Conflicts between unelected civil servants and elected officials in U.S. healthcare agencies

Policy

Democracy and Public Administration

This report is a theoretical essay on the inevitable conflicts that consistently occur between public agencies that are managed by unelected civil servants and the political environment in which these individuals and organizations operate in. Public agencies in the healthcare environment are prime examples of successful interdepartmental cooperation in most cases, but, there are also examples where they can demonstrate both internal and external in-fighting. "The health sector workforce, which usually comprises a significant element within the total public sector workforce, may be either directly employed by the public sector health system, or work in public-funded agencies or organizations (e.g., social insurance funded). In many countries healthcare will also be delivered by organizations in the private sector and by voluntary organizations." (World Bank Group) As concerns like the nation's aging population, a rapidly depleting Medicare Trust or the many potential pandemics such as SARs, Swine Flu, Aides and even the approach to dealing with the problems of our national mental health including the many seriously physically and mentally injured soldiers returning from two wars -- all of these issues need to be addressed.

The problem is that far too often, various departments of the United States Government have to work together even though they may or may not see eye-to-eye. "Health and Human Services was working diligently with the U.S. Department of Agriculture (USDA), the Department of State, and the U.S. Agency for International Development to monitor the situation and prepare for an epidemic should one occur. More importantly, a survey conducted by Bloomberg School's Center for Public Health Preparedness, published in the April 2006 edition of the journal BMC Public Health, found that of 308 respondents, half would not report to work during a pandemic. Although the healthcare industry would be in the center of the storm in the event of a pandemic, 'the workforce was not yet prepared for the crisis.'" (Encyclopedia of American Industries)

Consider that the objective of paying for many national or state-based health programs, oligarchy like bureaucratic environments and the need for a pristine public image alone are all grounds for predictable conflicts between most health related public agencies. One need only look at CNN, the New York Times or the Wall Street Journal to see that healthcare has become one of the most important issues that our nation is currently facing. So, as this national healthcare debate consumes the nation, behind the scenes, extremely powerful health related public agencies managed by unelected civil servants are all vying for control in order to maintain their grasp on the health related powerbase. This essay will try to understand some of these organizations' power structures and how their internal and external conflicts affect healthcare.

National or State

The goals of Public Health programs are logically to prevent disease while also promoting good health. This is done by applying both scientific and technical knowhow through focused effort. When funding becomes an issue, our public health system may be completely unprepared which in turn can escalate minor health scares into devastating health catastrophes. When one thinks of a large scale public health program, they may be thinking of the federal government's intent on safeguarding the public's health.

But what actually becomes a health system is more in line with state, local and municipal public health policies or programs managed by local civil service employees being instructed as best as possible by larger national entities also run by civil servants. Consider the H1N1 vaccine shortages around the nation. The problem is of course seen as a national issue, but it is managed as more of a shortage per local communities. Thus, a national organization like The Center for Disease Control may pass on requests that are then carried out by local entities. "Vaccination is the best protection against contracting the flu. Find H1N1 (Swine) flu and seasonal flu vaccines where you live. You need two vaccines to be fully protected this year. The seasonal flu vaccine is different from the H1N1 flu vaccine. The CDC is encouraging people to get both vaccinations. Nationwide distribution of the H1N1 flu vaccine is underway to all states. Vaccine production is now at or near full capacity." (Flu.Gov)

In this way, the public health system can cover large areas that need assistance but from a grassroots approach. Most Americans know very little about how the public health infrastructure looks at a state or even smaller local jurisdictional level. At each and every level of communication in this overall system, conflicts occur between the public agencies that are managed by unelected civil servants. The true public health system should be considered an ecosystem where each cell has its own infrastructure. For example, a local jurisdiction's healthcare system may consist of a partnership between numbers of schools, hospitals, universities, community-based organizations, employers, foundations, or any combination of other possible settings. The majority of the time, this system works quite well and makes a great contribution to the public's overall health program. However, these are also all prime areas for the communication of the entire system to potentially breakdown. "But, we as a nation lack a formal assessment process for the national, state and local public health systems and we also do not have a National Data System to describe the infrastructure at the state and local levels." (National Conference of State Legislatures)

To add another layer for potential intersystem bickering, adding a national communication capability would be very expensive to implement even though the system is desperately needed. New and prior federal support for broad public health infrastructure could allow more local communities to address obvious gaps in the broader perspective of our healthcare system. Again, at various levels of the political spectrum, unelected civil servants and the political environment in which they operate greatly affect the competency of the nationwide public health system. "There have been strides made through the Center for Disease Control and partner organizations -- through the National Public Health Performance Standards Program, the Bio-terrorism Core Capacities Project, and the Capacity Inventory-have developed assessment instruments and methodologies to measure the public health system in state and local jurisdictions. Core competencies for the public health workforce have been established, and the Health Alert Network has strengthened the communication capacity between federal, state and local public health agencies." (Center for Disease Control)

Who are These Organizations that are In-Fighting?

