Stewardship in Mental Health Policy: Inspiration ...

Stewardship in Mental Health Policy: Inspiration, Influence, Institution? Lawrence D. Brown Kimberley R. Isett Columbia University Michael Hogan New York State Office of Mental Health

Abstract The venerable but amorphous concept of stewardship has lately gained prominence in discussions of public policy and management and is sometimes offered as a “strategy” with a distinctive potential to mobilize effective public leadership in the service of broad social missions. In this article we explore how stewardship may be useful to the theory and practice of mental health policy, and, reciprocally, how examples from mental health policy may elucidate the dynamics of stewardship. After examining its key political ingredients — authority, advocacy, and analysis — we discuss the practical challenges in moving stewardship from moral inspiration to institutional reality.

[O]ne learned to adapt oneself to reality, and a person with a trained mind would finally end up limiting himself to his specialty and spend the rest of his life convinced that the whole of life should perhaps be different, but there was no point in thinking about it . . . Suddenly Ulrich saw the whole thing in the comical light of the question whether, given that there was certainly an abundance of mind around, the only thing wrong was that mind itself was devoid of mind. — Robert Musil, The Man without Qualities

Any casual peruser of the daily papers can see that stewardship covers a lot of ground — from national economies to human kidneys and much in between. For example, in Great Britain, Gordon Brown’s 2007 budget did “little to change one’s verdict on his stewardship of the . . . . economy” (Brittan 2007: 11). On kidneys available for transplants, physician Alan Leichtman laments that “waiting time is arbitrary. . . . It’s a real shame that Journal of Health Politics, Policy and Law, Vol. 35, No. 3, June 2010 DOI 10.1215/03616878-2010-004 © 2010 by Duke University Press

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we’re not being better stewards of the organs” (Meckler 2007). As concept and calling, stewardship boasts an impeccable provenance, Providence itself, which, as Jim Armstrong (1997: 18) notes, gave men dominion over earth on condition that they “steward creation.” Although this lofty aspiration suffered a downsizing to ships and planes, in which stewards show passengers to their places, it has lately enjoyed a revival in policy and management venues. To some authorities, stewardship embodies altruism and selflessness and thus delivers a reproach both to the excesses of market reforms that premise behavior on utility-maximizing “agents” and to oppressive and self-protective bureaucratic hierarchies ripe for overhauling by flat, participatory, enlightened management structures (Greenleaf 2001). In these accounts stewardship summons visions of a “third sector,” between private markets and public bureaus, reminiscent of the deep-seated traditional American affection for voluntarism as a benign alternative to profit and politics. Other commentators straightfacedly depict stewardship as an exercise in pre–(Herbert) Simonian unbounded rationality. As portrayed by the World Health Organization (Travis et al. 2003: 292 – 293), for example, stewards canvass “current and future trends in health and health systems performance,” articulate goals, identify policy instruments, outline feasible strategies, guide the setting of priorities, “set and enforce rules, incentives, and sanctions for other actors,” and much more. Amid this stewardship debate, the purpose of this article is twofold. First, we seek to make a case for the resurgence of research on stewardship. Stewardship issues are important in today’s environment of networked and dispersed service delivery, vexing “wicked problems,” and multiple areas of authority for single lines of service (for example, housing services addressed in multiple agencies for discrete sets of clients). As Robert Greenleaf (2001: 60) points out in Servant Leadership, today we rely on institutions to provide care for one another, an approach that demands creativity in “getting the right things done” and in finding individuals who are willing to take on that responsibility and to provide vision. Second, we aim to spotlight a substantive area fertile for stewardship research across multiple public services arenas: mental health service delivery. Throughout this article we use examples drawn from our substantive area of interest to argue that several aspects of mental health services and policy are especially salient for stewardship research that has implications for the delivery of other health and human services or any services that rely on joint production functions and collaboration among agencies. Mental health policy makers must cope with the complexity inherent in

