When is a Health Department not a Health Department?

When is a Health Department not a Health Department?

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Bureaucracies and Restructuring

What are the advantages and disadvantages of bureaucracies in healthcare?  How do they affect communication?  How are some health care businesses restructuring their environment to create improved communication?

When is a Health Department not a Health Department? The Case of the US Department of Health and Human Servicesspol_705 142..154 Beryl A. Radin Abstract Given the current policy debate over health reform in the United States, it is not possible to describe the organizational structure that might emerge from this process. This article explores five of the attributes that underpin the context for a discussion of the structure and operation of a health bureaucracy in the USA. First, ambivalence in the US society about a public commitment to health and a general scepticism about a significant public sector in this area. Second, separation within the system between types of activities (e.g. health research activities, provision of services, and financing of health efforts). Third, the health system operates in the context of a government with shared powers as well as federalism and an assumption that some issues belong to states, and sometimes localities, and not to the federal government. Fourth, difficulty in the US system when it attempts to focus on prevention activities. And fifth, the structure of HHS creates tensions between management initiatives and professional expertise and standards. The article concludes with a discussion of possible organizational alternatives. Keywords USA; HHS; Federalism; Public role; Organizational structure; Health This article has been written in Washington, DC, as the debate over health reform in the United States is in progress. Despite its intensity and the extensive public involvement, the legislative results of that debate are not predictable at this time. The result may be policy changes that evoke dramatic transformations in the organizational structure of the Department of Health and Human Services (HHS) or it may produce another failed effort at reform. A year from now the structure might change, additional components may be Address for correspondence: Beryl A. Radin, Department of Public Administration and Policy, School of Public Affairs, American University, 4400 Massachusetts Avenue NW, Washington, DC 20016, USA. Email: radin@american.edu Social Policy & Administration issn 0144–5596 DOI: 10.1111/j.1467-9515.2009.00705.x Vol. 44, No. 2, April 2010, pp. 142–154 © 2010 The Author(s) Journal Compilation © 2010 Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ , UK and 350 Main Street, Malden, MA 02148, USA added to the health organizational line-up, or the department may stay the same. This appears to be a point in time when American society is taking health policy seriously. All three scenarios are possible if one believes that structural form follows function. Organization forms reflect priorities but also convey messages in symbolic and subtext form. Yet the changes that might emerge are also likely to reflect historical and cultural approaches to health policy in the USA. It is not clear whether even dramatic changes in policy will be able to avoid a number of attributes of the American health system that are embedded in US history and political and economic relationships. The current debate often appears to be a clash between general societal interests (raising distributional questions) and the more specialized interests of health providers. This is not trivial since it is estimated that one-fifth of the American economy will be spent on health care by 2015 (US CMS 2006). The current debate over health reform has evoked renewed attention to the US approach to health policy. In an article in Newsweek, Jacob Weisberg, the editor-in-chief of the Slate Group, characterized the US health system as ‘an expression of our culture at its best and its worst’. Health care in America is innovative, entrepreneurial, expensive, litigious and wasteful. It is decentralized, driven by self-interest, excellent at the high end, and increasingly unequal. It resists acknowledging trade-offs or limits and is characterized by shocking gaps in basic care. (Weisberg 2009) One could characterize the current health system as an example of American exceptionalism; it highlights limited government, faith in markets, and individual rather than group responsibility (Morone 1990; Lipset 1996). But while the uniqueness of US history is often expressed as a rationale for American superiority and separation from international norms, there are also critics who argue that the concept is a way to avoid dealing with problems in American society generally. The contemporary health reform debate is an example of this conceptual conflict. Advocates for change are attempting to balance an acceptance of some historical patterns with the need to address problems faced by significant elements of the American public. These are issues that provide the context for an examination of the current and future structure of the US health system. It is interesting that the current debate about the federal role in health does not include a serious focus on the mechanisms of implementing the system that emerges from the policy process. This article explores five of the attributes that underpin the context for a discussion of the structure and operation of a health bureaucracy in the USA.1 First, it discusses the ambivalence in US society about a public commitment to health and a general scepticism about a significant public sector in this area. Second, it describes