The United States has a long history of interweaving civil service, politics and the public sector together with the intent of creating a viable solution to health, education and welfare. "The research facility founded as the Hygiene Laboratory in 1887 became the National Institutes of Health in 1948 with creation of the National Heart Institute, National Institute of Dental Research, National Microbiological Institute (which would become the National Institute of Allergy and Infectious Diseases in 1955), and Experimental Biology and Medical Institute (which would be absorbed into the National Institute of Arthritis and Metabolic Disease in 1950). Other institutes of health would be created later, beginning with the National Institute of Mental Health in 1949 and concluding with the National Institute on Aging in 1974." (Encyclopedia of American Industries)

The Hoover Commission on Executive Reorganization did its part by creating a Cabinet-level department for education and welfare in 1940. However, it was not until the 1953 executive order by Dwight D. Eisenhower that created the Department of Health, Education, and Welfare (HEW) which in 1979 became the Department of Health and Human Services. It was the breakup of the HEW into several competing agencies that the original power brokering began. For example, "the creation of the Department of Education, assumed all functions of the Federal Security Agency. Oveta Culp Hobby was appointed secretary of HEW, but administration of the Public Health Service remained with the surgeon general. The Public Health Service faced a major crisis soon after the reorganization." (Encyclopedia of American Industries)

The first sign of infighting occurred right around the time of Surgeon General Leonard Scheele endorsing Dr. Jonas Salk's vaccine for polio for the first time. The HEW had the power at the time to issue licenses to only six pharmaceutical companies to distribute the new vaccine and within two weeks, there vaccinated children around the nation were developing full-blown polio. "Scheele issued a statement calling for a halt to all vaccinations while the vaccine was reexamined. The problem was quickly traced to one pharmaceutical company, but more than 70 children contracted polio from the vaccine and 11 died. Secretary Hobby and her special assistant for medical affairs resigned two months later." (Encyclopedia of American Industries)

More political squabbling arose throughout the history as new expectations were added. For example, the United States Department of the Interior handed over the responsibilities of all Indian healthcare programs to the Public Health Service that then created the Bureau of Indian Affairs (BIA). The BIA today is in the trenches rooting out funding at every opportunity and interdepartmental bickering is a way of life. "The Indian Health Service is to receive $114 million for sanitation construction projects which would help support safe water and waste disposal to about 22,000 homes. The agency's budget would also provide $150 million for diabetes prevention grants -- a $50 million increase -- to 300 tribes and organizations." (American Public Health Association)

More responsibility came one year later as the Armed Forces Medical Library, renamed as the National Library of Medicine, was also added after the BIA. "Further expansions came with the Community Health Services and Facilities Act of 1961, the Vaccination Assistance Act and the Health Professionals Education Act of 1963, and the Nurse Training Act of 1964 -- each of which directed the Public Health Service to provide financial or research support for state health care programs." (Encyclopedia of American Industries)

US Department of Health and Human Services Organizational Chart (HHS)

"The Department of Health and Human Services (HHS) is the United States government's principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves." (HHS) Under their jurisdiction as mentioned, is one of the most important influential offices that come to mind when considering public health and political influence. Civil servants are classified that way because they are appointed by the decision of an authorized public institution and hopefully in accordance to civil service laws. "The employees concerned are within civilian central government or subnational government. There are many other employment arrangements in the public sector that provide something akin to civil servant status, under judicial career laws etc. However, common usage requires that civil servant status refers to employees within civilian central government, or subnational government." (World Bank Group)

