the local politics of brain surgery: it's not rocket science but economic development

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Abstract Local healthcare politics in the United States has been a neglected area of research. This article explores local healthcare politics in Louisvil le Kentucky as manifested in a conflict between two local institutions over the medical specialty of neurosurgery. This article identifi es the actors, their agendas, and thei r interactions. Local healthcare politics in thi s United States setti ng was not about redistribution or access to care, but it turned out to be a matter of c ommunity elitist bargaining over economic logic in wh ich the doctors were subordinate actors and elected government officials were largely excluded from the process. 1

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Abstract

Local healthcare politics in the United States has been a neglected area of 

research. This article explores local healthcare politics in Louisville Kentucky as

manifested in a conflict between two local institutions over the medical specialty

of neurosurgery. This article identifies the actors, their agendas, and their 

interactions. Local healthcare politics in this United States setting was not about

redistribution or access to care, but it turned out to be a matter of community

elitist bargaining over economic logic in which the doctors were subordinate

actors and elected government officials were largely excluded from the process.

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THE LOCAL POLITICS OF BRAIN SURGERY:

IT’S NOT ROCKET SCIENCE BUT ECONOMIC DEVELOPMENT

Health care reform has been a dominant issue since the Obama

Administration took office in January 2009. It has become reality with President

Obama signing into law the “Health care and Education Reconciliation Act of 

2010.” In light of this milestone, a group of health policy scholars recently

recognized health care is organized and delivered at the local level and declared

the local role to be critical for health care reform success because payment

negotiation reflects local market conditions (Robert Wood Johnson Foundation,

 p.1). However, health policy scholars have not clarified who these local

stakeholders are and have not articulated how local health care politics works.

Lennarson-Greer (1997) had already concluded over a decade ago that

health care delivery in the U.S. was a local responsibility. She also observed that

 both urban studies and health policy scholars had ignored that reality and so there

are few theoretical findings (p.356).1 Health policy scholars seem to expect

 policy outcomes out of a local political apparatus that they have failed to study

and define.

The ignorance of local how local health care politics works appears to be a

 product of paradigms. Health policy scholars have focused on national and state

levels and quantitative research methods. Urban studies scholars have not

considered health care to be a central matter of local governance. However,

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“urban studies” has useful tools in this case starting with the premise that politics

consists of a tension between political structure and agency; both tend to give

indication about each other.

This article explores local health care political activity in one United

States venue through examination of a local conflict over the specialty of 

neurosurgery. The conflict (with implications for the whole Louisville, KY

metropolitan area) was in 2009 between the largest healthcare provider and the

local state university with a medical school. This article first reviews the relevant,

existing scholarly literature. Then, using published media reports; it reviews the

timeline, identifies the actors, and analyzes the agendas of the actors. It then

draws theoretical conclusions from an urban political economy framework about

the findings.

LITERATURE REVIEW

Previous scholarly findings on local health care politics in the U.S. context

are from the schools of health policy, sociology, and urban studies. Most of the

work is in the form of case studies that identified political structure. Most

scholars failed to analyze local agendas and activity. The latest approach used an

urban political economy framework, suggesting a framework for both political

structure and activity. This section will review this literature.

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Sociological Studies

The sociological authors mostly reached elitist political structure

conclusions. Belknap and Steinle (1963) identified that business interests

dominated hospital board membership (pp.122-123), 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 (a contemporary of Belknap

and Steinle) co-authored several qualitative studies with repeated elitist

conclusions. Starr (1982) observed that physicians historically depended upon the

capital and philanthropy of influential business elites to establish hospitals

(pp.152-153).

Two later doctoral dissertations deserve mention. Morone (1982) studied

a number of citizen-led local health systems agencies (HSA’s) established by the

 National Health Planning and Resource Development Act of 1974 and found

sabotage by local politicians. Plano (1999) identified that some interest groups

decided hospital placement within Toronto Canada and Milwaukee, but he neither 

conceptualized an overall picture of the relevant community power structure or 

mode of political activity. While these studies contribute to knowledge, no one

has expounded on them.

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Health Policy Writings

Contemporary to Elling, Conant, and Wilson were health policy

researchers cited in later works. Conant’s (1968) decision-making study of five

communities found apathetic and ignorant publics and ad-hoc (not rational-

comprehensive) planning activities (pp.14-18). Wilson’s (1968) 21-community

study found economic elites as more influential than both politicians and

 professionals in health issues (p.98). Both Conant and Wilson identified several

 political tendencies 1) incrementalism; 2) a status quo; 3) inconsistent agendas;

and 4) paternalistic administrators with elite backing.