the separation within the system between types of activities (e.g. health research activities, provision of services, and financing of health efforts); this results in policies that often conflict with one another. This sometimes occurs because the policies emerge from different agendas and reflect distributional, redistributional and regulatory approaches (Lowi 1979). Social Policy & Administration, Vol. 44, No. 2, April 2010 © 2010 The Author(s) Journal Compilation © 2010 Blackwell Publishing Ltd 143 Third, it places the health system in the context of the American political system. This includes a government with shared powers as well as federalism and an assumption that some issues belong to states and sometimes localities, and not to the federal government. Fourth, it indicates how difficult it is for the US system to focus on prevention activities. And fifth, it describes how the structure of HHS creates tensions between management initiatives and professional expertise and standards. The Structure of HHS Today As figure 1 indicates, the current structure of the Department of Health and Human Services is an organization that reflects two characteristics: first, that health programmes and policies are located in the same agency as a number of human service activities; and second, that the health programmes within Figure 1 The structure of the Department of Health and Human Services, 2009 Office of Intergovernmental Affairs & Regional Representatives Assistant Secretary for Health (ASH)/Office of Public Health and Science (OPHS)* Agency for Toxic Substances and Disease Registry (ATSDR)* Centers for Disease Control and Prevention (CDC)* Food and Drug Administration (FDA)* Indian Health Service (IHS)* Office of Global Health Affairs National Institutes (OGHA)* of Health (NIH)* Administration for Children and Families (ACF) Office of the General Counsel (OGC) Office of Medicare Hearings and Appeals (OMHA) Office of the Inspector General (IG) Departmental Appeals Board (DAB) Office of the National Coordinator for Health Information Technology (ONC) Center for Faith-Based and Community Initiatives (CFBCI) Office for Civil Rights (OCR) Administration on Aging (AOA) Centers for Medicare & Medicaid Services (CMS) Agency for Healthcare Research and Quality (AHRQ)* Office of the Assistant Secretary for Administration and Management (ASAM) Program Support Center Office of the Assistant Secretary for Resources and Technology (ASRT) Office of the Assistant Secretary for Planning and Evaluation (ASPE) Office of the Assistant Secretary for Legislation (ASL) Office of the Assistant Secretary for Public Affairs (ASPA) Office of the Assistant Secretary for Preparedness and Response (ASPR)* Health Resources and Services Administration (HRSA)* Substance Abuse and Mental Health Services Administration (SAMHSA)* *Designates components of the Public Health Service The Secretary Deputy Secretary Chief of Staff The Executive Secretariat Social Policy & Administration, Vol. 44, No. 2, April 2010 © 2010 The Author(s) Journal Compilation © 2010 Blackwell Publishing Ltd 144 the Department are highly fragmented and operate under quite different assumptions and processes. Neither characteristic is surprising to a student of the American political system. The structure of shared power between the three branches of government (Congress, the White House, and the courts) has led to a system that is accurately referred to as a crazy quilt – a patchwork of different approaches that are not always compatible or consistent with one another. The programmes that are currently within the HHS portfolio have emerged at different eras, as a result of different decision environments, and through the pressure of separate constituencies. Over the years, the structure of HHS has changed dramatically. Indeed, one can look at the more than 50 years of the Department as a time of constant change, reflecting substantive policy changes but also use of shifts in organizational structure to communicate other agendas2 (see Radin and Chanin 2009: 3). It began in 1953 as the Department of Health, Education and Welfare (HEW). It was a relatively small organization that reflected the minimal federal role in social policy. Rufus Miles, a former top official in the Department, argued that the Department is ‘the foremost institutional expression of five social revolutions that have, within a single generation, completely altered the relationship between U.S. citizens and their national government’ (Miles 1974: Introduction). The five social revolutions were the New Deal, the education revolution, the civil rights revolution, the health revolution, and the consumer rights revolution. By 1973, HEW included 200 programmes administered through 13 operating agencies and 10 regional offices. At the same time as programmes were created utilizing broad social welfare strategy rhetoric, they were also devised in a form that acknowledged the limited role of the federal government. In the late 1970s, the education programmes within the Department were separated and moved into a separate cabinet department. During this period many of the health programmes were placed under an Assistant Secretary for Health who had responsibility for the Public Health Service that contained the National Institutes of Health, the Food and Drug Administration, the Centers for Disease Control, the Health Resources Administration, the Health Services Administration and the Alcohol, Drug Abuse and Mental Health Administration. Further shifts occurred in the early 1990s, when the Social Security Administration became a free-standing agency outside of HHS (Radin 2002). Despite the exit of these two programme areas, at the turn of the twenty-first