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HHS in the 21st Century: Charting a New Course for a Healthier America
1
Introduction
Men make history, and not the other way around. In periods where there is no leadership, society stands still. Progress occurs when courageous, skillful leaders seize the opportunity to change things for the better.
Harry S. Truman
The federal government’s largest department in terms of budget, the Department of Health and Human Services (HHS) spends almost $2 billion a day. It spends more money than the Department of Defense or the Social Security Administration, and its budget dwarfs those of all other departments (see Figure 1-1). HHS has more than 65,000 full-time employees (OMB, 2008b), and actual spending in fiscal year (FY) 2007 was more than $658 billion—most of which (85 percent) was used for Medicare and the federal portion of Medicaid (OMB, 2008a).1 The President’s 2009 HHS budget request, which will undoubtedly be adjusted in various ways through the appropriations process, is for $737 billion (OMB, 2008a).
1
Medicare is a federally administered entitlement program funded through payroll taxes that are set aside for that specific purpose and outside of the department’s control; the Medicaid program is a federal-state partnership program for some categories of low-income Americans (with the largest share of payments going to the elderly and disabled individuals needing long-term care). The federal government provides a portion of the funds, and the states provide the remainder and administer the program.
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FIGURE 1-1 Federal budget by department: actual spending FY 2007 (showing mandatory and discretionary spending).
*This category includes the Corps of Engineers, Environmental Protection Agency (EPA), National Aeronautics and Space Administration (NASA), National Science Foundation (NSF), and Small Business Administration.
SOURCE: OMB (2008a).
More than sheer size determines the importance of a governmental activity. HHS touches the lives of virtually every American. Its agencies help pay for medical care for elderly, disabled, and low-income Americans; they protect our population against domestic and global health threats; they ensure the safety of our food and medications—regulating more than $1 trillion of the U.S. economy annually (FDA, 2008); they search for new scientific advances, tools, and techniques to prevent, manage, and cure diseases, including through grants that support the work of universities and scientists in all U.S. states and territories; they
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provide a safety net of services for the poor and special populations; and they work to make the entire health care system better for everyone.
In addition to its health activities described below, HHS is responsible for two significant human services programs—the Administration on Aging and the Administration for Children and Families. These programs support a variety of services including community-based programs for older persons, Temporary Assistance for Needy Families, Head Start, adoption and foster care services, and prevention of family violence. As is discussed in Chapter 3, an individual’s health is determined by a variety of complex factors, including socioeconomic status, and the Administration on Aging and the Administration for Children and Families play an important role in assuring not only the financial well-being of their constituents, but also their health.
The sweep of the department and its many activities today is broad, though its beginnings were modest. For more than 200 years, the addition of new programs and agencies has created a patchwork of programs that is now the responsibility of HHS. Many units that began small are now large, complex enterprises in their own right. Carrying out these diverse roles involves agencies and people who represent multiple disciplines and organizational cultures. Biomedical researchers, regulators, service providers, payers, analysts, health education specialists—all have different priorities and ways of looking at the world and its problems. This makes it difficult to achieve organizational alignment—that is, to ensure that every agency, unit, and person in the organization is working toward a consistent set of goals.
If the department leadership had to deal only with achieving internal harmony, that in and of itself would be a significant challenge. However, it also must respond to the needs and desires of many other powerful players. The White House has health care priorities; so does Congress; and so do other departments, most notably, the Department of Homeland Security. HHS must consider the priorities and needs of the state and local health officials who implement its programs in communities; of advocacy groups that want attention to their issues; and of the health professions, provider groups, and institutions concerned about regulation and funding, as well as of a public that expects high-quality, affordable health care.
In today’s globally connected world, the department’s role and responsibilities do not end at the U.S. borders. People, knowledge, information, and goods travel across geographic boundaries more rapidly than ever. These transfers sometimes pose a risk to Americans: travelers may
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carry novel infections; food imports may be contaminated; products may be hazardous. Other times, information and knowledge gained elsewhere may help Americans, giving early warning of disease trends, suggesting how to prevent or treat medical problems, or providing more effective models of care. For reasons such as these, the department has an increasing role and expanding set of international relationships that it should pursue proactively.2
Responsibility for HHS activities is divided among many committees of Congress that oversee specific department activities, regularly legislate new programs and responsibilities, and control its funding. This type of oversight may address specific, current needs, but it militates against coordinated, efficient, cost-effective operations. The legislated requirements and budget mandates associated with specific programs also can inadvertently become a strait jacket—preventing deployment of resources for quick response to evolving circumstances and sustained investment in resolving enduring challenges.
