Tennessee's "Real People" Organize for Fair Health Care

Nashville, Tennessee hosts the corporate headquarters for seven of the nation's 11 largest private, for-profit health care corporations, including the largest one, Hospital Corporation of America. Nashville is also the home base of Tennessee's Real People's Coalition, an emerging coalition of citizens fighting for improved health care conditions. The coalition has shocked industry and government insiders by packing once-quiet hearing rooms of state government with concerned — and irate — citizens. 

Robert Everett is a retiree and one of the leaders of the Real People's Coalition. After a September 1984 hearing of the Governor's Select Committee on Health Care Cost Containment, he lashed out at the committee, which he said was "dominated by the health care industry, large corporations, and insurance companies." 

The rising cost of health care and decreasing access to health care for poor and working-class people are widening the gap between the people who can pay for medical services and those who can't. Though their lives are in danger, people without money or medical insurance are turned away from hospitals simply because they cannot afford excessive pre-payments. Spiraling costs of medical care also are making it more likely that people who can pay for care now will in the future be forced into the ranks of those who can't pay. Especially among the elderly, many who considered themselves firmly entrenched in the middle class have seen their possessions and entire savings swallowed by health care bills. 

"The real people of this state," Everett says, "were purposely left out of the [decision-making] process. Why? Because those boys think that real people don't know what is wrong. Instead, we end up having to rely on experts. Well, how in the world did we get in the mess we're in? Haven't the experts been handling the situation all along?" 

The Real People's Coalition, a statewide organization, grows out of the work of Nashville Communities Organized for Progress (NCOP), an umbrella organization of over 30 inner-city neighborhood, tenant, and church groups. In 1979 a group of inner-city Nashville community leaders got together to discuss the way federal Community Development Block Grant funds were being spent. Metropolitan Nashville was receiving millions of dollars from the federal government, but instead of investing this money in poor neighborhoods as intended, the city was decorating downtown business areas with ornate brick sidewalks. A citywide campaign was mounted to get these funds spent in low- and middle-income communities. In the process, NCOP was born. 

NCOP began work on a broad range of issues in Nashville's poor and working-class communities. It gradually gained the allegiance of a strong grassroots constituency and is now a political force in the Nashville area. Neighborhood groups have attacked problems ranging from health-threatening drainage ditches to insufficient street lights and noisy industrial neighbors. Committees monitor waste landfills, and high-crime communities have organized Fight Against Crime Together (FACT) groups. NCOP's organizational efforts are backed by the Cumberland Institute, which over the past seven years has provided professional training and organizing assistance for a variety of community and labor groups in Tennessee. 

NCOP has not won many friends among Nashville's present power structure for their organizing activities. City councilman Sam Underwood called NCOP "dangerous" in 1981, while councilman Guy Bates labeled the coalition "a hard-headed special interest group." Metropolitan Nashville Housing and Development Authority chief Gerald Nicely branded NCOP "disruptive." And the conservative Nashville Banner ran a 1981 series entitled "NCOP, A Thorn in Nashville's Side." 

Others are encouraged by the vigorous new community organization. "People have taken direct community action together on issues that affect their daily lives, and the results have been dramatic," says Kathleen Maloy, an NCOP leader. Some of Nashville's top country music songwriters have organized successful benefits for NCOP and its member community groups. One benefit, organized by songwriter Thom Schuyler, with performances by Paul Overstreet, Pam Rose, Mary Ann Kennedy, and Fred Knobloch, netted over $2,000. 

NCOP is governed by a delegate assembly that meets three times a year. Each member community organization is represented by two delegates to the assemblies, which set NCOP's agenda by submitting and voting on resolutions. NCOP has two chairs and a board of directors, elected every two years. Citywide action committees are formed by resolutions from the delegate assembly. 