Alford’s (1975) political-economic analysis focused on New York City’s

health system. He suggested that health care institutions “must be understood in

terms of a struggle between major structural interests operating within the context

of a market society.” Alford noted that a tension exists between bureaucratic

reformers and market reformers (pp.1-2). He suggested that the popular control

of health care is unlikely, because the public is too unorganized to negotiate with

the structural interests (pp.220-222). Alford’s findings were unique but like the

dissertation writers, there was no expounding on his work.

Ginzburg (1977) anecdotally observed that elites historically controlled

the typical nonprofit community hospital. He observed the norm of multiple

generations of affluent families sitting on the same local hospital boards (p.3).

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Litman and Robins (1984) devoted one-half of a page in their health

 policy textbook to political structure as it pertained to local health care. Litman

and Robins used “pluralism” to describe their view of local politics, but their 

citations are not about the pluralism of community power. They referred to

“pluralism” in terms of the autonomy of doctors and not in terms of popular or 

democratic community control. Their political structure discussion seemed

incidental with a focus on a standard of participatory democracy (p.20).

The later public health authors exemplify Lennarson-Greer’s point about

neglect of the local aspect. Tulchinsky and Varavikova (2000) only discuss the

local level of health care governance in bureaucratic terms as part of the federal

system (pp.530-532). Gentile-Donnell (2004) discussed the closing of a

Philadelphia public hospital in terms of formal government but failed to discuss

community power structure. Bodenheimer and Grumbach (2005) described local

 policies in generalities, and only discussed the governance of community health

centers in federal versus local terms (p.60-62). Lastly, Shi and Singh (2008)

declared that “Federal, state, and local governments pursue their own policies

with little coordination of purpose or programs,” but Shi and Singh failed to

describe the local governance structure and nature of local activity (p.538). These

later health policy authors confirmed Lennarson-Greer’s point.

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Urban Studies

A number of urban studies authors produced some relevant work about

local health care governance. The studies were reflective of the paradigms of 

their times evolving from cybernetics to urban political economy.

Swanson’s (1972) “cybernetic” political model consisted of seven

variables where different formulations explain government’s health care activity

care on various levels. His variables are: 1) system output, 2) system stress

(political contention, controversy, and conflict), 3) system inputs, 4) power 

structure, 5) political ideologies, 6) political focus, and 7) system change

 processes (pp.443-454). Local health politicians then theoretically utilize

different mixtures of the variables to achieve desired policy results. Swanson

seemed to adapt a general process model to a particular policy realm and did not

identify general structural or agency tendencies, and there was no further 

expansion upon his work.

Dye (1973) stated, “In nearly every community, decision-making in health

and hospital matters is firmly lodged in the hands of leaders of the local medical

associations” (p.479). Dye did not empirically substantiate this statement and he

did not repeat it in later editions of his textbook.

Schussler (1994) explored corporatism in local health care politics through

the process of the state of Kentucky awarding the Humana Corporation the

management contract for the University of Louisville Hospital. In this case, a

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local proprietary health care corporation and government had a public-private

 partnership to deliver indigent care (pp.1-2).

Britton and Ocasio (2007) explored hospital and orphanage location in

Chicago between 1848 and 1916. They identified that hospital location placement

was such that created greater visibility of the “material and symbolic benefits

 provided by these facilities.”

Author (2008) conducted a case study on local health care politics in

Louisville that included historical analysis and social network analysis followed

up with field interviews on health care governance patterns. The recurring pattern

over several decades was that local politics consisted of elitist political structures

with an economic development agenda, which fit the conclusions of Molotch’s

(1976) growth machine thesis.

Within the limited body of literature on local health politics in the United

States, an elitist political structure is the most consistent theme, but as Lennarson-

Greer noted there are few findings. More recent urban studies findings have

evolved with the discipline to an urban political economy framework asking the

question “for what are the actors motivated,” which offers a more complete

 picture of agenda, activity, and political structure (See Vogel, 1992 for a further 

discussion of urban political economy).

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THE SETTING

This section discusses the background and setting of which the conflict

and political activity arose. It discusses the spatial setting and the nature of the

 pre-existing political relationships.

