The Accountable Juggler: The Art of Leadership in a Federal Agency
Publication Year: 2002
PUBLIC AFFAIRS AND POLICY ADMINISTRATION SERIES Edited by Donald KettlHow should a manager handle different accountability expectations? While a commonplace term in government lexicon, accountability has escaped precise definition, leaving managers at a disadvantage when trying to monitor the performance of their programs. Including more than 300 programs, over 60,000 employees, and a budget of over $400 billion, the U.S. Department of Health and Human Services is an ideal canvas for starkly illustrating competing accountability demands. With a bird's-eye view of the agency's inner workings, Radin tackles big issues such as strategies of centralization and decentralization, coordination with states and localities, leadership, and program design, while using the apt analogy of a juggler to show how managers must keep in the air disparate demands and ...
- Front Matter
- Back Matter
- Subject Index
- Chapter 1: Introduction
- Chapter 2: Thinking About Accountability
- Chapter 3: Can Anybody Manage This Organization? The HHS Case
- Chapter 4: Accountability and the Policy Lens
- Chapter 5: Accountability and the Politics Lens
- Chapter 6: Accountability and Management Processes
- Chapter 7: Dealing with the Public
- Chapter 8: Advice to a New HHS Secretary
Public Affairs and Policy Administration Series[Page ii]
- The Accountable Juggler: The Art of Leadership in a Federal Agency
Beryl A. Radin
- Working with Culture: How the Job Gets Done in Public Programs
Anne M. Khademian
- Governing by Contract: Challenges and Opportunities for Public Managers (forthcoming)
Phillip J. Cooper
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Library of Congress Cataloging-in-Publication Data
The accountable juggler: the art of leadership in a federal agency / Beryl A. Radin.
p. cm. —(Public Affairs and Policy Administration series)
Includes bibliographical references and index.
ISBN 1-56802-643-9 (alk. paper)
1. United States. Dept. of Health and Human Services—Management. 2. Public administration—United States. 3. Leadership. I. Title. II Series.
There is a scene in the movie Ben Hur, in which Ben Hur tries without success to get his four new chariot horses to run swiftly around a track. The bedouin who owns the horses tells him that each horse has its own personality and skills and that they must be harnessed together in a way that allows them to run as a team. That story underscores the essence of successfully managing a large, complex cabinet agency.
Beryl Radin, a distinguished scholar of public administration, has taken on a task almost as difficult as managing and leading the U.S. Department of Health and Human Services (HHS). She has decided to analyze and explain the management and strategic challenges that government leaders face.
Her context is the public administration literature and what it tells us about large, complex public agencies. Her protagonist is a fictitious, newly nominated secretary of HHS. Professor Radin tells this hapless patriot what he needs to know not just to get through his confirmation hearing but also to make a difference during his tenure. Making a difference, according to Professor Radin, requires understanding the different cultures of the various agencies within the department and using accountability and management processes to make the sum larger than the parts.
Not since Professor Roscoe Martin dissected the Tennessee Valley Authority have any scholars steeped themselves in the culture of a large government agency over a substantial period of time and reported their findings with such insight. Professor Radin is an outsider with keen and thoughtful things to say about the work of HHS, the single federal agency that impacts the lives of most Americans. Her discussion of accountability inside and outside the department is a particularly important contribution to the literature.
The most important lesson for a successful leader is flexibility: Standing on principle is not the same as standing in cement. The writers of our Constitution did not create a system in which one side wins all the time. In fact, that was the last thing they wanted. What they wanted was a system in which men and women of good will—although of differing views—could hammer out compromises that would, over time, bring a better life to every citizen. This book tells us how that political and administrative process works.
[Page x]For any policymaker or student of public administration, this book is the best ever written on a modern cabinet agency. I hope every new cabinet secretary and agency head will read this book after winning confirmation. If they read it before, it might scare them away from public service. If they read it after, it may help them to become stronger, more effective leaders., Secretary of Health and Human Services, 1993–2001
I cannot avoid making explicit what is apparent to anyone who knows me. This book is the work of an HHS/HEW groupie. For many years—longer than I'd care to admit—I have followed the machinations of a department that contained policies and programs that preoccupied me both as a scholar and as a citizen. I began my encounter with what was then called the Department of Health, Education and Welfare when I worked with the U.S. Commission on Civil Rights, concerned about the implementation of civil rights policies within HEW. My doctoral dissertation (and first book) focused on an aspect of that effort—implementation of Title VI of the 1964 Civil Rights Act in the education programs within HEW. I spent a year in the department during the Carter administration, working on a policy document that reviewed the multiple programs within the agency. Coauthoring a book on the creation of the Department of Education gave me still another perspective on what had become the Department of Health and Human Services in 1979. In the years that followed, I continued research on human services policies and the role of the federal government as it attempted to influence the programs that were actually administered by others, particularly state governments.
By the fall of 1995, it seemed that it was again time for me to spend time in HHS. The secretary of the department, Donna Shalala, arranged for me to come into the federal government through the Intergovernmental Personnel Act (legislation that allows faculty members to be hired for short-term appointments). For two years I worked out of the Office of the Assistant Secretary for Management and Budget, first cochairing a departmentwide task force looking at the use and potential of technical assistance efforts within the department and then working with ASMB on the implementation of the Government Performance and Results Act. When I returned to my teaching position in the fall of 1998, for two years I continued to spend a day a week as a consultant with ASMB. In addition, through grants from the PricewaterhouseCoopers Endowment for the Business of Government, I was able to write two monographs on management issues during the Shalala regime in the department.
[Page xii]The combined experiences within the department gave me an appreciation of the challenges faced by a cabinet secretary who attempts to deal with the multiple accountability expectations imposed on him or her by nearly every possible interest group and constituency I could imagine. I felt that much of the literature on cabinet officers and on accountability minimized the cacophony of voices and demands aimed at the secretary. I wanted to present a picture of this job that would give readers a sense of the complexity implicit in the role.