In the spring of 1981 NCOP astounded Metropolitan Nashville's city council when at least 800 citizens wearing blue NCOP buttons stormed public meetings on a proposed water and sewer line expansion. Massive public opposition to a plan that would have overtaxed inner-city residents caused city lawmakers to negotiate a fairer plan with NCOP leaders. According to Nashville! magazine in 1981, "newly politicized citizens flooded council members with telephone calls. . . , filled the council chamber and hallway and forced defeat of a three-year water and sewer plan that would have hiked residential rates by 58 percent." 

In 1983, the NCOP jobs committee successfully worked to secure employment on a downtown convention center project for unemployed inner-city residents. The committee negotiated 51 percent of the jobs on the project for people living in Nashville's "pocket of poverty." This included 51 percent of the top level management jobs, a feat that was accomplished after the committee staged a 300-person "March of the Unemployed" on city development offices. The story of NCOP's success spread to other Tennessee communities, and the Cumberland Institute was asked to assist developing community organizations throughout the state. 

NCOP and its health care committees have combined strong researching and organizing abilities to win a string of impressive victories. Their research committee has looked at alternative plans for containing hospital costs, the effect of Medicaid reimbursement on public hospitals and alternate plans for funding hospital care for indigents. Among their victories have been: 

• successfully pressing for public disclosure of Medicaid reimbursement records, or cost reports, for health care facilities, 

• winning a commitment from the state health department to inspect at least once a year every nursing home in the state without prior notification, 

• gaining new funds for the home weatherization and insulation program for elderly and handicapped people in Tennessee. 

One of the major issues of concern to the health and hospitals committee centers on a local public hospital, Nashville General. The committee analyzes the Metro Nashville budget for the hospital, which has come upon increasingly hard times due to Medicaid and Medicare cuts and because a growing number of private, for-profit hospitals are skimming off valuable private-pay patients and serving far less than their fair share of low-income patients. The committee also has discovered that the bankruptcy court docket is filled with the names of people who went broke over medical bills. "We cannot just sit back and watch while these people drown in their medical expenses," says NCOP leader Jean Smith. 

Said Kathleen Maloy in 1983, "We understand this is a tight budget year and priorities have to be established. However, General Hospital should be a very high priority." NCOP protests were instrumental in stopping plans by Metro Nashville from cutting one million dollars from General's budget that year. 

"We've had to work hard for the victories we've won," says Maureen Waldron, a member of NCOP who experienced great difficulty at a Nashville area nursing home, Imperial Manor, when her husband fell sick. She and 50 other NCOP supporters invaded the Tennessee capital building in 1982 to pack the state comptroller's office in support of public disclosure of nursing home Medicaid reimbursement records. 

A hundred and fifty people packed a legislative hearing on spiraling hospital costs in mid-November 1983 at which NCOP member John Lozier said he believed "a large part of the growth in hospital charges is due to the rapid rise in for-profit corporations. We are all being taken advantage of so that these companies can make large profits for their investors." 

Support for NCOP's charges came even from some officials in the industry. D. Gene Clark, administrator of the nonprofit Johnson City Medical Center Hospital, testified at the same hearing that "the plight of the health care system today is caused by those who are apparently manipulating the system for their personal and private gain. I think we will look back upon the 1970s and 1980s and see that the robber barons of these years were in the health care industry, just as the robber barons of the early 1900s were in railroads, steamships, and steel." 

Two weeks after the legislative hearing, NCOP sponsored a public hearing in Nashville on escalating hospital costs. "The legislature here in Tennessee must take steps to help Tennesseans deal with rampant health costs and the painful and often tragic results of being unable to get necessary health care," said Linda Mitchell, a spokesperson for NCOP's health and hospital committee. 

That public hearing was intended to educate legislators, but only two of the 60 invited showed up. "We put a lot of time and effort into this hearing," said Mitchell, "and we came to be heard. But apparently the legislators are not listening. We will be heard if we have to track them down." 