There is no more highly placed an individual in the healthcare industry today than the Office of the Surgeon General who is considered to have access to unsurpassed scientific data in regard to our citizens improving their health and thus reducing risks associated with illness or injury. The main function of the office is to serve as the nation's chief health educator and the office currently falls under the direction of Dr. Regina M. Benjamin. The office "oversees the operations of the 6,000-member Commissioned Corps of the U.S. Public Health Service and provides support for the Surgeon General in the accomplishment of his other duties. The Office is part of the Office of Public Health and Science in the Office of the Secretary, U.S. Department of Health and Human Services." (OSG)

The next great influence in the healthcare industry under the U.S. Department of Health and Human Services is not a person, but it is considered a very influential entity. This department is probably the biggest cause of inevitable conflicts that consistently occur between public agencies managed by unelected civil servants and the political environment they are currently involved in is nothing short of a financial mess. Everyone knows the name Medicare. "The Centers for Medicare & Medicaid Services (CMS) administers Medicare, the nation's largest health insurance program, which covers nearly 40 million Americans. Medicare is a Health Insurance Program for people age 65 or older, some disabled people under age 65, and people of all ages with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant)." There are some very real underlying concerns in this area. The population of the nation is aging and more people will depend on Medicare to provide their healthcare. The problem is the fund is going broke: "the Medicare trustees issued their annual report on Medicare's financial outlook, and the news is ominous. Medicare spending is projected to exceed its dedicated sources of revenue, accumulating to an $85.6 trillion shortfall (measured in present value terms). This represents an unprecedented catastrophe. However, after a day or two of perfunctory reporting, Medicare's problems have dropped out of sight until this time next year. The increase in Medicare's shortfall since 2007 was more than $10 trillion -- ten times the size of the expected mortgage market losses." (Antos)

What are the real problems civil servants face in healthcare and the political spectrum?

The majority of cases that inevitably cause conflict between public agencies that are managed by unelected civil servants and the political environment they operate in are often based on money. Consider Medicare; the federal government is currently considering the nation's aging population while at the same time the very fund needed to support this growing population base is running out of money. Congress is now considering a Medicare restructuring worth a proposed $400 billion over next ten years including all new prescription drug benefit subsidies. But what about all of those other programs mentioned earlier?

The federal government, whether run by political, private or civil entities, utilizes multiple options when funding the public healthcare sector. Some examples of funding can be seen through Department Of Health And Human Services grant program. An example of the grant program would be the Substance Abuse and Mental Health Services Administration block grants distributed around the nation to individual abuse-based health clinics. This block grant program would be used to maintain many areas of the mental health community but because of the process to receive the grants, they are also many aspects of conflict. Financial assistance in the form of block grants "assists the States and Territories and enables them to implement each State's Plan for providing a comprehensive community mental health services program for both adults with a serious mental illness and to children with a serious emotional disturbance. This particular grant also aides in establishing a process to monitor the progress for implementing a comprehensive community-based mental health systems and to provide technical assistance to States and the Mental Health Planning Council that will assist the States in planning and implementing a comprehensive community-based mental health system." (Department Of Health And Human Services)

This type of program is universal in the healthcare arena and is a major source for public health maintenance. But what actually are these block grants? Based on Webster's, a Block Grant is a Federal grant made by formula under broad and general subject areas with grantees given broad latitude in specific activities. Recipients are normally States or local governments. Block Grants are sometimes called a Formula Grant. A formula Grant is an allocation of Federal money to States or their subdivisions in accordance with distribution formulas prescribed by law or administrative regulation, for activities of a continuing nature not confined to a specific project.

How can some of the conflict be eliminated in the process of receiving grants? To qualify, state or local healthcare entities are required to meet whatever the holding departments' prescribed criteria are. In the majority of cases, service funding for grants is more than likely only provided through the appropriate qualified state or community program. A major cause of conflict in regard to grants is based on the stipulations of the funds usage. Often other stipulations range from the reasons funds could be used to purchase or improve land or even to construct new buildings or facilities.

