• public health policies and programs that focus on the community rather than on the personal health services that are the central concern of health care reform.

In addition, other elements may be considered part of the administrative apparatus necessary to promote the goals of health care reform in the longer run or to advance other important social goals. Among these are, for example, the definition of clinical malpractice, the creation of better legal responses to clinical errors, and the protection of the privacy and confidentiality of sensitive patient data that reside in computer-based records and databases.


Different reform proposals involve vastly different and difficult-to-catalog levels and distributions of governance and administrative responsibilities. The committee does not take a position on the "ideal" administrative structure for health care reform; that structure must be fitted to the specifics of a particular proposal. Whatever the specific, however, reform proposals should be clear about the roles, responsibilities, accountabilities, and interrelationships of the public and private sectors in implementing the proposal and achieving its objectives. Proposals should define explicitly:

  • the program management responsibilities that will reside in the public sector and the level of government—federal, state, local, or some combination—that should discharge them;

  • the administrative tasks to be undertaken by private sector entities such as employers, fiscal intermediaries, or health care providers; and

  • the role, if any, of quasi-public organizations such as a commission or board that might define covered services or certify health plans for which public enrollment subsidies would be available.

Most reform proposals will probably require some reorganization of the Department of Health and Human Services to accommodate new responsibilities and realign existing activities. The nature of this

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