses of individuals and organizations in Louisville using UCINET were not meaningful due to the large dataset size.
Centrality Analysis results
For example a manufacturing facility can be built in any geographical location that serves the firm’s maximization of profit within the bounds of all applicable governmental regulation. Therefore the fortune of a national or multinational corporation is not dependent on any one locality and therefore that entity does not get tend to get involved in the politics of any particular locality. Logan and Molotch (1987) noted the absence of branch plant managers in local politics (p.85). 7 SNA is a formalized, quantitative approach for studying networks (Adam and Kriesi 2007, p.130). It “is useful for investigations of kinship patterns, community structure, interlocking directorships and so forth” (Scott, 1991, p.2). Knoke and Kuklinski (1982) define a network “as a specific type of relation linking a defined set of persons, objects or events” (p.12). The SNA results were generated from an initial dataset of 8420 cases from a snowball sample of board members and officer rosters of hospital and other organizations in the Louisville area between 2005 and 2006. It is assumed that the sample used to create the dataset is representative of the community and the healthcare actors. 8 The UCINET 6 (version 6.145) software package was used for all SNA analyses in this study. Its multiple routines generate tabular, numerical and graphical analyses. 9 UCINET 6 can be instructed to look for cliques of different sizes.
The rest of this section discusses the centrality results.10 While actual organization names are used the individuals are discussed only by unique identification numbers and sectors.11 Centrality Rankings of Organizations in Louisville Table 2 displays the steep gradient of Bonacich rankings of Louisville organizations that is dominated by the development sector. The most central “Greater Louisville Inc” (GLI), the local chamber of commerce is an extreme outlier as it is 603 percent more central than the second most central entity. 12 Metro Government was ninth on the list. The Metro United Way and the now-defunct “getCare Health Network” are anomalies given they are charitable concerns.13 Healthcare organizations and typical growth coalition entities rank high in centrality. To correct the skewness the GLI cases were removed from the dataset. Table 3 displays the results. Eight entities dropped out of the rankings including Louisville Metro Government and Norton Healthcare. However, the Frost Todd Brown law firm (FBT) and Jewish Hospital Health Services (JHHS) increased in centrality and became the outliers14, which suggested inherent centrality and organizational interlock. The now-defunct getCare Network stayed in the top 20, suggesting participation by highly central individuals. GLI is therefore a “knot” or “cut-
The centrality rankings of individuals and organizations were the same whether n= 7515 or n=4438. The dataset likely could have been reduced further with similar ranking results. In SNA centrality is a relational matter and that the most central individual or individuals in a network holds the most power. Hanneman and Riddle (2005) state, “An individual does not have power in the abstract, they have power because they can dominate others—ego’s power is alter’s dependence”(chapter 13). The Bonacich power measure of centrality accounts for the number of connections an actor has and the numbers of connections the connections have. Bonacich’s equation gives “each actor an estimated centrality equal to their own degree plus, a weighted function of the degrees of the actors to whom they were connected” (Hanneman and Riddle, chapter 13). This is mathematically stated as cj = Σ jrij(α +β cj). 11 It is SNA convention not to identify individuals. Since the individuals were all members of the potential subject pool for field interviews, they were protected by Institutional Research Board regulations. 12 Mean = 1.799 Std Deviation = 8.654 13 They are redistributive or charitable organizations and of a different nature than the rest. The getCare Network was an organization spear-headed by the Louisville-Metro Health Department and primarily funded by a RobertWood-Johnson Foundation “Communities in Charge” grant to provide free or reduced medical services to uninsured individuals. 14 Mean =0.488, Standard Deviation = 5.827
point” (Scott, pp.110-111) connecting numerous entities in the network. This adds support to the existence of growth coalition interests and their hegemony. Centrality Rankings of Individuals The Bonacich centrality for individuals further strengthened the picture of growth coalition hegemony as individuals from law, utilities, finance and education dominate the top 20 Table 2 about here Table 3 about here as shown in Table 4. The highest-ranking elected politician is ranked sixth. Like the organization scores, the individual Bonacich scores evidenced positive skewing of the data, but with a less steep gradient.15 There appears to be correlation between membership or leadership in GLI and membership on a hospital board. In the correction for skewness (GLI dataset cases removed), the individual rankings followed the organization ranking patterns and are displayed in table 4. Case M1476 gained in value and 18 of the 20 in table 4 are attorneys at the Frost Brown Todd (FBT) law firm. While GLI is most central in the network, many FBT members have centrality by firm membership. The more central FBT members have more known civic involvement. Again, GLI proved to be a central knot or cut-point connection in the network. Table 4 about here Table 5 about here
Mean =1.799, Standard Deviation = 8.654
Clique Analysis The clique analysis on the dataset of 4438 cases identified 28 cliques with an average eigenvalue of 12 or higher; this was the approximate “floor” of table 4. 16 The predominant clique, listed in table 5 had seven members and a cumulative eigenvalue of 113.091 with an average of 16.156. This clique consisted primarily of healthcare executives and physicians but had other growth coalition sectors represented, who had been on hospital boards. Table 6 about here The next central clique, listed in Table 7, was the same size as the most central clique but with a lower cumulative (187.981) and average (15.665) eigenvalue score. Eight members in the second clique were unique to it from the predominant clique. There was little redundancy between the two cliques. Table 7 about here Given that a clique is a group of individuals that is not a sub-group of any other group, we can conclude that there is support for an elite-group of individuals that relate to each other exclusively within this network. In both central cliques, growth coalition sectors are present alongside healthcare figures, supporting both elite and growth coalition hegemony. Analyses of the network in terms of sectors Despite the centrality and clique analysis results, where the growth coalition fit in the overall picture of Louisville healthcare politics remained a pertinent question since Molotch’s theory is stated in terms of specific interest groups or sectors (versus individual types or
Given the gargantuan size of the network and the fact that it was a snowball sample versus survey, it cannot be determined whether these cliques were strong cliques or weak cliques (Scott, p.118).
