Case Studies Reveal Why Innovative State Health Programs Often Fail

Beginning in August 1996, researchers at the Massachusetts Institute of Technology (MIT), Cambridge, Mass., examined options for strengthening the managerial capacity of states to implement and sustain innovative health care programs.

Limited managerial capacity at the state government level was a widespread problem, often jeopardizing programs in health care reform.

Key Findings

The investigators examined three examples of organizational mechanisms for maintaining expertise in state government that could be applied to the health policy arena. They were:

  • Case Study #1: New York's hospital rate-setting system from 1984 to 1996, which survived shifts in the health care system because Gov. Mario Cuomo's long tenure afforded the stable, well-protected base necessary to attract and maintain talented staff.
  • Case Study #2: The Massachusetts Water Resources Authority, which managed the cleanup of Boston Harbor, exemplified the second mechanism: creation of an independent public authority or corporation insulated from politics and civil service rules.
  • Case Study #3: A partnership between a public agency and a not-for-profit with technical and managerial expertise was exemplified by the relationship between the U.S. Air Force and a MIT research group.


From all three case studies, the investigators found that to achieve long-term success, a talented team that combines technical, organizational, and political skills must continue staffing the program.

  • Case Study #1: Classic executive leadership provides the stability and power to sustain innovation, but it is rare and cannot be relied on as a solution to institutionalize reform efforts.
  • Case Study #2: The creation of a public authority or public corporation as a mechanism for circumventing state civil service can provide the needed independence to make changes.
  • Case Study #3: An ongoing partnership between a public-sector agency and a nonprofit college, university, or foundation can provide a marriage of technical expertise and resources, but tensions between the two may arise.