exploring local healthcare politics in louisville

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Exploring Local Healthcare Politics in Louisville

Sole Author: David Houvenagle, Ph.D, LCSW

Biographical Sketch:

Dr. 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.

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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 1960s and early 1970s 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). Molotchs (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.

Molotchs (1976) theory offers a both and sense of the local political situation as

opposed to only identifying a political structure. In Molotchs thesis a central, elite set of local

business interests called thegrowth 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).

1For Lennarson-Greer, Urban health politics and policies attempt to define and fulfill the responsibilities of citiesfor 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).

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This article examines thegrowth 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. Thegrowth 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.123-

124) 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

2 Belknap and Steinle list board memberships in tabular form along with the professions of the members (p.123).3 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.

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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 (HSAs)

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 ininstitutional governancea pluralistic, class-based system (p.20). 4

While Litman and Robins usepluralism 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 Grumbachs

4 Vogel (1992) summarizes that Pluralists contended that government dominates the communitys 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.

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(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 hospitals 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.

Swansons (1972) complex cybernetic political model

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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 corporations 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

5 This model seems similar to the model by Clark (1968) on community decision-making (pp.15-21).

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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 agrowth 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).

Molotchs 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 locally-

oriented 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 areanot 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

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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 UCINET8software 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

6For example a manufacturing facility can be built in any geographical location that serves the firms 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).7SNA is a formalized, quantitative approach for studying networks (Adam and Kriesi 2007, p.130). It is useful forinvestigations 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.8The UCINET 6 (version 6.145) software package was used for all SNA analyses in this study. Its multipleroutines generate tabular, numerical and graphical analyses.9 UCINET 6 can be instructed to look for cliques of different sizes.

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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-

10The centrality rankings of individuals and organizations were the same whether n= 7515 or n=4438. The datasetlikely 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 othersegos

power is altersdependence(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.

Bonacichs 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 ismathematically stated as cj = jrij( + 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 = 8.65413 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 Robert-

Wood-Johnson Foundation Communities in Charge grant to provide free or reduced medical services to uninsured

individuals.14 Mean =0.488, Standard Deviation = 5.827

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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 Molotchs

theory is stated in terms of specific interest groups or sectors (versus individual types or

16Given the gargantuan size of the network and the fact that it was a snowball sample versus survey, it cannot bedetermined whether these cliques were strong cliques or weak cliques (Scott, p.118).

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organization types). To explore this question the original dataset was modified to 7470 cases17 to

include an individual persons sector.

Strict adherence to Logan and Molotchs 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

17

Cases that were not actual human beings were removed from this dataset. As listed with the Kentucky Secretaryof 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 setshould 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.

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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 GLIs 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 ( ) 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

20 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.

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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) 2122

Figure 1 is the initial result from the UCINET MDS routine. The public health and

health-related business sectors are extreme outliers in the networkthey 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.

21 For a discussion of network mapping of the sectors see Houvenagle (2008).22MDS has broad applications and is an alternative to factor analysis (Wasserman and Faust, p.288). Its generalgoal 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 aglance (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 Shepards

diagram similar to a Cartesian plane. (http://www.statsoft.com/textbook/stmulsca.html)Borgattis 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 isarbitrary. 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 citys elites. Galaskiewicz

(1979) used smallest space analysis to analyze the organizational networks in a Midwestern city.

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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

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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.232425

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

networkthere 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

23 There have been few studies of a community power structure using MDS. Laumann and Pappi and Galaskiewiczwere 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 Galaskiewiczs (1979) smallest space analysis MDS (SSA-1) on an

anonymous Midwestern community which suggests that these results can be generalized.24According to Galaskiewicz, SSA-1 is a MDS routine that maps points in a Euclidean space as a function of theirestimated 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 moralsupport. 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

Galaskiewiczs 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 butthe state university in the town was in closer proximity (p.1355). Galaskiewiczs variance was in his information

network where the information was arranged to they types of activities than auspices (p.1352). GalaskiewiczsMDS/SSA-1 results support a growth coalition type constellation of organizations being connected with healthcare

especially hospitals. Galaskiewiczs 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).25

26 Furthermore some sectors are distinctively not in this network, and some sectors (especially doctors) are

distinctively on the fringe of the central power.

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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,

27 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.

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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

30 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.

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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 agenda-

setter. Medical school department chairs have influence over the placement and operation of

indigent care services. However, the responding informants said the Medical Schools influence

stays within the downtown Medical Center and does not extend to the larger community.33

Where is Greater Louisville Inc?

31 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.32Informants 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 beindependent business people with mobility throughout the city to practice in different hospitals.

33 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.

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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 GLIs 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 theBoyle Report35 of 1996 (commissioned by GLIs

predecessor organization) as a source for understanding Louisvilles healthcare agenda, but

several informants did not understand GLI to be involved at all in healthcare. The informant

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 Mayors and Metro Governments36primary 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.

34 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 wasEconomic Development Strategy for the Greater Louisville Region. This report

identified Louisvilles 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.

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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 dont think there are even positions established that the designation or authority to reallytake that on beyond Dr. Troutman, and if there are positions, theyre relative weak

positions, I am not talking individuals; Im 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

37 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 QCCTto be an important but sensitive issue According to informants the QCCT contribution is a matter that is negotiatedat a high political level within the city. The Mayor and the University of Louisville President directly negotiate the

city of Louisvilles 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 ofLouisville/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.

38 This smoking ordinance initially prohibited smoking in all restaurants and public places with the exception of

Churchill Downsthe home of the Kentucky Derby horse race. A number of informants said that the smokingordinance 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.

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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

40 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.