organization types). To explore this question the original dataset was modified to 7470 cases17 to include an individual person’s sector. Strict adherence to Logan and Molotch’s growth coalition sector list (see table 1) would have meant a large, imprecise “other” category18 so other livelihood names were added for precision. 19 There were 28 nominal variables which allowed for meaningful analysis. The sector names are as follows. 1. Accountants 2. Advertising 3. Colleges 4. Branch (Corporate Capitalists of Multi-locational firms) 5. Development 6. Doctors 7. Elite (Social Organization) 8. Foundation (Charitable organization) 9. Government 10. HRB (Health-Related Business) 11. Healthcare (other than hospitals) 12. Hospitals 13. Insurance
Cases that were not actual human beings were removed from this dataset. As listed with the Kentucky Secretary of State some corporations were directors or managers of other corporations. Even though it was obvious from previous analyses that the larger set contained had 41 percent of essentially irrelevant actors, the larger data set should lend more credibility to such an analysis of the overall community picture. The added benefit of using the larger dataset also can inform about what sectors are outside of or inside the center of the community network. 18 With a large general “other” category that included all other different entities, much would likely be missed in analysis. Creating other unique categories seems to be in harmony with the growth machine thesis as the specific categories appear to be locally dependent. 19 There was an initial data problem in that the UCINET DL formatting routine did not read 377 cases. Reducing the sector names to one word reduced the missing cases down to 3.
14. Law 15. Media 16. MH (Mental Health) 17. National (Home Office of a Corporation based in Louisville) 18. Nonprofit 19. Other 20. Politicians 21. PI (Property Investing) 22. Public (Health organizations) 23. Finance (Real Estate Financing) 24. Retailers 25. Sports 26. Technology 27. Arts (Museums, Theaters, Expositions) 28. Utilities Bonacich eigenvalue results The Bonacich eigenvalues of sectors show why FBT subsumed GLI’s centrality, and why M1476 (an attorney) gained centrality when GLI cases were removed (see tables 3 and 5). The “law” sector had a total eigenvalue score of 141.380 out of a sum or (Σ ) of 149.229, which was 94.7 percent of the value.20 The “development” sector had an eigenvalue of 2.283. The “hospitals” sector was third with an eigenvalue of 2.208. The distribution of eigenvalues was, positively skewed given that the mean was 5.330 and the standard deviation was 26.189. Local
The Bonacich measure is akin to Factor Analysis. Only so much probability is generated and therefore 149.229 was 100 percent of the value or probability. A more base way of stating this is that the lawyers in Louisville as a group are overwhelmingly the most powerful group of individuals in town.
attorneys are central in the “development” sector and are the foremost central sector in the network of healthcare politics in Louisville, Kentucky. Multi-Dimensional Scaling (MDS) 21 22 Figure 1 is the initial result from the UCINET MDS routine. The public health and health-related business sectors are extreme outliers in the network—they are isolated from the other sectors. In contrast, the other sectors are densely compacted or tightly clustered. Figure 1 about here Figure 2 is a magnification of the tight cluster in Figure 1. The “neighborhood” of sectors overall are close to each other and could be called a cluster in and of itself. However, within the MDS results there appears to be a tighter cluster composed of hospitals, development, law, property-investing, non-profit, and finance. Mental health and health-related businesses were extreme outliers and do not appear to relate to the cluster.
For a discussion of network mapping of the sectors see Houvenagle (2008). MDS has broad applications and is an alternative to factor analysis (Wasserman and Faust, p.288). Its general goal is “to detect meaningful underlying dimensions that allow the researcher to explain observed similarities or dissimilarities (distances) between the investigated objects” (http://statsoft.com/textbook/stmulsca.html). Borgatti (1997) states that the purpose of MDS is “to provide a visual representation of the pattern of proximities among a set of objects.” It is used to “provide a visual representation of a complex set of relationships that can be scanned at a glance” (http://www.analytictech.com/borgatti/mds.htm). Therefore, MDS goes one step farther than factor analysis to give us a valued, graphical depiction of a network. MDS has both numerical and graphical components that can add additional understanding to the network of actors. Its output “is a set of estimated distances among pairs of entities, which can be expressed as coordinates in one-, two-, or higher dimensional space” (Wasserman and Faust, p.288). Its graphical depiction is a “Shepard’s diagram” similar to a Cartesian plane. (http://www.statsoft.com/textbook/stmulsca.html) Borgatti’s guidelines for interpreting a MDS map are as follows. First, “All that matters in an MDS map is which point is close to which others.” Second, the axes are “meaningless” and “that the orientation of the picture is arbitrary.” Furthermore, Borgatti notes that the two keys to interpretation are noting the “clusters” or groups of points that are closer to each other than to other points and the “dimensions” that are “item attributes that seem to order the items in the map along a continuum”(http://www.analytictech.com/borgatti/mds.htm). There are two prior, known examples of MDS used to study community elites. Laumann and Pappi (1973) used the “smallest space analysis” (a form of MDS) to identify the network of a German city’s elites. Galaskiewicz (1979) used “smallest space analysis to analyze the organizational networks in a Midwestern city.
