2
Define a Twenty-First Century Vision

Where there is no vision, the people perish.

Proverbs 9:18

RECOMMENDATION 1

Define a Twenty-First Century Vision

To meet twenty-first century challenges to America’s health, the secretary of the Department of Health and Human Services 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.

  1. The secretary should lead a thorough and thoughtful process to identify and prioritize the nation’s key health challenges.

  2. 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.

  3. 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



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2 Define a Twenty-First Century Vision Where there is no vision, the people perish. Proverbs 9:18 RECOMMENDATION 1 Define a Twenty-First Century Vision To meet twenty-first century challenges to America’s health, the secretary of the Department of Health and Human Services 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 a. process to identify and prioritize the nation’s key health challenges. b. The secretary should, in this process, consult widely with internal department leaders, others in the execu- tive branch, Congress, governors and state-level offi- cials, health care providers, scientific and professional organizations, and public interest and advocacy groups. c. 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 ac- tivities on leading priorities, strengthen the public 39

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40 HHS IN THE 21ST CENTURY health infrastructure, facilitate assessment of impact, and lead to corrective action. d. The secretary, working closely with the White House and Congress, should take a major role in promoting and achieving health reform nationwide. CHARTING THE DEPARTMENT’S COURSE To provide greater value to the American people for its $700 billion in annual health expenditures, the Department of Health and Human Ser- vices (HHS) requires clear direction. The first step is to identify and pri- oritize key health challenges, which would then be used to guide the development of a compelling, well-articulated vision for the nation’s health, to ensure that the department’s mission statement adequately de- scribes its role in achieving the vision, and to identify a relatively small number of explicit, measurable goals that are geared to meeting the na- tion’s greatest health challenges. The secretary should launch a formal process for establishing these guidelines for action, building on, as appropriate, the department’s cur- rent mission and commitments, as well as its long history of ensuring health and human services, and special attention should be paid to the needs of vulnerable populations served by the department. The process not only should involve the many important constituencies whose advice is essential to moving forward but also should be one that can be com- pleted in a timely way. The First Step: Identify the Nation’s Top Health Challenges The uppermost challenge facing the nation at present is the funda- mentally flawed health care system and the need for health reform. Addi- tional challenges include • the rising prevalence of costly chronic diseases; • developing prevention and treatment methods for diseases that currently lack them; • persistent poverty (affecting more than 37 million Americans in 2007) (U.S. Census Bureau, 2008);

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41 DEFINE A TWENTY-FIRST CENTURY VISION • global threats to health (including pandemics, emerging infec- tions, bioterrorism, natural disasters, and climate change); • workforce shortages; • the crumbling public health infrastructure; • social, environmental, and behavioral factors affecting health; and • health disparities and the needs of vulnerable populations. The review of the nation’s top health challenges cannot begin with a blank slate; it must take into account HHS’s ongoing responsibilities and legislated commitments and should incorporate contributions from many quarters. It should include the White House and Congress, state govern- ment, the private sector, and a small number of individuals with unique perspectives, such as the head of the World Health Organization, or lead- ing scientists and innovators. Within the administration, the process of identifying the nation’s top health challenges needs to be a team effort involving the White House and leaders of other cabinet-level departments (Warshaw, 1996). Many federal departments have major health programs (see Box 2-1), and some health challenges—such as improving the response to national emergen- cies—cross traditional department jurisdictions. Much is to be gained by closer collaboration between HHS and other departments—such as Homeland Security—and agencies, such as the Social Security Admini- stration or Environmental Protection Agency—whose actions greatly affect the health of the public. The opinions of leaders of the congressional committees with over- sight or appropriations responsibility for HHS must be solicited. This would include members of the 12 Senate and House committees and 6 subcommittees that currently oversee the department or its component agencies (see Box 2-2). Participation in the priority-setting process might improve the department’s responsiveness to public concerns while also helping members of Congress take into account the enormous num- ber of challenges the department faces, stem the number of legislatively mandated programs layered on the department, and persuade members to allow the department more flexibility in program implementation (see Chapter 6).

