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PSC 307: Public Policy Analysis | Policy videos | PSC 303: International Relations | Internat'l videos

Student Notes on Video Documentaries on Public Policy

Compiled by Jeremy Lewis; revised 23 April 2013

Hedrick Smith, Poisoned Waters, PBS Frontline, 2009

Pollution in the Chesapeake bay

Environmental Protection Agency was cut back by the Reagan administration's deregulation effort, called voluntary compliance.
Chicken farm manure runoff from eastern shore increased grreatlyh with scale of Frank Perdue farms, that by contract own everything about the process except the manure, which is left to small farmers to dispose of.  Cheaper for them to dump it into streams.
In West Virginia:
in the headwaters of the Potomac river, a marine biologist finds fish with intersex characteristics (males with immature eggs of a female).
This is caused by endocrine disruption from powerful chemicals.
Unfortunately, fish hormonal systems are similar to humans, and water filters cannot remove this newer threat.
Puget sound:
the orca population is top predator in food chain and the population is declining, now an endangered species.
Tests show Orcas have PCBs, even though these were banned years ago -- shows bio accumulation over long term.
PCBs still found in mud on river bottom, toxic buildup from half century of industrial waste
Like other Superfund sites, the polluter (Boeing) struggles with the public authorities over whose pollution entered the flume, and therefore its liability.

Top of page

The GI Bill
introduction by Jeremy Lewis, 2008; the rest by Elizabeth McLain, 2004, with bulleted insertions by Jeremy Lewis 2008

  • American Legion campaigned for benefits for GIs during WW2.
  • Chair John Rankin (D-MS) opposed HR bill on grounds it would give benefits (50/20 club provision) to black servicemen, including 50,000 in MS.
  • bill passed after extensive search for a Rep. from GA whose vote was needed.
  • risk of unrest as GIs were demobbed in 1945
  • Atom bomb ended war with Japan earlier than expected, government unprepared for early peacetime economy
  • ethnic immigrant groups had limited choices of jobs pre war, but had worked in forces
  • many black and ethnic soldiers lacked training or education, unable to cmopete in civilian economy
  • all eligible after serving 90 days -- given a day (of education) for a day of service -- and could be paid to go to any college that would accept you.
  • books and tuition covered, plus $65 a month
  • "for blacks, the single most important thing in our lives" -- Harry Belafonte
  • -The G.I. bill, officially the Servicemen's Readjustment Act of 1944, provided many benefits to veterans of World War II.
    -It established veterans' hospitals, provided for vocational rehabilitation, made low-interest mortgages available, and granted stipends covering tuition and living expenses for veterans attending college or trade schools.
    -It provided books and tuition
    -It was especially important for black participants
    -It gave $65 a month for participants to live on
    -Many vocational schools and universities sprang up
    -Acting schools were paid by the government to hire these people and teach them, Walter Mathau, Belafonte, Rod Steiger being among them.
    -Many veterans went to trade schools and programs
    -Many had a higher thirst for knowledge, based on greater maturity
  • Veterans took only 1/5 of appropriated unemployment benefits, because they moved quickly into worplace.
  • -Education was not the most important aspect of it however; the unemployment benefits were. It was keeping unemployed veterans off the streets
    -Many could live comfortably from $20 a week.
  • HS graduation was considered the mark of an educated person before WW2

  • -Most people never even thought of going to college. Only the elite went
    -Now they too could go to college, not just children of alumni or the rich who wanted to become doctors and lawyers.
  • Bob Dole: half of the college students would not have gone without GI Bill
  • -Registration doubled, even quadrupled in some places.
    -University of Michigan ballooned from 10,000 students to 40,000
    -1.6 million GI’s went to school 1947 which was 49 percent of students
  • institutions were not prepared for an invasion like this: class increased from 11,000 to 15,000 at one institution alone.
  • libraries and dorms were built rapidly
  • -Schools had to adjust; naval buildings were used as dorms until new buildings could be built
    -New sections of schools were made for married GI’s with families
  • contrast with prewar policy of expulsion due to marriage or pregnancy
  • -People were very serious;
  • they normally took about 23 credit hours a semester and they usually did well because they had a reason to study.
  • School was much easier than war.
  • Quality issue?
  • -Harvard and University of Chicago thought this would destroy intellectual higher education.
    -but vets hogged Deans List and honor roll- even the president of Harvard said that they were more mature.
  • cultural contrast with other students: GIs were not interested in fraternity hazing or wearing sophomore beanies, wanted to work