On the other hand, in the center of the map, hospitals and development sectors are closest to one another with law and finance being the next closest, adjacent sector. The closeness of
the law, hospitals, and development sectors reflect their higher Bonacich centrality results. Figure 2 about here Validity of MDS results Table 8 is offered with the MDS coordinates along with the “stress” results to provide validity of the MDS results. Stress is either an indication of goodness of fit (www.statsoft.com/textbook/stmulsca.html) or “a measure of badness of fit” (Hanneman and Riddle, chapter 13). The stress score was 0.002 in 50 iterations. The extent of significance of stress scores varies among the different authors. Borgatti noted that a map with “non-zero stress” is distorted.” Borgatti suggests that any stress score under 0.1 is “excellent and anything over 0.15 is unacceptable” (http://www.analytictech.com/borgatti/mds.htm). Table 8 about here Therefore, the “stress score” of 0.002 shows excellent fit with little distortion of the distances between the points, especially with regards to the closeness of some points. The MDS results are therefore valid. What we can conclude from the MDS results is that the “development” and
“hospitals,” “law” and “finance” sectors are closely connected. There is cohesion among certain sectors within the network while other sectors are outsiders of the network. 23 24 25 Section conclusion Overall, the SNA results suggest that a coherent political network of relationships exists in Louisville Healthcare. The Bonacich centrality results identified a hegemony presence of the elite growth coalition both in terms of local elite individuals and local organizations in the network—there was no branch plant representation in the elite group of individuals. The clique analysis buttressed the centrality results by identifying two cliques of high centrality consisting of local healthcare and growth coalition individuals. In terms of the overall community network, the MDS results suggested the evidence of a central affiliation of hospitals, law firms, and economic development organizations.26 Under the premises of SNA, a reasonable conclusion is the relatively few elite actors at the top of a steep eigenvalue gradient are the controlling parties making decisions in the network. Field Interviews
There have been few studies of a community power structure using MDS. Laumann and Pappi and Galaskiewicz were identified as utilizing this method at the community level. Laumann and Pappi (1973) used a MDS/SSA-1 analysis on a German community The MDS results here have similarity to Galaskiewicz’s (1979) smallest space analysis MDS (SSA-1) on an anonymous Midwestern community which suggests that these results can be generalized. 24 According to Galaskiewicz, SSA-1 is a MDS “routine that maps points in a Euclidean space as a function of their estimated proximities on some criterion variable.” This particular routine also maps points in terms of a “centroid” (p.1351). The criterion variables of the different MDS/SSA-1 analyses were money, information, and moral support. Galaskiewicz and his research team gathered the information for the data points through elite interviews to determine transfers of money, information and support among the organizations in the community. In Galaskiewicz’s results on the money and support networks criteria there was similarity of results in the types of sectors connected with healthcare organizations. In the “money network” both the private and public hospitals in this community were in close proximity to the local banks, the local college, the chamber of commerce, the newspaper, the radio station, and the United Way (p.1353). A similar result was found in his “support network” but the state university in the town was in closer proximity (p.1355). Galaskiewicz’s variance was in his “information network” where the information was arranged to they types of activities “than auspices” (p.1352). Galaskiewicz’s MDS/SSA-1 results support a growth coalition type constellation of organizations being connected with healthcare —especially hospitals. Galaskiewicz’s information network was according to the types of problem-solving activities. Healthcare agencies were not in the center, but off to the left amongst themselves. City government and the United Way, media, and business associations were in the center of the network in this case. (p1352, p.1356).
Furthermore some sectors are distinctively not in this network, and some sectors (especially doctors) are distinctively on the fringe of the central power.
Interviews were conducted with 22 informants who were either central individuals identified by the SNA results or identified as being knowledgeable by central informants. The intentions were: 1) to confirm the validity of the SNA results, 2) to identify whether a particular agenda exists, 3) to determine whether there was a political modus operandi and 4) to understand the disconnect between local public and private healthcare organizations.