The Louisville Medical Center 

The Louisville (Kentucky) Medical Center consists of five teaching

hospitals affiliated with the University of Louisville Medical School. The

Louisville Area Development Association led in its incorporation in 1950 (Amster 

and Zingman, 1994, p.21). To create it the political actors used University of 

Louisville’s power of eminent domain to condemn and clear land around

Louisville General Hospital, Children’s Hospital, and the University of Louisville

Medical School.

Over 60 years time different non-profit hospital organizations built there

and collaborated with the University of Louisville. As a result, this hospital

complex of medical care, education and research has expanded to 22 square

 blocks in size, and is viewed as a growth pole for further high-tech economic

growth.

Part of the development included the state of Kentucky paying for a new

Louisville General facility in 1978. The state then gave the University of 

Louisville the deed in 1979 and the facility name was changed to University

Hospital.

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The Relationships

From 1981 through 1995, the University of Louisville Hospital had been

under the management of a proprietary manager (see Schussler for details).

Louisville-based Humana took over the management of the financially troubled

University Hospital in 1981 and managed it under contract until it divested itself 

of the hospital business. Columbia-Hospital Corporation of America (HCA)

assumed the contract when it bought Humana’s Louisville hospital properties.

When Columbia HCA violated the management contract by moving its

headquarters to Nashville, Tennessee in 1995, the state of Kentucky asked the

other two hospital organizations in the medical center Alliant Health System (later 

 Norton Healthcare) and Jewish Hospital Healthcare Services to collaborate in

managing University Hospital.

In 1996 Alliant and Jewish entered into an affiliation agreement with the

University of Louisville to manage University Hospital as a 501c3 nonprofit

organization entitled University Medical Center (UMC). Field interviews

conducted by Author (2008) identified that despite being competitors, Jewish and

Alliant had a shared interest to get Columbia HCA out of the Medical Center 

(pp.196-197).

Over the consortium’s life Alliant/Norton and Jewish gave more than $100

million, and other donations to University Hospital and the University of 

Louisville Medical School, which strengthened the hospital’s previously

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neglected infrastructure. However, University of Louisville officials in turn had

an agenda to grow University Hospital, which encroached on the status quo of 

Alliant/Norton’s and Jewish’s medical specialties and lines of medical expertise.

The University of Louisville eventually complained that UMC could not conduct

independent strategic planning apart from Norton and Jewish. The UMC board

stopped meeting due to the increasing conflict. In early 2007, the University of 

Louisville executed a clause in the UMC affiliation agreement terminating the

consortium and giving the University of Louisville full control of the hospital

(Author, pp. 197-200). The University of Louisville then became both a

competitor and collaborator with the other hospital systems in the medical center.

THE CONFLICT OVER NEUROSURGERY

This section will explore the timeline of the pertinent conflict that revealed

the actors and their agendas. Three distinct rounds of bargaining activity

 between the actors suggest the nature of the political activity.

Round #1: U of L Fires its Neurosurgery Faculty

Christopher Shields, MD, chair of the University Of Louisville

Department Of Neurosurgery and President of the Neurosurgical Institute of 

Kentucky (NIKY) had been unable to address recurrent criticism from the

Accreditation Council of Graduate Medical Education that U of L neurosurgery

residents were getting insufficient experience in treating aneurysms, epilepsy and

spine damage. Hiring additional neurosurgeons with the specific sub-specialties

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would solve the problem. However, under the auspices of the University of 

Louisville alone, Shields could not afford the higher salaries necessary to attract

new talent (Laidman, 2009, p.48).

Without the knowledge of University administration, Shields, made an

independent agreement on behalf of NIKY in December 2008 with Norton

Healthcare. (NIKY did 80 percent of its work at Norton facilities.) The

agreement stipulated that all of the NIKY neurosurgeons would be full-time

 Norton employees. As a result, Shields could finance salaries that were 33

 percent higher to attract new neurosurgeons with the desired sub-specialties to

 both NIKY and the University of Louisville faculty. The plan also provided for 

 NIKY paying a three-fold increase in “Dean’s tax” to the university (the amount

faculty pay to the University from their practice revenues) (Laidman, p.48). The

 NIKY and Norton plan had intended benefits for all the parties.