  • -Some went on to become great scientists (eg Nobel prize winner, eg inventor of pacemaker)
  • 60% chose engineering and science degrees, leading to middle class society for the first time

  • -They gave back their knowledge through programs such as NASA's Venus mission.
    -Many came from blue collar families and they could now have better jobs
  • e.g., African American economist earning a PhD at Harvard, a major breakthrough
  • Housing program: VA loan—federally backed loan so qualified GI’s could get a new home once they graduated
    -Housing developments were constructed at a rapid rate.
  • Levittown constructed by a former Seabee, with standard yellow kitchens
  • purchase with no money down, four rooms

  • -Houses came with washers and dryers which were never standard before.
    -2/3 prewar people were renters; now 2/3 were owners
  • Cost $14.5 Billion, but the return was inestimable -- helping all without hurting anyone
  • recipients point out college would have been impossible without the GI Bill.
  • -This was one of the most successful programs implemented in America.

    Divided Highways
    by Michael Pierce, 2004
    I. Introduction
       The United State's interstate system is a huge accomplishment for our nation. It is the largest public works program in history.
       The Interstate system made it possible for people to get anywhere they wanted quickly.
       Automobiles and modern roads were a huge cultural influence.
       Even though the interstate project lacks the dazzle of projects like the space program, it has affected our daily lives more than any other government program.
       There are also many problems associated with interstates, but they are a crucial in making our modern society work.
       Before interstates, roads in the U.S. were notoriously bad. The 'Build Roads' movement in the 1890's came about simultaneously with the advent of the first automobiles. Railways and other methods were too constricting. To reach their destinations people would have to wait until the train arrived and sometimes take a series of different trains to reach their final destination. Cars were the ultimate freedom, people could go where they wanted when they wanted. Cars were becoming part of our cultural identity.
       Carl Graham Fischer proposes a coast to coast highway. He owned a headlamp company and persuaded other businesses to support the road. His road, called the "Lincoln Highway," was privately funded. Construction on the Lincoln Highway stopped abruptly at the start of W.W.I. The military takes over the project. The roads weren't able to handle the pressures of heavy automobiles and as a result they were difficult to navigate. A caravan of automobiles was able to cross the country in 62 days.
       President Eisenhower appreciates the advantages of having reliable roads.  [He had led a military, coast to coast expedition across the mud.]
       Thomas McDonald becomes the Chief of Public Roads. His aim is to build roads to help people.
       McDonald presses congress for money to build roads and is successful in adding 10,000 miles to the highway system. Soon the system connects every state and are dubbed "interstates."
         By the end of the 1920s there were 40 million cars on the road.
    People loved them and the economy was growing  to depend on them.
       When the depression hits, Roosevelt pumps $1.8 Billion into 'make work' programs. The roads that were built by the programs gave work to the people and supported our new car culture.
       Roosevelt developed a plan for 6 major roads that would connect North with South and East with West. These roads would be toll roads, paid for by those who used them
       McDonald believed that roads should be free for all to use, he also advocated improvements to inner city transit systems rather than expansion of interstates.
       General Motors builds "Futurama," an exhibit at the World's Fair depicting the miracle of interstate travel through cities. People start to get excited about the expansion of public roads.
       The dream highway becomes a reality in the Pennsylvania Turnpike. The turnpike was toll road with no speed limits.
    Adolph Hitler's Autobahn was the model for the American Interstate system. The U.S. government also recognized the military advantage to having an extensive interstate system.
    W.W.II freezes the Automobile craze. Gasoline rationing, speed limits, and other regulations dampen the rapid expansion of the interstate.
       When Americans returned from Germany after the war, having seen the German Autobahns, they wanted them built in America.
       After the war the highways fueled the economy with jobs, commerce.
       Suburbs become the norm for the new middle class. People begin to  depend on the interstates for daily transportation into the city.
       As people depend more and more on their automobiles, congestion  becomes a problem.
        Constant expansion of the interstate system angers environmentalists who dislike the destruction of the country's natural areas. Sometimes people are forced to abandon their homes and neighborhoods to make room for new interstates.
        Trucking becomes vital to the economy. Industry and Commerce depend on Interstates to move product and raw materials.
        When earthquakes destroyed much of the interstate system in L.A. people rapidly made the switch to public transit, but then returned immediately to their cars once the highways were fixed.
        Interstates tended to destroy small town economies, they made it possible for people to leave town, spend their money in the city and return home very quickly.
         Texas has more miles of interstate than any other state.
        Shopping centers or 'malls' spring up everywhere. Commerce flourishes wherever interstates have an off-ramp.
        Edge Cities spring up around interstates, no one has to go "downtown" anymore.
        Americans love cars more than practically anything else, they are extremely reluctant to give them up for any reason.