Other times block grants are asked for based on the Request For Proposal (RFP) process where organizations apply and holders of the grant decide which civil servant team could best utilize the funding. "The Centers for Disease Control and Prevention is exploring ways to streamline and improve business processes with the agency's customers. To this end, the Centers for Disease Control and Prevention is planning an Electronic Grants (E-Grants) system to enable the submission of electronic grant proposals, their review, and award. The Centers for Disease Control and Prevention is reviewing other federal E-Grants systems for potential use." (Center for Disease Control)

Internal and external in-fighting are often triggered by the formal grant process. For example, "Approximately $13,000,000 for Community-Based Participatory Prevention Research is available for fiscal year 2003 from the Centers for Disease Control and Prevention's Center for Disease Control Office of Extramural Prevention Research. Based on the "Healthy People 2010" focus area, Educational and Community-Based Programs, this grant program will strengthen the capacity of our Nation's communities and population groups to address health promotion and the prevention of disease, disability and injury through participatory research." (Health Pro)

Public health is often geared towards training and prevention so other possible grants available are the $5.9 million used to annually fund Injury and Violence Prevention Initiatives. "These announcements focus on such areas as parent training, fall prevention for older adults, acute care, rehabilitation, and dissertation awards for minority doctoral candidates. Individual awards for these Fiscal Year 2002 grants were expected to range from $100,000 to $1.5 million, with project periods from one to three years." (American Public Health Association) A serious problem and a major cause of conflict occur when governmental agencies advertise grant programs that at first may not necessarily look like public health type block grants.

A good example of this type of problematic grant can be seen in the United States Department of Housing and Urban Development grant opportunities that are used to keep the public health infrastructure complete. The Department of Housing and Urban Development the Indian Community Development Block grant (ICDBG) program also would qualify. "The Indian Community Development Block grant program provides eligible grantees with direct grants for use in developing viable Indian and Alaska Native Communities, including decent housing, a suitable living environment, and economic opportunities, primarily for low and moderate income persons. Eligible applicants include any Indian tribe, band, group, or nation including Alaskan Indians, Aleuts, and Eskimos or Alaska Native village, which has established a relationship to the Federal government as defined in the program regulations. In certain instances, tribal organizations may be eligible to apply." (U.S. Department of Housing and Urban Development)

The federal government and various agencies within the fed only provide substantial block grants that are used to fund the public health system after certain proofs are provided. The American public changed funding on tobacco product research after an onslaught of legal cases against the tobacco industry. Once there was overwhelming evidence that tobacco and mainly cigarettes were the root cause of cancer in lab rats, the American public began to realize how dangerous first and second hand smoke were. "The Ohio Tobacco Use Prevention and Control Foundation has approved nearly $7 million for 28 community-based tobacco cessation and prevention grants, including three in Greater Cincinnati. These grants represent an important milestone toward the foundation's goals to reduce and prevent tobacco use in Ohio," said Larry McAllister, foundation chairman. "We are fortunate to have been able to tap into an existing infrastructure across Ohio to mobilize experience and expertise toward saving lives." (Cincinnati Enquirer)

Another strange block grant that often causes a great deal of interdepartmental and interagency conflict occurred right after September 11, 2001. There were block grants introduced because to the September 11th attacks that was designed to strengthen the public health system against inevitable Biological Warfare first strikes. Senators' John Edwards and Chuck Hagel were the writers of the bill that potentially made $1.6 billion to improve biological and chemical weapons defenses as well as the public health infrastructure. "The bill would establish $555 million in block grants to state and local governments to prepare for and respond to biological and chemical attack, according to a fact sheet released by the senators. Within that allotment, funds would be provided for training and equipping those who are the first to respond to such attacks such as emergency medical personnel, law enforcement officials, physicians, and nurses. Funds also would be provided for local health agency planning and training, disease surveillance and information, laboratory readiness, hospital preparedness, agricultural counter-terrorism, and health care workforce strengthening." (aphanet)

The purpose of many disease surveillance funds and grants were supposed to be used to improve the state and local public health services as well as the Centers for Disease Control and Prevention. They were to provide "sophisticated, electronic, nationwide access to medical data, treatment guidelines and health alerts," a fact sheet on the bill said. (aphanet) The bill went on to authorize $100 million in block grants for strengthening our hospital emergency, trauma and intensive care units capacity.

As mentioned early on, the "Dark Winter" games showed health officials that there was a definite shortage of vaccines available for a serious smallpox attack. The senators' addressed this issue by setting aside $571 million for vaccine and antibiotics research. The $571 million was also intended to begin a stockpiling project and to initiate other "critical research in preparedness for the Center for Disease Control and Prevention, the Department of Energy, the Food and Drug Administration, and elsewhere; and $350 million for agricultural and food safety preparedness. In announcing their proposal, the senators said biological and chemical weapons present a "serious threat" to the United States. Edwards said there was no excuse for the country not to be prepared. "We need to have a system that's prepared to be efficient and respond quickly," he said at a press conference." (aphanet)

What is the result of the conflict?