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42 HHS IN THE 21ST CENTURY BOX 2-1 Other Federal Departments with Major Health Programs A number of other federal departments and agencies are responsible for im- portant health-related activities: ● The Department of Veterans Affairs has an undersecretary for health in charge of hospitals, clinics, and other health services for eligible military vet- erans. ● The Department of Defense has an assistant secretary for health affairs and separate surgeons general for the Army, Navy, and Air Force, who oversee health care services for active military service members and their families, and a joint staff surgeon, who serves as medical advisor to the chairman of the Joint Chiefs of Staff. ● The Department of Homeland Security has an assistant secretary for health affairs, who also serves as the department’s chief medical officer and is re- sponsible for advising the DHS secretary and the Federal Emergency Man- agement Agency administrator on health-related issues. ● The Department of Labor oversees ERISA (the Employee Retirement In- come Security Act), the statute that governs employer-sponsored health in- surance. ● The Office of Personnel Management manages the Federal Employees Health Benefits Program, which is often cited as a possible model for the ex- pansion of health care coverage. State involvement in setting priorities is crucial, because Medicaid, health care financing innovations, and most public health activities— such as disease control and surveillance, emergency preparedness, and public information campaigns about tobacco and obesity—are carried out not just at the federal level, but in states and communities, as well. Greater inclusion of states in HHS strategic planning would be an impor- tant step forward, as states, despite their vital role in implementing HHS programs, frequently perceive that they are treated as an “interest group just like any other” (Boufford and Lee, 2001). Health care experts outside government—such as professional asso- ciations, researchers and scientists, care providers, product manufactur- ers, business and labor, insurers, and health care associations—also should be consulted, as should consumer groups and organizations repre- senting people with chronic diseases and disabilities and their family caregivers.

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43 DEFINE A TWENTY-FIRST CENTURY VISION BOX 2-2 Committees That Oversee HHS and Related Appropriations Senate Committees Appropriations Subcommittee on Agriculture, Rural Development, and Related Agencies Subcommittee on Labor, HHS, and Education Budget Finance Health, Education, Labor, and Pensions Homeland Security and Governmental Affairs Labor and Human Resources Subcommittee on Public Health and Safety House Committees Appropriations Subcommittee on Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Subcommittee on Labor, HHS, and Education Budget Education and the Workforce Energy and Commerce Subcommittee on Health and Environment Oversight and Government Reform Ways and Means SOURCES: IOM (1998); see www.kaiserEDU.org; see www.frac.org. Such a broad effort to obtain input about the nation’s key health challenges and priorities would ensure that the result will reflect a com- prehensive awareness of the problems, promote acceptance of the goals the department ultimately chooses, facilitate implementation of related programs, generate partnerships, encourage longer-term investments, and foster continuity. Related Recommendations The secretary should lead a thorough and a. thoughtful process to identify and prioritize the nation’s key health challenges.

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44 HHS IN THE 21ST CENTURY b. 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, scien- tific and professional organizations, and public interest and advocacy groups. Vision The analysis of current, emerging, and potential health challenges and priorities facing the nation would provide the department with con- sensus-based background information—a type of “environmental scan”—necessary to construct a twenty-first century vision for the na- tion’s health. It would describe what the department sees as a compelling vision for the future state of the nation’s health, and it should combine elements of aspiration and inspiration—not only desire, but also motiva- tion to work toward that desire: • “I have a dream today” (Martin Luther King, Jr., March on Washington, August 28, 1963) • “These united colonies are, and of right ought to be, free and in- dependent states” (Declaration of Independence, 1776) • “With confidence in our armed forces, with the unbounding de- termination of our people, we will gain the inevitable triumph— so help us God” (Franklin D. Roosevelt, Address to Congress, December 8, 1941) A clear, central vision of a desired future state is essential to high performance (Peters, 1988). The articulation of a vision can reflect many possible outcomes. HHS’s vision for the nation’s health might, for ex- ample, express a determination to make the United States one of the world’s healthiest nations or orient the nation toward health promotion and disease and injury prevention. Although the choice of a vision is not always obvious, without it, or- ganizations become diffuse and distracted, spend time on noncritical ac- tivities, and fall short of their potential effectiveness. Ideally, HHS’s vision for the nation’s health would be compelling enough to endure be- yond a single secretary’s tenure.