Who do the Central Players say Move and Shake? The informants identified movers and shakers in Louisville healthcare politics as coming from one of four groups: health administrators, educational figures, political figures, and board chairs of hospital organizations. The health administrators were mostly hospital executives who also were board members of the Kentucky Hospital Association but a few public health administrators were named.27 The educational figures most often named were the president of the University of Louisville and the dean of the University of Louisville Medical School. Both the Louisville Mayor and the Louisville Metro Department of Health and Wellness Executive Director, were the primary government figures. Informants repeatedly identified three hospital board chairs (two bankers and one accountant). Overall, individuals who were both community elites and executives were identified to be the movers and shakers. 28 Overall informants identified a short list of organizations that move and shaker. The leading three leading hospital organizations (Norton, Jewish, and Baptist) were the most identified leading organizational actors. The University of Louisville was identified next in terms of frequency. Informants repeatedly identified the proprietary organizations: Humana29,
As discussed below, there was a repeated sentiment that there was a detachment between the public health and private administrators. 28 One respondent also said “I may be using the wrong term, the unions or the company, Ford, GE, UPS, are major players in this, and then you get into the healthcare companies themselves . . . like Humana, Ventas.” 29 As noted elsewhere Humana was first a Louisville-based proprietary healthcare organization that then evolved into health insurance and then divested itself of hospitals. It is a hometown company that wields sizeable influence.
Kindred and Rescare30 as a third tier. A number of informants identified the Family Health Centers as a player (a leading public health provider). Given the list, overall informants saw the hospital organizations as the main organizational players in local healthcare politics.
Sectors Some informants framed answers in terms of sectors with a great divergence existing between the public and the private sectors. Informants most frequently identified the Family Health Centers and the Louisville Metro Health Department as the main public sector actors. Informants overall framed the private sector in terms of proprietary and non-profit players. The private non-profit hospital (Jewish, Norton, and Baptist) organizations were identified as clear movers and shakers. The proprietary actors (Kindred and Humana) were not seen as central to local healthcare politics, as both have a national focus and minimal local involvement. Humana was identified as the exception when it had owned three Louisville hospitals and had the management contract for the University of Louisville Hospital for 13 years. Where are the Doctors? As noted in the MDS results, doctors were somewhat distant from hospitals and development and informants did not identify doctors when asked the open-ended question about movers and shakers. Informants consistently did not name doctors and only answered when asked the specific question: How have you seen the role of doctors in the political realm? The informants consistently confirmed that the physicians as a group in Louisville are marginally involved at best in the local political process and that physicians do not wield power or influence over healthcare goals in the community. Despite the existence of the Greater
Rescare is a Louisville-based proprietary organization that primarily specializes in running residential care facilities across the United States. The residential facilities historically have been called “group homes.”
Louisville Medical Society,31 informants did not recognize strong organization among physicians at the community level and they are quiet unless they have strong opinions on a particular issue. However, informants identified that physicians do have more political power at the facility or institutional level of the hospitals. Physicians are advisors and economic drivers as they direct business to the different hospitals. One informant said that doctors did not have a strong say until it was discovered that hospitals could “construct a lot of profit under the guise of doctors’ offices” and that doctors are cheerleaders for a hospital getting new equipment already in use at other hospitals. Another informant said a specialty practice of physicians that makes significant revenue for a particular hospital has much more pull and can extract concessions.32 On the other hand, some informants noted the Louisville Medical Center as an exception in terms of physician political power and influence on account of the University of Louisville Medical School. The dean of the University of Louisville Medical School is seen as an agendasetter. Medical school department chairs have influence over the placement and operation of indigent care services. However, the responding informants said the Medical School’s influence stays within the downtown Medical Center and does not extend to the larger community.33 Where is Greater Louisville Inc?
Historically, the Jefferson County/Greater Louisville Medical Society has facilitated a process whereby a physician can apply for credentials at all the desired facilities in town through its auspices. 32 Informants repeatedly described physicians as independent business people who sell their time and can influence placement of facilities. However, a change in the trend of doctors as independent business people was noted by a number of informants as hospital organizations have been hiring physicians (especially family practice doctors) as employees. The employed physicians are required to refer within the hospital organization and therefore hospital organizations are controlling the referrals under the guise of an established continuum of care. One informant declared that this is a ‘de facto’ closed staff system in place in the various hospitals and the doctors are ceasing to be independent business people with mobility throughout the city to practice in different hospitals.
One respondent suggested that as part of an overall agenda by the University of Louisville Medical School to build the “U of L” brand, it is looking to be a full competitor with Jewish, Norton, and Baptist. There is some news coverage to that extent where U of L is contemplating outpatient facilities outside the downtown Howington, (2007 July 12), but no other informant confirmed this.
Like the doctors, Greater Louisville Inc (GLI) (the local chamber of commerce) was not automatically identified as a mover and shaker.34 This was surprising given GLI’s overwhelming centrality score. However, when specifically asked, most informants saw GLI driving research and economic development agendas related to healthcare but did not see GLI having a consistent role in healthcare. Two informants cited the Boyle Report35 of 1996 (commissioned by GLI’s predecessor organization) as a source for understanding Louisville’s healthcare agenda, but several informants did not understand GLI to be involved at all in healthcare. responses reflect SNA indications that GLI is a central cut point. Where are Local Government and the Mayor among the Players? Like the doctors and GLI, informants did not consistently name government officials as actors in healthcare politics. Therefore informants were specifically asked: In your opinion, what is the Mayor’s and Metro Government’s36 primary role in the healthcare system? The Mayor Informants generally saw Louisville Mayor, Jerry Abramson as involved in economic development issues pertaining to healthcare and not in redistributive issues. He was recognized as the originator of the Louisville Medical Center Development Corporation and a passive, but well informed behind-the scene player supporting and cheerleading development. Informants said that the Mayor will talk to the hospital executives to influence agendas, but he does not wield control over the hospital organization agendas. One informant said there was no “mechanism” set up for the Mayor to be involved in identifying health needs in the community.