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divisions of labor that create a hollow state (Milward and Provan 2000); governmentally regulated but privately provided goods and services; a mainstream health care system designed for all and privately funded versus a publicly managed and funded, specialty mental health system; and the intergovernmental tensions in a public system that is managed on state and local levels but dependent on mainstream federal programs, which are poorly specialized to the task, to fund the services. Mental health services research is particularly instructive because these services intersect with many other health and human service areas now that individuals with mental illness are no longer housed in institutions and may instead access an array of services in the community (Isett and Provan 2005; Steinwachs 1992) — for example, housing services, criminal justice and legal services, employment services, education, and social insurance programs. Unpacking Stewardship

Why is stewardship important? Issues of leadership and paternalism in public policy and programs are as old as democracy itself. But in modern times, public policy makers and administrators face new challenges from “wicked problems,” namely, “those that are bundled with uncertainties and [for which] a solution is unclear and relies on socially constructed resolution” (Koppenjan and Klijn 2004; O’Toole 1997). Solutions to wicked problems often require that myriad organizations concert action to address the problem; in doing so, joint production functions and shared understandings of the issue must be negotiated (Koppenjan and Klijn 2004). The field of new public management suggests possible solutions to wicked problems, including network forms of organizations (Isett and Provan 2005; O’Toole 1997), collaborative bodies (Agranoff and McGuire 2003; Page 2004), and contracting out (Milward and Provan 2000). But each of these potential solutions leaves accountability diffuse, leadership responsibility vague, and, often, role delineation unclearly articulated. In short, would-be solutions may aggravate stewardship problems because getting the right things done — to revisit Greenleaf — does not fall to anyone in particular. Indeed what those “right” things are may remain unspecified and contested. Stewardship is less a concept with (as Wittgenstein said) “blurred edges” than one with a core so blurred as to display no obvious edges or boundaries at all. To demand denotations may be too much, but the myriad connotations and nuances seem to yield three distillable “spirits” of the term: trust, wisdom, and home.


Trust

Stewardship gains force from bringing front and center a highly under valued and underexamined element in policy: trust. Stewards take charge and exercise oversight in ways that transcend “mere” leadership and management by expanding civic or organizational common ground. They embrace a charge that is a kind of moral gift, holding this charge “in trust,” and displaying the ethical qualities that make one trustworthy. The objects of stewardship are at once valuable and vulnerable — at risk of being ravaged and despoiled, like the environment, for instance, or neglected and abused, like the mentally ill. (The 1926 Gershwin tune captures stewardship perfectly in its image of “little lamb[s] lost in the woods,” who “could always be good,” with “someone to watch over” them.) Unable, in Hirschman’s (1970) terms, to opt for exit or voice, the vulnerable are reduced to loyalty, which ought to be honored and repaid. In essence, stewardship is taking care to take care. The steward is careful and deliberative, also compassionate, and it may be no accident that the rise of stewardship to public prominence coincides with the arrival of coinages such as “compassion fatigue” and “compassionate conservatism,” which may catch the same something in the social policy air. The steward has a duty of careful caring, violation of which adds insult (moral betrayal) to injury (vulnerability). So construed, the notion can resonate not only with liberals but also with conservatives whose sensibilities prefer noblesse oblige to laissez-faire and paternalism to social Darwinism. Wisdom

Stewards run the (policy) show, as do leaders and managers, but they do so in a special way — that is, with a high degree of knowledge and wisdom. Stewardship must somehow reconcile a host of antinomies that plague modern social policy: generalist/specialist, forest/trees, vision/expertise, macro/micro, mainstream/exceptionalist. The story is of course old and familiar. The growth of science and industry fuels the division of labor (specialization), which in turn creates new interdependencies that cry out for coordination and integration; these interdependencies trigger endless arguments over how coordination might best be achieved — by the market’s invisible hand, social norms, charismatic leadership, state building, and so on. Within the narrower (albeit ever-widening) sphere of public policy, the more “wicked” the problem (i.e., the more numerous and fragmented the providers, institutions, payers, clients, conditions, evidence,


and so forth), the more urgent grows the need for such transcending reconciliations. Stewardship is a plea not (only) for political leadership or for leadership in administration (Selznick 1957) but for something broader and deeper — social, indeed moral, leadership. Even as the notion harks back to the voluntarist’s quest for a third sector, between market and state, profit and politics, so too the steward is neither the clueless generalist nor the introverted specialist but rather a third type of leader, one that all at once embodies expertise, a broad view of the public interest, and a properly intense devotion to the special needs of the vulnerable. The question, of course, is whether this ideal type is a realizable policy construct or a mere experiment in imagination akin to a unicorn or mermaid. Home

