TOWARD RESPONSIVENESS-EXTERNAL PROCESSES

SO FAR, I have been talking almost entirely about the way in which we can and should take care of our own household, how we should plan, evaluate, manage, and the like. I want to turn now to our relations with others.

THE HEW ROLE

HEW has two main roles, one direct and leading, the other indirect and supporting. In our direct role, we administer programs in which the sharing of responsibility would not be administratively feasible. Such, notably, is the social security system. Since both eligibility for benefits and benefit levels depend on contributions to the system over a working lifetime, payroll records must be centralized, and eligibility determinations must be uniform. Federal administration is a practical necessity. Much the same considerations underlie the provisions of H.R. 1 calling for Federal administration of the income-maintenance aspects of the President's Welfare Reform program.

So it is, too, with every other activity in which HEW has a direct role: The reasons why it is direct are practical, not theoretical. We provide health services for Indians and Alaskan Natives because there are no other health care providers who normally live and work in the places where Indians and Alaskan Natives live. HEW monitors the safety and efficacy of drugs and biologicals because uniform national standards could not otherwise be enforced. And although our Public Health Service "marine hospitals" may seem to be an exception to the practicality principle, there were no local facilities able and willing to take care of sick merchant seamen when this system was born.

We perform our direct roles well, I believe-and, with due recognition of budgetary constraints, outstandingly so. Indeed, the consistency of the Social Security Administration's performance in meeting ever-higher standards of efficiency is the strongest evidence we have that HEW can do an outstandingly good job of administering the Welfare Reform program.

Our prevention of dependency and institutional reform strategies, however, will primarily engage our indirect, supporting role, rather than our direct, leading

one. The teachers, the healers, the social workers, and the rehabilitation counselors, after all, are not employed by HEW, but by State and local governments and by private agencies. And while this is in a sense only an historical consequence of our Federal system, the system itself was built on a pretty solid understanding of the needs and problems of people. Even if, in other words, the Constitution had not originally contemplated a secondary and supporting role for the Federal Government in providing services to people, a sensitive awareness of human needs and a sensible understanding of the structure required for responding to them would have brought us out at the same place. To paraphrase Voltaire, if we did not already have a Federal system, we would have had to invent one.

It follows that the success with which HEW carries out its indirect, supporting role depends on our effectiveness in backing up those who teach and heal and serve. They are the frontline troops. Our mission is to provide planning and logistical support. Our job is to help by identifying the needs to be met; to help by making sure that the people who can make good use of better methods of providing services are made aware of them; by supplying financial support of such services; by increasing the supply of service providers where there are shortages; and by improving communications within the whole service system.

These, at any rate, are the things we should be doing. The trouble is that in attempting to do them, we all too often get in our own way as well as in the way of the service providers.

At the head of the list of self-created obstacles is the needless multiplication of categorical grant-in-aid authorities. The multilayered network of specialized and autonomous agencies which the Federal Government has spawnedcombined with constricting and frequently conflicting Federal guidelines-yields fragmented, overlapping, inefficient and unresponsive service delivery. This Department administers more than 200 special-purpose social, educational, and health-related service programs, generally administered through separate State agencies and, in turn, through their separate local affiliates. The result is too much scattering of resources, too little coordination and consolidation. The examples are endless of the dedicated people seeking to respond to some urgent community need who have been driven to despair by their inability to penetrate the categorical jungle.

To become fully effective, we must "disenthrall ourselves" from the existing system. We must wrench our attention away from the tending of governmental machinery and turn it outward to people and their problems, to the neighborhoods and communities where they live, and to the effectiveness of what we do in seeking to give them help.

CUTTING AWAY RED TAPE

THE MOST UBIQUITOUS outgrowth of program proliferation is the strangulating vine called "red tape." We have launched a three-pronged attack against it. The first prong is headed by the Federal Assistance Streamlining Task Force.

Inaugurated by Secretary Finch, FAST has studied 225 grant programs representing approximately $15 billion in HEW domestic assistance. It has offered, and helped to implement, a number of recommendations on ways to improve administrative and operational procedures. For example, in 1965 under Federal formula grant programs for Health, Maternal and Child Health, and Crippled Children, Tennessee submitted a plan 790 pages long, a budget of 35 pages, and another 94 pages of expenditure reports-919 pieces of paper! In the present fiscal year, after FAST, Tennessee need submit only a one-page, preprinted certification plan, a one-page budget, and a one-page annual expenditure report— three pieces of paper, satisfying all Federal requirements.

Following other FAST recommendations, the Health Services and Mental Health Administration has delegated all decisionmaking for specific individual projects to the 56 regional medical programs around the country. Local projects no longer have to be approved individually in Washington; the job can be done faster and more simply at the local and regional levels.

From a second direction, the Office of Grant Administration Policy is seeking to standardize and simplify the requirements we place on a varied lot of grantee institutions and organizations. A single, standard form has been developed for all HEW construction grant, loan, and interest subsidy programs. A single form to replace 14 forms for reporting expenditures under research grants is in process. Other matters being considered include a common timetable for processing grant applications and the desirability of giving program managers discretion to use either grants or contracts.