Some informants identified the Health Enterprises Network, which is a “network” of GLI, but few spontaneously mentioned GLI or the Health Enterprises Network as a player. 35 The formal title of this was Economic Development Strategy for the Greater Louisville Region. This report identified Louisville’s biomedical sector as an area for economic growth. 36 The term “Metro Government” is being used in lieu of the 2003 consolidation of Louisville and Jefferson County, Kentucky governments.
However informants identified the Mayor as having two public health interests as the Quality Care and Charity Trust (QCCT)37 and health and wellness. Informants lauded the Mayor for his wellness campaigns and his leadership in the smoking ordinance restricting smoking in public buildings and restaurants.38 Involvement by Metro Government as an Entity Overall, the informants saw that beyond the Mayor and the Health and Wellness Executive Director Adewale Troutman, the Louisville Metro (Consolidated) Government is a minor and passive player in healthcare politics. One informant said, I don’t think there are even positions established that the designation or authority to really take that on beyond Dr. Troutman, and if there are positions, they’re relative weak positions, I am not talking individuals; I’m talking positions that have somewhat perfunctory leadership roles. Informants do not see the Louisville Metro Council as a central player in healthcare politics.39 Summation about the Players
The QCCT is the principal funding mechanism for indigent care at the University of Louisville Hospital. The QCCT itself is a 501c3 non-profit organization administrated by the office of the Controller of the University of Louisville. The QCCT has been a cooperative, public funding source that the University of Louisville hospital bills on a monthly basis for indigent patients residing in Jefferson County. A number of informants identified the QCCT to be an important but sensitive issue According to informants the QCCT contribution is a matter that is negotiated at a high political level within the city. The Mayor and the University of Louisville President directly negotiate the city of Louisville’s contribution to the QCCT. The QCCT was created in connection with the Humana management contact in 1983 for the University of Louisville Hospital. As it existed in 2006, the QCCT is contractually laid out to exist until 2016. The QCCT itself is financed through a matching fund process, which has changed at least one time in its existence. Initially the money was officially a combination of local, state and federal funds enhanced through the Disproportionate Share Fund mechanism and matched with federal Medicaid dollars. Now, the funds are strictly from the state of Kentucky and Louisville Metro governments. There were two consistent controversies pertaining to the QCCT. The longest running controversy has related to the choice of the City of Louisville/Louisville Metro Government to not contribute its legally, contracted amount. The second controversy identified by informants pertains to UMC competing with Norton and Jewish for insured patients while being reimbursed by the QCCT for indigent care while Norton and Jewish would not be reimbursed for giving some of the same type of indigent care.
This smoking ordinance initially prohibited smoking in all restaurants and public places with the exception of Churchill Downs—the home of the Kentucky Derby horse race. A number of informants said that the smoking ordinance got passed after Brown and Williamson Tobacco merged with Phillip Morris and left town. However, in December 2007 a judge struck down the original ordinance as unconstitutional given its Churchill Downs provision. The Mayor quickly moved and the Metro Council passed a stricter version of this ordinance including Churchill Downs. 39 Informants saw GLI as being the driver of the 2006 indoor smoking ban ordinance and the Metro Council as only the official ratifying body. Informants saw the Mayor and the University of Louisville president as the primary negotiators of the QCCT.
This section reported the informants’ identification of the actors in local healthcare politics in Louisville. The hospital organization heads are the primary players. The University of Louisville President and the Dean of the U of L Medical School are influential in the downtown Medical Center. Despite its centrality GLI was not seen as a player. Physicians are peripheral actors. The Mayor is passive, but informed and interested in economic development40 with Louisville Metro Government not seen as a central player. Overall, the informants confirmed that local healthcare politics is not a matter of formal government and controlled by a small group of actors outside government. What is the Agenda of the Local Players? Some informants spontaneously identified the local political agenda. However in some interviews, the following question needed to be asked: Do you think that there is any particular agenda overall in this political realm? A recurring theme was that informants saw the city agenda is a combination of the agendas of the different hospital organizations where each institution looks first to its own interest. The hospital organizations will litigate against each other to prevent competitive advantage and maintain marketplace parity. However, the different organizations will cooperate when it does did not threaten their own interests.41 One informant said that all the hospital organizations have a mission to provide care for more and more people. In this context basic market logic appears to determine the political positions. Two examples of this cooperation were the joint venture of Norton Healthcare, Jewish Hospital, and the University of Louisville to govern the University of Louisville Hospital as
Before he had his second tenure as Mayor of Louisville, Abramson was on the Jewish Hospital Healthcare Services Board. 41 One example of this was cooperation by the hospital organizations to make a joint announcement in May 2007 that all facilities would be smoke-free. Some informants said that this was a way of preventing turnover and transience of employees from one organization to another in order to smoke at work.