Stewardship has something to do with institutional homes: ports in a storm, run by kind and caring people, places where, as Robert Frost said, “when you have to go there, they have to take you in.” Stewards include pastors of churches and keepers of inns. Even stewards and stewardesses on ships and planes, whose role is perhaps mechanical, have a duty, a calling, to help people away from home find their places in otherwise uncertain, confusing, intimidating, or even chaotic settings. More than mere instruments of order, stewards welcome, beckon, and foster a sense of belonging. Patients at sea in the health care system are said to need a “medical home” in which care can be managed. For years people with serious mental illness had such a home — the public mental hospital, founded as an “asylum,” which stewarded residents’ housing, food, health care, and other needs. Discharging residents made sense because (and only because) the community mental health center — or even more vaguely, a community support system — would seamlessly assume stewardship. Some patients’ problems with mental illness proved to be more serious and persistent than foreseen, however, and for them mainstreaming meant an abdication of stewardship, an unfair exchange of home for single room occupancy units and the streets. (Again, songs catch it best: the Harold Arlen–Johnny Mercer wartime classic, “My Shining Hour,” couples “the lights of home before me” with “an angel watching o’er me.”) The salience of home and centeredness to stewardship, clear enough in the case of vulnerable populations, is less obvious for public goods such as the environment, but these seeming exceptions prove the rule. Important and far-flung public functions such as national defense, economic management, and environmental protection give rise to institutional innovations —


the National Security Council, the Council of Economic Advisors, the Environmental Protection Agency — precisely to pull the programmatic pieces together into a suitable policy home. The benefits of a policy home, however, may be undermined, especially in the United States, by the multiple institutional avenues in legislative settings (Baumgartner and Jones 1993). Multiple jurisdictions increase the voice of the citizenry (Buchanan and Tullock 1965; Mueller 1996) but defeat the cohesiveness that a home, and stewardship of the home, imply. Ingredients of Stewardship

Stewardship, in short, is a plea for mindfulness within mind — a benign intelligence that knows and sees all and takes care to take care of valued, vulnerable people and priorities. That policy these days, or any days, ought to heed this plea is indisputable, but the old question nags: might what is good in this prescription be not particularly new and what is new not especially good (that is, useful)? As Greenleaf (2001: 20) observes, “Not everything that is old and worn, or even corrupt, can be thrown away. Some of it has to be rebuilt and used again.” Does the lingo of stewardship elevate the quality of policy discussion, or does it simply sugarcoat the sad realities of muddling through, the demands of rational choice, the pulling and hauling of group interests, and the myriad of other forces that drive higher callings out of sight and out of mind? What are the political and policy ingredients of stewardship, anyway? We see several. Authority

A position of authority does not a steward make, but stewardship presupposes that one playing that role has some authority or can influence someone who does. In mental health policy, authority was formerly a fairly compact and concentrated affair, resting as it did with the directors and staffs of public mental hospitals and with their state and local overseers and funders in the executive and legislative branches of government. For better and for worse, the system’s stewards were easy to find. Nowadays authority over mental health policy is famously fragmented and decentralized — this being, of course, one major driver of more insistent calls for stewardship. The most influential voices in mental health policy are “state Medicaid directors, the Social Security commissioner, the administrator of the Centers for Medicare and Medicaid Services (CMS), and human resources directors in U.S. corporations” (Frank and Glied