Some observers of this patchwork of responsibility, structure, influence, and oversight occasionally wonder, at least rhetorically, whether such complexity can be managed at all (Shalala, 1998).
CHARGE TO THE COMMITTEE
In a letter to the Institute of Medicine (IOM), Representatives Henry A. Waxman and Tom Davis, chair and ranking minority member, respectively, of the House Committee on Oversight and Government Reform posed the question of whether HHS is “ideally organized” to meet the public health and health care cost challenges that require a focused national response (see Appendix B). They requested a study of this question, which the IOM framed as follows:
What are the unifying elements of the mission of the department? What are the missions of its constituent agencies, and how
2
The Institute of Medicine’s Committee on the U.S. Commitment to Global Health recently evaluated the role for the United States in ensuring global health. The committee released a letter report in December 2008, titled The U.S. Commitment to Global Health: Recommendations for a New Administration, which outlined a vision for the U.S. government to improve the implementation of the U.S. global health enterprise. The committee’s final report is expected to be released in the spring of 2009.
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do their activities relate to the public health, health care quality, and health care cost challenges facing the United States?
Are the activities of its individual agencies aligned to optimally support the overall health mission of HHS? Should the operations of individual agencies be changed, consolidated, or realigned to make them collectively more effective in advancing the health of the nation?
How can the governance of HHS be best organized to support and manage its responsibilities, function, and mission? How could the focus of individual agencies be improved to enhance their accountability and efficiency?
How can relevant data be collected, integrated, and shared within and outside HHS in a way that is available, transparent, and useful for government and public decision making?
THE NATION’S HEALTH CHALLENGES
As the congressmen note, threats to the health of Americans are increasingly diverse and urgent. They have both global and domestic origins. We see an aging population and climbing rates of costly chronic diseases, evolving risks of infectious diseases, the need for stronger emergency preparedness, weaknesses in the public health infrastructure, health risks from climate change, new outbreaks of food-borne diseases, and serious shortages of many key health professionals—all in the context of rising national health care costs, which limits the degrees of freedom to make system changes. Yet system changes are needed, in order to ensure that all Americans have access to basic health care and that the care we do receive is of high quality. Clearly, prompt action is needed to position HHS for these challenges.
MEETING CHANGING NEEDS FOR 210 YEARS
The roots of HHS stretch back to 1798, when Congress established a network of federal hospitals to care for merchant seamen. Piece by piece, the scope and importance of public health activities grew as new activities were added (see Box 1-1 for a definition of public health and related terms).
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BOX 1-1
What Is Public Health?
The following definitions may help in distinguishing among several similar terms used in this report:
Public health (also “population health”)—the science and practice dealing with the prevention of disease and injury and the protection and improvement of the health, safety, and well-being of groups of people, as contrasted with the individual care a person receives from a doctor, nurse, or other health care practitioner. Public health programs operate at the national, state, and local levels to, for example:
Provide immunizations,
Prevent tobacco use,
Train communities in emergency preparedness,
Better manage the costly consequences of chronic diseases,
Ensure food safety,
Track disease patterns,
Prevent and control transmission of infectious diseases,
Operate health programs for pregnant women and infants, and
Research new disease prevention and treatment methods.
Health of the public—a broad construct that refers to the overall health of the American people, which is affected by public health actions as well as many other biological, social, and environmental factors—from individual genetic makeup, to the environments in which people live and work, to their own behavior, socioeconomic status, and the amount and kinds of health services they receive.
Public Health Service (PHS)—includes the Office of Public Health and Science, the department’s 10 regional health administrators, which are under the oversight of the assistant secretary for health (ASH), and the health-related operating divisions of HHS, which are:
National Institutes of Health (NIH),
Health Resources and Services Administration (HRSA),
Centers for Disease Control and Prevention (CDC),
Indian Health Service (IHS),
Substance Abuse and Mental Health Services Administration (SAMHSA),
Food and Drug Administration (FDA),
Agency for Healthcare Research and Quality (AHRQ), and
Agency for Toxic Substances and Disease Registry (ATSDR).a
The PHS has been reshaped and expanded many times over the years, and a 1995 reorganization of its leadership resulted in direct reporting of PHS operating division heads to the secretary rather than, as formerly, to the ASH (Office of the Public Health Service Historian, 2004; Parascandola, 1998).
aCDC administers the ATSDR, which, although small, is considered a separate agency of the PHS.