University Medical Center Inc (UMC), and the formation of the Louisville Medical Center Development Corporation (LMCDC). Despite being competitors Norton and Jewish had a mutual desire to see Columbia HCA leave town and so cooperated on governing a third hospital in the Louisville Medical Center. The governance agreement lasted from 1996 until 2007 when the University of Louisville terminated it for what some informants said were development purposes.42 The LMCDC was formed about the same time that Norton and Jewish entered into the UMC agreement that and backed away from it about the same time they left UMC.43 Informants indicated that Norton and Jewish decided that cooperation in this case stopped being in their interests.44 A third example of the informal cooperation reflective of the development agenda was the Norton Healthcare’s closing of the stagnant Southwest Hospital the moving its Certificate of Need (CON) to a new facility in a developing area of Louisville. Informants indicated that Norton, Jewish, and Baptist Healthcare all agreed on the need for growth and did not challenge each others plans for growth and development in an informal quid quo pro.
Informants said that initially Jewish and Norton spent significant money to revitalize the infrastructure of University Hospital, and that they could maintain a status quo in the area of medical specialties. The board of directors had members from Jewish, Norton, and the University of Louisville. However, University Hospital got stronger over time with the investment and conflict started when there was a push to upgrade certain specialty infrastructure that would compete with the specialties of Norton and Jewish. Some informants reported that in the last several months that Norton and Jewish participation, the conflict was so great that there was no quorum so the University Medical Center board of directors could not meet. A dynamic in this conflict was the University of Louisville has a state mandate to facilitate economic development and informants said that it is now the main leader in the healthcare development agenda. 43 Norton and Jewish are still members of the LMCDC now “Nucleus” but they are neither central members nor do they give as much money to the organization as they previously did. 44 In light of the detachment among the organizations within the Medical Center, a number of informants questioned whether there was a future in cooperation in Louisville healthcare. However, a number of informants saw cooperation as inevitable. The actors are connecting in other ways. For example, Jewish and the University of Louisville had cooperated in creating a cardiovascular research institute. One informant said that Norton and the University of Louisville were looking for other ways to cooperate despite the break-up of the governance consortium of UMC. The organizations operating in the downtown Louisville Medical Center are still working together in some form.
Some informants explicitly identified the healthcare politics agenda in Louisville as being economic development.45 A number of informants also saw it as a matter of national and international prestige, especially given the Abiocor Artificial Heart implantation trials and the first hand transplants. Besides the branding efforts, healthcare is recognized as a “hot issue” in the Louisville economy and thus of political importance. One informant said, Healthcare has been seen not only because of the services it provides, but as a way to provide lost manufacturing jobs so it is a critical service to the quality of life to the people but it’s also an economic cluster that is valued by our community. So I see that city government and the Mayor driving that role as well. One informant said, “Our local government has a vested interest in the healthcare system continuing to grow.” The Political Modus Operandi Informants generally answered the question of modus operandi of the healthcare movers and shakers by identifying that hospital executives and not board members were the primary negotiators in local healthcare politics.46 The chief executive officers (CEO’s) and executive teams are the prime negotiators because healthcare has evolved into a highly complex industry. Informants noted that the hospital executives talk both formally and informally. Some informants said the hospital organization executives have conversations under the auspices of the Kentucky Hospital Association (KHA). The executives of the different organizations are on various KHA committees and have conversations in a legal context that cannot be construed as fixing the market. However, other informants reported that the executives of the different organizations have a history of talking informally among themselves. The executives of the
It was interesting that a number of actors acknowledged that this was the agenda but also voiced criticism of this agenda as it led to inequities and was not a solid basis for Economic Development. 46 Informants reported that board members were not involved in outside informal negotiations with board members from other hospitals on behalf of the respective hospital organizations. One informant was emphatic that there are no such conversations that take place at “Fund for the Arts” meetings or at work places.
three hospital organizations have a history of engaging in quid pro quo with regard to different facility projects (i.e., we will not challenge you in front of the Certificate of Need board on your particular project if you do not challenge us on our project).
The Lack of Network Connection between the Private and Public Sectors As noted earlier, the MDS results showed a dramatic disconnect between public health agencies and the private/non-profit organizations. As illustrated in figures 1 and 2, the mental health and public health sectors were not part of the network in the UCINET-generated Multidimensional Scaling (MDS) results in figures 3 and 4. Why was this? The consistent
answer from informants was that the public sector agencies were required by federal law to be representative of the community—to include consumers. 47 Discussion The essential conclusion is that when it comes to local healthcare politics in Louisville the movers and shakers are elite, locally dependent business interests with a developmental agenda. This amounts to being a growth machine as explained Molotch. Recognizing that a U.S. city as a geopolitical entity is subject to the political and regulatory structure of the state and national governments a better statement is if any local healthcare policy can be locally shaped and driven by local healthcare politics in Louisville, it is growth and development driven by the configuration of actors called a growth machine. Local healthcare politics are not a matter of formal government or of pluralistic involvement of the general public
This phenomenon was similar to Houvenagle’s (2008) findings about Louisville healthcare planning in the 1960’s and 1970’s. The Louisville growth machine had initially started local healthcare planning through the Louisville Area Health Facilities Council in 1966. The organization was founded in private in the Louisville Area Chamber of Commerce. The elite were forced from the board in 1976 through the passing of the Health Systems Act of 1974. The elite had used health planning organization as a local vehicle for development and acquiring Hill Burton funds, but in the end the organization was transformed by federal policy into a regional vehicle for containment and restriction.