2006: 91). A bewildering array of institutions supply treatment: “shortterm mental hospitals, state and federal long-term institutions, private psychiatric hospitals, nursing homes, residential facilities, community mental-health centers, outpatient departments of hospitals, community care programs, community residential institutions with different designations in different states, [and] client-run and self-help services” (Mechanic and Grob 2006: 239), to which one should add behavioral health management organizations and prisons. The states run Medicaid and mental health departments, but community mental health care is often the province of local governments. Thus the care of people with a mental illness is subject both to the vertical tensions of federalism and devolution (the socalled hollow state in the public management literature) and to the horizontal tensions of siloed bureaucracies. As the Supreme Court’s landmark 1999 decision in Olmstead v. L.C. (527 U.S. 581 [1999]) demonstrated, judicial authority can reorient (or disorient) the system (Frank and Glied 2006: 85). And not least imposing on this list of stewards are people with mental illness themselves — consumers who now choose their source of treatment from a competitive market of providers (ibid.: 48). The splits and separations that accompany mainstreaming of care for the mentally ill enforce their own gulf, dividing the demands of mental health stewardship into two provinces: the provision of care and the formulation of policy. The watchwords for provision of services have been service integration (the aim of several public and foundation demonstrations that have, on the whole, registered lackluster results) and managed care (on which the verdict seems to be more favorable, albeit equivocal on the care of those with serious mental illness) (ibid.: 67 – 68). Meanwhile, stewardship in the making of mental health policy remains an Alphonse-Gaston routine in which the feds and the states stolidly defer to one another. Frank and Glied contend that stewardship is best vested in federal hands (their proposal is discussed briefly below), and there are sound reasons to agree. Federal funding for these services by means of Medicaid, Medicare, and Supplemental Security Income (SSI) was the key driver of the policy mainstreaming that aggravated the fragmentation that triggered the clamor for stewardship. What Mechanic and Grob (2006: 236, 233) flag as “in many respects the key turning point in mentalhealth policy” was the federal decision in 1964 to bypass the states and deal directly with community mental health centers (CMHCs) — entities that were themselves a product of a two-decade quest by the leaders of the National Institute of Mental Health (NIMH) to substitute communitybased policy for public mental hospitals.


On the other hand, mental health is a very small frog in a very large federal pond; the feds have done more to scramble lines of authority (bypassing the states in search of community-based services) than to repair them; and the NIMH has cultivated a research role, a niche that gained attractiveness after the agency’s attempts at services innovation during the Reagan years were rebuffed. Perhaps, then, stewardship starts with states, not feds. After all, central to the mainstreaming story (“still substantially untold”) is how state administrators used federal programs to empty public hospitals and design new arrangements (ibid.: 231). One might infer that the true source and center of stewardship would reside in favorable relations and strong connections between the directors of state mental health departments and state Medicaid offices. The most plausible models of stewardship then may be the “policy entrepreneurs” who attempt to reconfigure the mental health systems in states such as Ohio, California, and Texas (Frank and Glied 2006: 101). Unfortunately, the conditions that evoke and sustain this stewardship qua policy entrepreneurship are little understood. Do they turn on the meeting of innovative and progressive minds at the top of the mental health and Medicaid agencies? Is the prodding or backing of governors and legislative champions necessary or sufficient to trigger cooperation among agencies? What tends to generate such political support — personal philosophy, mental illness in the family, the influence of celebrity advocates? Or, to come full circle, is federal pressure on state Medicaid directors the sine qua non for bringing to the proverbial table parties otherwise separated by roles, rules, and resources? Advocacy

In principle, authoritative sources within a state — especially in such favorable circumstances as gubernatorial sympathy and availability of political or economic capital — could see the light and start to infuse stewardly thoughts and deeds into policy-making routines. As the scope and scale of government grow, so too does government’s perceived need to innovate in hopes of solving its problems (Brown 1982). Health maintenance organizations, managed care, and myriad regulatory interventions in health affairs, for example, came on the scene not because public opinion or influential organizations were demanding them but because the federal government sought the least painful means to contain health care costs (Brown 1983). In practice, however, policy measures for the benefit of vulnerable, stigmatized groups such as the mentally ill tend to advance