However, when Shields and a NIKY partner disclosed the plan to Edward

Halperin, the U of L Medical School dean, Halperin rejected it. Furthermore, on

February 14, 2009, Halperin sent each NIKY neurosurgeon who was also a U of L

faculty member a letter stating that an employment contract with Norton

constituted resignation from the University (Laidman, p.50). Shields sought to

 bargain directly with U of L President James Ramsey on behalf of NIKY to keep

their U of L faculty positions. On February 19, 2009 Shields refrained from

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further bargaining attempts when he obtained a Ramsey memo confirming the

stance that the neurosurgeons had resigned from the faculty (Laidman, p.52).

On February 20, 2009, Norton Healthcare went public with its hiring of 

the NIKY neurosurgeons and its new Norton Neuroscience Institute. Norton

 publicized its plan to invest up to $100 million in neurosurgical and allied

specialties over 10 years, and that five new neurosurgeons would join Norton

within the year (Adkins, 2009, February 20).

Five days later, The Courier-Journal began playing a diplomat role in the

emerging Norton-U of L neurosurgery conflict. In an editorial it related inside

knowledge of President Ramsey’s stance that University of Louisville’s medical

complex was an ‘”under-performing asset”’ and that “He wants to leverage the

university’s medical activities to generate more money for the institution.” The

Courier-Journal credited the medical center’s success over time to the status quo

of established partnerships and alliances. Despite giving Ramsey’s strategy some

credence, The Courier-Journal called it the wrong strategy and endorsed Norton’s

expansion to be in the community interest (Hitting a nerve, p.A10).

Two days later The Courier-Journal published a response from Halperin

as a guest editorial. Halperin countered that U of L’s strategy and actions were in

the best interest of the community and that Norton’s strategy instead endangered

the community. Halperin emphasized the university’s strategic importance as “an

outstanding academic medical center and serving as an economic engine for the

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city and state.” Halperin asserted that U of L could neither let the University

Hospital Trauma Center lose its Level-One accreditation status nor let it operate at

the mercy of a competitor (due to the neurosurgeons becoming Norton

employees). Halperin reviewed U of L’s commitment to being Louisville’s

“Level-One Trauma Center” and the potential consequences if the status was lost:

severely injured patients could be diverted to Indianapolis, Nashville, Cincinnati

or Lexington  (Halperin, A9).

Round #2: the Fired Neurosurgeons Agree to Help their Old Employer 

Three weeks later, local newspapers reported the agreement that the eight

 NIKY neurosurgeons would staff the U of L Hospital Trauma Center while U of 

L looked for new neurosurgical faculty. The arrangement would expire in the

middle of May 2009 (U of L begin search for neurosurgeons 2009, March 19)

(Howington, 2009, March 20).

Two days later the NIKY neurosurgeons made a collective statement in

The Courier-Journal opinion section. They endorsed Norton’s initiative and

framed U of L’s decision to terminate them in the context of U of L’s ending the

UMC management consortium with Jewish and Norton (Shields et al 2009, March

22).

The next month The Courier-Journal continued to play dual observer and

diplomat roles. It ran an analysis piece on the Norton-U of L dispute and its

implications for accreditation of the neurosurgery residency program at

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University Hospital. The accreditation surveyors were due in mid-May 2009.

The story reviewed all the details of the conflict up until that date (Howington,

2009, April 19).

In addition to its own analytical piece, The Courier-Journal gave both

sides a chance to state their cases through guest editorials by Norton CEO

Stephen Williams and U of L President James Ramsey. Ramsey’s content was

similar to Halperin’s February piece that defended U of L’s importance both as a

 provider and in its “economic engine being built at the Health Sciences Center”

(Ramsey, 2009 April 19, p.H3). On the other hand, Williams 1) reviewed the

 benefits of Norton plan, 2) criticized the U of L’s strategic moves away from the

Medical Center partnerships, and 3) noted possible consequences of service

duplication by U of L. Williams affirmed that Norton would still partner with U

of L when “the “goals of both organizations could be aligned” (Williams, 2009,

April 19, p.H3). The consistent theme in both executives’ editorials was growth.