Much of what follows in this volume is not only an attempt to draw on my personal experiences and observations but to place that experience within the academic literature. The book is not an attempt to write a firsthand account of what I saw and did, but it clearly draws on that experience as the basis for analysis. I have tried to use the HHS experience to bring life to a fairly wide range of literatures and theories involving policy and management. It is my hope that the readers of this volume will gain not only an understanding of one department but also with an appreciation of the incredible array of demands that are placed on the cabinet officials who are held responsible for running federal government departments.
My time inside this department reinforced my appreciation of the men and women who make up the federal bureaucracy. For some, the term bureaucrat is a pejorative word. For me, it is not. Rather, it describes a group of people who are committed to making the federal government an instrument of caring and respect for all within the society. Although this book highlights the role of the cabinet secretary, much of what is described makes up the world of public servants. They must deal with incredible complexity and with demands coming from nearly every part of American society.
This book therefore is dedicated to those individuals within HHS. I am indebted to their service and to their willingness to share their worlds with me. I am especially indebted to Donna Shalala, the longest-serving secretary of the department.
Several people read drafts of this book. I would like to thank John Callahan, Robert Durant, Judith Feder, Matthew Holden, Don Kettl, and Norma Riccucci as well as the reviewers, Stephen Percy, University of Wisconsin—Milwaukee; Marissa Golden, Bryn Mawr College; Carolyn Thompson, University of North Carolina at Pembroke; Fred Thompson, Willamette University; and Nancy Miller, University of Maryland—Baltimore County. In addition, I have found working with Charisse Kiino of CQ Press a real joy.
Annotated List of Abbreviations and Terms[Page xiii]
- AARP American Association of Retired Persons. Organization that represents the interest of retirees.
- ACF Administration for Children and Families. The unit within HHS responsible for programs for children and families. Includes Head Start, Foster Care and Adoption programs as well as the Low Income Heating and Energy Assistance Program (LIHEAP), Child Abuse and Neglect programs, and the Office of Community Services.
- AFDC Aid to Families with Dependent Children. The federal-state program that provided cash assistance to eligible low income families. Replaced by TANF.
- AHRQ Agency for Healthcare Research and Quality. The organization that focuses on the quality of health care. Formerly known as AHCPR, the Agency for Health Care Policy and Research.
- AoA Administration on Aging. A federal-state program providing services for the elderly.
- ASH Assistant Secretary for Health and the Office of the ASH.
- ASL Assistant Secretary for Legislation and the Office of the ASL.
- ASMB Assistant Secretary for Management and Budget and the Office of the ASMB.
- ASPA Assistant Secretary for Public Affairs and the Office of the ASPA.
- ASPE Assistant Secretary for Planning and Evaluation and the Office of the ASPE.
- ATSDR Agency for Toxic Substances and Disease Registry. Organization linked to CDC that implements environmental health-related laws.
- BRB Budget Review Board. The process used internally in HHS to develop the department's budget. Includes the ASMB, the ASPE, and the ASH.
- CDC Centers for Disease Control and Prevention. The organization located in Atlanta that focuses on health prevention.
- CHIP Child Health Insurance Program. A federal-state program administered by CMS.
- CMS Centers for Medicare and Medicaid Services. Formerly HCFA.
- DOI Department of the Interior.
- ED U.S. Department of Education. Part of HEW until it was made a separate cabinet department in 1979. [Page xiv]
- EPSDT Early and Periodic Screening, Diagnosis and Treatment. The program within Medicaid that provides health services for low-income children.
- Executive Secretariat The unit within the Office of the Secretary that coordinates all activities within the department.
- FACA Federal Advisory Committee Act. Establishes requirements for federal agencies to solicit advice from various groups in the society.
- FDA Food and Drug Administration. The organization that protects public health by regulating food and drug products. Includes the Hazard Analysis and Critical Control Point program.
- FTEs Full-time equivalents. The system for determining personnel levels in agencies.
- GAO General Accounting Office. Evaluation and oversight office in the Congress.
- GPRA Government Performance and Results Act.
- HCFA Health Care Financing Administration. The organization renamed CMS in 2001 that implements the Medicare and Medicaid programs.
- Head Start The program within ACF that supports preschool services largely for low-income children.
- HEW U.S. Department of Health, Education, and Welfare. Renamed the Department of Health and Human Services when the Department of Education was created in 1979.
- HHS U.S. Department of Health and Human Services. Sometimes called DHHS.
- HIPAA Health Insurance Portability and Accountability Act.
- HRSA Health Resources and Services Administration. The organization that implements programs that seek to promote access to health care services. Includes the Health Centers Program, the National Health Services Corps, the Maternal and Child Health Services Block Grant, the Ryan White HIV/AIDs program, the Organ Transplantation Program, and Emergency Medical Services Program for children.
- IHS Indian Health Service. The organization that provides health services to American Indians and Alaska Natives. Governed by the Indian Self-Determination and Education Assistance Act.
- Medicaid A joint federal-state program that provides health care for low-income citizens.
- Medicare The program administered by HHS that provides health care for retirees.
- NGA National Governors' Association.
- NIH National Institutes of Health. The unit composed of twenty-five institutes and centers that conduct and support medical research.
- NPR National Performance Review. The administrative reform effort during the Clinton administration, led by Vice President Gore.
- OEO Office of Economic Opportunity. The War on Poverty agency established in the 1960s. Many of the programs (including Head Start) moved to HHS.
- OHDS Office of Human Development Services. The program unit that became ACF.
- OIG Office of Inspector General.
- OMB Office of Management and Budget. The office within the Executive Office of the President with a number of responsibilities, particularly developing the president's budget. [Page xv]
- ONDP Office of National Drug Control Policy. Drug office within the White House.
- OS Office of the Secretary. Those units within HHS that report to the secretary and provide advice to that individual.
- OSTP Office of Science and Technology Policy. Science office within the White House.
- PHS Public Health Service.
- PPBS Planning, Program and Budgeting System. Developed in the 1960s to create a more focused budgeting system.
