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subfield code a C53-000432 USFLDC DOI0 245 E. Russell Jackson Jr. oral history interviewh [electronic resource] /c interviewed by E Prather.500 Full cataloging of this resource is underway and will replace this temporary record when complete.Transcription and timecoding of this interview is underway and will be added when complete. At that time the audio link will be replaced with the OHPi player link (player supporting syncronized audio and full-text transcription).7 655 Oral history.localOnline audio.local710 University of South Florida.b Library.Special & Digital Collections.Oral History Program.1 773 t USF College of Public Health oral history project4 856 u http://digital.lib.usf.edu/?c53.43
xml version 1.0 encoding UTF-8 transcript
text Charlton Prather (CP): Were privileged to have today, Mr. E. Russell Jackson, presently of the Florida Medical Association, where he is the executive coordinator working out of the executive vice presidents office. Hes been with the Florida Medical Association since 1984, but he returned to his home and to work, I can put it that way, in 1974, upon completion of his masters degree in public health at the University of Michigan.
He had under his belt, also, a degree in political science, but he joined the state health organization in 1974 as the legislative liaison between the state health organization and the Florida legislature. Did a super work there and had the opportunity of a significant promotion because of his background, hopefully, with the department of health and to the Florida Medical Association.
He was very instrumental in the development of the idea and the philosophy and theId like to saythe passage of the act that created the current Florida Department of Health. I hope hell review that story with us today. Mr. Jackson, its truly a pleasure to have you here.
And were complimented that you would take the time to come and review with us some of the interesting history thats behind the establishment of the Florida Department of Health, of whom I, personally, and a lot of others are exceedingly proud, having a Florida Department of Health and your role in that. Tell me, what in the world got you interested in public health to begin with because you started your career in political science?
E. Russell Jackson (EJ): Well, Dr. Prather, its great to be here. I am honored that anyone would want to hear what I have to say about public health.
EJ: But I think I was interested in it, at least initially, because my father worked for the old state board of health. In fact, he worked for Dr. Wilson Sowder, who was the state health officer at that time. Dr. Sowder was the state health officer for 29 years, as you know. So in any case, so Dr. Sowder tells me that, when I was two years old, that he held me in his arms at the old state board of health building in Jacksonville.
EJ: That is correct. I really was. So in any case, I grew up in the environment of public health and heard about the state board of health everyday of my life. My dad used to go down to what they call Pearl Street because that was the name of the street that the state board of health headquarters building faced, and so it had the address of Pearl Street. Everybody that went there went to Pearl Street. Im going down to Pearl Street today.
So, in any case, from time to time I would go down there. For example, on a Saturday, and there would be Dr. Sowder there, sometimes on a Saturday or whenever dad was going to the airport. Wed exchange carsthe state board of health car somehow there were cars involved. So I was very familiar with the historic site of the original state board of health there on Pearl Street.
The original building faces Julia Street, so not to be confused with Pearl Street. The original state board of health building was called, and was known as, the Julia Street building. Some of us, like me, initially thought it was the Pearl Street building, but its the Julia Street building.
So, in any case, I was familiar with the complex and also the people that were there. And there were people that wore white coats because they were laboratory people and doctors. And all the bureaus that they had were headed by physicians or professional public health people. And so you had a definite professional health aspect to it just by walking in the building.
EJ: Yes, it did. The state lab was there and they had the bureau of epidemiology, bureau of local health services, bureau of sanitary engineering, for example. My father worked both in health education and also in the bureau of sanitary engineering, and also the bureau of health facilities with Dr. Sowder.
So thats kind of the environment I grew up in. I mean, not that its something that I necessarily had aspirations to join, but I was familiar with it, obviously. I dont think a day went by that I didnt hear Dr. Sowders name, for example. So, then, my father was a state official, and I thought that was important, and I was proud of that.
In any case, thats not what I was interested in. So I was interested in government and political science, both at the state and national levels. So my collegiate career basically was focusing on government and, when I went to graduate school, also international relations. So I went to undergraduate school at Jacksonville University and majored in political science, and then I had a teaching fellowship at East Carolina University.
And we were focusing on international relations, but my major was in political philosophy because I thought that if you knew what the great thinkers thought, you know, that that way, at least you could apply that to any portion of political science, whether it be international relations or American national government. So I did think that the great thinkers had something to offer to me.
Also, after that, saw the University of Michigan was recruiting people from various fields, including political science, so I went to the school of public health there for three years. Medical care organization administration, which is, really, focusing on the health delivery system: the organization, delivery, and financing of healthcare services.
And the reason it was called medical care organization because theyre really talking about the revision of medical care, even though this was in the school of public health, medicine being viewed as a key part of that. And, in looking at medical side of the private healthcare delivery system, the doctor was viewed as the key player in what happens to patients, whether they go to the hospital or to a nursing home.
And so, if you looked at the healthcare delivery system and you drew a circle, and you had all the different entities in there, in the middle of the circle would be the physician. So part of the whole concept of health maintenance organizations [HMOs], or what they now call managed care organizations was, if you have the doctor as the key player, and you have the doctor as part of the system, and if you have the doctor having a contractual relationship with a managed care organization, you could manage what the doctor does and manage patient care.
And, ostensibly, that could control cost of healthcare, for example. And even health maintenance organizations, they were talking about maintenance of health, so even that term, initially, back around 1973, when the HMO law passed, had a focus on maintaining health, somewhat akin to public self-prevention.
Prevent disease. You obviously see patients early in the disease process and, also, prevent disease if they have a doctor supervising what to do. I think, as a matter of the courts and things that managed care organizations, or the HMOs, were not much different than any other provider of care.