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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 its also an economic cluster that is valued by ourcommunity. 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 (CEOs) 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

45 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.

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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 communityto 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

47This phenomenon was similar to Houvenagles (2008) findings about Louisville healthcare planning in the 1960sand 1970s. 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.

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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 Molotchs 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

Utilities_____________________________________

The Auxiliary Players______________________________

Universities

Theaters, Museums, Expositions

Professional Sports

Organized Labor

Self-employed professionals

Small retailers__________________________

(Logan and Molotch, 1987, pp.62-85)

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Table 2

Top 20 Bonacich Eigenvalues Values

_________for Louisville organizations in 2005__________

Organization Eigenvalue Score

Greater Louisville Inc..133.024

Fund for the Arts...22.059Jewish Hospital Healthcare Services.18.475

Frost Brown Todd Law Firm....15.096Norton Healthcare.12.143Louisville Development Foundation.10.875

University of Louisville Hospital8.269

Louisville Medical Center Development Corp...........8.238

Louisville/Jefferson County Metro Govt8.098Anthem Health Plans of Kentucky.7.928

Republic Bank and Trust7.765

Fund for the Arts Properties Foundation7.305Metro United Way..6.786

Leadership Louisville..6.729

Baptist Healthcare System..6.014Wyatt Tarrant and Combs Law Firm..5.604

Alliance for Life Science Technology

Commercialization, Inc...5.567U of L and Jewish Hosp.

Cardiovascular Institute...5.131

Getcare Health Network.. ...5.024

Kindred Healthcare.4.797

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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.................51.801Republic Bank and Trust.....11.995

Fund for the Arts...7.548Leadership Louisville6.948Louisville Development Foundation5.477

Yum Brands..4.738

Metro United Way....4.442

Fund for the Arts Properties Foundation..3.107Republic Bank and TrustIndiana..2.758

Branch Bank and Trust (BB&T)...2.666

Goldberg and Simpson Law Firm.2.596Indiana University Southeast2.425

Actors Theatre...2.309

U of L/Jewish Hospital Cardiovascular Institute..2.063Home of the Innocents..2.038

Baptist Healthcare System1.965

Louisville Zoo Foundation1.898Lynch Cox Gilman Maher Law Firm1.702

Getcare Health Network (now defunct)1.602

_____________________________________________

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Table 4

Top 20 individual Bonacich eigenvalues in 2005 with

_____________their economic sectors_____________

Individual actor_____________________Eigenvalue scoreM1476 (Attorney) ..27.005

M0031 (Healthcare) ...23.252

M2985 (Utilities)22.823M3715 (Healthcare)22.777

M2868 (Education).22.315M0044 (Politician).21.642M3590 (Health Insurance)..21.392

M1656 (Development)...20.680

W1259(Healthcare)20.654

M3389(Development)20.506M1799(Finance).19.563

M2919(Development)19.115

M3747 (Education).19.115W1084 (Development) 19.115

M1611 (Attorney) 12.925

M0634 Healthcare).12.687M3559(Healthcare).12.237

M3682(Healthcare).12.156

M2338 (Health-related field).....11.757

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Table 6

Clique with highest average Bonacich eigenvalue

_____________score with sectors_______________

Actor with corresponding sector

1. M0031 (Healthcare)


3. M1476 (Attorney)4. M1542 (Physician)

5. M2004 (Physician)6. M2357 (Development)7. M2868 (Education)

8. M3065 (Local Business Executive)


10. M3634 (Healthcare)11. M3682 (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)


11. M3715 (Healthcare)12. W1259 (Healthcare)

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Figure 1: Initial MDS result of sectors

in the Louisville, KY Metropolitan Area

5

4

3

2

1

0

- 1

- 2

A c c o u n ta n tsA d v e rtis in gA r t sB ra n c hC ol le g e sDe v e lo p me n tDo c to rsEliteFin a n c eF o u n d a tio nG o v e r n m e n t

H R B

H e a lth c a reHo s p ita lsIn s u ra n c eL a wM HM e d iaNa tio n a lNo n p ro f itO th e rPIPo litic ia n s

Pu b lic

Re ta ile rsS p o rt sT e c h n o lo g yUtilit ie s

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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

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

A c c o u n t a n t s

A d v e r t is i n g

A r t s

B r a n c h

C o l le g e s

D e v e lo p m e n t

D o c t o r s

E l i t e

F in a n c e

F o u n d a t io n

G o v e r n m e n t

H e a lt h c a r e

H o s p i t a ls

In s u r a n c e

L a w

M H

M e d ia

N a t io n a l

N o n p r o f i t

O t h e r

P I

P o l i t ic i a n s

R e t a il e r s

S p o r t s

T e c h n o lo g y

U t i l i t ie s

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Table 8

Non-metric MDS coordinates of

_______sectors in Louisville (stress = 0.002)48 ______

Sector MDS Coordinates

1 2

Accountants -0.198 0.114Advertising -0.219 0.104

Arts -0.207 0.116Branch -0.214 0.123

Colleges -0.208 0.105

Development -0.207 0.109

Doctors -0.205 0.103Elite 0.282 -1.097

Finance -0.210 0.108

Foundation -0.217 0.112Government -0.196 0.091

HRB 0.667 -0.622Healthcare -0.192 0.111Hospitals -0.207 0.109

Insurance -0.225 0.115

Law -0.209 0.112

MH -0.217 0.092Media -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 0.105Politicians -0.202 0.101

Public 4.848 0.241

Retailers -0.198 0.105Sports -0.208 0.088

Technology -0.204 0.133

Utilities -0.213 0.116

48 Th d i i d d th t th th di t b t i t Th li t d li i bit d

exploring local healthcare politics in louisville

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