The findings are that the actors in their political dealings with each other have focused on what growth and development can occur in terms of the interest of the actors. There were obvious examples of the actors being united by growth opportunities and there was no evidence that the general public were part of the discussions. The movers and shakers in healthcare in Louisville are not doctors, nor local government nor the general public but a small, elite group that has the markers of the growth coalition. What can be added to Molotch’s model of a growth coalition is that the non-profit hospital organization executives in Louisville turned out to be the central actors even though lawyers, developmental, and financial interests were on hospital boards and appeared to be central in the network of relationships. However like the other growth coalition livelihoods hospitals are locally dependent on the area in which they serve for revenue. Local non-profit hospitals are large employers and serve as an avenue of growth. Hospital organization executives integrate into the local business community and in a sense meld into the business interests of the community and serve on the boards of banks, charities and other local institutions and become involved in elite relationships with other elite business and economic figures. This seems to be a good framework from which to build further understanding of local healthcare politics as manifested in different issues and in different U.S. venues.
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Table 1 The political players of the local growth coalition
The Major Payers_________________________________ Property Investing Development Real Estate Financing Politicians Local Media
The Auxiliary Players______________________________ Universities Theaters, Museums, Expositions Professional Sports Organized Labor Self-employed professionals
(Logan and Molotch, 1987, pp.62-85)
Table 2 Top 20 Bonacich Eigenvalues Values _________for Louisville organizations in 2005__________ Organization Eigenvalue Score Greater Louisville Inc.…………………………….…133.024 Fund for the Arts.……………………………………..22.059 Jewish Hospital Healthcare Services.…………………18.475 Frost Brown Todd Law Firm…………………….…...15.096 Norton Healthcare…………………………………….12.143 Louisville Development Foundation………………….10.875 University of Louisville Hospital………………………8.269 Louisville Medical Center Development Corp…...........8.238 Louisville/Jefferson County Metro Govt………………8.098 Anthem Health Plans of Kentucky…………………….7.928 Republic Bank and Trust………………………………7.765 Fund for the Arts Properties Foundation………………7.305 Metro United Way……………………………………..6.786 Leadership Louisville…………………………………..6.729 Baptist Healthcare System……………………………..6.014 Wyatt Tarrant and Combs Law Firm…………………..5.604 Alliance for Life Science Technology Commercialization, Inc………….……………..………5.567 U of L and Jewish Hosp. Cardiovascular Institute………….……………………..5.131 Getcare Health Network……….. .……………………..5.024 Kindred Healthcare…………………………………….4.797
Table 3 Top 20 organization Bonacich Eigenvalues ______after GLI is removed from the dataset_______ Organization Eigenvalue Score Frost Brown Todd……………………………….130.022 Jewish Hospital Health Services……….................51.801 Republic Bank and Trust……………………….....11.995 Fund for the Arts…………………………………...7.548 Leadership Louisville………………………………6.948 Louisville Development Foundation………………5.477 Yum Brands………………………………………..4.738 Metro United Way………………………………....4.442 Fund for the Arts Properties Foundation…….…….3.107 Republic Bank and Trust—Indiana………………..2.758 Branch Bank and Trust (BB&T)…………………...2.666 Goldberg and Simpson Law Firm………………….2.596 Indiana University Southeast………………………2.425 Actors Theatre……………………………………...2.309 U of L/Jewish Hospital Cardiovascular Institute…..2.063 Home of the Innocents……………………………..2.038 Baptist Healthcare System…………………………1.965 Louisville Zoo Foundation…………………………1.898 Lynch Cox Gilman Maher Law Firm………………1.702 Getcare Health Network (now defunct)……………1.602 _____________________________________________