Through such work, it became evident that the spiraling cost of health care and the inaccessibility of health care for poor and working-class Tennesseans were issues of common concern in Chattanooga, upper-east Tennessee, Memphis, and rural west Tennessee, as well as in Nashville and the Cumberland plateau. Consequently in 1984 leaders from across the state worked with the Cumberland Institute to initiate a health care campaign in Tennessee, and the Real People's Coalition began. 

 

"I've been involved with several senior citizen's groups, but sometimes you need something stronger to grab the attention of officials," says Mildred Khoury, a coalition member whose mother is in a Nashville nursing home. "People in the Real People's Coalition don't just sit around and play cards or bingo. We're out there in the front lines." 

Under the Real People banner are the growing number of Tennesseans who, like Khoury, have become impatient with conventional channels for redressing health care grievances. They are organizing effective opposition to the powerful health care interests and pushing forward a platform to: 

• set up a health care rate-setting board, like a public utility commission, to approve and disapprove increases in medical costs; 

• provide adequate health care services for indigent patients; 

• publicly expose doctors who require up-front payments; 

• target doctors who refuse to accept the Medicare assigned rate as the amount charged for services; • tighten state surveillance over patient care and billing abuses in nursing homes and hospitals; 

• protect elderly and handicapped patients from human rights violations by active citizens' surveillance of health care facilities; 

• reinstate Medicaid funding to pre-1981 levels; 

• provide medical care for low-income children in two-parent families. 

 

A majority of the participants in the Real People's Coalition are elderly, and issues targeted by the group have special significance for seniors. But the campaign has attracted people of all ages and has drawn support from various other constituencies, such as health care workers angered by unreasonable work loads and conditions. Many of the group's most active members are themselves undergoing medical treatment and understand first-hand the urgency of this work. 

"I got involved with the organization when I began to see what was happening with my mother when she had to go to a nursing home," says David Wright, a machinist at a Nashville shoe factory. "I found out that too many prescriptions were being filled by the nursing home, prescriptions that were not needed. I found out that even after we took Mother out of the nursing home they were still filling prescriptions on her. I think there is only one word for that — stealing." 

"Nearly 600 of our members are elderly citizens," says Jean Stone of the Chattanooga Community Organization. "I wish they could all come to Nashville and take part in the Real People's public hearing like I did. We've been very concerned that many doctors refuse to take Medicare assignments. Because of this, senior citizens must pay more because doctors charge more than the Medicare rate, and senior citizens must pay cash up front and wait for reimbursement. This particularly hurts seniors who live on fixed incomes, leaving them no money for food and other things they need to live on. 

NCOP and the Real People's Coalition have a valuable resource in SAGA, the Social Action Group on Aging — a social service group founded in 1976 to help nursing home patients. SAGA has set up a visitation program for residents of Middle Tennessee nursing homes and initiated a telephone hotline for nursing home complaints. While generally avoiding confrontational politics, SAGA channels valuable information and research to NCOP and the coalition. Many of the people who now stand among the ranks of the coalition became involved after calling the SAGA hotline. 

The Real People's Coalition's first major public action came on Health Action Day in the fall of 1984, one of 90 events nationwide initiated by the Villers Foundation of Washington, DC. Villers, formed in 1983, is dedicated to advocacy on senior citizen's issues. The Real People's Coalition brought 250 members to a heated public meeting that focused on serious inequities in the present health care system. Speakers from community-based organizations across the state presented testimony. 

Gordon Bonnyman, a Nashville attorney and NCOP leader, spoke at the Health Action Day hearing. Bom in Knoxville and a graduate of Princeton and the University of Tennessee Law School, Bonnyman came to Nashville in 1973, and works with Legal Services of Middle Tennessee. "A group that is able to empower people to stand up on their own hind legs," says Bonnyman, "is going to have a whole lot of impact. NCOP and the Real People's Coalition bridges a lot of gaps and is the ideal group of people to do this in Tennessee. 