- PRWORA Personal Responsibility and Work Opportunity Reconciliation Act. Contains TANF.
- Regional Offices Ten offices located throughout the United States headed by regional directors.
- SAMHSA Substance Abuse and Mental Health Services Administration. The organization that focuses on mental health and substance abuse services and research. Includes the Center for Mental Health Services, the Center for Substance Abuse Prevention, the Center for Substance Abuse Treatment, and the National Clearinghouse for Alcohol and Drug Information.
- SSA Social Security Administration. Part of HHS until it was made an independent agency in 1995.
- Staff Offices The units within an organization that provide advice to those with formal authority, that is, those at the top of a hierarchy.
- Surgeon General The top medical officer in the federal government.
- TANF Temporary Assistance for Needy Families. The federal-state program that replaced AFDC and provides cash assistance to families who meet specific requirements.
- UNOS United Network for Organ Sharing. The organization that represents transplant centers.
- Y2K Process of ensuring that computer systems were able to respond to the demands of a new millennium.
- The Accountable Juggler: The Art of Leadership in a Federal Agency
Appendix 1. HHS Historical Highlights[Page 138]
The roots of the U.S. Department of Health and Human Services go back to the earliest days of the nation.
1798 The first Marine Hospital, a forerunner of today's Public Health Service, was established to care for seafarers. 1862 President Abraham Lincoln appointed a chemist, Charles M. Wetherill, to serve in the new Department of Agriculture. This was the beginning of the Bureau of Chemistry, forerunner to the Food and Drug Administration. 1887 The federal government opened a one-room laboratory on Staten Island for research on disease, thereby planting the seed that was to grow into the National Institutes of Health. 1906 Congress passed the first Food and Drug Act, authorizing the government to monitor the purity of foods and the safety of medicines, now a responsibility of the Food and Drug Administration. 1912 President Theodore Roosevelt's first White House Conference urged creation of a Children's Bureau to combat exploitation of children. 1935 Congress passed the Social Security Act. 1939 Related federal activities in the fields of health, education, social insurance, and human services were brought together under the new Federal Security Agency. 1946 The Communicable Disease Center was established, forerunner of the Centers for Disease Control and Prevention. 1953 The cabinet-level Department of Health, Education and Welfare, was created under President Dwight D. Eisenhower. 1955 The Salk polio vaccine was licensed. 1961 The first White House Conference on Aging was held. 1962 The Migrant Health Act, providing support for clinics serving agricultural workers, was passed. 1964 The surgeon general released the first Surgeon General's Report on Smoking and Health. 1965 The Medicare and Medicaid programs were created, making comprehensive health care available to millions of Americans. The Older Americans Act created the nutritional and social programs run by the Administration on Aging, and the Head Start program was created. 1966 The International Smallpox Eradication program was established. The Community Health Center and Migrant Health Center programs were launched. 1970 The National Health Service Corps was created. [Page 139] 1971 The National Cancer Act was signed into law. 1975 The Child Support Enforcement program was established. 1977 The Health Care Financing Administration was created to manage Medicare and Medicaid separately from the Social Security Administration. Led by the U.S. Public Health Service, smallpox was eradicated worldwide. 1979 The Department of Education Organization Act was signed into law, providing for a separate Department of Education. 1980 HEW became the Department of Health and Human Services. Federal funding was provided to states for foster care and adoption assistance. 1981 The Acquired Immune Deficiency Syndrome, AIDS, was identified. 1984 The National Organ Transplantation Act was signed into law. 1988 The JOBS program was created, and federal support for child care was initiated. The McKinney Act was signed into law, providing health care to the homeless. 1989 The Agency for Health Care Policy and Research was created. 1990 The Human Genome Project was established. The Nutrition Labeling and Education Act was signed into law. The Ryan White Comprehensive AIDS Resource Emergency (CARE) Act began in 1990 to provide support for communities to help people with AIDS. 1993 The Vaccines for Children Program was established, providing free immunizations to all children in low-income families. 1994 NIH-supported scientists discovered the genes responsible for many cases of hereditary colon cancer, inherited breast cancer, and the most common type of kidney cancer. 1995 The Social Security Administration became an independent agency on March 31. 1996 Welfare reform was enacted under the Personal Responsibility and Work Opportunity Reconciliation Act. Regulations were published providing for FDA regulation of tobacco products to prevent use of tobacco by minors. 1997 The State Children's Health Insurance Program was established. 1998 The Initiative to Eliminate Racial and Ethnic Disparities in Health was launched. The initiative focuses on six key areas of health: infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV/AIDS, and immunizations. 1999 The Ticket to Work and Work Incentives Improvement Act of 1999 was signed, making it possible for millions of Americans with disabilities to join the workforce without fear of losing their Medicaid and Medicare coverage. It also modernized the employment services system for people with disabilities. 2000 AIDS was dropped from the top fifteen causes of death. Scientists completed the map of the human genome. 2001 The Health Care Financing Administration was renamed the Center for Medicare and Medicaid Services.
Appendix 2. Secretaries of HEW and HHS[Page 140]
1. Oveta Culp Hobby April 11, 1953-July 31, 1955 2. Marion B. Folsom August 1, 1955-July 31, 1958 3. Arthur S. Flemming August 1, 1958-January 19, 1961 4. Abraham Ribicoff January 21, 1961-July 13, 1962 5. Anthony J. Celebrezze July 31, 1962-August 17, 1965 6. John W. Gardner August 18, 1965-March 1, 1968 7. Wilbur J. Cohen May 16, 1968-January 20, 1969 8. Robert H. Finch January 21, 1969-June 23, 1970 9. Elliot L. Richardson June 24, 1970-January 29, 1973 10. Caspar W. Weinberger February 12, 1973-August 8, 1975 11. David Mathews August 8, 1975-January 20, 1977 12. Joseph A. Califano Jr. January 25, 1977-August 3, 1979 13. Patricia Roberts Harris August 3, 1979-January 20, 1981 14. Richard S. Schweiker January 22, 1981-February 3, 1983 15. Margaret M. Heckler March 9, 1983-December 13, 1985 16. Otis R. Bowen, M.D. December 13, 1985-January 20, 1989 17. Louis W. Sullivan, M.D. March 1, 1989-January 20, 1993 18. Donna E. Shalala January 22, 1993-January 20, 2001 19. Tommy G. Thompson February 2, 2001-
Appendix 3. HHS Regional Offices[Page 141]
- Region I
- Boston, Mass.