Its just that they were dealing primarily with episodes of disease and so it became less and less the maintenance of health and also, the very cost of healthcare with HMOs, as far as when patients came in into the program with a prepaid plan, they didnt want sick patients. They didnt want sick people in there. So you had an element of adverse selection for the sick people because they didnt want them in the program necessarily.
EJ: Right. So in any case, throughout the United States, in schools of public health, there are programs like that. And it really, by virtue of the fact that its in the schools of public health, that means public health is interested in the organization, delivery, and financing of medical care.
EJ: Thats kind of the background that I had. And then about 1974, you succeeded Dr. Sowder as the state health officer.
EJ: Well, it is definitely rememberable [sic]. And you had basically wanted a legislative liaison for the division of health by that time it was called. It used to be the state board of health, and its reorganization occurred, and it became a division within a larger department, which Ill talk about in a minute.
So in any case, thats established here in 1974. And you had another liaison officer here, Dr. Dale Miller, who was the liaison officer for you with the department at large. As things turned out, we both, Dr. Miller and I did things together, whether it is with the department or with the legislature.
EJ: As it turned out, at an early age, because I was about 29 then, I think Dr. Miller may have been about 50, but I got to work at a very high level because the division of health was headquartered in Jacksonville, so the liaison office was here in Tallahassee. We basically were the first two employees to be headquartered here, full-time, to represent the state health officer, which was you, at that time.
So in any case, its a long story about what happened after that. But I just would say that, at that time, I became very closely involved with public health at the state level in Floridaits organizational place, if you will, in the scheme of things, within Florida state government, which interested me from a political science standpoint.
And so, my father, when I was at East Carolina, had sent me some information about the new constitution. I think he sent me a draft of the new constitution from 1968 that was being prepared by the Constitutional Revision Commission, and he had noted to me that the state board of health was excluded from the proposed new constitution. He was unhappy about it, and everybody in public health was unhappy about it.
But Dr. Sanford Mullen, who was a representative of the FMA who I got to know later in my life, was involved with that Constitutional Revision Commission. I think, Dr. Ed Annis, who was also president of the American Medical Association. And they were concerned about it and expressed their concern. But they were told by the legislators involved, Dont worry about it. The legislature wouldnt do anything to do away with the state board of health.
And, of course, the very next year, 1969, the state board of health was abolished. It was put in as a division within the department of HRS, the Department of Health and Rehabilitative Services, one of many divisions. And that was done under a theory of reducing the complexity of the constitution and many myriad independent agencies in consolidation.
Which was somewhat of a goal within political science circles, itself, was also looking at state government and ways to streamline it. The state constitutions are very complicated anyway. Theyre far more complicated than the US Constitution. So, in any case, that occurred in 1969. And the Department of Health and Rehabilitative Services was established, and the division of health was put in there.
The state board of health was eliminated but was taken intact as a division of health. And, by that, I mean the administrative super-structure of the state health officer remained in tact, it just was called a division. And also, the term state health officer, I believe, was taken out of the statute at that time as well. And I believe Dr. Sowder refused to use the term on his correspondence, as the state health officer, after it became the division of health.
EJ: But in terms of being intact, the 67 county health departments in the state still had the same line relationship with the state health officer that they had had in the state board of health.
CP: Yes, when the board was abolished, the policy board was abolished at the same time. But they became an advisory committee to the state health officer, to the director of the division. Is that true, my memory serving me right?
EJ: Well, there was an advisory body to the state health officer, so I assume that replaced the state board of health, if you will. I havent said that just to say what the state board of health was from a historical standpoint. In 1885, the president of the Florida Medical Association, Dr. John Wall from Tampa, was very instrumental.
And the FMA was, the Florida Medical Association, very instrumental in establishing the constitutional revision that occurred at that time for a state board of health. So that was in 1885. The legislature did not create it for several years after that simply because they thought it cost too much money, which was several hundred dollars, I think, back in those days.
But in any case, Dr. John Wall still really understood the need for a state health department, and he was very much interested. He was a private physician, but he was very much interested in public health and the vectors of disease, which he studied, and that sort of thing. He also knew the county health departments, as they existed at that time and the city health departments, whatever they had, were independent of each other.
And they had all kinds of different ordinances in one county and another county, so there was, really, no statewide, uniform effort to protect the publics health. In fact, with the yellow fever epidemics that they had, sometimes inter-county travel was restricted, and you couldnt go from one county to another. And that was just simply because there was no uniform, state effort in public health to have the states coordinated effort to control disease. And, without that, even commerce was adversely affected.
So, as it turns out, in 1888 there was a yellow fever epidemic in Jacksonville. And Dr. J. Y. Porter, who had been a military physician in Key West basically went to Jacksonville to combat the yellow fever epidemic because he had as much knowledge as anybody in the United States about yellow fever because he had experienced it in the military and, actually, had succeeded Dr. Mudd, who was a prisoner at the fort there, Fort Jefferson in Dry Tortugas. And he kind of built somewhat on Dr. Mudds good work, while he was there
EJ: Yes. So
EJ: So Dr. Porter was there in 1888, and this is an epidemic that is in Jacksonville, and a lot of people are dying. And they dont know what the source of the diseasethey didnt know it was a mosquito. And they were burning blankets and mail and all kinds of things and putting the mail in quarantine out in an area in Jacksonville by the St. Johns River. But in any case, the governor, Francis Fleming, who was from Jacksonville, became governor, elected in 1888.
And when he became governor in 1889, based on his firsthand experience with yellow fever in Jacksonville and with the influence of Dr. Wall and the Florida Medical Association, Governor Fleming, as soon as he became governor, called the legislature in special session for the express purpose of creating the state board of health, which the authorization had been provided for in the constitution of 1885.