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In 1887, the federal government opened a one-room research laboratory within the Marine Hospital Service. This small Staten Island laboratory was the modest forerunner of the National Institutes of Health. The 1906 Pure Food and Drugs Act added regulatory authority to a small chemistry department—then in the Department of Agriculture—that we now know as the Food and Drug Administration. The Social Security program, enacted in 1935, was placed in the department, and in 1946, the Communicable Disease Center—parent of today’s Centers for Disease Control and Prevention—was born, when a highly successful Public Health Service (PHS) program on malaria control was expanded to include other communicable diseases.
Congress created the cabinet-level Department of Health, Education, and Welfare (HEW) in 1953. Twelve years later, the department acquired two new programs—Medicare and Medicaid, which in the past 40 years have completely reshaped the U.S. health care system. Despite its growing size and multiplicity of responsibilities, the department’s three-part mission remained intact until a separate Department of Education was created in 1979. Loss of the “E” in HEW prompted a name change, and the department became HHS the following year. In 1995 it lost much of the “W,” when the Social Security Administration became an independent agency.
THE HHS BUDGET
Today, the department has 11 operating divisions, has 15 staff divisions, and implements more than 300 programs (HHS, 2008). Figure 1-2 shows how total department spending for FY 2007 was distributed across agencies and programs, and Figure 1-3 shows the trend in financial resources of the PHS agencies, with the National Institutes of Health (NIH) accounting for the largest share.
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FIGURE 1-2 Distribution of HHS actual expenditures, FY 2007.
*The AHRQ is shown as representing 0 percent of the department’s budget because it receives funds only from other PHS agencies through the PHS evaluation set-aside and has not had its own separate budget allocation since 2002. In fact, the President’s budget request for AHRQ has been zero since 2001. Its 2009 program-level expenses were projected at $326 million, making it by far the smallest PHS agency.
NOTES: ACF = Administration for Children and Families; AHRQ = Agency for Healthcare Research and Quality; AoA = Administration on Aging; CDC = Centers for Disease Control and Prevention; CMS = Centers for Medicare and Medicaid Services; FDA = Food and Drug Administration; HRSA = Health Resources and Services Administration; IHS = Indian Health Service; OCR = Office for Civil Rights; OIG = Office of the Inspector General; OMHA = Office of Medicare Hearings and Appeals; ONCHIT = Office of the National Coordinator for Health Information Technology; PHSSEF = Public Health and Social Services Emergency Fund; SAMHSA = Substance Abuse and Mental Health Services Administration; SCHIP = State Children’s Health Program, a component of Medicaid.
SOURCE: OMB (2008a).
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FIGURE 1-3 Public Health Service budgets, by agency (actual spending FY 2001, FY 2003, FY 2007, and President’s budget request, FY 2009).
NOTES: This figure does not include data for the Agency for Toxic Substances and Disease Registry (ATSDR) or the Agency for Healthcare Research and Quality (AHRQ). Funding for ATSDR is included in CDC’s budget. As noted above in Figure 1-2, AHRQ has not had its own separate budget allocation since 2002.
*Although the figure shows the President’s budget request for FY 2009, an additional $300 million was included to reflect funds available to the FDA for FY 2009 as a result of the June 2008 Emergency Supplemental Appropriations Bill and the September 2008 Continuing Resolution.
SOURCE: OMB (2004, 2008a).
As demonstrated in Figure 1-2, HHS’s budget is dominated by the Centers for Medicare and Medicaid Services, whose spending3 grew from almost $350 billion in FY 2001 to $570 billion in FY 2007, with the President’s budget request for FY 2009 standing at $635 billion—
3
The CMS spending figures for 2001 and 2007 include discretionary spending as well as the mandatory outlays for Medicare and Medicaid/State Children’s Health Insurance Program (SCHIP).
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more than an 85 percent increase over the last eight years (OMB, 2004, 2008a).
As Figure 1-4 shows, the vast majority of the department’s budget is designated for mandatory spending under entitlement and other service, training, and research programs. Only about 10 percent of the budget each year is discretionary (the largest share of which supports NIH).
STRUCTURE VERSUS RESTRUCTURING
Structure is a central contributor to the overall performance of any organization. It affects the movement of information up and down the chain of command, the level of cooperation between divisions, the development and implementation of policy, and workforce morale (Appendix G).