- Areas: Conn., Maine, Mass., N.H., R.I., Vt.
- Region II
- New York, N.Y.
- Areas: N.J., N.Y., Puerto Rico, Virgin Islands
- Region III
- Philadelphia, Pa.
- Areas: Del, D.C., Md., Pa., Va., W.Va.
- Region IV
- Atlanta, Ga.
- Areas: Ala., Fla., Ga., Ky, Miss., NC., S.C., Tenn.
- Region V
- Chicago, Ill.
- Areas: Ill, Ind., Mich., Minn., Ohio, Wise.
- Region VI
- Dallas, Tex.
- Areas: Ark., La., N.Mex., Okla., Tex.
- Region VII
- Kansas City, Mo.
- Areas: Iowa, Kans., Mo., Nebr.
- Region VIII
- Denver, Colo.
- Areas: Colo., Mont., N.Dak., S.Dak., Utah, Wyo.
- Region IX
- San Francisco, Calif.
- Areas: Ariz., Calif., Hawaii, Nev., Guam, Pacific Islands, American Samoa
- Region X
- Seattle, Wash.
- Areas: Alaska, Idaho, Ore., Wash.
Appendix 4. The HHS Portfolio[Page 142]The Administration for Children and Families (ACF)
The Administration for Children and Families is responsible for federal programs that promote the economic and social well-being of families, children, individuals, and communities. ACF programs aim to achieve the following: families and individuals empowered to increase their own economic independence and productivity; strong, healthy, supportive communities that have a positive impact on the quality of life and the development of children; partnerships with individuals, front-line service providers, communities, American Indian tribes, Native Alaskan communities, states, and Congress that enable solutions that transcend traditional agency boundaries; services planned, reformed, and integrated to improve needed access; and a strong commitment to working with people with developmental disabilities, refugees, and migrants to address their needs, strengths, and abilities. Several programs within ACF are of special interest.
Temporary Assistance for Needy Families (TANF) On August 22, 1996, President Clinton signed into law the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, a comprehensive bipartisan welfare reform plan that dramatically changed the nation's welfare system into one that requires work in exchange for time-limited assistance. The TANF program replaced the former AFDC and JOBS programs. In TANF, states and territories operate programs; under the new law, tribes have the option to run their own TANF programs. States, territories, and tribes each receive a block grant allocation; states have a maintenance of effort requirement. The total federal block grant is $16.5 billion each year through fiscal year 2002. The block grant covers benefits, administrative expenses, and services. States, territories, and tribes determine eligibility and benefit levels and services provided to needy families, and there is no longer a federal entitlement.
Head Start Head Start and Early Head Start are comprehensive child development programs that serve children from birth to age five, pregnant women, and their families. They are child-focused programs and have the overall goal of increasing the school readiness of young children in low-income families. The Head Start program is administered by the Head Start Bureau, the Administration on Children, Youth and Families (ACYF), and Administration for Children and Families (ACF). Grants are awarded by the ACF regional offices and the Head Start Bureau's American Indian and Migrant Program branches directly to local public agencies, private organizations, Indian tribes, and school systems for the purpose of operating Head Start programs at the community level.
The Head Start program has a long tradition of delivering comprehensive and high-quality services designed to foster healthy development in low-income children. Head Start grantee and delegate agencies provide a range of individualized services in the areas of education and early childhood development; medical, dental, and mental health; nutrition; and parent involvement. In addition, the entire range of Head Start [Page 143]services is responsive and appropriate to the developmental, ethnic, cultural, and linguistic heritage and experience of each child and family.
Foster Care/Adoption Assistance/Independent Living For those children who cannot remain safely in their homes, foster care provides a stable environment that ensures a child's safety and well-being while his or her parents attempt to resolve the problems that led to the out-of-home placement, or when the family cannot be reunified, until the child can be placed permanently with an adoptive family. Foster Care and Adoption Assistance programs provide federal matching funds to states, which directly administer the programs. Children in foster care numbered more than 560,000 in September 1998, up from 340,000 in 1988. Most of these children will return to their homes, but more than 120,000 cannot return safely. Many of these children are considered to have “special needs” because they are older; members of minority or sibling groups; or physically, mentally, or emotionally disabled. They often need special assistance in finding adoptive homes. Currently, more than 100,000 children receive Title IV-E adoption assistance, which is a subsidy to families.
Child Abuse and Neglect Programs Just over 900,000 children were victims of substantiated child abuse and neglect in 1998, and the states reported 1,100 child fatalities from maltreatment. About half were cases of neglect; a quarter, physical abuse; and about one in seven, sexual abuse. Maltreated children were found in all income, racial, and ethnic groups, and incidence rates were similar in urban, suburban, and rural communities. The Child Abuse and Neglect Program funds states and grantees in several different programs authorized by the Child Abuse and Neglect Prevention and Treatment Act (CAPTA). The programs provide funds and technical assistance for prevention and intervention; support research, service improvement programs, and demonstration projects; collect data about the problem, its consequences, and the effectiveness of prevention and treatment services; facilitate information dissemination and exchange; and support policy development and professional education.The Administration on Aging (AOA)
In response to the growing number of older people and their diverse needs, the Older Americans Act of 1965 as amended calls for a range of programs that offer services and opportunities for older Americans, especially those at risk of losing their independence. AoA is the federal focal point and advocate agency for older persons and their concerns. In this role, AoA works to heighten awareness among other federal agencies, organizations, groups, and the public about the valuable contributions that older Americans make to the nation and alerts them to the needs of vulnerable older people. Through information and referral and outreach efforts at the community level, AoA seeks to educate older people and their caregivers about the benefits and services available to help them.
