HHS in the 21st Century Charting a New Course for a Healthier America (2009) / Chapter Skim
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Appendix G The Reorganization Option:Views from Former Secretaries of the U.S.Department of Health and Human Services
Appendix G The Reorganization Option:Views from Former Secretaries of the U.S.Department of Health and Human Services
Pages 191-208
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From page 191... ...
Whether measured by centralization, job specialization, height and width, complexity, implied autonomy, professionalization, or administrative red tape, structure has been repeatedly shown to affect the profitability, innovativeness, customer satisfaction, and flexibility of organizations. This relationship between structure and performance is so powerful and easily designed relative to policy change that it has often prompted calls for reorganization -- dozens of bills are introduced in each Congress to create new departments and reshuffle existing agencies.
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From page 192... ...
. Drawing upon interviews with the six former secretaries who began their tenures at the start of the past six presidential administrations (Gerald Ford, Jimmy Carter, Ronald Reagan, George H
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From page 193... ...
That is certainly what Congress intended when it elevated the Veterans Administration to cabinet status in 1988. Although the bill was delayed in the Senate due to concerns re garding veterans appeals of benefits decisions, Congress eventu ally concluded that veterans policy merited the heightened visibility and importance that would come with a statutory seat at the cabinet table, and the perquisites that come with it.
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From page 194... ...
• Reorganization can increase accountability to Congress, the President, and the public by making a department's budget and personnel clearer to all, its presidential appointees subject to Senate confirmation, its spending subject to integrated oversight by Congress and its Office of Inspector General, and its vision plain to see. Although it is tempting to believe that such account ability is only a spreadsheet away, cabinet status conveys a megaphone that little else in Washington does.
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From page 195... ...
HOW THE SECRETARIES VIEW REORGANIZATION Department secretaries bring an important perspective to the analysis of reorganization and its costs and benefits. Some secretaries enter office at the beginning of the implementation process, while others are in office when the reorganization takes effect.
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From page 196... ...
was removed from the department, while Tommy Thompson was secretary when the Department of Homeland Security absorbed several high-profile units from HHS. A third spent his first months in office rationalizing a host of programs in one "fell swoop" -- Joseph Califano moved quickly to implement the most significant organizational reforms since the department was created.
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From page 197... ...
Large-scale reforms such as Reagan's war on waste or Clinton's reinventing government create significant obligations for the secretary, while smaller reforms that originate either outside or inside the department can be more easily delegated to the deputy secretary or an assistant secretary. According to the secretaries, the most successful process changes have involved efforts to create synergies between the operating units within the department, which sometimes act as quasi-independent states.
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From page 198... ...
Several secretaries noted that the department's primary problems involved organization culture, not structure. Yet whether culture was the problem or not, all of the secretaries were hesitant to embrace large- or small-scale reorganization as a particularly ef fective method for changing culture.
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From page 199... ...
I was used to a dif ferent style as a university president -- appoint very talented peo ple, coordinate them through the secretary's office." • Reorganizations can eclipse major policy concerns. The next HHS secretary will face a long list of major policy challenges, most notably the rapidly approaching Medicare crisis.
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From page 200... ...
Congress can lower the operating cost of the department without significant reorganization, for example. As the congressional role in limiting executive discretion has grown, so has congressional engagement in the fine details of program delivery, including floors and ceilings on spending and services, as well as a rising tide of earmarks, or what Congress now calls "congressionally directed funding." Some of these earmarks involve what appear to be backdoor requests by the department's own operating units, but others appear to reflect the more traditional dynamics of incumbency advantage and parochial interests.
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From page 201... ...
One device for avoiding the elongated process for securing organizational reform while honoring the separation of powers would be the restoration of the President's reorganization authority as a tool for smaller-scale reorganizations that must now wind their way through a highly complicated congressional structure. This authority once gave the President the freedom to propose reorganization plans to
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From page 202... ...
It could easily pass constitutional muster today under a fast-track process modeled on the approach used in the military base closing act and might be one way to give secretaries of all departments greater leeway in governing their organizations. Hence, the secretaries tended to focus more on the problems a new secretary might face, rather than the value of a particular reorganization strategy.
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From page 203... ...
"I brought 25 people with me," another secretary remembered. "The top operating people were experts, all knew health care, and I had veto authority because of my relationship with the President." The appointments process has clearly changed dramatically over the past 30 years, of course.
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From page 204... ...
Without indicting the current civil service for its own sluggish performance per se, several secretaries did emphasize the need for better recruitment, retention, promotion, and training programs to ensure a steady supply of talent as the baby boom generation retires over the next decade. Such reor ganization need not be restricted to one department but appears to be a prerequisite for effective performance as one generation of employees arrives and another leaves.
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From page 205... ...
Bush Secretary 3/1/89 1/21/93 1/24/01 Under or deputy Secretary 5/10/89 5/24/93 5/26/01 Assistant secretary for health 4/19/89 7/1/93 1/25/02 FDA commissioner 10/27/90 Holdover 1/25/02 Heath Care Financing Administration -- Centers for Medicare and Medicaid Services 2/1/90 5/24/94 5/25/01 Assistant secretary for program evaluation 1/30/90 5/28/93 5/25/01 Assistant secretary for management and budgeta 5/1/89b 5/24/93 1/25/02 National Institutes of Health director 3/21/91 11/20/93 5/2/02 Surgeon general 3/1/90 9/7/93 7/23/02 a The title and division of responsibilities associated with this position have varied over time. b This position was not subject to Senate confirmation in 1989.
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From page 206... ...
The past secretaries also put a premium on developing a strong relationship with the White House. Much as they may have bristled at White House involvement in the appointments process, they all understood that they had to forge strong ties to the White House surrounding key policy issues such as welfare and health care reform.
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From page 207... ...
Because this philosophy of reform originates in the scientific management movement spurred forward by operations research and Frederick Taylor, it also carries the hubris perhaps that there is "one best way" for building an efficient bureaucracy. Scientific management still holds promise for improving organizational efficiency, whether through shared administrative, or "back office" functions or through organizational synergies that might not otherwise exist under a "czar" or other integrative mechanism.
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From page 208... ...
208 HHS IN THE 21ST CENTURY Interview Schedule Tommy Thompson, July 7, 2008 David Matthews, July 8, 2008 Donna Shalala, July 10, 2008 Richard Schweiker, July 11, 2008 Louis Sullivan, July 31, 2008 Joseph Califano, August 19, 2008
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