Two days later The Courier-Journal again diplomatically editorialized and

argued for a path-dependent solution to the conflict. It suggested:

Whatever the solution to the current dilemma, the right strategic goal for the Louisville community is a carefully consolidated downtown medicalcenter built on the kinds of public-private partnerships that have developedover decades. Such a high-end health complex, and all the economic

development spinoffs it can produce will involve competition, but it alsowill require as much cooperation and collaboration as highly talented andmotivated folks can muster. (Looking for a fix, 2009, April 21)

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Round #3: Bargaining to Keep the Neurosurgery Territory

There was one more publicized round of bargaining.  Business First (the

weekly business newspaper in Louisville) reported that U of L bargained with

 Norton to extend NIKY neurosurgical coverage at University Hospital until it

could hire new neurosurgeons. This was the first report that the Kentucky’s

governor was involved as a mediator between Norton and U of L. U of L also

sought reimbursement from Norton for the cost of hiring new neurosurgeons, and

attempted to get Norton to drop pursuit of its own, neurosurgery residency

 program in exchange for giving unpaid faculty status to the neurosurgeons. The

deal fell through (Adkins 2009, May 1).

One week later U of L announced that it hired nine new neurosurgery

faculty members. Two were full-time and seven were part-time. Eight of the new

faculty were already locally practicing neurosurgeons. U of L was thus able to

resolve its accreditation issues in a timely fashion (U of L hires nine new, 2009,

May 8) (Ungar, 2009, May 9).

The Courier-Journal ran a retrospective editorial two weeks later 

(Looking ahead, 2009, May 22) that retrospectively summarized the conflict

 between Norton and U of L and called for peace. The Courier-Journal opined:

The best outcome would be (1) continuation of the high level of care thathas made the University Hospital trauma operation a point of community pride, and a reason for citizen comfort, and (2) full development of the planned Norton Neuroscience Institute to which Norton Healthcare says itwill commit $100 million.

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The Courier-Journal again acted diplomatically, but it espoused growth in every

instance.

THE ACTORS AND THEIR AGENDAS

Despite all the bargaining, the parties stood their ground. The University

of Louisville and Norton Healthcare both moved on after the crisis was over, and

the accreditation statuses were renewed. This section will review and analyze

what the conflict suggests about the actors and their agendas.

The Neurosurgeons of the Neurological Institute of Kentucky

The neurosurgeons of the Neurosurgical Institute of Kentucky (NIKY) and

its president comprised the first set of actors. They attempted to bargain as an

equal, independent party with Norton and the University of Louisville. Despite

 being embraced by Norton Healthcare, the University of Louisville did not

recognize them as equals by terminating them as disloyal employees. Their goals

through signing employment contracts with Norton as educators and physicians

were 1) to resolve an accreditation issue and 2) grow the U of L Neurosurgery

Department into the best in the country (Laidman, p.47).

 Norton Healthcare

 Norton Healthcare had a straightforward agenda of growth. At their first

announcement, Norton officials touted the planned investment of $100 million

over 10 years. Norton was going to “expand diagnostic and treatment services,

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research efforts and outreach into other portions of the state.” (Adkins, 2009,

February 20).

The University of Louisville

While University of Louisville officials emphasized the potential risks to

the Louisville metropolitan area, they intertwined economics and development in

their rhetoric. They mentioned more than once their need to have a strong

 bargaining position with insurance companies. However, the consistent theme in

Halperin’s and Ramsey’s rhetoric was the university’s importance to Louisville

and the state of Kentucky as an agent of economic development. Ramsey argued:

In our community, medicine is an important driver of our economy, U of L is at the forefront, currently engaging in millions of dollars in medicalresearch and attracting new scientists and researchers to our community.(Ramsey, 2009)

Therefore, from the University of Louisville standpoint losing the neurosurgeons

could have had the negative effect to the whole community in both health care

and economic terms.

The Louisville Courier-Journal 

While other local media outlets also covered the conflict, The Courier-

 Journal , as the daily paper for the Louisville metropolitan area uniquely stood out

in a diplomatic role. Besides the in-depth news coverage, The Courier-Journal 

acted as a self-appointed insider-statesman by elucidating the situation’s salient

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nuances on the editorial page. It also provided a public forum for the parties to

state their sides of the issue.

Consistent with Molotch’s (1976) growth machine thesis as a local

newspaper, The Courier-Journal, consistently supported growth and affirmed the

status-quo of public-private relationships that had been critical to the medical

center’s success. The paper supported the Norton Neuroscience Institute while

acknowledging the community risk of University Hospital losing its Level-One

trauma center status. Only in its last editorial on the conflict (Looking ahead,

2009, May 22) did the paper say something positive about the University of 

Louisville.