AoA works closely with its nationwide network of regional offices and state and area agencies on aging to plan, coordinate, and develop community-level systems of services that meet the unique needs of individual older persons and their caregivers. The Administration on Aging collaborates with federal agencies, national organizations, and representatives of business to ensure that, whenever possible, their programs and resources are targeted to the elderly and coordinated with those of the network on aging.
[Page 144]AoA administers key programs at the federal level mandated under various titles of the Older Americans Act. These programs help vulnerable older persons remain in their own homes by providing supportive services. Other programs offer opportunities for older Americans to enhance their health and to be active contributors to their families, communities, and the nation through employment and volunteer programs.
Program funding is allocated to each state agency on aging, based on the number of older persons in the state, to plan, develop, and coordinate systems of supportive in-home and community-based services. Most states are divided into planning and service areas (PSAs) so that programs can be effectively developed and targeted to meet the unique needs of the elderly residing in that area. Nationwide some 660 area agencies on aging (AAAs) receive funds from their respective state agencies on aging to plan, develop, coordinate, and arrange for services in each PSA. In rural areas an AAA may serve the needs of elderly people living in many different counties, whereas other AAAs may serve the elderly living in a single city.The Agency for Healthcare Research and Quality (AHRQ)
On December 6, 1999, President Clinton signed the Healthcare Research and Quality Act of 1999, reauthorizing the Agency for Health Care Policy and Research (AHCPR) until the end of fiscal year 2005. In 1999 AHCPR was renamed the Agency for Healthcare Research and Quality (AHRQ). The new name is significant because it reaffirms that AHRQ is a scientific research agency; corrects the misperception that the agency determines federal health care policies and regulations by removing “policy” from the agency name, and adds the word quality to the name, thus establishing AHRQ as the leading federal agency on quality-of-care research, with new responsibility to coordinate all federal quality improvement efforts and health services research. The agency has been fulfilling this function since 1998 through its leadership role in the federal Quality Interagency Coordination (QuIC) Task Force.
AHRQ is the lead agency charged with supporting research designed to improve the quality of health care, reduce its cost, improve patient safety, decrease medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps health care decision makers—patients and clinicians, health system leaders, and policy makers—make more informed decisions and improve the quality of health care services. The legislation also positions the agency as a “science partner,” working collaboratively with the public and private sectors to improve the quality and safety of patient care.The Agency for Toxic Substances and Disease Registry (ATSDR)
In 1980 Congress created the Agency for Toxic Substances and Disease Registry to implement the health-related sections of laws that protect the public from hazardous wastes and environmental spills of hazardous substances. The Comprehensive Environmental Response, Compensation, and Liability Act of 1980 (CERCLA), commonly known as the “Superfund” Act, provided the congressional mandate to remove or clean up abandoned and inactive hazardous waste sites and to provide federal assistance in toxic emergencies. As the lead agency within the Public Health Service for [Page 145]implementing the health-related provisions of CERCLA, ATSDR is charged under the Superfund Act to assess the presence and nature of health hazards at specific Superfund sites, to help prevent or reduce further exposure and the illnesses that result from such exposures, and to expand the knowledge base about health effects from exposure to hazardous substances.
The mission of ATSDR is to prevent exposure and adverse human health effects and diminished quality of life associated with exposure to hazardous substances from waste sites, unplanned releases, and other sources of pollution present in the environment.The Centers for Disease Control and Prevention (CDC)
The Centers for Disease Control and Prevention, created in 1946, serves as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and educational activities designed to improve the health of the people of the United States. The CDC is recognized as the leading federal agency for protecting the health and safety of people at home and abroad, providing credible information to enhance health decisions, and promoting health through strong partnerships.
The CDC emphasizes health prevention. By charting decisive courses of action, collecting the right information, and working closely with other health and community organizations, the CDC has been putting science into action to tackle important health problems since 1946. With more than 8,500 employees across the country, the CDC plays a critical role in protecting the public from the most widespread, deadly, and mysterious threats against our health today and tomorrow.
The CDC seeks to accomplish its mission by working with partners throughout the nation and world to monitor health, detect and investigate health problems, conduct research to enhance prevention, develop and advocate sound public health policies, implement prevention strategies, promote healthy behaviors, foster safe and healthful environments, and provide leadership and training.
The CDC has developed and sustained many vital partnerships with public and private entities that improve service to the American people. In fiscal year 2000, the workforce of the CDC comprised approximately 8,500 staff in 170 disciplines with a public health focus. Although the CDC's national headquarters are in Atlanta, Georgia, more than 2,000 CDC employees work at other locations, including forty-seven state health departments. Approximately 120 are assigned overseas in forty-five countries. The CDC includes eleven centers, institutes, and offices. In fiscal year 2000, the CDCs total funding level was approximately $4 billion. This comprised funding the CDC received from all sources, including its annual appropriation, reimbursable income, and emergency funding in fiscal year 2000.
Infectious diseases, such as HIV/AIDS and tuberculosis, have the ability to destroy lives, strain community resources, and even threaten nations. In todays global environment, new diseases have the potential to spread across the world in a matter of days, or even hours, making early detection and action more important than ever. The CDC plays a critical role in controlling these diseases, traveling at a moments notice to investigate outbreaks abroad or at home.
By assisting state and local health departments, the CDC works to protect the public every day: from using innovative “fingerprinting” technology to identifying a [Page 146]foodborne illness, to evaluating a family violence prevention program in an urban community; from training partners in HIV education to protecting children from vaccine preventable diseases through immunizations.The Food and Drug Administration (FDA)
Congress laid the foundation for modern food and drug law when it passed the Food and Drugs Act of 1906. This first nationwide consumer protection law made it illegal to distribute misbranded or adulterated foods, drinks, and drugs across state lines. Every day, every American comes in contact with a host of products regulated by the Food and Drug Administration, from the most common food ingredients to complex medical and surgical devices, lifesaving drugs, and radiation-emitting consumer and medical products. In fact, FDA-regulated products account for about twenty-five cents of every consumer dollar spent in the United States.