Table 4 Top 20 individual Bonacich eigenvalues in 2005 with _____________their economic sectors_____________ Individual actor_____________________Eigenvalue score M1476 (Attorney) ………………………………..…27.005 M0031 (Healthcare) ………………………………...23.252 M2985 (Utilities)……………………………………22.823 M3715 (Healthcare)…………………………………22.777 M2868 (Education)………………………………….22.315 M0044 (Politician)………………………………….21.642 M3590 (Health Insurance)…………………………..21.392 M1656 (Development)….…………………………..20.680 W1259(Healthcare)…………………………………20.654 M3389(Development)………………………………20.506 M1799(Finance)…………………………………….19.563 M2919(Development)………………………………19.115 M3747 (Education)………………………………….19.115 W1084 (Development) ……………………………19.115 M1611 (Attorney) …………………………………12.925 M0634 Healthcare)………………………………….12.687 M3559(Healthcare)………………………………….12.237 M3682(Healthcare)………………………………….12.156 M2338 (Health-related field)..……………………...11.757
Table 5 Individual Bonacich eigenvalues after GLI _______Cases were removed from the dataset_______ Individual actor____________________Eigenvalue score M1476(Attorney)…………………………………..29.256 W0497 (Banking)……………………………….....15.593 M0568(Attorney)……………………………….....11.579 M1552 (Charity)…………………………………...11.498 W0207 (Attorney)…………………………………11.160 M0242 (Attorney)………………………………….11.153 M2633 (Attorney)………………………………….11.148 M1562 (Attorney)………………………………….11.080 M2822 (Attorney)………………………………….11.080 M0061 (Attorney)………………………………….10.984 M0098 (Attorney)………………………………….10.984 M0119 (Attorney)………………………………….10.984 M0127 (Attorney)………………………………….10.984 M0157 (Attorney)………………………………….10.984 M0176 (Attorney)………………………………….10.984 M0273 (Attorney)………………………………….10.984 M0275 (Attorney)………………………………….10.984 M0282 (Attorney)………………………………….10.984 M0301 (Attorney)………………………………….10.984 M0390 (Attorney)………………………………….10.984
Table 6 Clique with highest average Bonacich eigenvalue _____________score with sectors_______________ Actor with corresponding sector 1. M0031 (Healthcare) 2. M0634 (Healthcare) 3. M1476 (Attorney) 4. M1542 (Physician) 5. M2004 (Physician) 6. M2357 (Development) 7. M2868 (Education) 8. M3065 (Local Business Executive) 9. M3559 (Healthcare) 10. M3634 (Healthcare) 11. M3682 (Healthcare) 12. M3715 (Healthcare) Table 7 _____The next highest clique with sectors listed_____ 1. M0031 (Healthcare) 2. M0044 (Politician) 3. M0093 (Local Professional) 4. M0465 (Local Business Executive) 5. M0669 (Healthcare) 6. M0997 (Healthcare) 7. M2868 (Education) 8. M3081 (Healthcare) 9. M3389 (Development) 10. M3559 (Healthcare) 11. M3715 (Healthcare) 12. W1259 (Healthcare)
Figure 1: Initial MDS result of sectors in the Louisville, KY Metropolitan Area
1 Pu b lic TIndvrvnclthnpolols y ANeeliticniamfsit N v thuile L llew a DHcSsuPIloanrntain ets AFHUcapuredtoccrsrtiorennt t GPooMtapdgtisncleng eBElitero eh g RMtilitietsas s COahartsitam F insnone e D Aetior a a o o oH e 0
HRB -2 -2 -1 0 1 2 3 4 5
Figure 2: magnification of the cluster of sectors in the Louisville KY area
0 .0 6 6 0 .0 6 5 0 .0 6 4 0 .0 6 3 0 .0 6 2 0 .0 6 1 0 .0 6 0 .0 5 9 0 .0 5 8 0 .0 5 7 0 . 0 5 6 E lit e 0 .0 5 5 0 .0 5 4 0 .0 5 3 0 .0 5 2 0 .0 5 1 0 .0 5 0 .0 4 9 0 .0 4 8 0 .0 4 7 0 .0 4 6 0 .0 4 5 0 .0 4 4 0 .0 4 3 0 .0 4 2 0 .0 4 1 0 .0 4 0 .0 3 9 0 .0 3 8 - 0 . 2 -302. 2- 3 . 2 - 20 8. 2 - 20 6. 2 - 20 4. 2 -202. 2- 2 . 2 - 10 8. 2 - 10 6. 2 - 10 4. 2 -1 02 . 2- 0 . 2 - 00 8. 2 - 00 6. 2 - 00 4. 2 0 02 . 2 0 0 1 S p o r ts MH G o v e rn m e n t M e d ia U t ilit ie s O th e r A r t sN o n p r o f it Law N a t io n a l D e H e lo pp itma elsn t vos A c c o u n ta n ts F in a n c e PI D o c t o r s C o lle g e s P o lit ic ia n s H e a lt h c a r e R e t a ile r s F o u n d a t io n In s u r a n c e A d v e r t is in g T e c h n o lo g y B ran c h
Table 8 Non-metric MDS coordinates of _______sectors in Louisville (stress = 0.002)48______ Sector MDS Coordinates 1 2 Accountants -0.198 0.114 Advertising -0.219 0.104 Arts -0.207 0.116 Branch -0.214 0.123 Colleges -0.208 0.105 Development -0.207 0.109 Doctors -0.205 0.103 Elite 0.282 -1.097 Finance -0.210 0.108 Foundation -0.217 0.112 Government -0.196 0.091 HRB 0.667 -0.622 Healthcare -0.192 0.111 Hospitals -0.207 0.109 Insurance -0.225 0.115 Law -0.209 0.112 MH -0.217 0.092 Media -0.202 0.119 Mental -0.606 -1.257 National -0.203 0.112 Nonprofit -0.211 0.114 Other -0.207 0.119 PI -0.211 0.105 Politicians -0.202 0.101 Public 4.848 0.241 Retailers -0.198 0.105 Sports -0.208 0.088 Technology -0.204 0.133 Utilities -0.213 0.116
The reader is reminded that these are the distances between points. The scaling as noted earlier is arbitrary and not like a regular interval variable based on a specific metric.