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45 DEFINE A TWENTY-FIRST CENTURY VISION Mission A mission statement describes what the organization does, why it ex- ists, and its role in achieving the vision. It defines success for the organi- zation. The current HHS mission statement, which encompasses both its health and human services roles, accomplishes these purposes well (HHS, 2008b): to enhance the health and well-being of Americans by providing for effective health and human services and by fostering strong, sustained advances in the sciences un- derlying medicine, public health, and social services. With a newly articulated vision in mind, HHS should assess whether this mission is well designed to achieve the vision. Goals To establish accountability and to monitor performance, both inter- nally and externally, a set of time-specific, measurable goals is required, in addition to the vision and mission statements (see Chapter 6). 1 Goals should be few in number, reflecting hard and firm choices, since “to gov- ern is to choose” (Shalala, 1998). They should be measurable, so that progress toward them can be tracked. In addition, they should be pub- lished and accessed easily, similar to the objectives of Healthy People 2010. An example of a goal that was easily measured and inspiring was the National Aeronautics and Space Administration’s (NASA’s) goal of getting a man to the moon and returning him safely to Earth by 1970, which generated agency efforts so focused that it was achieved a year ahead of schedule. In general, HHS goals should do the following: • Support its vision and mission statements. • Reflect challenges raised in the internal and external assess- ments. • Focus its activities. 1 HHS currently has a large number of goals that are discussed in Chapter 6. These goals include four very broad goals that are not time specific; the secretary has nine pri- orities, and Healthy People has 467 objectives for the nation.

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46 HHS IN THE 21ST CENTURY • Be consistent with each other, across the department’s health and human services programs. • Balance ongoing responsibilities and new demands. • Be challenging, realistic, and achievable. Setting goals makes the secretary’s job even more complicated, be- cause the choices are so many and current responsibilities are so great. The goals should align with the vision and mission statement and should be designed to meet the established priorities. Some of the department’s goals should respond to the nation’s greatest health challenges, as the secretary and other key advisers perceive them. Other goals may need to address internal challenges related to the department’s organization and operations. The department faces an array of internal challenges that impede its efficiency and effectiveness. Some of the challenges listed below are general problems—such as the department’s likely workforce shortage; some are specific to certain departmental units; and some reflect organ- izational approaches that were better designed to deal with the health problems of yesterday, not today—and much less tomorrow. Progress in responding to these internal challenges will require attention and action from some combination of the secretary, Congress, and the White House. For example: • They must address the extraordinary diversity in the goals of the department’s individual health and human services programs, coupled with the need to customize programs to make them ef- fective. • The personal nature of health care and health maintenance re- quires that policies and programs take into account diversity among patients and tailor interventions to individuals. • The dominance of entitlement programs and other mandatory spending in the department’s annual budget leaves department leaders little flexibility in spending, while federal budget con- straints limit new funding. • At present, there is no mechanism to finance an effective re- sponse to public health emergencies (Lister, 2008). • Establishing effective partnerships with state and local govern- ments and the private sector is desirable, but difficult. • Currently, the secretary has significant management demands, providing direct oversight of 11 operating divisions and 15 staff

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47 DEFINE A TWENTY-FIRST CENTURY VISION divisions, without positions such as undersecretaries or assistant secretaries with line authority. • The department’s data and information systems inadequately support decision making and program assessment. • Responsibility for key issues is fragmented across agencies, making it difficult to leverage resources for maximum impact; for example, obesity—now generally considered one of the na- tion’s foremost health issues—is addressed by programs in nearly every health and human services agency. • The once-powerful position of assistant secretary for health (ASH) no longer has authority over the department’s major pub- lic health agencies and, consequently, has little capacity to gen- erate or inspire change in the public health sector. Instead, the ASH oversees 16 offices, many focused on socially sensitive ar- eas—such as biomedical ethics, reproductive health, HIV/AIDS policy, and minority and women’s health (HHS, 2008a). • The department has made insufficient progress toward achieving the nation’s current health goals—for example, of the Healthy People 2010 objectives set a decade ago, only one-third have seen progress (HHS Office of Disease Prevention and Health Promotion, 2005). • The HHS workforce needs major strengthening. Each such internal issue should be evaluated to determine whether the secretary has authority to remedy it or whether the involvement of Congress is required. VISION, MISSION, AND GOALS AS MANAGEMENT TOOLS The process of establishing vision, mission, and goals relates to the seven elements of organizational success noted in Chapter 1—most no- tably, strategy, systems, and shared vision (Bradach, 1996). All three of these expressions of purpose are essential for the effective functioning of any organization. This report does not recommend what the department’s vision for the nation, its own mission, or its goals should be. Instead, the committee firmly believes that these choices belong to the President and the secre- tary, that they must be articulated clearly and forcefully and promulgated

