Silver, George A. American Journal of Public Health; Washington Vol. 87, Iss. 4, (Apr 1997): 681-6.
In response to professional and political pressures in 1967, an incident occurred at the Department of Health, Education, and Welfare that illustrates the delicacy and complexity of the legislative process. In an effort to bypass interest group influences, the undersecretary of the Department undertook a maneuver that backfired and frustrated an opportunity that might have resulted in the establishment of a Cabinet office of Health. In addition to demonstrating the sensitivity of the legislative process, and the dangers of overconfidence in dealing with the process, the events also offer moral guidance: too stubborn, idealistic convictions of good people, however well intentioned the actions, may serve to defeat the desired ends. (Am J Public Health. 1997;87:681-686)
Introduction
History chronicles what happened, including the successes or failures inherent in specific events or actions. Participants and observers enliven or embellish the record with "anecdotes"-their reflections on and responses to those events or actions. As an observer and a minor participant in an event that left no trace on the record, I believe that a description of that event and of the light it throws on the political process deserves to be recorded, even if anecdotally. This might be considered the tale of the dog that didn't bark-a nonevent, so to speak, or a "might-have-been" that, had it not been aborted, could have had an impact as great as or even greater than that of some historically transcribed events.
Such a nonevent was the frustration of an effort by the Department of Health, Education, and Welfare (DHEW) to lay the groundwork for a Cabinet office of secretary of health in 1967. How might the national organization of health services in the United States have developed had there been a Cabinet office for health? Would the situation today be any different from what it actually is?
As a cautionary tale, the following report serves a number of purposes. It illustrates how a good idea, developed by a good man, failed in part because of the hubris of that good man and in part because of the stubborn idealistic convictions of other good men. It points up how trivial events may precipitate large misfortunes. And it serves as a snapshot of how casually a critical social issue may be addressed and how equally casually a solution may fail to be realized.
Background
In 1967 I was the deputy assistant secretary for DHEW. The job was relatively new; by that time I had held the position for barely a year, and I was the first with that title. DHEW itself was not yet 15 years old, having been cobbled together in 1953 from the Federal Security Administration agencies. That organization had its origins in Franklin D. Roosevelt's administration as a compromise, a kind of collage of existing agencies aimed at reducing multiple access to the president without magnifying the power of the combined organization in the change. A new Cabinet office was rejected then out of concern that it would elevate the welfare bureaucracy. Congress feared and disliked the word welfare much as it does today, and it insisted on finding other language; thus, the first cluster of agencies in the newly (1958) organized Federal Security Administration included the National Youth Administration, the Civilian Conservation Corps (both of which were dropped after World War II), the Social Security Board, the Public Health Service, the Office of Education, and the US Employment Service. In 1940 the Food and Drug Administration, St Elizabeths Hospital, and Freedmen's Hospital were added; Howard and Gallaudet Universities and the Office of Vocational Rehabilitation were added in 1943; and the Childrens Bureau and the National Office of Vital Statistics were added in 1946.
President Truman tried twice to make the Federal Security Administration a Cabinet office and failed, largely because of congressional opposition to national health insurance but also because of agency pressures. Each of the included agencies had its own powerful constituency: beneficiaries, longtime staff, and congressional protectors-the often-described "iron triangle" of political power in government.' Previous presidents and advocates of a national department of health, both in the l9th century2 and in the early 20th, had failed as well.3
When President Eisenhower succeeded in making the Federal Security Administration a Cabinet office-the Department of Health, Education, and Welfare-he was following the recommendation of the 1950 Hoover commission. But the agencies relentlessly sought to maintain their independence from this upstart department, and Congress helped by harshly constraining the budget and limiting the positions that the department could fill to effectively carry out its objectives.
The first secretary was Oveta Culp Hobby, who had served under Eisenhower in the European theater in World War II as head of the Women's Army Corps, which she had organized. She was also the wife of the millionaire publisher of the Houston Post. The appointment of Mrs Hobby, the first woman to head a Cabinet department since Frances Perkins, was also in all probability a reflection of the traditional political attitude that health, education, and welfare were "women's work," consistent with the "maternalistic" social policy concepts of the time.4
With "a tiny staff of her own choosing and an unusually small number of supporting civil servants," Secretary Hobby did not mind the constraints inherent in the reorganization plan testimony that the "new department status would not require any substantial buildup" in her staff.5 These constraints were, of course, part of the effort of agency officials to prevent the secretary from seizing administrative control. The Bureau of the Budget officials also had reservations about putting too much authority in the hands of a new secretary for fear that pressure groups would manipulate the new bureaucracy, so it moved to restrict any line authority. Instead of an "assistant secretary" grade common to other Cabinet departments, only an official called "Special Assistant to the Secretary for Health and Medical Affairs" was named.
The politicians selected to be secretaries of this department found the situation humiliating and, in Secretary Abraham Ribicoff's word, "unmanageable." I suspect that appointing a woman to the Cabinet job was another ploy in those heedless sexist days signifying the intention to inhibit the secretary's power and the department's functioning. (This background of the origin and rather halting growth of DHEW is well covered in Rufus Miles's book.)
Then came the fatalities associated with the nationally trumpeted poliomyelitis vaccine, which seemed to testify to bureaucratic inertia in certifying the safety of the Salk polio vaccine. Subsequently, there was a slow, quiet shake-up in the department. Mrs Hobby resigned, Surgeon General Scheele moved on to a job in the private sector, and National Institutes of Health director William Sebrell took early retirement. It hardly seemed as though DHEW could ever become a vital Cabinet office.6 Successive appointeesArthur Fleming, Anthony Celebrezze, and Abraham Ribicoff-strained to add muscle and authority to the department, but without much success.
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