Going It Alone

Abstract

In 1993, Washington State passed its landmark Health Services Act designed to reorganize the state’s health care system. The crafters of the act acknowledged that having a strong public health system was essential to the achievement of health systems reform and therefore embedded public health reform into the act’s strategies for comprehensive change. Midterm elections resulted in legislative changes that spawned a repeal of most of the Health Services Act, except for mandates for public health reform. This study discusses the unintended consequences of enacting policies written as embedded components of larger reform processes. Findings suggest that under these unexpected conditions, attempting reform reveals how local public health jurisdictions strategically respond to the reinstitutionalization of that which defines public health as a unique institutional form. Without the original policy in place, there is no system wide mechanism to effectively influence the coupling dynamic that characterizes this loosely coupled system.