century HHS contained approximately 300 programmes and a budget of nearly $880 billion. As the current structure indicates, when the health programmes within the Department are aggregated both in size and in budget, they represent the majority of activities within HHS. However, the programme units each report directly to the Secretary, and the Assistant Secretary for Health has been moved from an operating programme role to one of a staff function. Until 1995, the programme units found within the Public Health Service reported to an Assistant Secretary for Health (called OASH – the Office of the Assistant Secretary for Health). Although some of the units actually bypassed this intervening level and in practice dealt directly with the Secretary, the OASH played a formal decision role within the Department, particularly as it Social Policy & Administration, Vol. 44, No. 2, April 2010 © 2010 The Author(s) Journal Compilation © 2010 Blackwell Publishing Ltd 145 involved the budget development process. The change in the structure removed this level and defined the role of the Office of the Assistant Secretary for Health as a staff unit. In spite of the shifts that have taken place in the Department structure (both as HEW and as HHS) over more than 50 years, few people have been satisfied with the management, mission, structure and governance of the agency. When the federal government’s involvement in social programmes increased dramatically in the1960s, new attention was focused on the operations of the Department of Health, Education and Welfare (Radin 1999). To that point, the Department operated much like a collection of separate entities. Some described the Department as a feudal system where power and authority were found in separate components. By the mid-1960s, however, the Office of the Secretary had emerged as a force within the Department. The span of activity grew wider as the federal government became a more important force in American society. Building on two processes – controlling the budget process as well as the determination of departmental positions on legislation – the Office of the Secretary grew and played a role attempting to mould together the separate forces within the programme components and reaching for a common set of policy goals within the Department. From that time on, most secretaries of the Department have searched for management systems that provide policy leadership as well as offering a way for them to oversee departmental administrative matters and programmes. In a few cases, efforts at management reform have accentuated attempts to identify interdependencies and shared issues across programme elements. Most efforts, however, emphasized attempts to control the separate elements within the Department. This agenda drew on several strategies. In some cases, the attempt to control the programme components was done through manipulation of the organization structure, moving programmes into new configurations in which they were required to work with previously separate and autonomous elements. A report issued by the General Accounting Office (GAO) in 1990 depicted the approach that was predominant until 1993 (US GAO 1990: 3). According to GAO, a management system should be able to identify issues, define goals and objectives, develop strategies, create monitoring systems, oversee operations, and receive feedback on performance. In its analysis, GAO wrote that the efforts within the Department did not go far enough and that HHS was not able to create a system that actually required the operating programmes to respond to the will of the Secretary. GAO found that the lack of departmental strategic planning was a ‘key element missing’ from the HHS system. Although the GAO report did acknowledge some of the forces and constraints that made it difficult to encourage central management in HHS, it was clear that the GAO analysts sought ways to overcome these difficulties. During the first term of the Clinton administration, a new organizational structure was put into place that embodied the pre-eminence of the operating units. The change in the structure removed this level and defined the role of the Office of the Assistant Secretary for Health as a staff unit. As new cabinet secretaries have been appointed, they have searched for ways to organize a coordinated national response to the nation’s health Social Policy & Administration, Vol. 44, No. 2, April 2010 © 2010 The Author(s) Journal Compilation © 2010 Blackwell Publishing Ltd 146 challenges. Two recent reports represent this recurring effort to rationalize what is viewed as an extremely difficult and less than effective system. One of the reports was issued by a committee of the Institute of Medicine of the National Academies of Science, a study that was commissioned by two members of the US House of Representatives. The chair and ranking member of the House Committee on Oversight and Government Reform asked the Institute of Medicine to ‘undertake a study of whether HHS is really organized to meet the public health and health care cost challenges that our nation faces’ (Congressman Henry Waxman and Congressman Thomas Davis, Letter to Harvey V. Fineberg, President of the Institute of Medicine, 20 June 2007). The report did not call for a major reorganization but crafted a strategy that emphasized the importance of reaching both White House agreement and congressional support or action on health policy. It emphasized five goals: • define a twenty-first-century vision • foster adaptability and alignment • increase effectiveness and efficiency of the US health-care system • strengthen the HHS and US public health and health-care workforces • improve accountability and decision-making (Institute of Medicine 2009: 4–5) There is little in this report that deals with the non-health portions of the Department or the institutionalized attributes of the US political system that created the fragmentation found in the system. The report reads as if HHS is a health department that emphasizes the direct provision of services. The second report that was issued by a study panel from the National Academy of Social Insurance and the National Academy of Public Administration focused on administrative issues in expanding access to health care. The report (National Academy of Social Insurance 2009) was funded by the Robert Wood Johnson Foundation. One of its chapters focused specifically on designing administrative organizations and outlined proposals to create new organizations, considering issues related to organizational design, funding, operational flexibilities, levels of political independence and accountability, and the structure of its management. The findings and recommendations of the chapter emphasized three issues: • Organizations that use governmental powers and funds and make public policy must be accountable as well as effective. • Many administrative problems do not have solutions that require new organizational designs. • The Federal Reserve System does not provide an appropriate model for an entity to manage a national health insurance system. (National Academy 2009: 43–4) Both of these reports indicate a high level of frustration within the US political structure about the ability to address problems that are entrenched in the health policy system. While structural and organizational issues are emphasized, the critics of the current system have not settled on a strategy that seems Social Policy & Administration, Vol. 44, No. 2, April 2010 © 2010 The Author(s) Journal Compilation © 2010 Blackwell Publishing Ltd 147 to shift the debate in a way that addresses these entrenched problems. Both of these reports indicate that there has been very limited consideration of the detail of organizing the federal health system, and that which has been developed appears to be somewhat unrealistic or limited in scope. The Political and Structural Context American ambivalence about creating a public health sector Critics of the current health system often note that the USA is one of the very few developed countries that has neither a separate and free-standing department of health nor a serious governmental commitment to providing health services to its citizens. At the same time, the USA spends more money on health services than any other country. Efforts to address this situation have been made for more than 50 years and presidents from Harry Truman on have advanced proposals to remedy the situation. Thus the current drive by Barack Obama to enact a health reform policy appears to move along a political path that has been well travelled and yet has not produced much success beyond the enactment of the Medicare and Medicaid programmes in 1965 under Lyndon Johnson. The scepticism about the federal role in health is built around three areas – financing responsibilities, a regulatory role, and responsibility for actually delivering services. As the current debate indicates, disagreement about the appropriate path to take transcends the two major political parties. The ambivalence about confronting this issue has resulted in two often conflicting policy strategies. First, the US health system rests on dependence on the private sector to provide services; and, second, the public role has been defined in a fragmented, sub-optimizing way that operates at the margins of the system. Even the Medicare programme – the most extensive of the national health programmes – is constructed around the private sector, where private third parties play an important role in administering the benefits. Rather than attempting to develop a universal system, the USA has emphasized programmes and policies in areas that do not appear to be addressed by private activity. Thus the federal programmes work at the margins of the system. A sizeable sector of the current federal health portfolio is designed to compensate for limitations of the private sector. For example, programmes involving Indian health services, rural health services, and services for lowincome citizens are now included in the repertoire of federal activities because services in these areas have not been provided by the private sector. In addition, a number of federal programmes focus on a research and development role, ranging from funding for research itself to the development of health professionals in underserved areas. These separate programmes have resulted from the fragmentation of the US political system – both the shared powers among the legislative, executive and judiciary as well as the separate jurisdictional authority within the Congress, where programmes are the responsibility of different committees and subcommittees. The ambivalence about creating a comprehensive health system is also expressed in the structure of HHS itself. The current system emphasizes free-standing programme units that operate as silos with distinct legislative Social Policy & Administration, Vol. 44, No. 2, April 2010 © 2010 The Author(s) Journal Compilation © 2010 Blackwell Publishing Ltd 148 supporters and interest groups. These interest groups include organizations that represent clients of programmes but, more importantly, the providers of programmes with large budgets. These separate programmes have to compete inside of HHS with welfare programmes, a range of programmes for children, and activities focused on the elderly. In addition, health programmes are also found in other departments and agencies such as the Department