Our healthcare industry is literally in turmoil. Ironically, there are a plethora of reasons for this. But healthcare will continue to be a major part of all aspects of life. The simple mantra to fix the doctors and all the issues will be resolved is too naive. Every citizen and every private and business decision in one way or another are affected by the public healthcare agencies managed by unelected civil servants. The reasons are often much hidden from the people affected. Consider that even the price of milk in a grocery and the total cost of an automobile have been affected by the crisis in healthcare because the simple business decision of hiring an employee in any business sector involves healthcare, taxes and block grants. This is how internal and external conflicts in the healthcare sector influence healthcare.

In the private sector, consider sending someone in a family to college. Health insurance is mandatory in the educational system. Each student is required to be covered by health insurance: whether a parent pays or if the school pays for coverage, either way the overall cost of that education has been altered. In another sense, healthcare costs as well as reforms in the medical and healthcare industry directly affected all areas of the nation. Our Medicare trust fund is nearly broke at a time when the nation's population continues to grow older and will require more medical attention. People over 65 are forced to break the law and get their medicines from Canada because infighting in the United States' will control costs.

A good example of how the system works and how it affects each citizen can be seen by the current other Flu pandemic. The new bird flu virus reared its head first in 2005. "The newest strain of avian influenza had emerged in Asia and Europe, brought on by the H5N1 strain of the Influenza A virus. If this particular type of influenza could transfer from person to person, a worldwide pandemic could kill millions of people. While there have been reports of the spread of H5N1 from person-to-person, these were among individuals who had come in direct contact with an infected bird." (Encyclopedia of American Industries)

In December of the same year, President Bush signed a new bill called the 'Department of Defense, Emergency Supplemental Appropriations to address Hurricanes in the Gulf of Mexico, and the Pandemic Influenza Act of 2006.' "Under this act, $3.8 billion would be utilized for an initial "pandemic influenza preparedness" phase aimed at combating this threat. An additional $2.3 billion was allotted for 2007, for a second phase directed toward readiness at all levels of government. On September 26, 2006, the House of Representatives passed the Biodefense and Pandemic Vaccine and Drug Development Act (H.R. 5533). The bill would lead to the establishment of the Biomedical Advanced Research and Development Authority, a new agency within the U.S. Department of Health and Human Services." (Encyclopedia of American Industries) The objective for this new agency was a duplication of the Centers for Disease Control and the Department of Health and Human Services. Even though the new agency had access to funding of $160 million for fiscal years 2007 and 2008, they were still the foundation for all new interdepartmental infighting.

Conclusion

In conclusion, this report aimed to present general information in the form of a theoretical essay. "The essence of civil servant status is that the legal basis for employment -- the laws and regulations that shape the nature of employment contracts -- is different from that found elsewhere in the economy as defined by the general labor law. It also is generally different from that found elsewhere in the public sector, such as in the health or education sectors or in state-owned enterprises." (World Bank Group) The goal was to present the many opportunities inevitable conflicts that can consistently occur between public healthcare agencies managed by unelected civil servants and the political environment in which these individuals and organizations operate in. Concerns such as the nation's aging population, the depleting Medicare fund, potential pandemics such as SARs, Swine Flu, Aides and dealing with national mental health concerns all need to be addressed. In the rush to solve these issues, organizations and departments need funding. That funding is often the basis for strife.

Consider the cost associated with Medicare. "There is immediacy to the mortgage mess that generates empathy even among those not directly involved. We can imagine how we would feel if we were unable to continue to make payments on the McMansion that has become overnight an overpriced liability. Even people who do not have a subprime mortgage and are not directly involved in the meltdown can identify with the second part of that statement -- living in a suddenly devalued home. To the man on the street, this crisis is real. The Medicare financing problem is eighty times larger and, for that reason, must be attended to very soon -- a point the trustees have been making for years." (Antos) Medicare and healthcare have become some of the most important issues that our nation is currently facing and as this national healthcare debate consumes the people of this nation, behind the scenes, extremely powerful health related public agencies managed by unelected civil servants vie for control in order to maintain their grasp on the health related powerbase. This essay attempted to present some of these organizations' power structures and how their internal and external conflicts affect the healthcare debate.