    Divided Highways (PBS video, 10/97)
    outline by Jeremy Lewis.

    Theme: Social transformation through infrastructure.

    PART 1: (the glory of progress)
  • Does congestion reduce through building highways, or do they create further demand?
  • Lincoln Highway pre-WW1, never completed.
  • WW1 soldiers trip across USA, led by Ike.
  • Bureau of Road Engineers run as traditional hierarchy.
  • Progressive movement connected with technological change.
  • Eras of road building:
  • Roman Empire, Napoleon and modern America.
  • Scale of car ownership by 1929.
  • New Deal road construction.
  • 1939 NY World's Fair: cars as modernity.
  • PA turnpike 1940.
  • German autobahns.
  • Post WW2 suburban ideal.
  • Car subsidized by smow removal, property tax ...
  • Powerful highway lobby in 1950s.
  • Commission.
  • Effect on States of 90% Federal funding.
  • Defense connection.
  • Production line experience.
  • PART 2: (The costs of progress.)
  • Destruction of slums and swamps.
  • Divided communities, especially black.
  • Public reaction shocked engineers (professional ethic meets political environment).
  • Effects on society:
  • Trucking system.
  • Loss in earthquake makes us realize normal benefits.
  • Maintenance costs massive.
  • Shopping centers.
  • Cognitive dissonance: love car, hate the consequences.
  • 1970s oil shock did not slow highway development.
  • Reform?
  • Combine trust funds?
  • Maintain and connect roads?
  • Avoid China following automobility.



    Marshall Plan Video
    By Brandy Smith, 2004
  • Marshall appeared for a private meeting with Stalin who delayed the meeting for several hours. Marshall thought that the Soviets had everything to gain by delaying.
  • Stalin wanted western Europe to collapse to communism
  • Marshall plan is “against chaos, hunger, and poverty and for free institutes to exist” according to Marshall. American press reported this speech.
  • Lincoln Gordon (economist) thought it was the most important thing in foreign policy.
  • Molatov demanded more information at the conference. He said let each country determine their own needs. A cable came to him on June 30th at the press conference saying it’s a plot against us. He walked out.
  • Even though there was much relief from this, there was also great concern.
  • The 2nd Paris Conference was represented by American, British, and French officials.
  • Europeans had to calculate their individual dollar amount needed and compare and then present the amount to the Americans for consideration.
  • 28 billion dollars over 4 years is what they needed, but it was eventually cut down to 19 billion after the Americans said absolutely not.
  • In December, Marshall took the plan to Congress. Many did not want to get so deeply involved in foreign affairs.
  • Marshall himself set out campaigning for this plan. He said “it is the American tradition to help”. This convinced people that this was an interest of humanity. Marshall mobilized Congressional support while the urgency became more obvious.
  • April 1948, 10 months after it started, the president signed the plan.
  • Europeans set up the OEEC to regulate and allocate the Marshall Plan funds.
  • Stalin tried to dissuade this German progress. Soviet Union tanks barricaded the only entrance to West Berlin. The challenge was lifted with  the Berlin airlift carrying Marshall Plan supplies. The blockade ended. Germany joined the OEEC.
  • Communists launched an anti-marshall plan campaign and tried all kinds of tricks to sabotage the plan.
  • Marshall plan publicists fought back with their own propaganda. By the 2nd anniversary of the Marshall plan there were obvious changes on account of the plans success.
  • Most of the funds were used to finance goods and services from America so it actually stayed in America.
  • North Atlantic Treaty Organization was modeled after the Marshall Plan.
  • 1951 after 12 ½ billion dollars, the Marshall plan came to an end. It had created a trans-atlantic union. Europe was on the brink of instability and the U.S. could not sit back and watch, they helped create a stable Europe. The rebuilt the entire infrastructure of Europe with government money.