Over the years, organizational management literature has suggested many approaches to structuring large private-sector entities, and current analysis tends toward the view that “there is no single best way to organize” (Bradach, 1996). In the federal government context, numerous reorganization efforts have been attempted, but many have not achieved substantial or long-lasting change (Radin, 2000).
FIGURE 1-4 HHS mandatory and discretionary budget allocations, 2007.
SOURCE: HHS (2008).
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The organizational difficulties of the Department of Homeland Security provide a cautionary tale. Since its formation in 2003, it—and its 16 operating components and more than 170,000 employees—has been internally reorganized at least twice (Appendix G). In addition, Congress stepped in with a legislative reorganization (the Post-Katrina Emergency Management Reform Act) in 2006. Despite the enormous national attention, priority, and resources placed on homeland security after 2001, it still was not easy to “get it right” the first time.
Since its creation in 1953, HHS has been led by 20 secretaries whose tenures in the earlier years tended to be relatively short. Since 1985, average tenures have more than doubled (see Appendix D). Successive HHS secretaries have favored markedly different approaches and degrees of reorganization and report mixed success (Balutis, 1979; Appendix G).
Interviews performed for the IOM committee with six former secretaries, who began their tenures at the beginning of the past six Presidencies, revealed varying views on the usefulness of a major departmental reorganization. However, these former secretaries unanimously agreed that the process of changing the underlying culture that influences day-to-day operations of individual units and the department as a whole is difficult, distracting, time consuming, and often unsuccessful (see Appendix G). If restructuring is to be attempted, it must begin immediately upon the secretary’s taking office. The larger—and longer—the restructuring project, the more turmoil and the longer are the delays in acting on the agenda of the new President and secretary.
Upon deliberation, the IOM committee concluded that, given consensus among management experts, there is “no one best way” to organize a huge, complex entity such as HHS—a large-scale reorganization at this juncture would take too much time and attention away from pressing challenges that the department currently faces. Nor would it be timely, given the likelihood of at least some health reforms in the next few years, which themselves may necessitate some structural changes within the department.
The committee also recognized that success in large-scale reorganization is not guaranteed, and in any case would be difficult because of the short time the secretary has to act. In an interview, HHS Secretary Michael Leavitt explained the short time frame this way (Schaeffer, 2007):
The government runs in four-year cycles, but it’s really not four years. Because when it starts, there’s about a six-month period when
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no one’s in place, and people are trying to find their way around. Then the last year, there’s an election. So you’ve really got about two and a half years.
By contrast, the Government Accountability Office (GAO) has observed that it generally takes government entities five to seven years to successfully complete major change initiatives (GAO, 2004).
Although most recent secretaries caution against embarking on a major reorganization, even a secretary who wanted to do so would encounter the growing number of restrictions Congress has placed over departmental operations, job descriptions, and details of program delivery. Negotiating those restrictions—many of them statutory—would be another lengthy process of uncertain outcome (see Appendix G).
Opportunities for Change
Even without major structural change in the department, the committee saw many opportunities for improved alignment and performance and for building more value into departmental operations. As noted, HHS is a large, complex enterprise with many constituencies, each of which wishes that the department’s activities and performance would meet its particular needs; collectively, these external forces create the complex environment that the secretary must skillfully navigate.
Organizational management literature is replete with advice and tools related to improving efficiency and effectiveness. A widely used management framework that the IOM committee found useful during its deliberations takes into account the following seven essential elements, distilled from research in the private sector (Waterman et al., 1980):
Strategy—the ways in which an organization achieves its ends
Structure—how tasks and people are organized to accomplish the work and what they are responsible for
Systems—the formal processes and procedures the organization uses to plan, allocate resources, measure performance, manage information, and so on
Staff—the organization’s human resources
Skills—its distinctive attributes and capabilities
Style—how both top management and the overall organization operate
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Shared values—the organization’s fundamental, widely shared values that signal what is important to it (Bradach, 1996)
The committee believes that the department will derive great benefit from comprehensive organizational reform strategies that take into account fundamental structures and processes, such as those listed above.
While significant alterations in HHS structure would not be easy—or even possible—the decision-making and management processes at all levels of the department can change, and this is where the new secretary can make the most progress in responding to the concerns the House committee has raised.