So that was the birth of the Florida State Board of Health, way back in 1889. It was created by the legislature. And Ill have to say, Dr. Wall was also a member of the Florida House of Representatives at that time, and his brother was president of the Florida Senate. So just goes to show you that he had some influence in that. So in any case
EJ: Thats correct. So was Dr. Porter. Porter was president in 1886. So the FMA was there right at the early beginning, the birth, of the Florida State Board of Health. And I have to say, just to take a moment here about historical events.
I think the next important legislative event was 1931, with the County Health Department Enabling Act, which basically created the state-county partnership for the delivery of public health services at the state level. And this was the statewide system, if you will.
So which has endured to this day, despite changes that occurred at the state level. So getting back to what happened in 1968 with the constitutional revision, which basically took the state board of health, which had been established in 1889, and they took that out of the constitution in 1968.
So in 1969, the legislature, again under the concept of consolidating and streamlining state government, they decided to abolish the state board of health and put it in larger consolidated agency, which is pretty much called an umbrella agency. Thats what it was known as, at those times.
Those types of agencies which housed several divisions, both health-type divisions and social and economic services, sometimes known as welfare services of the state, which focus on the needs of low-income people for social services and the like. So health was thrown into that as one of several divisions. One of the problems with that is that sometimes youre mixing apples and oranges.
Also, the state officer, instead of being appointed by the governor, basicallyalthough he also reported to a board but on a day-to-day basis, he was dealing directly with the governor of the Florida legislature and so, the state health officer, under the state board of health, had direct access to the governor and to the Florida legislature.
And when HRS was created and the division of health replaced the state board of health, the state health officer was appointed by the secretary of the Department of Health and Rehabilitative Services. So he no longer had direct access to the governor or to the Florida legislature. He basically had to have that access on the consent of the secretary of the department and under the rules that the department would impose on any division director about when and where and what they would say to the legislature and the governor.
I have to say, the concept of HRS in itself was not bad. I mean it just basically was looking at ways to provide services in a more coordinated fashion to the people of Florida. Although in HRS, there became more of a focus on the indigent, whereas public health does serve all the citizens in Florida, not just the indigent.
So there was a philosophical difference, if you will, from that standpoint within the department. Which, on a practical standpoint, though, it meant that public health had to compete with other divisions, other social welfare services, in terms of what the priorities of the department
EJ: The secretary established. So basically, that meant that the state health officer, he felt there was a public health need, and he thought this was a priority, hed have to get the approval of the secretary, which he might get or he might not. Also, budgets that were prepared would be competing with other scarce resources and what the other priorities were of the department.
So it basically, at that time, put public health in a subordinate position in terms of what it could or could not do at the state level. But the state health officer did retain direct line authority to the county health departments.
So then, I came in 1974, as you know, when youd just become the state health officer. And although the term itself wasnt in the statute anymore, you became the state health officer, officially the director of the division of health, and succeeded Dr. Sowder, who had retired. I think he served in 1945 to 1974.
EJ: So when I arrived on the sceneand I remember very clearly going down to the old state board of health, now division of healths headquarters, and started hearing things like the integration of services, and decentralization. So, basically, what that meant was more people were looking at HRS and how to make it better and to meet the needs of people. And they thought that having these independent divisions did not allow for coordination of activities.
So, basically, under the concept of integration of those services, the legislature, in 1975, abolished the division of health and all other divisions within HRS. The state health officer, again, he wasnt in the statute [as] that. He was director of the division of health. He now became a staff director of the health program office.
And, by statute, the staff director could only have 150 employees, secretaries and everything. So he was very limited in what he was responsible for at the state level under this new concept. And the program office director, parenthesis, state health officer, now, instead of reporting to the secretary of HRS, reported to an assistant secretary for program planning.
CP: Oh. And the duty of the health program office was planning the statewide public health program, is that right?
EJ: Right. And, basically, the state level public health entity became planners, including the state health officer. And another entityand there were three entities that were main organizational entities within HRS, which were planning.
And so there was an assistant secretary for planning, there was an assistant secretary for operations, and an assistant secretary for administrative services. The assistant secretary for operations basically had the major responsibility for overseeing the day-to-day operations of HRS, including public health.
EJ: It did because the county health departments were taken out of line authority with the planning state health officer and was put under operations. But another interesting aspect of that law that was created was decentralization. So there were 11 service districts around the state, the geographical districts, as such. So each district had a district administrator.
And since they were like smaller departments of HRS so they also had planners and operators and administrative services. But the county health departments, 67 county health departments, basically came under the district, one in each of the 11 service districts and the district administrator.
So basically, at the local levelregional level, if you willthe most powerful people in the department outside of the state level, as far as the secretary and the like and the assistant secretaries or the district administrators. And the health departments found themselves no longer reporting directly to the state health officer. They were reporting, probably not even to the district administrator, but to a health programs supervisor, I think it was called.
And so they didnt even report directly to the assistant secretary of operations. So, again, what happened in 1975 was that the public health was subordinated, both at the state level, by now being dropped another notch in the organizational scheme of things. And the state health officer, now, is just a staff director of 150 people. And the state lab also went into something called the Central Operations Services, along with other public health functions, including the bureau of health facilities.
EJ: All those things went into something called Central Operations Services. So public health was fragmented for the first time, at the state level. Most things being taken out, state-level functions, from under the state health officer to a non-public health assistant secretary of operations.