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48 HHS IN THE 21ST CENTURY widely, and that the department’s activities must be aligned to achieve them (see Chapter 3). A focus on purpose—vision, mission, and goals—is preferable to a focus on structure, because attention paid to purpose should result in a strategic cohesiveness within the entire department, while attention paid to structure and reorganization is likely to yield more limited benefits, at high cost (Waterman et al., 1980). The vision and mission statements should be intended to endure. They should provide program continuity in the face of presidential transitions and when new secretaries and new executive leadership comes aboard. Also, the vision and mission state- ments should encourage rather than stifle creativity and innovation. 2 Clear purpose can help inform budget decisions and focus attention on long-term needs, including how to achieve sustainability in the de- partment’s programs, especially Medicare and Medicaid. Guided by de- partment goals, the budgets of the leading Public Health Service agencies—the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and Food and Drug Administration (FDA), in particular—could be more predictable, rather than showing wide year-to-year fluctuations (see Chapter 3). If more predictable fund- ing arrangements could be worked out with Congress, this budgetary continuity not only would aid federal public health efforts, but could also stabilize federally funded community-based programs. Clear purpose facilitates program evaluation, discussed in Chapter 6. Evaluation results should help refine goals, while the vision and mission remain intact. Finally, clear purpose helps others—in Congress, throughout gov- ernment, throughout the health sector, and in the nation at large— understand the role and importance of the department’s work. Just as words are no substitute for action, vision and mission state- ments are no substitute for leadership. The department needs an effective leader to set it on course and keep it there, to achieve real progress. Within the limits imposed by Congress, ultimately, it will be the secre- tary’s responsibility to ensure department-wide integration of the vision, mission, and goals into HHS daily activities and operations. 2 In the HHS Human Capital Survey (HHS, 2007), less than half of respondents agreed with the statement, “Creativity and innovation are rewarded.”

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49 DEFINE A TWENTY-FIRST CENTURY VISION Related Recommendation The secretary should establish a vision, mission, c. and goals that respond to twenty-first century chal- lenges, 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. SECURING HEALTH REFORM A major theme of this report is about building value into the work of HHS, and it is equally vital to build greater value into our nation’s health system. HHS is deeply affected by current problems in the system and can be a major force in their solution. High health care costs, lack of ac- cess to care, poor quality and outcomes—a Venn diagram of overlapping influences—are the major sources of mounting pressure for health re- form—among the public, health professionals and providers, and policy makers. When Congress requested this report, it asked that the Institute of Medicine (IOM) consider the department’s preparedness to meet the na- tion’s greatest health care challenges: advancing health and controlling health care costs. The consensus of many experts—and the IOM commit- tee—is that these challenges cannot be met without comprehensive health reform. Comprehensive reform would result in a health system that produces more value for Americans. It would be characterized by improved access to care and coverage; it would promote higher quality care, including all the attributes identified by the IOM (safe, effective, patient centered, timely, efficient, equitable) (IOM, 2001), and it would emphasize health promotion and prevention of disease and disability. Efforts at health re- form should take this comprehensive approach, the committee believes, so that a reformed system is sustainable and accountable, has the neces- sary and appropriate workforce, and again, creates value in response to the massive investments of the American people. As far back as the 1930s, attempts have been made to rationalize the U.S. health care system by proposing changes in the way the nation pays for health care (Committee on the Costs of Medical Care, 1932), but powerful interest groups and opponents of federal and state government