The IOM committee’s recommendations (see Box 1-2) are interrelated and mutually supportive. Many of them would require involvement and approval from Congress and the White House. They would ensure value in HHS operations and would focus the department squarely on purpose, which is essential to both performance and accountability. The committee believes that improved performance and accountability could strengthen the cooperation with Congress that the department urgently needs in order to move forward. The recommendations would
focus the department on the most important health challenges for the nation (Recommendation 1),
strengthen its organizational capacity to address these challenges (Recommendation 2),
foster improved performance of the nation’s health system overall (Recommendation 3),
ensure the necessary workforce (Recommendation 4), and
increase the department’s accountability and give it more flexibility (Recommendation 5).
HHS has a long history of accomplishment and evolution to meet new needs, but it cannot afford to become stalemated by its own processes and precedents or by statutory restrictions that impede its ability to function effectively. Implementation of the committee’s recommendations would better position HHS to meet both rapidly emerging and enduring health challenges in the twenty-first century.
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BOX 1-2
Recommendations
To meet twenty-first century challenges to America’s health, the secretary of HHS should clearly articulate and actively promote a vision for the nation’s health, ensure that the department’s mission supports that vision, and establish a small number of measurable goals focused on critical challenges.
The secretary should lead a thorough and thoughtful process to identify and prioritize the nation’s key health challenges.
The secretary should, in this process, consult widely with internal department leaders, others in the executive branch, Congress, governors and state-level officials, health care providers, scientific and professional organizations, and public interest and advocacy groups.
The secretary should establish a vision, mission, and goals that respond to twenty-first century challenges, enable greater programmatic continuity over time, and that can be used to focus department staff and activities on leading priorities, strengthen the public health infrastructure, facilitate assessment of impact, and lead to corrective action.
The secretary, working closely with the White House and Congress, should take a major role in promoting and achieving health reform nationwide.
To improve the public’s health and achieve the department’s goals, the secretary should align and focus the department on performance and encourage creative use of scientifically based approaches to meet new and enduring challenges.
The heads of all department units should ensure that their activities and operations are aligned with the department’s vision, mission, and goals and marshal their resources to achieve them.
The secretary should reduce directly reporting senior-level officials to a manageable number. Although secretarial management styles differ, a rigorous decision-making process for both policy and operations must be established, along with accountability for results.
The secretary should ensure a more prominent and powerful role for the surgeon general, who, in addition to leading the Commissioned Corps, should be a strong advocate for the health of the American people and work actively to educate Americans on important health issues. The secretary should work with the President and Congress to establish a process for identifying surgeon general candidates for Presidential appointment that gives high priority to qualifications and leadership, and Congress is strongly urged to consider a longer term for this office.
The secretary should work with the President and Congress to establish a selection process for the department’s senior-level officials that protects the scientific and administrative integrity of major departmental units, promotes progress toward departmental goals, and is based primarily on the candidates’ qualifications and experience. Congress again is strongly urged to consider longer terms for some of these officials—especially the directors of the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC), and the commis
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sioner of the Food and Drug Administration (FDA)—which would provide critical continuity in the nation’s public health and scientific endeavors.
The President should make timely appointments and Congress should expedite the confirmation process for key HHS officials, including the secretary, deputy secretary, surgeon general, and the heads of FDA and NIH. Secretarial appointments, such as the director of CDC, should also be expedited.
The secretary should ensure that all department health programs, including the reimbursement programs, reinforce public health priorities and strategies in order to provide a consistent framework for protecting the public from health risks, promoting health, preventing disease and disability, and providing health services for vulnerable populations in the most efficient, cost-effective ways.
To maximize value in the health care system, the secretary must strengthen the scientific base and capabilities of the department and ensure that agencies’ research findings are shared department-wide and that current best evidence is used for departmental decision making, including the Centers for Medicare and Medicaid Services (CMS) reimbursement policy.
Congress should allocate sufficient, predictable funding for NIH, CDC, FDA, and AHRQ in order to preserve and enhance these agencies’ scientific missions. Congress should also establish a specific budget line for AHRQ that is independent of appropriations to other HHS agencies.
To address the growing threat of food-borne illnesses, Congress should unify the U.S. Department of Agriculture’s (USDA’s) Food Safety and Inspection Service and the food safety activities of FDA within HHS and ensure provision of adequate resources for high-quality inspection, enforcement, and research.
The secretary should accelerate the establishment of a collaborative, robust system for evaluating the health care system that would incorporate existing department and external research, stimulate new studies as needed, synthesize findings, and provide actionable feedback for policy makers, purchasers, payers, providers, health care professionals, and the public.
