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Memo, dated 2006 |
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By Grantland Johnson The Secretary of California's Health and Human Services Agency plans to transform a patchwork of categorical programs during an eight-year term. |
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Grantland Johnson was Director of Health and Human Services for Region IX of the U.S. Department of Health and Human Services before becoming Secretary of California's Health and Human Services Agency. He served previously on the Sacramento County Board of Supervisors and the Sacramento City Council. LAST APRIL I had the pleasure of listening to my old boss, Health and Human Services Secretary Donna Shalala address the California Health Forum in Sacramento. As is her fashion, she spoke eloquently and frankly about the challenges that lie ahead in healthcare as she nears the end of her eight-year-tenure as the nation's health czar. Her presentation took the form of a memo to her successor as head of HHS. Her memo showed her pride in the achievements of the agency under her stewardship and her musings about her legacy. The Secretary noted that our nation has experienced higher rates of child immunization, lower rates of teen pregnancy, fewer deaths from HIV/AIDS, expanded enrollment in Head Start, a significant increase in government-sponsored preventive health-screening, and a 30 percent higher budget for the National Institute of Health in just two years. Despite these accomplishments, Secretary Shalala clearly stated that her successor would not have a stress-free ride-there are many challenges left to overcome and much to be done to ensure adequate healthcare for all Americans. As I listened to her speech, I could not help reminiscing about the five years during which Secretary Shalala was my boss while I was Region IX Director of Health and Human Services, in San Francisco. More than an employer, she was my mentor and my model for excellence in public service. Her speech also resonated with me as I recognized in it the challenges facing me as the State HHS Agency attempts to fulfill Governor Davis' commitment to enhance and improve the health and well-being of all Californians. I have only been Secretary of CHHSA for 17 months, but if I remain in this job until the end of Governor Davis's second term, or until December 2006, what would I like to be able to say to my successor about health care accessibility and delivery for all Californians? What impact would I like to have had on the future of health care in this state? Date: December 2006 To: The New Secretary, California HHSA You are taking over the largest state agency in the country. When I began, it had 15 departments and boards, 43,000 employees, over $50 billion in expenditures and far-ranging responsibilities. The Agency was vast. One department ran state hospitals for the mentally ill and another regulated them. We sited hospitals (and also cited some of them) and oversaw emergency services. We dealt, and still deal, with the economy, benefit payments and drug addiction treatment. We offered, and still offer, services to employers and employees, and we cared for, and still care for, the State's most frail and vulnerable-the elderly, the disabled and children. One way or another, this agency affects the life of every Californian. Under Governor Davis we made great strides. We began by increasing child and family access to health care through expanded coverage of Medi-Cal and Healthy Families. We enabled seniors to stay in their communities and their homes longer through the Aging with Dignity Initiative and improved access to cancer treatments for poor women and men. The Administration reached out to the faith-based community in a historic effort to provide job training and placement for those hardest to employ, in some of the California's poorest neighborhoods. These were among the many bright spots, but we still had huge challenges-like the lack of access to healthcare and how we delivered healthcare to many Californians. Momentous national demographic shifts were ahead, particularly among the elderly, whose number in California is well on its way to doubling in 30 years from the day I took over. We not only faced the challenge of an aging population, but of incredible diversity of income, race, country of origin and ethnicity. In many ways, California's greatest strengths-economy, diversity and sheer population size-made our problems more difficult to solve. We were able to reduce the wide disparities in the rates and risks of disability and death among African-Americans, Hispanic-Americans, Pacific Islanders and American Indians and Alaska natives when compared with the white population. For example, when we assumed the responsibilities of the Agency:
Poverty was an overriding cause of some of these disparities. There is a natural barrier between poor communities and neighborhoods and good health care, balanced diets, adequate housing, education and training, and jobs that pay livable wages. Even during a time of unparalleled wealth, many California families contended daily with the hardships of poverty. When the Davis Administration took office, less than half of working families with low or moderate incomes received job-based health insurance, compared with 84 percent of those with higher incomes. That is no longer true. Our road was made more difficult by the historic framing of solutions to the challenges facing our communities. Rather than addressing the whole fabric of neighborhoods and the problems of the people who lived there, we had a patchwork of isolated, categorical programs. This approach ignored how unemployment and low employment related to the absence of health insurance. It discounted the relationships between poor education, alcohol and drug abuse, and domestic abuse. It disregarded the connection between teenage pregnancy and child abuse. It dismissed the relationship between racial and immigrant group stereotypes and biases to those groups' crime statistics and high arrest rates. It failed to recognize how the historical stigma of welfare related to the low number of eligible people who applied for publicly funded health care programs. We began to reverse those trends, but it was not easy and it was not quick. We set out to create a healthcare system that maintains and improves the health of all Californians by adopting an approach to these systemic problems that simulated how we would approach any public health challenge. Our approach was scientific and data driven. It dealt with entire populations, as well as individuals. It identified and monitored trends in the "health and disease" of entire communities, neighborhoods and groups of people. It not only examined causes and effects, but factors related to or contributing to the progression of a community malady to see whether early intervention could prevent the "disease" or alter its course. Public health measures had effectively reduced the worldwide toll of malaria, smallpox, hypertension, and motor vehicle injuries. I believed we could use similar approaches to reduce poverty, decrease the number of uninsured, and thereby increase the overall health of the entire population. And it has begun to work. We have reframed the discussion about health care solutions to provide a system focus to the departments in the state's Health and Human Services Agency. First, we set about changing the mindset of the agency from a divided collection of departments and programs having little relationship with each other to one in which programs became part of a holistic system. We encouraged the departments to think across programs and develop strategies that affect entire communities. Then we redesigned old programs and implemented new ones to support the system goals. We believed that addressing issues, problems and programs collaboratively would lead to a more efficient and effective delivery of services. This required an organizational environment that encouraged fresh ideas, new approaches, and pertinent solutions. Although we deserve to be proud of the changes we have made, there is more to do. We have only begun to interact better with communities so that we establish interdependent, yet self-sufficient, communities. We need to do better at including at the table people who traditionally have been left out of decision-making. We must use the expertise and knowledge of local policy makers and indigenous leaders to identify problems better, and we must then provide them with more technical assistance to enhance their capacity to resolve and manage the issues that confront their communities. We have not ended poverty, but we have moved this huge Health and Human Services Agency from a collection of categorical programs to a high performing, integrated organization driven by outcomes and always learning from the communities served. We leave you with a system that will enable our new governor, and you, to continue to contribute positively to the health and well-being of all Californians. Sincerely, Grantland Johnson |
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