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50 HHS IN THE 21ST CENTURY solutions have pointed out the risks of change, and reform has repeatedly stalled. Inaction may not be possible for much longer, as increases in health care costs, which were $2.1 trillion in 2006 (Catlin et al., 2008), are rising faster than the gross domestic product, prompting one group of prominent analysts to predict that “By the early 2030s, assuming health care costs grow at their historical rate, the three major entitlement pro- grams [Medicare, Medicaid, and Social Security] will absorb all of the federal government’s projected revenues” [emphasis added] (Frenzel et al., undated). Health care costs also are prime contributors to escalating national debt and pervade economists’ concerns about the state of the entire economy. A September 2008 Congressional Budget Office (CBO) report concluded that current trends in federal spending and revenues are “un- sustainable.” The CBO identified health care spending and, “to a lesser extent,” the aging population (which requires Social Security spending, as well as increased health care spending) as two of the largest ongoing contributors to growing demand for federal resources (CBO, 2008). Dismay about high health care costs (see Box 2-3) is deepened by evidence that the money being spent on health care does not produce commensurate gains in population health. Much research comparing ex- penditures and care patterns in different areas of the country has shown that “spending more” does not improve health outcomes (Wennberg et al., 2008). Additional dismay stems from revelations regarding severe quality problems in individuals’ health care—problems that every year cost tens of thousands of lives, much needless suffering, and untold dol- lars (IOM, 2001). BOX 2-3 The Results of Increasing Health Care Costs • Nearly 46 million Americans were uninsured in 2007—15.3 percent of the popula- tion (U.S. Census Bureau, 2008). • Eighty percent of the uninsured live in families with at least one employed indi- vidual, and a third have family incomes above 200 percent of poverty (Kaiser Commission on Medicaid and the Uninsured, 2008). • Some 18 million mostly poor and uninsured Americans now rely on publicly funded community health centers for their care (NACHC, 2008a). • These centers’ patient populations grew 56 percent between 2000 and 2006 (NACHC, 2008b). • A third of U.S. adults spend at least 10 percent of their income on health services or health insurance. • Medical debt is a factor in nearly half of personal bankruptcy filings (IOM, 2002).

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51 DEFINE A TWENTY-FIRST CENTURY VISION The leadership for reform may emerge from various congressional committees, private-sector interests, a new working group established by the President, or various other organizational arrangements. Lessons from the failed 1993 reform effort—including the need for greater trans- parency—would undoubtedly underpin the design of a new reform proc- ess. Regardless of the entity that takes the lead, the secretary and the department inevitably will be required to give sustained attention to the development and assessment of reform options. Any health reform strategy ultimately put forward will affect every aspect of department activities: • Reform will affect departmental priorities and whether and how well it can meet its mission and goals. • Reform will influence the structure, alignment, and interrelation- ships of departmental agencies and units. • Reform will affect many aspects of HHS agencies’ daily opera- tions and the expertise their staff will need. • Reform will change the outcomes for which the department is accountable. In fact, reform will have an impact on all of the seven elements of organizational success: strategy, structure, systems, staff, skills, style, and shared values. If only because health reform would have such a major impact on the department, the secretary cannot afford to be merely a passive observer of the process. The department has both motivation and opportunity to play a significant role in creating a high-value health system because of the enormous costs—and powerful leverage—of Medicare and Medicaid and its role in setting quality standards across government health pro- grams (IOM, 2003). The department also has important expertise and information to con- tribute, too. Because it is the principal advocate within the federal gov- ernment for public health and advancing the health of the population, it may be up to the secretary to make the critical case that “health reform” is more than just reforming the insurance coverage and payment systems. HHS has paramount operational knowledge about the complex workings of the health sector, and the secretary will want to use the extensive data available from Medicare, Medicaid, CDC, FDA, the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, and other federal, state, and private-sector agencies to help

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52 HHS IN THE 21ST CENTURY shape and assess options. HHS will want to leverage its relationships with many important constituencies that also can contribute to the reform process. A successful health reform process would require transparency and strong communication and would undoubtedly be collaborative, cross- governmental, and involve many public- and private-sector entities. The department should clarify its role early in the process and marshal its resources to contribute its unique data resources and the perspectives gained from long and diverse experience. Specific ways in which the department should participate in a reform process include the following: • Set up a capacity to quickly conduct or coordinate external research on proposals offered by the White House, Congress, and others. • Pull together cross-department work teams on key issues as they arise. • Communicate knowledge to the public about what is known regarding important aspects of reform. • Organize new forms of demonstration or state waiver pro- grams to test specific aspects of reform proposals. • Ensure health promotion and disease prevention are ade- quately included in reform efforts. • Assess the adequacy of the workforce to support reform pro- posals. • Ensure that the new system can be both sustainable and ac- countable. • Generally, emphasize creation of more value in the health system. The combination of a health system that is widely considered fun- damentally flawed, competing external demands, internal organizational complexity, and impending large workforce losses due to retirement pre- sents HHS with serious challenges, as well as opportunities for new thinking about the important themes the IOM committee considers in this report: vision, focus, alignment, effectiveness, and accountability.