And then the state health officer no longer had line authority to the local level. He only reported upward to an assistant secretary for planning. So it was very complicated, but it sounds complicated, and it was complicated. Also, as a result of that law, the state health officer was mandated to move me and his staff, what was left of it, from Jacksonville to Tallahassee.
So Tallahassee then became the headquarters for public health in Florida in 1975 as a result of that law. And basically, there was a state lab still over in Jacksonville in state-level vital statistics. But for a period of time I think the old Pearl Street building and even Dr. Sowders very office was the office of the district administrator for a period of time.
EJ: So in any case, public health got significantly subordinated. At the state level, it also got fragmented at the state level. It also got separated from the local health departments, if you will. So all public health folks, employees throughout the state, were very upset about that, including you and me and the like.
So basically, at that time, I know you had interest in resurrecting public health as a statewide system. And so the concept emerged of a separate department of health. Separate, meaning that public health and all health functions would be taken out of HRS and that HRS would just be a social services agency.
So that arose early on, shortly after the 1975 law passed that abolished the division of health. So in any case, early on after that, I got interested in such a piece of legislation and had a hand in drafting such. And it would find its way into the Florida legislature by appropriate sources.
But legislature wasnt very much interested in hearing about a separate department of health. What they had done, they were proud of and thought it was a good thing. And one could not go around talking about a separate department of health and be an employee of HRS.
And, that is understandable. Thats Organizational Theory 101 that you are loyal to the place that you work for. And even though the place you work for can be, to a certain extent, created by entitiesin this case, the Florida legislatureif you want to stay there, youve got to support it. And so everybody understood that.
However, state government is a product of both the constitution and the Florida legislature. And those things, which the legislature has responsibility for, are created by them, and they can be changed by the Florida legislature. And its fair to address issues like this. It was just the right thing to do. And those issues in our democratic system should have the opportunity to be heard in public forum.
I dont know of anyone more public than the Florida legislature. So to have a bill in there, advocating for the concept of the department of health, in and of itself, I think, was a good thing because at least it put it in the public forum that maybe with all the things that resulted in the HRS, all the significant activity that went on with the constitutional revision, and all the complications of that, trying to consolidate and streamline.
As I understand it, more or less, the division of health got thrown into HRS in the first place after a lot of political considerations and more or less as an afterthought at the last moment. So it was a legitimate issue, as to whether it should have been in there in the first place. So in our democratic system, the Florida legislature is the place to address those issues, and there was a bill there. And it didnt really get heard, but it was there.
So I would say, you subsequently left being state health officer around 1979 and went to the district level. And a lot of people left public health entirely, a lot of people that had been headquartered in Jacksonville, particularly. And then I ultimately left and went to work with the Florida Medical Association in 1984.
Now, the FMA, as I said, had been very concerned and upset, if you will, about the abolishment of the state board of health back in 1969. My contribution, as far as when I went to work for the FMAI was medical economics there and medical services in the FMA, and the FMA has interest in public health, as well. But I did, at least, take with me the goal of someday creating a separate department of health.
And I staffed a committee on public health. They now have a council on public health, but that basic concept is something that I certainly took advantage of having discussed. And it wasnt hard because there were physicians that were on the committee on public health, and many of them were county health officers that were all unified in their desire to have a separate department of health.
And so that became the policy of the Florida Medical Association. And it had been the policy before I got there, but it was reiterated and reaffirmed. And then the physician leadership of the FMA, because the FMA is run by its elected officers, they also came to increasingly espouse this. But, again, the political situation in the early 80s, mid 80s, and the late 80s did not reallythe politics werent there to create the department of health.
But the FMA kept pressing for changes within the HRS system. So basically, as a result of the efforts by the FMA, the state health officer was at least elevated to a deputy secretary for health. However, he did not have line authority over the county health departments.
And Id have to say, the county health officers did make, after the initial HRS was created, efforts to address that issue of not necessarily creating a separate department of health but trying to work within the HRS system along those lines of having a deputy secretary for health with line authority down to the local level. And that was not well received at all by any secretary of HRS while I was there.
And so the health officers were frustrated by that. And obviously, given that situation, their only alternative was to advocate a separate department of health. So basically, I would say the effort to establish a department of health even within the FMA was always there on the books as our policy and, from time to time, we would say it. But, nevertheless, the politics werent there.
However, with Sen. William G. Doc Myers, who became a state senator very much interested in the issue of public health. He became the leading advocate within the legislature for a separate department of health. And he was a practicing physician from Hobe Sound, which I believe is in Martin County or Indian River, one of the two.
EJ: Martin County. So Doc Myers always had a separate department of health bill. Now, the difference with Senator Myers and what we had filed back in the mid 70s was that it was Senator Myers, who was at least in the leadership of the minority party at that time. Senator Myers is a Republican. But in any case, that bill was always there and Senator Myers and the FMA were always advocating a separate department of health.
And I had had a hand in a draft of the department of health bill that was established, I think, around the early 90s. And it was pretty much the draft that had appeared in the mid 70s. But in addition to that, there was a new agency that was created in 1992. I believe it was the Agency for Healthcare Administration.
And the Agency for Healthcare Administration really was created out of the interest of the legislature in dealing with theagain, something I was studying at the University of Michiganthe organization, delivery, and financing of health services and the spiraling costs, and how could the state better have input into that whole process.
So when AHCA, as its known, the Agency for Healthcare Administration, was created, in it was put Medicaid, which was transferred out of HRS. Also what used to be the bureau of health facilities in the state board of health, which became Health Facilities Licensure and Central Operation Services at HRS, was also transferred to AHCA.
