The Missing Option From Jackson Health System Governance Proposals, Real Democracy

S. Nappalos

With the recent barrage of crisis, attacks, corruption, and mismanagement at Jackson Memorial Health System, it is reasonable to wonder what the public stands for in public health. Miami-Dade Mayor Carlos Alvarez has attempted to reopen debate over Jackson’s governance structure through calling for an overhaul of the present system and replacing it with the county commission in charge. The Miami Herald on May 5th 2010 reported Alvarez as saying, “My opinion is that the PHT should cease to exist and the county commission should be in charge” (1).

Presently Jackson has a hybrid system of decision making made up of the Public Health Trust, a 17-member board that overseas the hospital. The trust chooses the CEO and overseas management, while the county ratifies union contracts, the budget, and land purchases, sales, and revisions to infrastructure. Commissioners also sit on the board, and other county administrators are non-voting members. Elsewhere, public health systems largely exist as either privatized NGOs, private-public hybrids with non-elected management and public funding, or publically run through the cities, counties, or states.

Mayor Alvarez’s proposal would make Jackson fully under the control of the county. The Herald suggests, in less than subtle terms, some alternatives. They cite a 2008 report of the National Association of Public Hospitals as recommending Jackson become an independent entity from the county with an appointed board by the governor, and funding through an autonomous “taxing district”. Broward county already uses such a system (2).

In an unrelated article about business leaders urging action on Jackson, John Dorschner of the Miami Herald inserts a line at the end of the article suggesting a 3rd option. “Tampa General and Grady Memorial in Atlanta have moved in recent years to private nonprofit facilities, with tax support and boards of directors consisting of local business and civil leaders” (3). The article is a short piece summarizing a letter signed by major capitalists in Miami urging the county to supposedly save Jackson by unilaterally reducing labor costs. They instruct the commissioners to “…seriously contemplate declaring a state of fiscal urgency or some other legal device (such as transforming Jackson into a 501(c)(3) entity with leased facilities from the county), which would create the opportunity to allow the total restructuring of costs” (4). The letter is signed by ruling elites including the chair of the Greater Miami Chamber of Commerce, a retired president of the Mercy Foundation, retired CEO of Carnival Cruise Lines, lawyers, entrepreneurs, accountants, presidents of Banks, health insurance companies, hospitals, etc (5).

The logic for these proposals is briefly the need for accountability and oversight, democracy, and efficiency. Mayor Alvarex argues that Jackson should be accountable to voters through the county commission, and probably assumes it would be more efficient. The publically funded autonomous proposal argues that having independent management unaccountable to voters would allow for the unpopular management decisions that would cut costs and keep the hospital efficient. The report by the National Association of Public Hospitals “…determined that county oversight `limits PHT’s [Public Health Trust’s] autonomy in developing operating and capital budgets’ and negotiating collective bargaining agreements” (6). The letter by business leaders argues that privatizing the hospital through creating a NGO would allow for similar unilateral imposition of cuts, which presumably would lead to greater efficiency.

It is worth reflecting on who these people are however, their interests in which way things go for Jackson, and what the interests of the public is. All of these proposals come from various sectors of large management. Miami-Dade county is infamous for corruption, waste, nepotism, and using public funds for private gain. The recent Marlin’s stadium, which dumped public money into a project of private profit is a glaring example of the supposed accountability that would come through control by supposed representatives. Likewise, we should be nervous about the idea of appointed administration who are unaccountable to the public, and given the mandate to cut services and working conditions. After exposing the existence of ghost employees on Jackson’s books and extravagant spending by management not related to direct care (7), we should be nervous about a proposal which seeks to weaken public and worker oversight on management. Likewise, it should give pause as to why executives from banks, hospitals, health insurance companies, and the chamber of commerce want to put Jackson into the private sphere. All of these folks stand to directly gain from a privatized health system which potentially funnels tax payer money into the stock market, and further undermines public health care. It is arbitrary to speculate, but it’s hard to imagine that the same individuals who oversee the crumbling health care system we have as being those we should look to for advise on how to save one of the last life rafts for those without care.

These are the wrong people to ask about our future, our health, and how to run hospitals. The private sector has failed us. Companies are cutting jobs, the stock market destroys pensions overnight, working conditions are ever worsening, all the while management receive bonuses, increasing salaries, and rampant profiteering off the misery of working Americans (and the rest of the world). Likewise public officials and public hospital management have a clear track record of serving their own interests against those of the patients, citizens, and employees. It should strike as absurd that nurses and doctors having safe levels of staffing is being considered a liability for Jackson.

The health system is not endangered because staffing levels are near the levels for safe practice demonstrated repeatedly throughout the literature, and implemented in California. The health system is failing because of uncontrolled price increases through the industries that feed off hospitals and clinics (pharmaceuticals, machinery, and insurance), systematic underfunding, short-sighted management decisions that wait until patients are acutely ill to treat them, and lack of access to care that exacerbates illness and drives up cost of treatment. The proposed solutions for governance will not address these issues and worse, it’s the fox guarding the hen house.

There is an alternative that is never put on the table, real democracy. The politicians, capitalists, and reformers have failed us. Ultimately it is the patients, communities, and workers who know our needs best. Rather than empower bureaucracies that stand to benefit off the system, we need to impose our own cuts, cuts on management and profiteers. Public health could be run through participatory democracy where all effected county residents directly vote and participate in deciding on the budget of the health system (8). Likewise an assembly of community members collaborating with health care workers should decide the direction, conditions, and care provided. Health care workers understand how to protect patients and eliminate the managerial and political bureaucracy that threatens patients care and drives up cost. Democratic accountability through the community having direct democratic control would solve the problem of governance.

We must recognize that this proposal is a threat to all the above parties. It would endanger their jobs, as it argues they are not necessary. Recently the teachers of Miami-Dade, students, and supporters lead an illegal sick-out strike to stop an attack by the bureaucracies on our schools. They won that fight not with advisory boards, representatives, or lobbying; they won it through direct action and organizing. To save Jackson we need to get in the streets and fight to take back control over our communities and our health resources.

(2) ibid.
(4) ibid.
(7) Dorschner, John. JACKSON HEALTH SYSTEM: Report: Workers hidden on Jackson payroll. Miami Herald, The (FL)-February 27, 2010
(8) Though limited in it’s practice and scope, Porto Alegre, Brazil has had a system where people can vote on the allocation of local money directly for years, and which the World Bank has shown measured improvements of the usage of public money for communities. This system however is limited in its impact because it must be filtered through the State which is organized as a hierarchy to protect its own interests against that of its peoples.