of Labor, the Environmental Protection Agency, the Department of Education, the Department of State, the Department of Veterans Affairs, the Department of Defense, and the Social Security Administration. All of this means that the boundaries between various types of health programmes are difficult to define. It is logical to view fragmentation as a way of keeping the federal role in health to a minimum. Although one might have assumed that the departure of the education programmes and the Social Security Administration would create some momentum to clarify the definition of organizational mission, to this point this has not really occurred within HHS. All of this allows many health programmes to stay beneath the radar and only to surface when some major problem or crisis emerges. The current debate over health reform also reinforces the American ambivalence about the responsibility of the public sector in this policy area. None of the serious proposals is constructed as pure public interventions; none of the congressional or Obama schemes focuses on the government as the single payer or the sole deliverer of services. The controversy about a very limited public option is evidence of the continuation of this classic American approach. Separation of functions within HHS The individual programme units within the Department are organized around three separate functions: service delivery, financing, and research.3 Even when all of the programmes seemed to report to an Assistant Secretary for Health, they operated in very independent ways. Service delivery functions are the major task of the Health Resources and Services Administration, the Indian Health Service, the Substance Abuse and Mental Health Services Administration, and some parts of the Centers for Disease Control and Prevention. Financing functions are mainly found in the Centers for Medicare and Medicaid Services, which emphasize the fiscal role. The research functions predominate in the National Institutes of Health and the Agency for Healthcare Research and Quality, but are also found in the Centers for Disease Control and Prevention as well as the Food and Drug Administration (which also plays a regulatory role). Most of the units also have some level of investment in training activities, but these are not at the core of their work. In addition to varied functions, the programme units’ accountability relationships are also fragmented. They report to different congressional committees and subcommittees. They also respond to the perspectives of different interest groups and employ staff members with different training and perspectives. Despite efforts to centralize responsibilities in the Office of the Secretary (or even in the Office of the Assistant Secretary for Health), the decentralized accountability relationships limit the ability of the top official in the Department to pull programmes and policies together. This fragmentation has led to Social Policy & Administration, Vol. 44, No. 2, April 2010 © 2010 The Author(s) Journal Compilation © 2010 Blackwell Publishing Ltd 149 situations that seem to many to be highly irrational. For example, it has been difficult to integrate research findings into fiscal reimbursement policies or actually to find ways to deliver services that include the practices that flow from the research. Similarly, drug developments that are financed through federal funds are controlled by pharmaceutical companies and integrated into the private sector market rather than the public sector. This problem reaches beyond HHS itself because health-related programmes reach into other departments and agencies. During the Clinton administration, efforts by public health officials to develop a needle exchange programme to limit the spread of HIV-AIDS were stopped by Justice Department officials, who believed that such an exchange programme seemed to be supporting illegal drug use. The reality of federalism and separation of powers In addition to the constraints imposed by historical reliance on the private sector, the US health system is also limited by the institutional structure of the American political system. It is extremely difficult for the executive branch to define clearly a national or federal role in health policy because it does not have the authority to create policies and programmes on its own. Rather, it is limited by the system of shared powers with the legislative branch as well as the judiciary. As has been noted, the fragmentation that has been a part of the US system has largely emerged from the role of Congress and those who influence the legislative decision-making process. The second major constraint that inhibits efforts to achieve a national ‘alignment’ in health policy stems from the structure of the US federal system. Fifty states have significant differences in the way that they approach the health system, reflecting population, historical and cultural experiences. In addition, a number of states have given authority and responsibility for health programmes to counties and other local levels of government. As a result, health programmes have been constructed around shared responsibility between the federal government and states and/or localities. For example, the large Medicaid programme requires states to contribute approximately 50 per cent of the cost of the programme (the specific percentage of the reimbursement formula is determined by state attributes). Efforts to develop data systems were constructed on voluntary grounds; states were provided funds to devise data systems if they agreed to particular requirements. A number of programmes are structured as block grants that provide the state with significant discretion to determine how the federal