All the professional licensing boards were taken out of the department of business and professional regulation and put into AHCA. So basically, AHCA had, at that time, when it was created, in essence, control of the health professions, including the board of medicine and physicians and what was called the division of health quality assurance. There also was a division of health policy created.
And there was a division ofI dont know if its called healthcare financing, but basically, Medicaid came under that. So, and to a certain extent, AHCA became really looked at as more of the glamorous agency because it was dealing with those things that I was studying back in the 70s, which was the cost of healthcare. How can it be better organized? How you can deal with increased access to care for everyone, the people that are uninsured?
So it was dealing with the unsolved problems of the health delivery system. And it was envisioned that it would create a policy and a program so it enables the state of Florida to deal with those.
And those were not generally perceived as being responsibility of public health. As defined under Florida law, public health was over there in the department of health and rehabilitative services. So what AHCA is, if you take that line of thinking, is not public health because public health is in HRS.
So having said that, the Florida Medical Association felt that the department of health should have in it all of the states responsibilities for health, including mental health and the public health component and childrens medical services and all those things that were in AHCA.
So about 1974, there was a bill that was introduced by Senator Myers and Rep. Brad Lipmann, who was a pharmacist from Broward County in the House. And that bill saw its way into the 1995 session of the Florida legislature, and it passed the House of Representatives at that time. In 1995, the president of the FMA at that time was Dr. Dick Van Eldik from Palm Beach County.
And, also, concurrently with that on the senate side of the ledger, there was a great debate about Governor Chiles had a proposal, which also came out of the Agency for Healthcare Administration, for a Medicaid waiver plan, which would allow the state to get federal matching funds for non-Medicaid eligibles. I believe its called the Florida Health Security Act.
And there was a philosophical difference between, at that time, the Republican-controlled senate, which had just become the Republican-controlled senate, and the Democratic governor over that program. Basically, the Senate just decided not to hear any more health legislation that year.
So the bill that passed, which would have included all the mental health, included all the public health, included all the childrens medical services in AHCA in a single department of health, died in the 1995 legislature, even though it had passed the House. A question one would have is whether Governor Chiles would have allowed that bill to become law, even if it passed the senate, we dont know that.
But, nevertheless, that would have been a factor as to whether, philosophically, the governor would have allowed that to pass, because I know Governor Chiles was not particularly enamored with large agencies, even though he already had one in HRS. And HRS, incidentally, had over 40,000 employees and was the largest single-state agency in the United States.
So, in any case, that was where it was in 1995. And it just so happens that in the Representative Lipmanns and Senator Myers bill, the new agency, had it passed at that time, would have been called the department of healthcare services. I saw it in there. Didnt like it, but it had happened that way. I guess people in bill-drafting over in the legislature somehow thought that if you were taking AHCA in there that maybe that would more accurately reflect some of what AHCA does because its concerned with the delivery of healthcare services.
But, nevertheless, I will have to at least say that after the 1995 session was over and as the legislature was preparing for the 1996 session, I had a hand in getting that changed to the department of health through the FMAs lobbying team and some discussions with Representative Lipmann and Senator Myers.
So, the incoming president of the Florida Medical Association who was installed in the FMAs annual meeting in May of 1995 was Dr. Alvin Smith, who is a clinical oncologist from Ormond Beach, and he also practices in Daytona and New Smyrna down there.
Dr. Smith was, also, a close friend with Governor Chiles, and he also was a strong supporter of the governors efforts, with regard to the tobacco issue. And, basically, the state and the legislature passed a law, which allowed the state to sue tobacco companies for the tobacco-related illnesses of Medicaid patients.
And so, in any case, there was a bill that passed subsequent to that which would have repealed that law. Again, the governor vetoed that in 1995. So, as 1996 was rolling along, there was this issue whether the legislature would override the governors veto of that repeal. And Dr. Smith had lent the FMAs full support of the governors position on that.
And so, Dr. Smith, as a clinical oncologist, had seen the ravages of cigarette smoking, tobacco use, and the like and the end result of that. So he was impassioned in his commitment to Governor Chiles. So, also, about that time, I was asked to go speak to different staff people within the Florida legislature about the department of health bill, some of the staff in the House.
For example, the person who was drafting the bill that ultimately did pass, she was interested in, how did things get the way they are? So I more or less told her, or maybe her misfortune though, Im telling you. The significant difference is that in 1995 to 96 there was interest in this, whereas there was no interest in the 1970s and 80s in the history of that.
So, the staff within the legislature is certainly important. And if they certainly understand the importance of something like why you need a department of health, and how come its not that way now, and what happened and the like, its all to the good because more people will have knowledge. At least they have an understanding upon which to make their decisions.
So that interested me. Also, wound up in a meeting where there was some discussion about how much the department felt it was going to cost. And that particular meeting became more of an issue of why do you need the department of health? So it was an interesting meeting. But basically, how are you going to provide services to children that are in the department of juvenile justice? My answer to that would be: well, you have an inter-agency agreement between the department of health.
So there were all kinds of ways to do these things. So just because something is the way it is, doesnt mean you cant change it and, also, create the environment in which people that do have needs can be taken care of.
So I was in a meeting like that, for example. And there were also ongoing meetings that Dr. Smith had Governor Chiles that I was privy to and present at. So as the department of health bill, which, again, would have had both all the health functions that are in HRS and in AHCA, was moving along with some degree of solidarity in the House. There became some concern in the administration, the governors administration, about that.
And also, the director of AHCA, I think, had some concerns about that, as well. So, basically, the governors office at that time offered a compromised proposal in which there would be created, basically, a department of public health. And AHCA would not go into that and would become the department of healthcare administration. So AHCA would have been elevated to a department.