"With the exception of a few narrow interests who profit from the health care system, people do not accept it when a child is left to go blind, or someone is left to die because they can not come up with an exorbitant [hospital] pre-payment. After dealing with access to health care problems for a long time, I've come to two conclusions. One is that people tend to accept the authority of doctors and hospitals and health professionals. When they get shorted, it is usually a hidden problem. Second, the laws do not reflect the values of society. It is an outrage when someone goes blind because he doesn't have ready cash, and the laws don't reflect that outrage." 

At the Health Action Day hearing, Bonnyman cited a number of examples of abuse by hospitals: 

• a 29-year-old Robertson County woman who raised a family and worked most of her adult life stripping tobacco at a warehouse could not obtain surgery to remove a cancerous tumor because she did not have a $700 cash deposit for the nonprofit Vanderbilt Hospital; 

• a nurse at HCA-owned Hendersonville Hospital got sick and had to become a patient at the same facility; she was transferred to Donelson Hospital, another HCA facility, but was discharged before her treatment was completed because her insurance wouldn't cover it; 

• a carpenter from Morgan County was bitten by a brown recluse spider and began losing vision in both eyes. Vanderbilt Hospital refused to perform surgery. Six months later, when he received a lump sum Social Security disability payment, he put down a $1,500 deposit and had the surgery. The deterioration of his vision was halted but it was too late to save the vision lost in the months he had to wait. 

The Real People's hearing occurred the day after a meeting of Tennessee Governor Lamar Alexander's Select Committee on Health Care Cost Containment. That committee was formed in the spring of 1984 in response to growing public demand for studies of possible approaches and solutions to the health care cost problem. Public enthusiasm dimmed, however, when it was revealed that the committee would be dominated by health industry and government insiders. 

"The Governor's Select Committee has been a dog and pony show from the outset," charged Robert Everett. "There were no grassroots consumer appointed to the committee at all. Although public hearings have been held by the Select Committee, the real people of Tennessee have not been able to participate because hearings were held in the middle of the day when working people can't come. They were also very poorly advertised. The real people need their own select committee and that's why we are here." 

Everett, a retired postal worker from north Nashville, a predominantly black community, was a sergeant with the U.S. Army in World War II. "When Truman set out his order to desegregate federal buildings after the war, we had to organize postal workers to make it happen," says Everett, who takes pride in watching out for "the underdog." From 1959 to 1969 he was president of the local postal workers union and was later in charge of the Equal Opportunity Office of the post office. 

"I first heard of our community organization when I got a flyer in the mailbox a few years ago," Everett said "It was a flyer about a meeting of the NCOP nursing home committee, which had already attracted a great deal of public attention. I didn't realize we had a group of this magnitude here in Nashville, and when I began to hear about the work to improve nursing homes and hospitals, I decided to get involved." 

Everett's father, a disabled brick mason, had to sell his home to pay medical bills. Everett says, "He had little money and he lost just about all he had. He kept his union membership, which paid some of his insurance, but before it was over he had to go to the government till. When I became aware of the work Nashville Communities Organized for Progress was doing to improve the situation, I became interested. I saw progress was being made and this really turned me on." 

Everett said that because the Select Committee's meetings were poorly publicized, of the people who attended the first five hearings "only 14 were real people — the rest were from the health care industry, the hospital association, the insurance companies and the industrial representatives of major employers. To sum it up, the real people were once again left out of the process." 

The Select Committee dissolved late in 1984 and issued its final report in December. It acknowledged that indigent care was a problem but made no proposals for solutions. As for hospital cost containment, the committee affirmed its faith in the competitive model supposedly being practiced. Its only concrete suggestions dealt with peripheral issues such as mandatory seat belt legislation and prohibiting smoking in public buildings. 

 

The power of the for-profit hospital companies in Nashville makes it tough for citizens to organize around health care issues. Hospital Corporation of America hired the popular former Tennessee Governor Winfield Dunn to "run interference" for health care interests at the state capital in Nashville, and the Tennessee Hospital Association has invested heavily in swaying the minds and opinions of the people. In 1984 hospital owners ran an extensive prime-time radio advertising campaign arguing that rising costs are the fault of malpractice lawsuits, high-tech investments, and indigent patient care. 