in tandem with the power of such groups to apply old-fashioned political pressure — advocacy — from below, which is most likely to succeed when some triggering event focuses the public’s attention on an issue and empowers a policy community to push elected officials to pass sympathetic legislation (Kingdon 1995; Hilgartner and Bosk 1988). Although advocacy politics for the mentally ill and its impact on policy making have not been well studied (for one notable exception, see Weiss 1990), there seem to be three main sources of stewardship at work. First, government itself may take the lead, achieving the authority-advocacy fusion evident in such cases as HMOs. Important examples of this fusion include the NIMH’s diligent advocacy of community-centered care, which bore fruit in federal authorization for community mental health centers in 1963; the Supreme Court’s Olmstead decision, which gave fresh force to “least restrictive” strategies; the Americans with Disabilities Act of 1990, which expanded work options for the mentally ill and other disabled individuals; miscellaneous (and apparently unchronicled) projects of the Substance Abuse and Mental Health Services Administration (SAMHSA); and proactive innovations by state mental health directors, such as investing resources in consumer- and family-empowering programs that broaden the reach and amplify the voice of the mentally ill. One example is the National Alliance on Mental Illness (NAMI) Family-to-Family Education Program that one of the authors (Hogan) installed in communities across Ohio. (Family-to-Family is an educational and support program conducted in small groups in which participants learn about diagnoses, treatments, and other information; it prepares most participants for caregiving but some for advocacy.) Though often important and sometimes transformative, this internal path to stewardship tends to be intermittent, and may not be seen as an appropriate role of managers and bureaucrats within the famous politics-administration dichotomy (Wilson 1887). A second source of advocacy is, of course, interest groups. In the mental health advocacy arena, voices create a kind of policy babel, with more dissonance than convergence of interests. A leading case in point in mental health policy, NAMI, illustrates the challenges. The alliance represents constituencies (mostly families and consumers) with differing aims, serves many functions (education and support as well as advocacy), and aims to influence a wide range of policies (the most important of which, Medicaid, is arcane, variable across the states, and far from preoccupied with the mentally ill alone) (Mechanic and Grob 2006: 230). The policy decentralization that makes mental health a striking island of exceptional-


ism in a widening mainstream sea seems to encourage NAMI to stay on the island, as it were, focusing less on big federal and state programs than on such comparatively low-hanging fruit as the SAMHSA block grant (Frank and Glied 2006: 100). Consumer groups are another imposing presence on the advocacy scene, but they train their attention less on the key social insurance institutions that pay for care than on such process innovations as case management (ibid.: 100 – 101). Until these advocacy groups find a unifying agenda and voice that enable them to promote their core values together, they will lack powerful impact on policy (Sabatier and Jenkins-Smith 1993). Third, in mental health policy, as in Medicaid (Brown and Sparer 2003), a broad base of politically and financially engaged providers is a crucial advocacy resource for groups that are ill equipped to fight for themselves. Here the tale is one of simultaneous broadening of the provider base and diffusion (perhaps dilution) of provider influence. In olden times, employee and community constituencies of mental hospitals often successfully lobbied for funds from state legislatures (Mechanic and Grob 2006: 244). As mental health mainstreaming advanced, a greater range of programs paid a more motley crew of providers. On the meaning of this development for politics and policy, the literature offers two interpretations that seem to conflict. One reading emphasizes a loss of influence; the lack of prominence of mental health issues within Medicaid, the largest funder of mental health services (ibid.: 244); and the muffled voice of mental health advocacy within the policy mainstream (Frank and Glied 2006: 103). The other reading underscores the success of the swelling ranks of providers at capturing the policy process and exploiting it for their own ends rather than for those of consumers. Neither version is very heartening for stewardship. An expansion of provider types arguably unique to mental health care has encouraged psychiatrists, psychologists, social workers, psychiatric nurses, counselors, generalist physicians, and staff of CMHCs and the mental hospitals that remain to become unusually adept at capturing and manipulating the political process (ibid.: 70 – 71). In their quest for legislative and regulatory goodies, such as prescribing privileges, mandated benefits in insurance plans, freedom-of-choice laws, licensing restrictions, and the continued existence of hospitals, they aggravate the difficulties of managing the mental health system with a unifying vision (ibid.: 84 – 85). Chalked up as a latter-day instance of regulatory capture as depicted and deplored by George Stigler, Milton Friedman, and their acolytes, this pattern looks like the opposite of stewardship — purely self-interested agents


maximizing their utility by using politics to gain enactment of policies that disfavor that eternal fall guy, the public. That interpretation is debatable even for such classically aggrieved publics as users of utilities, railroad services, and public schools. (Anyone but a flaming ideologue can see, for example, that the relative merits of, say, a voucher system over public schools depend entirely on how vouchers are designed and funded.) Unadulterated capture theory is of equally questionable application to stigmatized and otherwise special publics such as the mentally ill. Under the old state hospital– and county hospital–centered system, administrative arrangements “often protected patients only to the extent that their interests coincided with those of staff,” leading to states and counties operating what were essentially warehouses, not treatment facilities designed to move people toward productive lives (Frank and Glied 2006: 72; Grob 1991). The key questions about providers as advocates are, first, does the provider-driven equation hold for today’s enlarged and decentralized system, and, second, if so, is it a case of stewardship in action or in retreat? After all, the past several decades have seen the arrival of new psychotropic drugs, mental health parity laws, and stronger evidencebased care in communities, each of which benefits both the mental health industry (providers and pharma, for example) and consumers to differing degrees. Analysis