    Video: PBS, Frontline, After Drug War
    [Unknown student's outline, mixed with Dr. Lewis's comments in brackets.]
    Strategy of Interdiction of supply:
    -aerostats are placed on the southern cast of the US in order to prevent air drug trafficking
    -weather related accidents lower the percentage rate of an aerostat to work
    -some see then as a waste of money because smugglers can still get by.  Flying thrugh mountains or just waiting for high winds when the aerostat can't stay in the air
    -when smugglers fly under 500 feet, it impairs the ability to detect as well.
    -smugglers have ways to make it seem that they are landing in mexico, but in actuality he crosses through "the gate" that is near power lines that make it even harder to be detected and land in the US on a small rural runway.
    -[Pork barrel issue] Senator Deconcini works on the aerostat project.
    -Tcom is an organization connected to former staff of Deconcini
    -the favors given by the senator was hidden, although it is not considered illegal.
    -Pentagon had concerns on the Aerostats.  shortcomings were apparent in the program.  but congress mandated the purchase of the new aerostats although the pentagon didn't think it was cost effective.
    -some agree with military in that aerostats are a waste of money
    [-other possibilities are reducing supplies by burning crops in colombia and other places (special forces get shot at)
    or reduce demand at home.  Americans are 60% of illegal and dangerous drug demand.]
    -boats are sent on a patrol for "go fast" an idea to stop smugglers by boat wasn't effective because radar wasn't effective in rough seas.
    -would have been more efficient with a larger boat, such as used by the coast guard
    Border control on land:
    -the ground war is an even bigger challenge, led by the marines
    -1000 reservists were trained by Br. General John
    -They aren't allowed to make a rest.
    -only four marijuana seizes in 6 months, $660,000 was spent.
    -In El Paso Texas, illegal immigrants enter the city everyday, smugglers just drive across the border with a huge flow of traffic.  it is impossible to stop every car.  They did it for 21 days in 1968 [Nixon's Operation Intercept] but the cost was too high and almost nothing was found.
    -Now they randomly search with dogs and electronics
    -trained agents survey the drivers for signs of nervousness.
    - [probably ineffective without intelligence to conduct targetted operations]
    Case of failure of ground interdiction:
    -Raphael Munoz is the head of a very profitable cocaine trafficking group, that made fortune 500 money.
  • -He dealt with Colombian suppliers and moved the cocaine into the US.
  • they would haul loads in luxury sedans
  • -they crossed the border and were never caught.  they would change cars and take the drugs to a warehuse, put it in a cargo truck full of piñatas and party supplies, then they would go to LA on a different route then the norm.  They would send people ahead of the truck to make sure there were no dogs or anything to impair there crossing checkpoints.
  • -when caught they had 22 tons of cocaine and 12 million dollars in cash
  • -over 250 tons of cocaine total was dealt from the Tapea family.
  • -an informant knew of the operation 11 months before the family was caught and never told anyone, [DEA agent] claimed she was too busy to check it out and the leads weren't developed enough to check out.
  • [DEA agent claimed too busy to check out leads and received no help from supervisor]
  • -the performance of custom inspectors was questioned and [witness testified] customs agents received ten thousand dollars a load.
  • - were given to agents if a member of the family was about to get caught.
  • [28 bridges are fertile ground for smuggling -- and under NAFTA, trade expected to grow between Mexico and US.]
  • Corruption of local officials:
    -Candalaria, Texas is an extremely small town with a population of 60 people near the Rio Grande, [a small stream at this point]
  • Chambers and Rick Thompson smuggled drugs by driving across the Rio Grande in their truck.  Chambers convicted on large scale smuggling.
  • Rick Thompson was a [powerful Sheriff in Presidio county Texas, past president of Sheriff's association, and on regional narcotics task force.  He campaigned against drug smuggling,] and popular politically.  They both received life in prison after making 1 million dollars a truckload.
  • Prediction is someon eelse will continue the flow of drugs
  • despite $2Bn spent on federal interdiction
  • [-three ways to reduce drug abuse:
    1) shoot the residents of Columbia and Peru and infiltrating territory and spray crops with poison.  pay them not to produce drugs.  US imperialism.
    2) reduce demand among Americans by going to schools and tell the children about the dangerous drugs and why not to abuse them. either by police officers, teachers, parents, and ministers.  police officers (D.A.R.E.) is proven to be ineffective.  parents and teachers make more of an impact.
    3) most expensive and ineffective.  interdict the flow of illegal drug trafficking.  stop the supply from entering the country.  applying technology is only partial solution.
    -most effective is human intelligence, but it is the most dangerous.
    Must pressure arrested pushers and couriers, get them to admit act then get them to tell on their superior.]