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53 DEFINE A TWENTY-FIRST CENTURY VISION Related Recommendation d. The secretary, working closely with the White House and Congress, should take a major role in promoting and achieving health reform nation- wide. REFERENCES Boufford, J., and P. Lee. 2001. Health policies for the 21st century: Challenges and recommendations for the U.S. Department of Health and Human Ser- vices. New York: Milbank Memorial Fund. Bradach, J. 1996. Organizational alignment: The 7-S model. Boston, MA: Har- vard Business School. Catlin, A., C. Cowan, M. Hartman, S. Heffler, and the National Health Expendi- ture Accounts Team. 2008. National health spending in 2006: A year of change for prescription drugs. Health Affairs 27(1):14-29. CBO (Congressional Budget Office). 2008. The budget and economic outlook: An update. Washington, DC: CBO. Committee on the Costs of Medical Care. 1932. Medical care for the American people: The final report of the Committee on the Costs of Medical Care. Chi- cago, IL: University of Chicago Press. Frenzel, W., C. W. Stenholm, G. W. Hoagland, and I. V. Sawhill. undated. Tam- ing the deficit: Forge a grand compromise for a sustainable future. Washing- ton, DC: Brookings Institution. HHS (Department of Health and Human Services). 2007. HHS human capital survey—2007. Washington, DC: HHS. HHS. 2008a. Office of public health and science. http://www.hhs.gov/ ophs/ (accessed October 15, 2008). HHS. 2008b. Performance highlights. Washington, DC: HHS. HHS Office of Disease Prevention and Health Promotion. 2005. Healthy people 2010: Midcourse review. Washington, DC: HHS. IOM (Institute of Medicine). 1998. Scientific opportunities and public needs: Improving priority setting and public input at the NIH. Washington, DC: Na- tional Academy Press. IOM. 2001. Crossing the quality chasm: A new health system for the 21st cen- tury. Washington, DC: National Academy Press. IOM. 2002. Health insurance is a family matter. Washington, DC: The National Academies Press. IOM. 2003. Leadership by example: Coordinating government roles in improv- ing health care quality. Washington, DC: The National Academies Press.

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54 HHS IN THE 21ST CENTURY Kaiser Commission on Medicaid and the Uninsured. 2008. Five basic facts on the uninsured. Palo Alto, CA: Henry J. Kaiser Family Foundation. Lister, S. 2008. Public health and medical preparedness and response: Issues in the 110th Congress. Washington, DC: Congressional Research Service. NACHC (National Association of Community Health Centers). 2008a. Access transformed: Building a primary care workforce for the 21st century. Be- thesda, MD: NACHC. NACHC. 2008b. A sketch of community health centers: Chartbook 2008. Be- thesda, MD: NACHC. Peters, T. 1988. Thriving on chaos: Handbook for management revolution. New York: HarperCollins. Shalala, D. 1998. Are large public organizations manageable? Public Admini- stration Review 58(4):284-289. U.S. Census Bureau. 2008. Health insurance coverage status and type of cover- age by selected characteristics: 2007. http://pubdb3.census.gov/macro/ 032008/health/h01_001.htm (accessed September 9, 2008). Warshaw, S. 1996. Powersharing: White House–cabinet relations in the modern American presidency. Albany, NY: State University of New York Press. Waterman, R., Jr., T. Peters, and J. Phillips. 1980. Structure is not organization. Business Horizons 23(3):14-26. Wennberg, J., E. Fisher, D. Goodman, and J. Skinner. 2008. Tracking the care of patients with severe chronic illness. Hanover, NH: Dartmouth Atlas of Health Care.