And, incidentally, AHCA, when it was createdthere was a constitutional limit on the number of state departments that you can have so, at that time, there was such a constitutional limit. So AHCA, when it was created, was made an agency, not a department.
And it was housed administratively within the department of business and professional regulation, although the director of AHCA did not report to the secretary of that department, reported [to] and was appointed by the governor. That also became a constitutional issue by the tobacco company that challenged whether that was constitutional to do that.
The Supreme Court later ruled that it was constitutional, but prior to that, part of the concern was that AHCA would be declared unconstitutional and the whole issue of the states ability to sue the tobacco companies through AHCA, under Medicaid, would also be thrown out. So there was some good reason for AHCA wanting to be elevated to a department status at that time.
So basically, a proposal was put on the table, which would create a department of public health. And part of the incentive to the Florida Medical Association was that all the health professional licensing boards would be in the department of public health. Also, the compromises, it was proposed, would have elevated the state health officer to be the secretary of the department of health.
And that actually was not in the FMAs proposal or Senator Myers or even Fred Lipmanns at that time. The state health officer would have been a division director within the department of health, you see? So that was kind ofI saw that, and I said, Gee, isnt it great?
So I was very supportive of, at least, that aspect of it. But on the other handand also, mental health would have been in there and childrens medical services. And public health, as it had been configured at that time, would have been put in there. Although, you can make the case that public health encompasses all of those things, and it is all of those things.
So in any case, as things went along here with this compromise, there were lots of meetings in the legislature and it became one of the key issues of the 1996 Florida legislature was this department of health or department of public health and department of healthcare administration. There were a lot of players involved and a lot of people that are regulated by those types of things.
So there was interest both in the corporate sector and in public health sectors. And people that never been interested in something called the department of health. Now, all of a sudden, everybodys interested in it. So, I even went to a meeting involving the leadership in the House, which did address the very subject of what is public health? What is a department of public health as opposed to a department of health?
So, in any case, Dr. Smith was again in Tallahassee visiting with the governor and with the leadership in the House and the Senate. So this was a very much discussed issue, and, as it turned out, the leadership in the House and in the Senate would not go along with elevating AHCA to department status.
So what occurred was a compromise in the last week of the session of 1996, which basically would allow there to be a department of health created, to get it started, and then it would be public health because theyre separated from mental health and, at that time, childrens medical services. So all that would go into the department of health.
And they kept the governors proposal that the secretary be, under law, an MD or DO [Doctor of Osteopathic Medicine], trained or experienced in public health, and he also, by law, would be the state health officer. So, as it turned out, that bill passed the legislature unanimously, both the House and the Senate.
The bill was named afteralthough it was sponsored by a Representative Lipmann on the House side and a lot of other representatives, as well. In the Senate, the primary sponsor in the House was Representative Lipmann. And there were others involved like Representative Graver, Rep. John Thrasher, and others who were key players in all that.
And in the Senate, of course, Senator Doc Myers and Senator Sullivan and a whole host of people and Tony Jennings, who is the president of the Florida Senateso all those people and Dan Webster, who was also minority leader in the House at that time. So the bill did pass, and the bill was named after William G. Doc Myers. So it was called the Senator William G. Doc Myers Public Health Act of 1996.
And Ill have to say, that was a great moving moment because Dr. Myers has not always been in the best of health. Although, Ive seen him recently, he looked pretty good, but he had dedicated his life to medicine and to public health. And that was a great contribution, to have that bill named after him and it was appropriately so.
So Id have to say, when the department of health was established, it had the licensing boards. It had public health, childrens medical services, and all the county health departments. And the secretary is an MD or DO and, as I said, state health officer. So Dr. James Howell, who had been a deputy secretary in HRS and had been a director of a division of health policy within AHCA, became the first secretary.
And Dr. Howell, as you very well know, served for many years under Dr. Carl Brumback before he came to Tallahassee and actually succeeded you as health officer back in the 70s. So, Dr. Howell had a long and illustrious career.
So the new department of health basically did not have all the things that the FMA thought it should have, meaning all the functions that are in AHCA and both mental health, and primarily mental health, that was left in the department that succeeded HRS.
As far as the social services, which was and is, department of children and family services so all the things that did not go into the department of health that were in HRS became the Department of Children and Family Services. Mental health is still there. Were hoping that mental health will ultimately be transferred to the department of health.
CP: If my memory serves me right, the community mental health programming began with the state board of health, did it not?
EJ: Right. And I think with all the issues and concerns relating to mental health, including adequate insurance coverage, as any other physical disease, that mental health certainly deserves to be insured just like every other disease is. And hopefully that will happen. I think there are efforts to do that.
But in terms of public health, in terms of its major philosophy, which is the prevention of disease and the maintenance of health, that mental health certainly is part of every human beings needs and, certainly, what it addresses is a concern of public health. One can see how mental health services could be better coordinated if it was working more closely with the public health system in the state.
So thats the goal, and maybe it will happen someday. I think, with regard to the Agency for Healthcare Administration, there are a lot of considerations there, and they have a new administrator, Mr. Ruben King-Shaw, and seems to be very well liked and has been working very close with the Florida Medical Association.
They also have a chief medical officer, Dr. Darrell Shea, who had been a member of the FMA Board of Governors and had to resign that to take that position, but they do have some medical direction there that they had not had for awhile. So, how that will ultimately pan outsomething that I think were going to look at.
As long as the public health interests of the people of Florida are carried out and public health is part of what the Agency for Healthcare Administration does then maybe you can make a case for it remaining as it is. But I do think its certainly worthy of looking at and certainlyagain, going back to the original introduction of bills relating to a separate department of health.