    From "The American Experience" series with David McCollough.
    PBS, Silent Spring by Rachel Carson
  • Significance:
  • by 1955 600 M lbs./yr pesticides used
  • Carson: not insecticides, but "biocides"
  • changed nation's way of thinking
  • Biography of policy entrepreneur:
  • grew up in Western Pennsylvania
  • always wanted to be a writer, wrote books at age 10
  • BA: Biology Penn College for Women; MA: Zoology at Johns Hopkins
  • Experience:
  • 1936 - U.S. Fish & Wildlife Service
  • science writer and researcher
  • 1941 - First book Under the Sea-Wind
  • Post WWII - Editor for publications at Wildlife Service
  • 1951 - Second book Sea Around Us -- railed against arrogance of man
  • revenues allowed Carson to quit job
  • The problem: D.D.T.
  • used in WWII to fight typhus fever
  • cheap, effective, and apparently safe
  • crop production expanded as a result
  • government endorsement
  • sprayed public and private lands
  • use expanded into the suburbs
  • Spraying of her friend's bird farm.
  • Attempted to expose the problem through Reader's Digest. Rejected.
  • Evidence of chemicals killing insects but preventing birds reproducing
  • annual use of pesticides on farms increased postwar to 600 M (lbs?)
  • Problem was denial within gov't. -- and endorsing products
  • Massachusetts bird sanctuary (owned by Carson's friend) sprayed, massacring large numbers of birds.
  • Long Island lawsuit against spraying failed, but shows rising consciousness before Carson.
  • Preparing the Silent Spring manuscript
  • Houghton Mifflin editor believes her popular writing could overcome lack of interest of readers in pesticides
  • fortunate find in a secretary, amid mass of materials
  • manuscripts were packed with data slipped to her by individual government scientists
  • Carson outraged by government attitude of secretiveness and denial of wildlife damage
  • Dept. Ag refused to publish safe pesticides disposal.  Industry insisted on lack of harm.
  • Officials named in book sometimes lost their jobs.
  • Simply can't eradicate an insect with a chemical
  • Federal programs when spread to private lands caused loss of private property such as horses
  • Carson argued Gov't exag'd significance of insect effects, e.g. fireants.
  • Dieldrin
  • highly effective against insects but 40 times more toxic than D.D.T.
  • spread in the South by Dept. of Ag.
  • treated 1 M acres in the first year, despite protests
  • Agriculture department denied damage -- but her colleague found thick Dieldrin in Georgia had killed many farm mammals around the fire-ant mounds.
  • Tepp
  • derived from nerve gases, parathion, highly dangerous to humans and required moon suits.
  • some found on drugstore shelves, capable of killing if dropped
  • Publication:
  • 1960 Carson suffering two breast tumors, needed radical left mastectomy, radiation
  • had suffered illnesses for many years
  • race against time, for 1 Jan. deadline for the publisher
  • manuscript grew from 6 chapters to 17
  • 1961 exerpts in the New Yorker -- editor had read manuscript in one sitting
  • Fall 1962 first printing
  • Reactions:
  • Opposition to pesticides is a "tool of Communist menace"
  • Chemical companies attempted to stop publishing after New Yorker
  • Book carefully footnoted with data, could defend it from industry
  • Sec. of Interior Mo Udall strengthened own scientists in support of Carson
  • President Kennedy confirmed in press conference that scientists were checking into the matter
  • American Medical Association, Monsanto & American Cyanamid (Dr. Roger White Stevens) all criticized
  • "real threat to future of man is horde of insects"
  • some of her data are good, but misplaced emphasis
  • industry writer: people still afraid of pesticide residues, even though no longer present
  • Carson convinced, saw no other side of story
  • increased publicity, attempts at suppressing backfired
  • 40 state legislatures enacted pesticide laws
  • Carson interviewed by CBS: credible
  • Ecology and "balance of Nature" terms coined and popularized -- natural laws that cannot be repealed by scientists
  • Chemical industry scientists argued (eloquently) Man was beginning to control nature.
  • Senator Ribicoff's Hearings
  • Support from President Kennedy  and Sec. Interior "Mo" Udall report
  • Book translated into 23 languages, 1963.
  • Carson died two years later, but environmental movement was active and successful within a decade.