Stated most simply, the FDA's mission is to promote and protect the public health by helping safe and effective products reach the market in a timely way and by monitoring products for continued safety after they are in use. The FDA has streamlined its review process in recent years to help speed important new medical treatments to patients. For example, the average review time for an innovative new drug is now only six months, and some drugs and other products have been approved even faster. Products receiving accelerated reviews include new treatments for breast cancer; a rapid, reliable diagnostic test for pneumonia; and devices to improve the monitoring and treatment of diabetes.
The last several years have seen an increase in the number and severity of food-borne illnesses around the country. The FDA has launched a major initiative to prevent the spread of these food-related infections. The initiative promotes safer food-handling practices by producers and consumers and more effective detection, tracking, and prevention of food-borne illness. A similar initiative aims at improving the safety practices in the blood-banking and plasma industries. The FDA works continuously to improve donor screening, blood testing, and other quality control procedures in blood donation and blood banking. The agency helps the industry develop and use new, more accurate tests to detect hazards in the nation's blood supply.
The FDA's regulatory approaches are as varied as the products it regulates. Some products—such as new drugs and complex medical devices—must be proven safe and effective before companies can put them on the market. Other products—such as x-ray machines and microwave ovens—must measure up to performance standards. And some products—such as cosmetics and dietary supplements—can be marketed with no prior approval. At the heart of all the FDA's product evaluation decisions is a judgment about whether a new product's benefits to users will outweigh its risks. No regulated product is totally risk-free, so these judgments are important. The FDA will allow a product to present more of a risk when its potential benefit is great—especially for products used to treat serious, life-threatening conditions.
Medical products need to be proven safe and effective before they can be used by patients. The product categories covered by this requirement include medicines used for the treatment and prevention of disease; biologies—a product category that includes vaccines, blood products, biotechnology products, and gene therapy; and medical devices. Although the FDA regulates all medical devices, from very simple items like tongue depressors or thermometers to very complex technologies such as [Page 147]heart pacemakers and dialysis machines, only the most complex medical devices are reviewed by the agency before marketing.The Centers for Medicare and Medicaid Services (CMS)
The Centers for Medicare and Medicaid Services, known as the Health Care Financing Administration before 2001, runs the Medicare and Medicaid programs. These two national health care programs benefit about 75 million Americans. And with the Health Resources and Services Administration, the CMS runs the Children's Health Insurance Program, a program that is expected to cover many of the approximately 10 million uninsured children in the United States. The CMS also regulates all laboratory testing (except research) performed on humans in the United States. Approximately 158,000 laboratory entities fall within its regulatory responsibility. With the Departments of Labor and the Treasury, the CMS helps millions of Americans and small companies get and keep health insurance coverage and helps eliminate discrimination based on health status for people buying health insurance.
The CMS spends more than $360 billion a year buying health care services for beneficiaries of Medicare, Medicaid, and the Children's Health Insurance Program. The CMS ensures that these programs are properly run by their contractors and state agencies; establishes policies for paying health care providers; conducts research on the effectiveness of various methods of health care management, treatment, and financing; and assesses the quality of health care facilities and services.
The agency has a comprehensive program to combat fraud and abuse. Working with other federal departments and state and local governments, it takes strong enforcement action against those who commit fraud and abuse, protects taxpayer dollars, and guarantees security for the Medicare, Medicaid, and Child Health Insurance programs.
Agency staff members working in the Baltimore, Maryland, headquarters and in ten regional offices nationwide oversee the CMS programs. The headquarters staff is responsible for national program direction. The regional office staff provides the agency with the local presence necessary for quality customer service and oversight.
The agency's vision is to lead the nation's health care system toward improved health for all. Its goals are to
The Health Resources and Services Administration (HRSA)
- Protect and improve beneficiary health and satisfaction
- Promote the fiscal integrity of programs
- Purchase the best value health care for beneficiaries
- Promote beneficiary and public understanding of the agency and its programs
- Foster excellence in the design and administration of programs
- Provide leadership in the broader public interest to improve health
The Health Resources and Services Administration directs national health programs that improve the nation's health by ensuring equitable access to comprehensive, quality health care for all. HRSA works to improve and extend life for people living with HIV/AIDS, to provide primary health care to medically underserved people, to serve women and children through state programs, and to train a health workforce that is both diverse and motivated to work in underserved communities.
[Page 148]HRSA is the leading federal agency in promoting access to health care services that create and improve the nation's health. With a statutory emphasis on special needs, underserved, and vulnerable populations, HRSA mobilizes its bureaus, programs, staff, and partners to ensure access to quality health care. HRSA is an agency with multiple programs but with a single strategic goal: to ensure 100 percent access to health care and 0 percent disparities for all Americans. It works to establish alliances and partnerships with a broad array of organizations, ranging from state and local governments to foundations and corporations. In order to support its goal, HRSA has established four strategies: (1) eliminate barriers to care, (2) eliminate health disparities, (3) ensure quality of care, and (4) improve public health and health care systems. Its portfolio includes a range of programs or initiatives designed to increase access to care, improve quality, and safeguard the health and well-being of the nation's most vulnerable.
HRSA accomplishes its mission by working with states and communities that form the foundation for developing integrated service systems and the appropriate health workforce to help ensure access to essential high-quality health care. It ensures that these systems take into account cultural and linguistic factors, geographic location, and economic circumstances, and it assists states and communities to identify and address unmet service needs and workforce gaps in the health care system. It also promotes continuous quality improvement in the delivery of health services and the education of health professionals; supports innovative partnerships to promote effective, integrated systems of care for all population groups; and promotes the recruitment, training, and retention of a culturally and linguistically competent and diverse health care workforce.The Indian Health Service (IHS)
The Indian Health Service, an agency of the U.S. Public Health Service, is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services to members of federally recognized tribes grew out of the special government-to-government relationship between the federal government and Indian tribes. This relationship, established in 1787, is based on Article I, Section 8, of the Constitution and has been given form and substance by numerous treaties, laws, Supreme Court decisions, and executive orders. As the principal federal health care provider and health advocate for Indian people, the IHS strives for maximum tribal involvement in meeting its goal of raising their health status to the highest possible level. With an annual appropriation of approximately $2.2 billion, the IHS currently provides health services to approximately 1.5 million of the nation's 2 million American Indians and Alaska Natives who belong to more than 557 federally recognized tribes in thirty-four states.