Those kind of issues will ultimately be determined by the governor, in terms of what the governor feels are appropriate, as far as what the executive branch has proposed. And then, as far as the law itself is concerned, that decision would be made by the Florida legislature. And I think the main thing is that in our democratic society we have the opportunity to discuss those issues and that they should be at least examined.
And part of being able to address those issues appropriately is based on knowledge. And you must have knowledge of history in order to make the best, informed decision that you can.
Because if you understandor in this case like the history of public health and the significance to the state of Florida and where it was organizationally within the scheme of things, meaning the state government, then at least you can understand when people say, Well there ought to be a separate department of health. Because there was a separate department of health, it started out as a separate department of health.
And politics being what it is and differing philosophies, sometimes things get changed. It doesnt mean they get changed for the better. And as far as the new department of health is concerned, the fact that it was created, we think it is for the better because it brings into a single agency the states public health system with the line authority to a secretary who is trained in medicine and public health to be able to make the best decisions for the people of Florida.
In one sense, Ive heard Dr. Howell say it and also Dr. Brumback, who was the health officer for many years for Palm Beach County, is that the county health officer, in this case, the physician, is the communitys doctor. And you can make the case that the state health officer is the statewide community doctor and hes trained to make decisions on the basis of his medical knowledge, his public health expertise, and medical science.
And thats generally why in public health circles there has been an emphasis on having a physician, for example, as secretary state health officer or at the county level. And you cant always have that, in some cases. But, nevertheless, that was generally the historic reason why the doctor was looked to as the leader of the public health team.
And, again, as I said, the Florida Medical Association was there at the beginning of the first department of health, known as the state board of health. And it definitely was there at the institution of the new department of health in 1996. And there was an article that was published by the New York Academy of Medicine on a grant from the Robert Wood Johnson Foundation.
And they were looking at examples of collaboration between medicine and public health throughout the United States and there were some several hundred cases that they looked at and about 30 of them were ultimately published. And the FMAs involvement with the establishment of the department of health was one of those 30 that was published.
And this went out all throughout the United States. But in that article includes that the department of health would not have happened without the Florida Medical Association. And I dont think the Florida Medical Association can take all the credit for it, obviously, but it certainly was a key mover and leader in the process.
A lot of other important people, such as the governor of Florida, who, incidentally, did sign that into law, the new department of health, and certainly Senator Myers and Representative Lipmann and others. As Ive mentioned, Dr. Graber, Representative Graber, and the current speaker of the Florida House of Representatives, John Thrasher, all those people were instrumental in the creation of the new department of health.
Now, the department of health is three years into its existence, and they have a new secretary who succeeded Dr. Howell. Its Dr. Brooks, Robert Brooks. And Dr. Brooks is obviously a physician because you have to be, under law, to be secretary. He, also, was a key player in the establishment of the department of health because he was a member of the Florida legislature, as well, when all this happened.
So, to make a long story short, I think that public health has a renewed life, which I think by virtue of the establishment of the new department of health. How it is ultimately configured relates to a lot of political and governmental decisions, as to whats the best organizational structure for housing the states responsibilities for health. And that in itself is a political science question, if you will.
And there are people who are all over the country that study that everyday. And they have their ideas as what that is the best. But, in any case, whatever happens to the department of health, in terms of its ultimate configuration and whats in it thats not in it now, at least public health is there.
So public health, in a sense, has returned to its former position of the state health officer being appointed by the governor or appointing directly to the governor, and the county health departments report directly to the secretary of the department of health without any intervening districts, if you will.
EJ: It does. Its an opportunity for better coordination. And the public health system was really built with that county health partnership from that 1931 law, and the HRS system more or less departed from that.
And this returns the concept of the partnership directly with the state level by the county health departments and the county board of commissioners. And, really, public health is carried out at the local level, and the county health departments are the key thing. But you need a state health department to make sure that the services are uniform throughout the state and that sound public health policies are implemented on a uniform basis for the benefit of all the people of Florida.
And I have to say that public health is interested in the organization, delivery, and financing of health services and access to healthcare for all people because, obviously, the extent that people have access to care, they can be treated and diseases can be prevented and monitored by an individuals family physician.
And there is an effort to increase the cooperative relationship and involvement by public health and the private sector of medicine, nationally, which is an effort by the American Medical Association, the American Public Health Association, and the Robert Wood Johnson Foundation. And we have a grant, the FMA does, along with the Florida Public Health Association and the department of health.
And there are some educational programs going around the state, coming up in August and September of this year, which will have the county health department directors and county medical society executive directors and their officers and the secretary of the department of health, Dr. Brooks. So I do believe there is a renewed interest, nationally, in public health.
But Ill just have to say that there was this movement which Florida got caught up in, which resulted in umbrella and integrated services type of agencies, which more or less was a national trend. And people, nationally, are looking at Florida to see what this new department of health is actually going to do.
CP: As many states that followed the umbrella concept, is there not a majority of them still functioning as an umbrella agency or have the majority separated out there?
Then, on the other hand, from the public health standpoint, you can look at what is the best organizational structure to provide public health services on a statewide basis? And what should be the configuration of a state department of health?
CP: How do you make out? The fact that HRS came in in 69, and particularly in 75 with the reorg, with so much fanfare and so much media coverage as a good thing, 75? By 95, it was dead.
And during that period of time, the original divisionssome six of the original divisionshad been moved out by legislative act. How do you, as a political scientist, see that? Do we agree that it was a bad thing to begin with or as the wheel turns, we see better ways of doing it?