  • PBS, Dr. Solomon's Dilemma (2000)
    notes by a student, 2006, with insertions by Dr. Lewis
  • Reforms of health care in 1990s
  • Develop a greater sense of trust between doctors and patients
  • doctors are put back in control of treatment, but also of costs
  • Lower patients' rates of using expensive test and procedures
  • Doctors vie for patients, which pits doctors against each other with patients caught in the middle
  • Care Group Example,
  • Beth Israel Deaconness, a Harvard teaching hospital in Longwood, the mecca of teaching hospitals:
  • Dr. Martin Solomon (practising over 20 years, grew up locally) has over thirty five patients per day and takes over one hundred phone calls.
  • This flood of patients lowers the standard of care per patient.
  • Doctors are being instructed on how to judge expense of the care they give.  Hopefully this will lower the cost of patient care and make healthcare more affordable.
  • CareGroup medical director, Dr. Kim Saal, believes that the key to lowering healthcare costs is reigning in doctors.
  • CareGroup lost $100M on $1 B delivery
  • doctors responsible for 80% of cost decisions
  • There is a new focus on data, which makes healthcare more manageable.
  • CareGroup's Pod 11
  • Solomon's colleagues are losing money and have joined CareGroup by selling their practices
  • a pod of about 20 doctors collectively attempt to monitor their spending
  • Lower payments from employers & federal government squeezed them with rising costs for pharmaceuticals, etc
  • One cost analysis doctor shows the comparative cost figures, Dr. Solomon is spending more than his pod average on radiology (graphs shown, and trend lines are up, not down)
  • Tufts, rival Partners Health Care also losing money ($47 M) -- a widespread problem
  • Deaconness suffered six years of staff cuts in 1990s, forced to respond to business imperatives
  • CareGroup took over spending in return for a greater share of premiums, not failed to save enough
  • Critiques:
  • Some opponents of this new system believe that you cannot be that statistical about something so complex as healthcare.
  • Many doctors do not like the feeling of having someone looking over their shoulders all the time.
  • In the 90's employers started revolting against paying the high premiums, which resulted in the healthcare agencies going into debt.
  • Veteran doctors dislike healthcare being refered to as a business, focusing more on making the patients more comfortable in a caring enviroment.
  • organizational culture issue: contrast between business side and doctor-patient relationship
  • time is money in new managed care system
  • Hospital time for patients has been cut 25% in ten years
  • Hospitals negotiate per capita rates with care systems
  • Example of cardiac operation:
  • example of Mr. Steven Bookbinder (52) undergoing heart catherization, discovering he needs a bypass operation
  • same day admission and discharge is equally safe -- but patient care not the same
  • patient has little time to adjust to new information
  • discharge after 72 hours following $30,000 bypass operation -- fits medical guidelines
  • Bookbinder had to return to hospital with staph infection, which costs hospital substantial money
  • Patient with diabetes and pregnant at the Joslin clinic
  • pregnancy stresses blood sugar levels in diabetics, risks for both mother (kidney, heart and vascular) and baby (premature and abnormal)
  • example: patient visits 30 times, an hour each time
  • The Joslin clinic pioneered safe delivery -- but costs 4-5 times the normal delivery
  • but only reimbursed at normal level, hence loss making
  • Loss of time with doctor, average now 7 minutes -- but Joslin needs much longer time
  • World famous Joslin loses $5M per year -- made it unattractive in merger wars of 1990s.
  • Perverse incentives -- Joslin has too many sick people
  • CareGroup decided could not afford to include the Joslin
  • in three years of 1990s, Congress dramatically cut medical reimbursements
  • Care Group reaction
  • nurse speaks to director about excessive patient loads on nurses, and excessive paperwork
  • administrator: maintain state of emergency -- but avoid a state of panic
  • Solomon: we have gone from Mecca of medicine to a medical Beirut
  • Formerly, doctors paid more for doing more to patients, now paid more for doing less -- both extremes of incentives are wrong
  • now affects personal income of doctors -- they lose if Group is in deficit
  • paid $120,000 to $320,000 per year
  • if they send patients outside their system, it costs the Group a loss
  • Insurance Co may allow special treatment elsewhere, but doctors now have to resist
  • Example of educated patient who found another system that specialized in her pregnancy malignancy and when Solomon declined to pay, after 14 years she bitterly left for Brigham and Women's next door.
  • Old People as a burden
  • SecureHorizons care plan seemed good but capitation system meant that doctors would be globally responsible for all costs of patient care.
  • Many practices have trouble with Medicare HMOs, because rates go down and doctors may be forced to drop a plan.
  • After several years of it being financially successful, Solomon's pod faced the reality that $5,000 premium only covered four days in hospital -- after that, making a loss.
  • If at end of the year, they lost money, they would have to pay the insurance company -- and it happened
  • Undeniable that cost controls affect the way doctors treat the patients
  • Patient died after 67 days in hospital, which caused huge bill.
  • Afternote: $130M loss in 1999, layoffs in December and four doctors of pod left.