Intermittent assertion of stewardship by public authorities, difficulties in finding a unified organizational voice for the diverse interests of the mentally ill, and stewardly ambiguities about whose interests the political demands of mental health providers really serve make it clear that advocacy cannot be the last word in realizing effective stewardship. Taking care to take care also entails an astute reading of who needs what and of what works well, less well, and not well at all and for whom — analysis, in short. In mental health as in other policy arenas, authorities find themselves besieged by advocacy agendas in the face of which cluelessness and short attention spans can have high costs. The historical record, Mechanic and Grob (2006: 245) remark, shows the high price of “implementing ideologies ungrounded in empirical reality and [of] making exaggerated rhetorical claims.” Mental health policy pervasively reveals “extraordinary effects that were neither anticipated nor desired and consequences that had dire effects on the lives of those who were most vulnerable” (ibid.).


Short time horizons among would-be stewards confound this problem. The heads of state mental health agencies average less than three years on the job. Logic and some evidence suggest that success in initiatives for change is related to tenure. Beyond “first, do no harm” lies “next, do some good.” The base of information and evidence on which policy makers may draw has impressively expanded and improved recently. Research sponsored and conducted by the NIMH (the funding and research agenda of which such advocates as NAMI have “enormously” enhanced [Frank and Glied 2006: 100]); the American Psychiatric Association; the federal government’s Patient Outcome Review Team for schizophrenia; and by academicians, pharmaceutical firms, and practitioners permits a detailed charting of which treatments and settings are coming, going, gone, apparently here to stay, and still awaiting a verdict (see ibid., esp. chap. 7). All the same, mental health care (by no means unique within the health system) is “often entirely disconnected from evidence” (Szalavitz 2007: A21), and the research base, particularly for applied and policy-relevant knowledge, is small (Brousseau, Langill, and Pechura 2003). The funnel that filters analytic findings to policy makers is disturbingly narrow because the mental health expertise found among these bastions of exceptionalism is at once increasingly concentrated on “an ever-shrinking part of the resources that treat mental illness” and unable to make an impact within the big programs that matter most (Frank and Glied 2006: 102 – 103). Meanwhile, “boundary spanners” who map and navigate common and contested terrain among the worlds of mental health, employment, housing, schools, substance abuse treatment, income support, medical care, and nutrition are in short supply (Kastan 2000). All this leaves a void at the analytical center of the stewardship enterprise. Institutionalizing Stewardship

Stewardship in mental health policy is not one thing but rather three resources — authority, advocacy, and analysis in creative combination, mutually enriching and drawing strength from one another. Moral inspiration and political influence can carry these stewardly synergies only so far. The question, then, is can stewardship (so construed) be institutionalized, and what are the means to advance and sustain it?


Commissions

Presidential and national commissions on mental health may seem to be an odd, even oxymoronic, institutional vessel for stewardship. Although their unveilings, deliberations, and proclamations lift the needs of the mentally ill into prime time, they are here today, gone tomorrow. The dynamics of the President’s New Freedom Commission on Mental Health, which President George W. Bush created in 2002 and which one of us (Hogan) chaired, tells a subtler story, however (Cunningham 2003). The commission not only drew analysts, advocates, and public officials into its deliberations but also, taking a leaf from a precursor commission in the Carter years, followed a rough-and-ready model of interaction among these three groups. Implicitly acknowledging the obstacles to influence — chiefly, the absence of levers with which to translate the glossy final report into a durable commitment to policy change (especially for a complex and midrange issue within an arguably disinterested administration) — the commission aimed to leave behind a body of work on which advocates and authorities might build. Analysts wrote policy papers, many of which were published not under the auspices of the leery feds but rather in journals to which advocates, mobilized and given a forum and voice by the commission, could recur in their efforts to influence government officials whose participation in the commission had motivated them to take up the cause of mental health in their own agencies. If the aim is to sow seeds of change from below and within the policy process, commissions have considerable appeal. If the objective, however, is to assemble fragments and fortify the stewardly mind from above, they fall short of the mark. Agencies