funds are used. Negotiated agreements (such as performance partnerships) have been advanced as collaborative and shared responsibilities. As a result, there is significant variation in the health policy and programme landscape across the country. Difficulties focusing on health prevention approaches The US public health community has long recognized that policies and programmes which emphasize health prevention are effective both in terms of Social Policy & Administration, Vol. 44, No. 2, April 2010 © 2010 The Author(s) Journal Compilation © 2010 Blackwell Publishing Ltd 150 dealing with health problems and also in achieving cost savings. However, many of the programmes that are in the federal government repertoire have a crisis orientation and do not lend themselves to approaches that require a longer-term perspective. To some degree this reflects the ambivalence within American society about a public investment in health. But it is also supported by the commitment within the US system to an annual budget process; focusing on annual expenditures makes it difficult to assess outcomes that require a multi-year perspective. There have been attempts within the federal government to try to compensate for this short-term orientation. Healthy People, a set of national health objectives that emphasize prevention, was first published by HHS in 1979 and subsequently revised for changes for 2000, 2010 and 2020 (see website at www.healthypeople.gov/). Although issued by the federal government, many of the recommendations in the documents called for action by nongovernment players. Healthy People has been created by scientists both inside and outside of government and identifies a range of public health priorities and measurable objectives around two overarching goals: increasing quality and years of healthy life and eliminating health disparities. Although the health sector has one of the most robust data sets within the federal government, there have been both budget and authority limitations placed on some attempts to gather information that would provide the basis for a sophisticated assessment of policy and programme outcomes. This is a problem that is likely to be experienced no matter what the structure of health programmes within the federal government. Conflict between management approaches and the expertise of health professionals One of the classic problems facing professionals in the government is the conflict between the perspective of managers and that of the professionals who work within the bureaucracy. This is not a problem that is unique to the USA, nor is it limited to the health sector. The bureaucratic managers tend to emphasize issues related to efficiency and control while the professionals focus on the norms defined by their professions and also tend to highlight issues related to quality and personal autonomy (Freidson 2001). This conflict is similar to the tension that is found in hospitals, where there are differences between doctors and administrators, or in research settings, where there is stress between scientists and managers. Although the current health reform debate has focused on the decisions by insurance companies that limit the discretion of both providers and consumers, the broader issue of conflict between managers and health professionals is likely to surface in the implementation of any new health policy design. During the past decade or so, efforts to impose performance standards and measurement on health programmes provided a snapshot of problems facing health professionals (Radin 2006).4 In 1998, three of the nation’s pre-eminent health-care accrediting organizations – the American Medical Association’s Accreditation Program (AMAP), the Joint Commission on Accreditation of Healthcare Organizations ( JCAHO), and NCQA (National Social Policy & Administration, Vol. 44, No. 2, April 2010 © 2010 The Author(s) Journal Compilation © 2010 Blackwell Publishing Ltd 151 Committee for Quality Assurance) – announced a collaborative effort designed to coordinate performance measurement activities across the entire health-care system. Each of the three organizations involved in the collaborative effort defined performance measurement at different levels of the health-care system. Others were also involved in the effort to assess and improve the nation’s quality of care. The Institute of Medicine of the National Academy of Sciences began an effort in 1996 entitled ‘Crossing the Quality Chasm’, documenting the serious and pervasive nature of problems in health quality through a series of reports and meetings. The Agency for Healthcare Research and Quality in the US Department of Health and Human Services was designed to support research that would help improve the quality, safety, efficiency and effectiveness of health care. Despite some scepticism, it was not surprising that the availability of these data created a set of dynamics that moved beyond the original concerns of those involved in creating a set of performance measures. Originally focused on behaviours in the private sector, the availability of the measures moved them to be used in the public sector both for performance requirements and for reimbursement policies. Some of the measures became the basis for the federal government in the Centers for Medicare and Medicaid Services to issue reporting requirements in Medicare. As the years have progressed, the quality focus of the measures seems to have been overpowered by a concern about cost savings. The effort to focus on quality seems to have collided with imperatives of cost savings and cost control. Conclusions All five of these attributes are elements that must be considered in the implementation of any structure that may emerge from the current health policy debate. Clearly, they will surface in different ways, depending on the construct of the policy change and the structural determination that might follow that decision. There are at least five possible structural scenarios that may emerge from this process. 