,,62 consists of competent, intelligent people in their respective fields. These characteristics are the most important. . . consumers know just as much about the health planning process as providers do." Unlike a number of the HSAs in the South, the South Florida HSA is not directly or indirectly controlled by the provider members. Nonetheless, staff members generally take the view that providers, if the opportunity arose, would dominate the decision making process. In effect, McCue regards the staff as the primary barrier to domination by providers. He also expressed fear of medical doctors gaining complete control of the board. "If more physicians controlled the executive board the public would not have a chance. 63 This is not in the best interest of the people." A major issue before the HSA has been whether hospitals in the area should be allowed to expand in a situation where there are already too many hospital beds. Sometimes the issue is the purchase of new expensive equipment used for radiation treatment of cancer. Concerns about the expensive dilution of scarce resources and duplication of existing services are pitted against doctors' and hospital administrators' desires to have large, modern facilities which can provide comprehensive service. At the HSA board meeting on July 20, 1976, two requests for costly linear accelerators were raised. A review committee had recommended that one request be granted and the other denied. After the presentations and discussions, the board voted to deny both requests. In the opinion of HSA President Budd Cutler, the request was denied because neither hospital had made any plans for providing care to indigents. 64 One comment from a board member was revealing. He said that because the staff had told him that there was no need for a linear accelerator at South Miami Hospital, he decided to vote against that request. It is possible that this member assessed the issue independently, but it appears that he relied totally on the staff recommendation in making his decision. 57 A common criticism of the South Florida HSA is that the staff makes the decisions while trying to give the impression that the board makes them. One staff member stated that because of the influence of the staff, consumer participation is an "empty ritual." The Rev. Charles Truax, a board member from Monroe County, described the decision making process as "semi-democratic." He stated that the staff does most of the research work, and that the board is Doctors, in particular, resent the fact that the board is influenced not by them, but by the staff. According to Dr. Charles F. Tate, President of the Dade County Medical Association, the staff makes the decisions, but claims they are the decisions of the committee. Dr. Edward St. Mary, editor of the monthly magazine of the Dade County Medical Association, charged that the consumers on the board seemed "brainwashed" by the staff at a meeting in July, 1976. Doctors Tate and St. Mary both feel their views are representative of the medical community. They believe that PL 93-641 is dangerous legislation. Dr. St. Mary described it as "another bad law" in an editorial in Miami Medicine, June, 1976. More recently, he said that the fears expressed in his editorial had been borne out. He believes there is far too little physician representation on the board. Concerning the consumers, he complains that "five out of ten" of them are disgruntled about some bad experience they have had with a physician and that they "have an ax to grind." He says that the effect of the rule requiring a majority of consumers on the board and the strict definition of "consumer" is that the board 66 does not have an informed majority. The problem facing most consumers in the South is that their HSAs are dominated by the provider members. An exception is the HSA of South Florida, where control of the agency's policies is exercised by the director and staff. The staff is consumer oriented and the agency attempts to provide health planning that is effective and comprehensive. However, the staff, not the consumer board members, dominates policy. Former director Wood McCue was highly involved 58 in shaping the agency's policies and in making it responsive to public needs. But a progressive staff is not an adequate substitute for an active consumer membership on the board. In many agencies, the staffs are comprised of individuals who are indifferent to the consumer role in health planning or who often share the provincial views of the providers. If the HSAs are to work for the best interests of everyone concerned, it is essential that the boards not be controlled by the providers or by the staff. It is the consumer who must have the ultimate power to make policy decisions. 59 STATE VS. LOCAL CONTROL PL 93-641 provides an important role for the states in health planning. The governor appoints members to the SHCC and exercises veto power over decisions made by local agencies. The SHPDA, as an arm of state government, is subject to the administrative and political power of the governor. It also exerts considerable influence by administering the state Certificate of Need program. As a result, the issue of state control is one that faces every HSA. Many planners and knowledgeable consumers feel that too much health planning authority exercised at the state level weakens the HSAs. The two following profiles give a view of the sharp contrasts that exist between a state (Texas) where the HSAs are hampered by opposition and controls and a state (Mississippi) where consumers have taken the initiative to create a representative agency that is responsive to the public. CENTRAL TEXAS HEALTH SYSTEMS AGENCY The Central Texas Health Systems Agency located in Austin is a relatively progressive agency that is attempting to bring effective health planning to the area it serves. Keith Markley, executive director, sought to include representative numbers of minorities and low-income individuals on the governing board. There are five blacks on the thirty member board and three members who have SpanishAmerican surnames. The most significant indication of the agency's concern for inclusive representation is the fact that 10% of the members have annual income below $7,000. One early problem the agency encountered, as is common among HSAs, was that the consumer members tended to defer to the providers on policy matters. The agency has made a fairly successful effort to alleviate this situation; the director and staff have worked with the National Health Planning Information Center and arranged training sessions for the consumer members. Consumer participation in the HSA is now described by Keith Markely as very good. "Consumers are very much on top of things and now some of the providers are paranoid. The providers do not have as much time to devote to the HSA as do consumers. Both consumers and providers contribute actively, but many times providers are overestimated. We have very capable consumers and some are better informed than providers." 67 The Central Texas and the other Texas HSAs are forced to operate under state restrictions and controls that preclude effective health planning. After the state agencies voiced objections to Central Texas Health Systems Agency's proposed administrative, employment, and work procedures, the issue of control at the state level clearly emerged as a primary factor in delaying its operations. The role of the Governor is extremely important in the development of the HSAs, because his lack of cooperation can impede their progress and render them ineffective. The major decision-making powers reside with the state agencies and the governor's office. This has proved to be one of the most serious constraints on the HSAs, for it means that the HSAs must please those state agencies which are controlled by and accountable to the governor. Governor Dolph Briscoe's basically unsympathetic approach to the HSAs has served as a formidible block to their progress. Texas is further behind in the development of its HSAS than most other Southern states. Not until May, 1976, did HEW begin conditionally designating the state's twelve HSAs. The Texas SHPDA was not established until July, 1976. When one health official was asked if the designation of the SHPDA would serve to lessen constraints on the HSAs he stated, "No, the designation of the SHPDA is a sham. 1,68 Governor Briscoe's support for the concentration of health planning authority at the state level has been detrimental to the Texas HSAs. His unwillingness to establish a SHCC means that the HSAS lack the essential coordination between the state and local agencies. He has attempted to delay implementation of PL 93-641 in Texas in other ways. Members of the Texas Coordination Committee on State Health and Welfare Services recommended to Briscoe that none of the HSA applications be reviewed by HEW during the first |