Third, we're trying to facilitate access to grant funds. One useful device will be the "switching station," a mechanism invented by a group headed by the Assistant Secretary, Comptroller. Because many worthwhile projects deserving HEW support are too broad in scope to be wholly financed by one categorical grant-in-aid program, a prospective grantee is forced to divide his project into pieces which match the Federal categorical programs. He must then hunt separate funding for each piece.

The switching station will change this. If a future grant applicant has a project requiring funding from several different HEW project grant programs, he will submit a single application to the switching station. The station will review his project as a single entity and, if it is approved, will arrange to combine funds from the applicable categorical programs into a single, integrated grant award. This is our most promising approach so far to establishing a grant-packaging capability in HEW. We are continuing work on others.

GRANT CONSOLIDATION

EVEN THE BEST administrative expedient cannot be more than a partial solution. More efficient and straightforward is the legislation this Administration has proposed to consolidate separate but related categorical authorities. Our pro

posal for special revenue sharing in education, for example, would consolidate 33 categorical activities into a single authority embracing five broad aspects of elementary and secondary education. In so doing, special revenue sharing would reduce the number of regulations and guidelines, broaden existing programs, and foster comprehensive planning to use Federal funds more effectively. For the States and local school districts, it would mean both a larger responsibility and a greater ability to deal with their educational problems in ways adapted to their own requirements.

The Assistant Secretary for Health and Scientific Affairs is formulating a similar initiative for health. There are about 40 separate Federal health grant programs, making it almost impossible for consumers and for health agencies and professionals to put together anything resembling comprehensive health services. With the advice and assistance of such groups as the National Advisory Health Council and the Association of State and Territorial Health Officers, we hope soon to have a health revenue-sharing proposal comparable to the one in education.

SERVICES INTEGRATION

CUTTING AWAY RED TAPE, grant packaging, and grant consolidation will, separately and in combination, make Federal support less hampering and more useful. They will help to bring about more comprehensive, less categorical servicedelivery systems. But the fragmentation of services is by no means a consequence solely of Federal policies and procedures, and it cannot be overcome by Federal action alone.

At the community level, the agencies devoted to helping people are too numerous, too limited in function, and too isolated from each other. Local agencies tend to be fully as jealous in protecting their own turf as any Federal entity. Professional disciplines do not lose their guildmindedness at the local level. As a consequence, an individual in need is all too often forced to go from agency to agency, none of which is capable of dealing with him as a whole person.

It is not enough, therefore, simply to improve the ability of each provider of services to perform its particular role. We must also promote communication among the various service providers, joint planning among them, coordinated program operations, and comprehensive systems of dealing with the needs of people.

This effort to help service providers break down the barriers that impede concerted and effective action is going forward within HEW in two allied thrusts. First, we are working with State and local service providers to design various. R. & D. models for testing the desirability and feasibility of services integration, and our regional offices are assisting a number of States and communities that are already committed to the principle of services integration. Second, we are developing Federal legislation to help local service providers break down the categories that slice the individual into segments, bridge the barriers between the

helping professions, and build an integrated approach to the goal of reducing dependency.

Working With Service Providers

We now have about 20 projects built around a variety of services integration models. In one promising experimental project, social services are being provided after school hours in a public school building. We are also testing the feasibility of integrating social services in hospitals. And, in another approach, four agencies providing separate services are joining in a common outreach capability.

Our aim is not simply to put all services under one roof, if that indeed were possible. Nor is it simply to be able to say that all services in a community have been linked together. Our most important model is a conceptual model developed by the Community Services Administration of the Social and Rehabilitation Service in which goals are clearly formulated and progress will be measurable. This model assumes a continuum ranging from total institutional dependency to economic self-sufficiency, with people being assisted at every stage in the continuum. The goal is to move as many as possible up to the next stage, and finally to self-sufficiency.

Our Regional Directors have already found 24 cities with a strong desire to integrate local services and pull together relevant HEW resources. The HEW response ranges from assisting service centers to expand the range of their services to helping local governments coordinate a diversity of services. Several Governors and State officials, with our assistance and encouragement, are also trying to pull together social services at the State level.

Services Integration Legislation

Legislation we are now developing will make possible a quantum leap beyond the work with service providers that is now in progress. Its aim is to make it easier for Federal, State, and local governments to work together to deliver services to people in a coordinated and effective way. It will help to build the capacity of service providers for joint plans and operations across program lines to alleviate conditions of dependency. It will also widen the flexibility of Federal support for States and localities through provisions for transfers of Federal funds between programs, waivers of inconsistent Federal program requirements, and limited funding for planning and administrative costs. In turn, States and localities will organize themselves to provide services to their citizens in a more comprehensive and cohesive manner.

The proposal will encourage, assist, and support-but not require—the integration of services. It epitomizes our institutional reform efforts: It would not pay for additional programs, but underwrite the administrative costs of improving the