EJ: Well, it was a bad thing in concept. I think the intentions were honorable, that you were going to try to deliver services in a more coordinated way to people in need. I think its flawed from the standpoint of creating such a large bureaucratic agency that has composed of so many different entities, professional disciplines, and the like, which is essentially what happened in 69 because they were put in there as divisions.
What happened in 75 might be viewed as a bad thing from the standpoint that, by the abolishment of the divisions, which in a sense were along the lines of professional disciplines, such as public health, that there was a subordination of public health professionals to what you might call professional administrators, who really didnt have any professional discipline other than being a professional administrator.
And so, I guess that was a concept that professional administrators can administrate better, and physicians, for example, shouldnt be administrators, they should be clinicians working in the health department. And that you, for example, the state health officer, you might plan for health services, but you cant really decide whats best. The professional administrators should make those decisions, and professional administrators should carry them out.
So, on top of that, I think HRS became 40,000 employees. It was, again, the largest state agency in the United States. And I think it was flawed from that standpoint. It just was too large. It tried to be too many things to people. And it became rather controversial, too, because, for example, there were issues related to the children, youth, and families.
And issues involving children and their parents, and sometimes taking a child out of a homewhatever the issue was. And, sometimes, the right things were done; sometimes, they werent done. But, whatever it was, it got a lot of media attention. And there were other administrative problems within HRS that got a lot of negative publicity.
So HRS in itself, from a public image standpoint, even though it started out as being this wonderful thing, over time, again, I think it was an administrative problem of effectively running the organization that problems did occur. And, naturally, when you get into things, such as children and their care in their family and that sort of thing, you can get some negative publicity, no matter whether you are right or wrong.
But, as a result of that, the public health folks, they are just known as that at HRS. They are HRS employees. Theyre HRS. Thats the HRS county health department.
CP: So the negative publicity was a broad brush to public health folks, too, who historically, I thought, were doing a good thing and were praised.
EJ: So, again, I think the original intention of HRS was good. I think, at least, one can say it is good, as far as the trying to meet the needs of people. And how the state does that, again, that gets into political science, as to what is the best way to do it. HRS, again, was initially created as a constitutional change, by getting rid of the state board of health but also the concept of streamlining and consolidating.
What happened in 75 Reorganization Act was more into such concept, again, of integration of services, being all things to all people, and better coordinating those and getting rid of any office that might be identified as the public health office, if you will.
EJ: Right. And, incidentally, one of the things that made it easier to create the department of health was that, again, the key entity within public health at the local level is the county health department. And the county health departments, from 1969 right through 1996, pretty much remained intact.
EJ: Although there were efforts to integrate services there and have all the social services on site, there, and take awaylater, there was a proposal to take away their personnel system, for example. That would be housed at the district level and that they would become more dependent upon the district and not have a self-sustaining personnel system and their financial officers and that sort of thing.
But that did not happen. So, when the department of health was created in 1996, the county health departments were still intact.
EJ: Right. Reaffirmed and reporting directly to the secretary of the new department of health. So I think its been interesting to see how public health has emerged from the ashes, if you will. And there were a lot of people that were interested in seeing that happen, including yourself, people like Dr. Sowder, who is still alive, and Dr. Miller, who is not still alive, but he was very much supportive of that, as you know.
So in any case, it has been my privilege to at least have a hand in it, with the Florida Medical Association. And Florida Medical Association has had some great physician leaders who I have at least assisted in some way. And theyve espoused this philosophy, and I am very pleased about that.
And I have to say, the current president, Dr. Glenn Bryan, is also very supportive of that. And our incoming president, Dr. Mathis Bedford, has an interest in the restoration of the old state board of health building, and we want to make that to be a museum of medicine and public health.
And, that building, incidentally, there was a law that was passed this past session, which the FMA and others supported, to name that building after Dr. Sowder. So that will happen at the building that was built by Dr. Porter. It was built in 1911its construction started in 1911. It was unnamed all these years, only known by the street that it faced as the Julia Street building.
Dr. Sowder, when he was state health officer, he named one of the buildings over there after Dr. Porter, so he already has one. And also, Dr. Henry Hanson, who was state health officer earlier in this century, the state lab was named after him, the laboratory building.
EJ: So public health has a very rich history. I think its a history thats medicine and has been closely entwined with at state level, certainly, at the local level, with the county medical societies and the county health departments. It continues to be closely involved. And the FMA will continue to be involved with the future of public health in Florida.
CP: In your humility, Id want our listeners to know, though, Russ, youve been very directly involved in that processin the smoke-filled room, so to speakin the nurturement [sic] of the FMA leadership.
For their opinions in the matters of the publics health, I would ascribe to you as the main teacher and the stimulator and the motivator, the reasons that the FMA presidents are so favorably disposed to the matters of the publics health. I am going to make you carry that burden. Its because of you that they were there. And on behalf of the public health family, I say, thank you very much for that, Russ.
EJ: Well, it is a great honor to have worked with all the people that were involved in that, including you.
EJ: Well, there are a lot of people that obviously one cant mention, just simply because there is not time, but there were many people who gave their lives to public health.
CP: Your dad. Your dad is one. Yeah. Spent his entire professional career in public health.
EJ: So you just have to say that the department of health was for all the people of Florida, but it also justifies those people who did give their lives to it.
CP: Yes, yes. Its worthwhile. Well, Russ, let me tell you, on behalf of the libraries of the University of South Florida, particularly the College of Public Health and myself, I say, thank you sincerely for coming back today and sharing with us this fascinating piece of Florida public health history. And your efforts and your sweat have been worthwhile, and I think history will show that you [have] done good. Thank you, Mr. Jackson, for coming with us. And I am Skeeter Prather.
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