The IHS combines preventive measures (involving environmental, educational, and outreach activities) and therapeutic measures into a single national health system. Within these broad categories, the agency carries out special initiatives in such areas as injury control, alcoholism, diabetes, and mental health. The IHS appropriates most of its funds for American Indians who live on or near reservations. Congress also has authorized programs that provide some access to care for American Indians and Alaska Natives who live in urban areas.
IHS services are provided directly and also through tribally contracted and operated health programs. Health services also include health care purchased from more [Page 149]than two thousand private providers. As of March 1996, the federal system consisted of 37 hospitals, 64 health centers, 50 health stations, and 5 school health centers. In addition, 34 urban Indian health projects provide a variety of health and referral services. The IHS clinical staff consists of approximately 840 physicians, 380 dentists, 100 physician assistants, and 2,580 nurses. The IHS also employs allied health professionals, such as nutritionists, health administrators, engineers, and medical records administrators.The National Institutes of Health (NIH)
Begun as a one-room Laboratory of Hygiene in 1887, the National Institutes of Health today is one of the world's foremost medical research centers, and the federal focal point for medical research in the United States. The NIH mission is to uncover new knowledge that will lead to better health for everyone. The NIH works toward that mission by conducting research in its own laboratories; supporting the research of nonfederal scientists in universities, medical schools, hospitals, and research institutions throughout the country and abroad; helping in the training of research investigators; and fostering communication of medical information.
Comprised of twenty-five separate institutes and centers, the NIH has seventy-five buildings on more than 300 acres in Bethesda, Maryland. From a total budget of about $300 in 1887, the NIH budget has grown to more than $17.8 billion in 2000. Simply described, the goal of NIH research is to acquire new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold. A principal concern of the NIH is to invest wisely the tax dollars entrusted to it for the support and conduct of biomedical research.
Approximately 82 percent of the investment is made through grants and contracts supporting research and training in more than 2,000 research institutions throughout the United States and abroad. In fact, NIH grantees are located in every state in the country. These grants and contracts comprise the NIH Extramural Research Program. Approximately 10 percent of the budget goes to the NIH's Intramural Research Programs, the more than 2,000 projects conducted mainly in its own laboratories. About 8 percent of the budget is for both intramural and extramural research support costs.
Final decisions about funding extramural research are made at the NIH headquarters. But long before this happens, the process begins with an idea that an individual scientist describes in a written application for a research grant. The project might be small, or it might involve millions of dollars. The project might become useful immediately as a diagnostic test or new treatment, or it might involve studies of basic biological processes whose practical value may not be apparent for many years.
Each research grant application undergoes a peer review process. A panel of scientific experts, primarily from outside the government, who are active and productive researchers in the biomedical sciences, first evaluates the scientific merit of the application. Then, a national advisory council or board, comprised of eminent scientists as well as public members who are interested in health issues or the biomedical sciences, determines the project's overall merit and priority in advancing the research agenda of the particular NIH funding institute. Altogether, about 38,500 research and training applications are reviewed annually through the NIH peer review system. At any given time, the NIH supports 35,000 grants in universities, medical schools, and other research and research training institutions both nationally and internationally.
[Page 150]The Intramural Research Programs, although representing only a small part of the total NIH budget, are central to the NIH scientific effort. First-rate scientists are key to NIH intramural research. They collaborate with one another regardless of institute affiliation or scientific discipline, and they have the intellectual freedom to pursue their research leads in the NIH's own laboratories. These explorations range from basic biology to behavioral research and studies on treatment of major diseases.
Scientific progress depends mainly on the scientist. About 50,000 principal investigators—working in every state and in several foreign countries, from every specialty in medicine, from every medical discipline, and at every major university and medical school—receive NIH extramural funding to explore unknown areas of medical science. Supporting and conducting the NIH's extramural and intramural programs are about 15,600 employees, more than 4,000 of whom hold professional or research doctorate degrees. The NIH staff includes intramural scientists, physicians, dentists, veterinarians, and nurses, and laboratory, administrative, and support personnel, plus an ever-changing array of research scientists in training.
The NIH has enabled scientists to learn much since its humble beginnings as a one-room laboratory in 1887. But many discoveries remain to be made. Among them are better ways to prevent and treat cancer, heart disease, stroke, blindness, arthritis, diabetes, kidney diseases, Alzheimer's disease, communication disorders, mental illness, drug abuse and alcoholism, AIDS and other unconquered diseases; ways to continue improving the health of infants and children, women, and minorities; and better ways to understand the aging process and behavior and lifestyle practices that affect health.The Substance Abuse and Mental Health Services Administration (SAMHSA)
The Substance Abuse and Mental Health Services Administration was established by Congress under Public Law 102–321 on October 1, 1992. Its goal is to strengthen the capacity of the nation's health care delivery system to provide prevention, diagnosis, and treatment services for substance abusers and those with mental illnesses. SAMHSA builds on federal-state partnerships with communities and private organizations to address the needs of such individuals as well as to identify and respond to the community risk factors that contribute to these illnesses. In fiscal year 1999 SAMHSA's budget was approximately $2.5 billion. The agency employs approximately 550 staff members.
SAMHSA itself serves as the umbrella under which three centers are housed: the Center for Mental Health Services (CMHS), the Center for Substance Abuse Prevention (CSAP), and the Center for Substance Abuse Treatment (CSAT).