1. Pull out all of the health programmes and put them in a new cabinetlevel department. It is not likely that a separate department would avoid any of the problems discussed in this article but would give symbolic status to a separate department. 2. Spin off the separate entities within the health portfolio but keep them inside HHS, organized by function. The research, financing, services and regulatory functions could be given more autonomy. This would continue the fragmentation but organize the programmes by function rather than historical organizations. 3. Spin off the separate entities within the health portfolio as individual agencies organized either by function (e.g. a regulatory body) or by programme type. Some might be independent or highly specialized while others could have minimal change. This would give visibility to the priority areas defined by the policy change. Social Policy & Administration, Vol. 44, No. 2, April 2010 © 2010 The Author(s) Journal Compilation © 2010 Blackwell Publishing Ltd 152 4. Keep all existing programmes within HHS but consolidate them inside the department. This would provide a way to address the problems discussed through internal decision-making and might minimize external opposition to change. 5. Maintain the current structure. This would minimize internal disruption and allow the policy changes to be implemented incrementally. None of these possible options avoids the attributes that provide the context for the structure and operation of a US health bureaucracy. It will be impossible to avoid acknowledgement of the ambivalence in the US society about public health; it will not avoid the complex and diverse functions and activities within the health portfolio; it must operate in a government structure of shared powers and federalism and assumptions about the decision-making processes; and it has to assume tension between managers and health professionals. Given all that, a US health department is likely to continue to look quite different from its international counterparts. Notes 1. Many of the issues that are discussed in Margitte Mätzke’s article on Germany in this issue are included in this piece. However, the discourse and conceptual frameworks that are used are quite different; her work is presented through the lens of a sociologist, while this piece calls on the frameworks of public administrators and policy analysts. 2. Among the reasons for reorganization decisions are the following: surrogate for policy change, public demand for change, imprinting of new actors, subordinating to private sector values, diffused innovation, improving policy technology, and a drive for stability and conflict avoidance. 3. Each of the programme units may contain activities in all three functions, but their major goals tend to emphasize just one of the functions. 4. These have taken two forms that require performance information and measures across the federal government. They are the Government Performance and Results Act of 1993 and the Program Assessment Rating Tool used by the George W. Bush administration. References Freidson, E. (2001), Professionalism, The Third Logic: On the Practice of Knowledge, Chicago: University of Chicago Press. Institute of Medicine of the National Academies (2009), HHS in the 21st Century: Charting a New Course for a Healthier America, Washington, DC: National Academies Press. Lipset, S. M. (1996), American Exceptionalism: A Double-Edged Sword, New York: W. W. Norton. Lowi, T. J. (1979), The End of Liberalism (2nd edn), New York: W. W. Norton. Morone, J. (1990), The Democratic Wish: Popular Participation and the Limits of American Government, New York: Basic Books. Miles, R. E., Jr. (1974), The Department of H.E.W, New York: Praeger. National Academy of Social Insurance and the National Academy of Public Administration (2009), Administrative Solutions in Health Reform (July), Washington, DC. Radin, B. A. (1999), Managing in a Decentralized Department: The Case of the US Department of Health and Human Services, Washington, DC: PWC Endowment for the Business of Government. Social Policy & Administration, Vol. 44, No. 2, April 2010 © 2010 The Author(s) Journal Compilation © 2010 Blackwell Publishing Ltd 153 Radin, B. A. (2002), The Accountable Juggler: The Art of Leadership in a Federal Agency, Washington, DC: CQ Press. Radin, B. A. (2006), Challenging the Performance Movement: Accountability, Complexity and Democratic Values, Washington, DC: Georgetown University Press. Radin, B. A. and Chanin, J. M. (eds) (2009), Federal Government Reorganization: A Policy and Management Perspective, Boston: Jones and Bartlett. US Centers for Medicare and Medicaid Services (CMS) (2006), Health Spending Projections through 2015. Available at: www.cms.hhs.gov/ NationalHealthExpendData/03_NationalHealthAccountsProjected.asp. US General Accounting Office (GAO) (1990), Management of HHS: Using the Office of the Secretary to Enhance Departmental Effectiveness, GAO HRD-90-51 (February), Washington, DC: GAO. Weisberg, J. (2009), We Are What We Treat: Fixing Health Care, American Style, Newsweek (27 July): 27. Social Policy & Administration, Vol. 44, No. 2, April 2010 © 2010 The Author(s) Journal Compilation © 2010 Blackwell Publishing Ltd 154 Copyright of Social Policy & Administration is the property of Blackwell Publishing Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.

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