What has happened in the U of L-Norton confrontation is a hugelyimportant consequence of strategic decisions the university has embracedand public policy it has made and enforced. The public deserves to knowhow all this is working out. The best outcome would be (1) continuation of the high level of care that has made the University Hospital trauma

operation a point of community pride, and a reason for citizen comfort,and (2) full development of the planned Norton Neuroscience Institute towhich Norton Healthcare says it will commit $100 million (p.A10).

Elected Politicians

There is no published evidence that elected politicians had a bargaining

 position in the Norton-U of L conflict. It was two months into the conflict before

the Courier-Journal (Howington, 2009, April 19) had reported that Louisville

Mayor Jerry Abramson had talked to both sides about resolving their differences

and he was concerned about University Hospital losing its Level-One trauma

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status. It was also about the same point in time that Kentucky Governor Steve

Beshear had talked to both sides about resolving the conflict (Howington, 2009,

April 19, p.A6) (Adkins, 2009 May 5). The local newspapers portrayed elected

 politicians as late appearing minor actors attempting to mediate and not taking

sides.

ANALYSIS AND CONCLUSION

This case study reviewed local health care politics through a particular 

conflict over the medical specialty of neurosurgery. It identified the actors, their 

roles and their agendas. The findings do not derivate from the previous structural

findings of elitism; the public did not have any formal input in this matter. The

findings support the relevance of the growth machine thesis in terms of political

structure and agenda given the emphasis of both the local university and local

newspaper on growth and development.

However, in terms of local political structure, this conflict indicated more

who was not in power than who was in power. In this case, the conflict showed

the neurosurgeons collectively to be in an economically dependent position on the

organizations and thus they did not have the bargaining power on a par with the

University given that the University terminated them as disloyal employees. The

elected state and local politicians were late-appearing minor players attempting to

mediate. The conflict showed that the local state university and the largest non-

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 profit healthcare provider were the parties in control and the main parties at the

 bargaining table.

What this conflict revealed about the essential agenda of local healthcare

 politics is clearer—it was more about growth and economic development than the

quality of neurosurgical services, or increasing the access to healthcare. The

 primary actors were institutions or groups driven by a growth agenda in each of 

their own interests, and not redistribution or indigent care. The NIKY

neurosurgeons wanted to grow as a practice, which would in turn improve the

University of Louisville Medical School neurosurgery program. Norton wanted

to grow its neurosurgery specialty. Besides maintaining its territory of “Level-

One” trauma care, the University of Louisville wanted to strengthen its bargaining

 position in getting improved commercial insurance reimbursement rates and

expand its economic development role. The Louisville Courier-Journal always

espoused growth in its editorials even though it tended to side with Norton’s plan

as part of the old status quo of collaboration and was critical of the University of 

Louisville for going rogue. In a grand sense, this was a conflict over economic

logic more than risks to accreditation.

The earlier cited editorial comment of the neurosurgeons regarding the

how the Norton-U of L conflict over neurosurgery should be interpreted in light

of the 2008 UMC consortium dissolution does suggests a political-economic

framework for interpreting the local political environment. A dynamic of both

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 political and economic tension had evolved between Norton and the University of 

Louisville. The University of Louisville needed Norton’s collaboration over a

decade earlier to rejuvenate University Hospital. However, the intense

collaboration in the form of the UMC management consortium eventually ceased

having economic value for all the actors. The previous local status quo of 

 political and economic structure ceased serving the University’s economic interest

as the condition of the University Hospital improved.

This was one of three case studies on local healthcare politics in

Louisville, which in a sense is a limitation because Louisville is not representative

of all U.S. venues and case studies cannot be generalized. This study invites

future research on other localities to examine local healthcare politics in like

manner to understand the actors and their agendas. Exploring different incidences

of both local healthcare conflict and cooperation in different locations is

necessary to understand this political arena and to begin identifying possible

implications for federal healthcare reforms on the local level.

ENDNOTES

1 For Lennarson-Greer used the term “urban health politics” to describe the local aspect. Her definition of this was “Urban health politics and policies attempt to define and fulfill theresponsibilities of cities for the health of their population, especially in regard to the hazards anddangers of urban life and the uneven concentration of disease in cities (p.356).

2 Molotch’s growth coalition is composed of local elites from the sectors of property investing,development, real estate financing, politicians, local media, universities,theaters/museums/expositions, professional sports, organized labor, self-employed professionals,and small retailers (Logan and Molotch, pp.62-85).

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