Needs for New Knowledge to Support Policy-Making
As policy-making related to health and human services devolves from the federal government to states and municipalities and as the private sector comes to play a larger role, the Department and other stakeholders need to track the transformations closely. Comparing policies and monitoring policy changes all across the expanding network of decision loci will be crucial.
Examples of the many topics that warrant increased attention are the ways states and municipalities organize to perform their decision-making, the decisions that result, and the respective roles of public and private organizations in the delivery of health and human services. Case studies of particular policy initiatives at the community level could be invaluable if limited to the appropriate contexts. Perhaps most important in this area, policy-makers need comparative assessments across states and communities with respect to the impacts of particular transformations for which the goals are essentially identical but the approaches differ in fundamental ways -- e.g., Medicaid cost- containment and welfare-to-work initiatives.
Policy-makers also need better information about how different programs interact to influence access to services as well as the types, quality, and effectiveness of services people actually receive. Moreover, the opportunity is not limited to the interplay between or among DHHS programs; it also encompasses the interplay of DHHS programs with those of other government agencies at the national, state, and local levels and with activities of commercial and philanthropic organizations.
Of all the areas where a cross-modality perspective could do much to enhance current knowledge, none is more promising than programs serving vulnerable populations. Members of these groups typically are beneficiaries of more than one service program at any given time; and changes in any one modality can have a material influence on the effectiveness of the whole. Studies that fail to address all major program interactions in such instances are almost certain to yield inconclusive, if not misleading, results.
Finally, policy-makers need to assess whether changes in the goals or strategies for service programs exert indirect influences on the well-being of Americans and, if so, how. In particular, such changes already are affecting institutions such as health departments and welfare agencies within state and local governments as well as academic health centers and community-based social-service organizations. Some of these infrastructure changes could be of sufficient significance to warrant reinforcing or compensating actions by the Department. Further, if not accounted for adequately in studies, infrastructure changes could distort or mask important direct effects of health-services and human-services programs upon their target populations.
DHHS agencies and offices already are sponsoring a wide variety of evaluation projects that focus directly on changes in the financing, organization, and availability of health and/or human services. The evaluations associated with state-specific Medicaid and welfare-reform demonstrations, respectively, are leading examples. Other foci are the Head Start Program, job-training/placement efforts for welfare recipients, Community Health Centers, health care for Native Americans, mental-health services, and treatment programs for substance abusers.
DHHS evaluation projects provide an excellent base on which to build an expanded array of studies related to the role of the Department as both sponsor and provider of services. In particular, DHHS programs are well-positioned to mount a coordinated effort to examine the effects of devolution in general and selected programs and policies in particular on the well-being of children (especially low-income children) -- including their development, health, and ability to become productive members of society.
Further, the ferment within health-services and human-services systems is attracting interest among social scientists in universities, foundations, and other research-oriented institutions throughout the nation. Many of these scholars already have affiliations with state governments, local governments, and/or community-based organizations and thus may be able to describe and assess transformation initiatives that DHHS evaluation projects are not likely to encompass.
Many of these scholars also are motivated to conduct relevant basic research in social-science disciplines such as demography, ethnography, social psychology, and microeconomics. Such research is highly likely to yield new knowledge and better tools for assessing transformations and their effects -- e.g., new measures of well-being that are easy to use in data collection and readily incorporated into survey instruments. Appropriately tailored solicitations for grant and cooperative-agreement proposals, including modifications of current program announcements, would enable DHHS programs to tap more deeply than at present into the rich expertise and diverse perspectives within the social-science research community.
The Agencies and Offices of the Department should ensure that their portfolios of program evaluations and research projects include initiatives that focus on transformations in health/human services -- especially as they relate to changes in the well-being of Americans.
Agencies and Offices should sponsor research into the effects of devolution on the scope, characteristics, and efficacy of particular health/human services.
Agencies and Offices, when evaluating their service programs, should collaborate in addressing the interplay of health services and human services in those instances where beneficiaries rely significantly on both types and where changes in any particular service could affect materially the efficacy of others.
Agencies and Offices that fund extramural research should include the following types of projects in their programs:
- investigator-initiated social-science research relevant to ongoing or likely transformations; and
- projects that are likely to lead to improved methods for collecting, analyzing, and disseminating data related to transformations in health and human services.
Agencies and Offices should collaborate in sponsoring program evaluations and research related to transformations -- especially where their interests are closely related, where the scope of work extends beyond the mission of any one program, or where the requisite resources exceed those that any one program can commit.
The Office of the Secretary should ensure a coordinated Department-wide approach to monitoring and assessing transformations in health/human services.
The Assistant Secretary for Management and Budget should ensure that needs and opportunities for investments in relevant program evaluations, research projects, and data resources receive appropriate attention in the Departmental budget processes.
The Assistant Secretary for Management and Budget, in the course of coordinating DHHS-wide efforts under the Government Performance and Results Act, should ensure appropriate linkage between the development of performance measures and corresponding data-collection needs.
The Assistant Secretary for Planning and Evaluation should ensure that the Department-wide planning and evaluation processes foster cooperation -- both within the Department and with outside organizations -- with respect to monitoring and assessing transformations.