The secretary should work with Congress to establish a capability for assessing the comparative value—including clinical- and cost-effectiveness—of medical interventions and procedures, preventive and treatment technologies, and methods of organizing and delivering care. The assessment of comparative value should begin by leveraging department-wide data sources in conjunction with supportive evidence from providers, payers, and health researchers.a
The secretary should work with Congress to ensure that the department’s programs and reimbursement policies are outcomes based, reflecting best available evidence of value and creating incentives for adoption of best practices, including integration of care, in order to improve quality and efficiency.
The department should collaborate with state and local public health agencies and community-based organizations, as both sources and users of practical program guidance.
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The department should provide authoritative, plain-language, and current evidence-based information to the public regarding prevention and treatment options.
To assess the health of the American people and overall health system performance accurately, the department needs current data from the nation’s health system. To facilitate collection of these data, the department should actively promote the universal adoption of electronic information capabilities—including health information exchange and electronic medical, personal health records—for administrative and clinical purposes.
The secretary should place a high priority on developing a strategy and tools for workforce improvement (1) in HHS, (2) in the public health and health care professions nationwide, and (3) in the biosciences.
The secretary should immediately strengthen workforce planning in the department and develop a comprehensive strategy to recruit highly qualified public- and private-sector individuals in order to offset the large number of experienced staff expected to retire soon.
Congress should authorize the department, in cooperation with the Office of Personnel Management, to assemble a package of current and innovative programs and benefits designed to encourage talented, experienced individuals to transition back and forth between government and private-sector service, thereby identifying ways to leverage the best of both.
Congress should provide the secretary with additional authority to reward performance, innovation, and the achievement of results, through bonuses, merit-based pay, recognition awards, or other mechanisms of proven effectiveness.
The secretary, in concert with other public and private partners, should develop a comprehensive national strategy to assess and address current and projected gaps in the number, professional mix, geographic distribution, and diversity of the U.S. public health and health care workforces.
To help close projected gaps, the department should evaluate existing health care professional training programs, continued education programs, and graduate medical education funding and should encourage Congress to invest in programs with proven effectiveness.
Congress should give the secretary authority to create new programs that invest in the future generation of biomedical and health services researchers, enabling the continued discovery of new, more effective methods of preventing, treating, and curing disease; promoting health; improving health care delivery and organization; and controlling health system costs.
A “new compact” between Congress and the department is essential as HHS works toward achieving its vision for a healthy nation, departmental mission, and key health goals. Under this compact, the secretary would provide Congress and the nation regular, rigorous reports about departmental activities and assume greater accountability for improving performance and obtaining
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results; in return, Congress should allow the department greater flexibility in its internal operations and decision making.
To enable greater accountability, the secretary should oversee development and implementation of a department-wide data, evaluation, and information system. The system should be based on a broad analytic framework designed to aid in managing departmental operations, learning from program experience, evaluating the costs and impact of programs, and determining whether they provide sufficient value for the investment of public funds.
Congress should authorize the secretary to direct funding from the budgets of all departmental units to support the development of an HHS-wide information system. Funding for such a system would benefit all department units.
The department should use the data, evaluation, and information system to
enable the secretary to provide Congress with regular reports on progress toward achieving departmental goals,
inform policy development,
facilitate cross-department activities,
provide operational information to program management for quality improvement and midcourse corrections, and
support effective long-range planning.
For those outside the department, the system should
be accessible, transparent, timely, and reliable, and
provide useful, privacy-protected information regarding department activities.
The department should demonstrate accountability through continuous critical assessment of program efficiency, equity, impact on health, and cost-effectiveness, and through corrective action for underperforming programs.
The secretary, in collaboration with the surgeon general, should present Congress and the public with an annual “State of the Nation’s Health” report that describes progress toward achieving the vision for the nation’s health and the department’s key health goals.
Congress should establish a new, strategic initiative fund to enable the secretary to support cross-agency and cross-departmental activities that exhibit innovation in responding to twenty-first century challenges, and to respond quickly to new, unforeseen, or expanding public health threats.
aThe committee did not reach consensus on recommendation 3a. Although the majority of the committee supports the language of the recommendation, David Beier, J.D., Senior Vice President of Global Government and Corporate Affairs, Amgen; Kathleen Buto, M.P.A., Vice President, Health Policy, Johnson & Johnson; and Myrl Weinberg, C.A.E., President, National Health Council, did not agree with the majority’s view and provided dissenting opinions, which can be found in Appendix F. They were not able to agree on a common statement.
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