The "Teeth" in the Law That Didn't Work
Thus far I have discussed the Urban HSA's accomplishments from the point of view of the participants. However, I have not ventured to take a position on whether the HSA was, in fact, successful in its endeavors. The answer depends on one's level of expectation. This was illustrated by the fact that the providers interviewed were less satisfied than the consumers because the changes they had hoped the HSA would produce were far more extensive than the changes the consumers had in mind. The answer also requires that the measure of success be specified. In reviewing the literature, I pointed out that the reports employing sophisticated, quantitative evaluation techniques use health care cost or capital expenditure trends to determine the degree of success or failure of the planning agencies in the area (usually the state). The other major branch of the health planning literature, which focuses on participation in the decision-making process, does not identify a concrete measure of success.
The discussion evaluating the Urban HSA's performance focuses on the three goals stated in the Health Planning and Development Act, which was responsible for creating HSAs: (1) the Urban HSA's success in controlling health care costs and/or expenditures; (2) its success in ensuring that all people in the area have access to health care services: and (3) its success in affecting positively the quality of care in the area. In sum, I intend to consider the performance of the HSA with respect to each of the goals mentioned and in doing so focus on the reasons why an accurate evaluation is so difficult to produce.
1. According to its own periodic reports, the Urban HSA's cost containment record is reasonably impressive. A number of possible interpretations might be considered to explain its success. The evaluation research literature suggests the following possibilities: the staff became more experienced and more confident in processing proposals over time; the HSA committee members became more