The Center for Mental Health Services and its programs are the legacy of decades of work to create an effective community-based mental health service infrastructure in the United States. The center's foremost goals are to improve the availability and accessibility of high-quality community-based services for people with or at risk for mental illnesses and their families. Although the largest portion of the center's annual appropriation supports states through the Community Mental Health Services Block Grant Program, the CMHS also supports a broadly based portfolio of grant programs designed to identify, test, and apply knowledge about the best community-based practices to reach the most at-risk people in our communities: adults with serious [Page 151]mental illnesses and children with serious emotional disturbances. Issues of stigma and consumer empowerment are also on the center's program and policy agenda. In addition, the center collects and disseminates national data on mental health services, designed to help inform future services policy and program decision making.
The Center for Substance Abuse Prevention serves as the national focal point for nationwide efforts to identify and promote effective strategies to prevent substance abuse—whether the abuse of illegal drugs, misuse of legal medications, use of tobacco, or excessive or illegal use of alcohol. As the sole federal agency with this charge, the CSAP's goal is to provide all Americans with the tools and knowledge they need to help reject substance abuse by strengthening families and communities and by developing knowledge of what interventions work best for which people. With grantees representing states, communities, and organizations at the national, regional, and local levels, the CSAP's grant activities support programs that promote the development, application, and dissemination of new knowledge in substance abuse prevention, whether focusing on preschool-age children and youth, or on older Americans. Further, the CSAP supports the National Clearinghouse for Alcohol and Drug Information (NCADI), the federal government's foremost source of information on substance abuse research, treatment, and prevention available for use by states, educational institutions, health care providers, and the public.
The Center for Substance Abuse Treatment provides national leadership in efforts to enhance the quality of substance abuse treatment services and ensure their availability to individuals who need them, including those with co-occurring drug, alcohol, mental, and physical problems. It works to identify, develop, and support policies and programs that enhance and expand science-based effective treatment services for individuals who abuse alcohol and other drugs and that address individuals' addiction-related problems. The CSAT administers the state block grant program for substance abuse prevention and treatment. While engaging with states to improve and enhance existing services under the block grant program, CSAT also undertakes significant knowledge development, education, and communications initiatives that identify and promote the best practices in the treatment of substance abusers and in intervention in finding resources when they need help.
Suggestions for Further Reading[Page 152]
On HHSGoverning America: An Insider's Report from the White House and the Cabinet. New York: Simon and Schuster, 1981.The Administrative Behavior of Federal Bureau Chief. Washington, D.C.: Brookings Institution, 1981..The Department of H.E.W.New York: Praeger, 1974.“The Challenge of Managing Across Boundaries: The Case of the Office of the Secretary in the U.S. Department of Health and Human Services.” Grant Report, PricewaterhouseCoopers Endowment for the Business of Government, November 2000.“Managing Decentralized Departments: The Case of the U.S. Department of Health and Human Services.” Grant Report, PricewaterhouseCoopers Endowment for the Business of Government, October 1999.“Are Large Public Organizations Manageable?”Public Administration Review58 (July-August 1998): 284–289. http://dx.doi.org/10.2307/977557“Policy Analysis in the Office of Inspector General, U.S. Department of Health and Human Services.” In Organizations for Policy Analysis: Helping Government Think, ed. Carol H.Weiss. Newbury Park, Calif: Sage Publications, 1992., and .“The Generalist Perspective in the HEW Bureaucracy: An Account from the Field.”Public Administration Review40 (March-April 1980). http://dx.doi.org/10.2307/975624.
On Accountability and Related IssuesKeeping a Watchful Eye: The Politics of Congressional Oversight. Washington, D.C.: Brookings Institution, 1990.In the Web of Politics, Three Decades of the U.S. Federal Executive. Washington, D.C.: Brookings Institution Press, 2000., and .Rethinking Democratic Accountability. Washington, D.C.: Brookings Institution Press, 2001.Bureaucratic Responsibility. Baltimore: Johns Hopkins University Press, 1986..Leadership and Innovation: Entrepreneurs in Government. Baltimore: Johns Hopkins University Press, 1990., and , eds.The Politics of the Administrative Process., and .2d ed.Chatham, N.J.: Chatham House, 1996.Controlling Bureaucracies: Dilemmas in Democratic Governance. Berkeley: University of California Press, 1987.A Government of Strangers: Executive Politics in Washington. Washington, D.C.: Brookings Institution, 1977.. [Page 153]The Administrative Behavior of Federal Bureau Chiefs. Washington, D.C.: Brookings Institution, 1981..Agendas, Alternatives, and Public Policies.2d ed. New York: HarperCollins College Publishers, 1995.Making Government Work: How Entrepreneurial Executives Turn Bright Ideas into Real Results. San Francisco: Jossey Bass, 1994., and .Monitoring Government: Inspectors General and the Search for Accountability. Washington, D.C.: Brookings Institution, 1993.Thickening Government: Federal Hierarchy and the Diffusion of Accountability. Washington, D.C.: Brookings Institution, 1995.Creating Public Value: Strategic Management in Government. Cambridge: Harvard University Press, 1995.Beyond Machiavelli: Policy Analysis Comes of Age. Washington, D.C.: Georgetown University Press, 2000.“Accountability in the Public Sector: Lessons from the Challenger Tragedy.”Public Administration Review47 (May-June 1987): 227–238. http://dx.doi.org/10.2307/975901, and .Holding Government Bureaucracies Accountable..3d ed. Westport, Conn.: Praeger, 1998.Building a Legislative-Centered Public Administration: Congress and the Administrative State, 1946–1999. Tuscaloosa: University of Alabama Press, 2000.The Federal Budget: Politics, Policy, Process..Rev. ed.Washington, D.C.: Brookings Institution, 2000.“The Question of Accountability in Historical Perspective.”Administration and Society31 (September 1999): 451–494. http://dx.doi.org/10.1177/00953999922019201Bureaucracy: What Government Agencies Do and Why They Do It. New York: Basic Boob, 1989.