The Real People's Coalition is moving to counter the propaganda and activities of these health care tycoons. With an active research committee and the ability to develop new community leaders, the coalition has won support from the Chattanooga Community Organization, Knoxville's Tennessee Committee on Occupational Safety and Health (TNCOSH), the Consumer Coalition on Health of Nashville, the Social Action Group on Aging, the United Furniture Workers, the National Alliance of Federal and Postal Employees-Retired Division, and over 20 neighborhood groups from around the state. Also working within the coalition are the United Neighborhood Organization of Upper- East Tennessee, the Service Employees International Union, the Tennessee Federation of Aging, Memphis ACORN, and the Haywood County Action Committee. 

Hundreds of Tennesseans — urban and rural, white and black, employed, unemployed, and retired — have banded together. Their backgrounds and the ways in which they became involved with the Real People's Coalition vary like the countryside of this hub state of the South. Rebecca Cummings is from Brownsville, in the heart of the western Tennessee cotton belt. With a little help from the Nashville group she and at least 100 others organized the Haywood County Action Committee to monitor area nursing homes. "When conditions start to slip in the nursing home, we all go down to the administrator's office and stay there until we get a commitment to improve the situation," says Cummings. "They've called us radicals, but the way we see it, we're just looking out for our loved ones." 

Nashville resident Mary Fitzpatrick, whose mother lived in a local nursing home, says, "We have approached nursing home staff with problems that we see, and because of staff shortages we find nurses and aides overworked, frustrated, underpaid and tired. We're told by the administrator not to worry, but when we come back we find the same thing — the same old business. We are organizing so conditions at these health facilities improve." 

"You know, when they put Medicaid and Medicare on a patient's ID band, that becomes a license to charge," says Mildred Ward, co-chair of the North East Organized Neighbors (NEON). "My husband needed new glasses recently and upon requesting an appointment, I was told, 'Your appointment is on the fifth at 2:30 p.m. That will be $48 payable when you come in.' After 40 years as a physician's assistant I was astounded. If I had made such a statement to a patient my employer would have terminated me before I hung up the phone." 

"You know the black people have been getting organized here in Nashville for some time," says Minnie Bryan, a white woman of 60. She recalls the lunch counter sit-ins for civil rights in the early 1960s and says, "It's about time that white people started getting involved this way. It makes our organizations stronger when we are black and white together." 

Mrs. Clint Pickens of Lewisburg, Tennessee, has a formidable power base of her own. As former head of the state Commission on Aging, she was instrumental in setting up a network of senior citizens' centers across the state. Many of her fellow members of the Tennessee Federation on Aging feel helpless about skyrocketing medical costs. "I have a file cabinet full of cases people brought to me about being taken advantage of by the hospitals," Pickens says. "I was reading my bill from a recent stay in the hospital and saw that I was charged for oxygen. I didn't have one drop of oxygen while I was in that hospital!" 

As these people and their growing number of supporters plan for their next public action, and once again pin on their "Real People" buttons and badges, they are determined to keep pressing for more equitable solutions to the problems of today's health care delivery system. And within this Real People's Coalition there is strong evidence that the people in this region can put aside the differences and dividing lines that have kept them apart for so many years and form a genuine mass organization for positive social change. 

W. H. Brown, a retired Du Pont employee from Old Hickory, helped organize a citizen's committee in a Nashville area nursing home. He sums up his beliefs in a story: "When we were all children, Father would get us all together and take out a match box. He'd give each of us a single match and say, 'Try to break it.' We could. Then Father would give us seven of those wooden matches in a bundle — there were seven of us children. He'd say, 'Now try to break all seven.' We'd try and try and we couldn't. He said, 'That's why you have to get organized. If you stick together, no one can break you.'"