If stewardship demands, above all, a guiding, rationalizing intelligence beyond the fray of fragmented interests, why not create a new presidential agency to supply it? Calling explicitly for a new stewardship structure, function, and institution within the federal bureaucracy, Frank and Glied (2006) suggest as a possible model the Office of National Drug Control Policy (ONDCP), which has the power to review and comment on the adequacy of the budgets of agencies engaged in drug control. This sophisticated suggestion raises several complex questions. If the coordinating agency is located not within the federal bureaucracy per se but rather (like the National Security Council [NSC], the Council of Economic Advisors [CEA], and the ONDCP itself) within the Executive Office of the


President (EOP), it will join a crowd of agencies that some critics view as too dense to promote effective presidential management. Most EOP agencies—the NSC, the CEA, and (arguably) the ONDCP — pursue broad national goals and missions recognized as collective (national security, a sound economy, a drug-free society), not the interests of subsets of the population. Exceptions to this rule — most notably, the Office of Economic Opportunity (OEO) of the Johnson years — tend not to fare well within the EOP, where their presence may be viewed as largely symbolic. The influence of presidential agencies is a nearly pure function of presidential priorities (and those of top aides), so a new agency begs the question of how to make mental health policy a prominent political commitment. The power to review, comment, and recommend on agency budgets could be a salient attention getter, but the terrain to be scrutinized is vast — Medicaid, Medicare, SSI, employment, education, housing, substance abuse, and more — so credibility for the agency would seem to presuppose a large staff with expertise not only in mental health policy but well beyond it. The ONDCP may be good at infighting over budgets (there seems to be little literature on the matter), but its record is spotty in other respects. The GAO, for example, has questioned the quality of the ONDCP’s internal (especially financial) management, and its public face lately features not accomplishments in coordination but rather controversies over the content and wisdom of its advertising campaign against drug use. The risk, in short, is that in the mental health arena such an agency would be hamstrung by intra- and interorganizational politics and by vagaries of the presidential agenda. Institutional choice, as Terry Moe (1990) pointed out, can embody tokenism as well as promote effectiveness. Process

Perhaps the guiding image of stewardship should not be one of integrating structural fragments from on high but rather of promoting mechanisms that concert federal and state efforts within a dispersed and fragmented federal system. Medicaid (1115 and Health Insurance Flexibility and Accountability, or HIFA) waivers provide a vehicle, and the New Mexico Interagency Behavioral Health Purchasing Collaborative offers a case study. The collaborative seeks to centralize leverage for behavioral health care — not by organizing agencies but rather by means of pooled purchasing of behavioral health services wherever they occur. This herculean effort includes seventeen agencies and departments across state


government. No less critical than the new internal state mechanism is New Mexico’s effort to involve and energize stakeholders (e.g., consumers, families, Native American groups) to participate in design and governance by authorizing local collaboratives in fifteen regions throughout the state. Finally, a robust evaluation of the effort sustains a dialogue about underlying issues and efforts to resolve them (see Coleman-Beattie and Isett 2005 and Isett and Miranda 2007). Waiver authority and its accompanying funds may give both the feds and the states leverage to catalyze change and material incentives to resolve internal differences among constituencies. Such procedural innovations should proceed with caution to avoid unintended empowerment of a few, however. Umbrella governance has its limits (Mott 1968) and a long record of failed efforts (Agranoff 1991). Conclusion

Stewardship is less an answer or solution to what ails mental health policy than a heuristic — a conceptual lens through which to contemplate and more cogently interrogate the status quo. Such experiments in perspective do little directly to create “learning organizations” or to reform policy making, but they clear intellectual and ideological underbrush and point the way to answers that may come to seem — and be — newly feasible should the political and organizational will to take care to take care of the problems besetting both service and clinical issues for the mentally ill one day gain strength.

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