In December, 1995, Secretary Shalala launched a Department-wide effort to develop a " research strategy to understand the major transformations that are taking place across the nation with respect to health and human services " (see Dec. 4, 1995 Memo - Attachment A). Following through on the Secretary's charge, the Assistant Secretary for Planning and Evaluation established a working group with broad representation from DHHS agencies and offices, as shown in Attachment B. This report presents the findings and recommendations of the working group.
At the time the working group began its deliberations, the Congress was considering a series of legislative proposals that, if enacted, would have produced abrupt, large-scale shifts of policy-making and fiscal responsibility from the federal government to state and local governments and the private sector. Two proposals had special significance for vulnerable populations served by the Department -- i.e., the proposals to convert Medicaid and Aid to Families with Dependent Children (AFDC) from entitlements to block grants.
Most of the major devolutionary proposals, including those focused on Medicaid and AFDC, are sufficiently controversial that they have not become law. But substantial changes in health services and human services are occurring nevertheless:
- Managed-care arrangements of ever-increasing variety are proliferating within the health-care industry and are affecting virtually every health program funded by the Department.
- Continuing a policy introduced early in this decade, the Health Care Financing Administration is granting waivers under Section 1115 of the Social Security Act allowing demonstrations of redesigned Medicaid programs in states that have submitted meritorious proposals to that end. Most feature managed-care arrangements.
- In a similar vein, the Agency for Children and Families is granting Section 1115 waivers allowing demonstrations of redesigned AFDC programs in states that have submitted meritorious proposals toward that end. Welfare-to-work requirements are a feature in most of these demonstrations.
- Governors, county executives, and mayors -- exercising authorities that traditionally have resided in states and local governments -- in recent years have mounted ever more ambitious efforts to contain the costs of health and human services and/or increase their effectiveness. Integration of services is a feature of many of these initiatives.
The preponderance of evidence suggests that these trends will continue through the foreseeable future and, if anything, both the diversity and pace of the changes will increase.
Desire for more cost/effective services is driving virtually all of these efforts to a significant degree; but they differ considerably among themselves in both scope and content. Health and human services for Americans thus are not being reshaped through a strategically unified, nationally coordinated campaign of wholesale reform. Rather, the current national picture is a dynamic mosaic constructed primarily from transformations that stem from particular governmental or private-sector initiatives and that, in general, are individualized, incremental, and asynchronous. Assessing the course and consequences of these transformations is the challenge to which the research initiatives described below are addressed.