WASHINGTON -- It takes someone with real fortitude, like a fan of the last-place New York Mets, to become administrator of the Health Care Financing Administration at such a difficult time.
But Bruce C. Vladeck, 43, arrived from New York this spring with faith in the future, an attitude honed by allegiance to a baseball team for which the present is a nightmare. Perhaps to remind himself that patience is a virtue, he has hung a Mets souvenir clock on his office wall.
Budget cuts notwithstanding, Mr. Vladeck's goals include improving services to Medicare and Medicaid beneficiaries and making it easier for doctors and hospitals to deal with the bureaucracy -- reducing paperwork and regulations, for example.
Ideally, he'd like more patients to have the option of joining health maintenance organizations, where they could receive more comprehensive services than many now do by going to individual practitioners.
Mr. Vladeck, who is dividing his time between offices at both locations, has told union leaders of a possible management shake-up in the agency, which employs 3,000 workers in Woodlawn and 1,000 in Washington.
"I think he's going to move to flatten management out -- more of a horizontal approach to management, rather than the current vertical one, which means there probably won't be as many management positions at the present levels," says John Gage, head of Local 1923 of the American Federation of Government Employees.
"He's a very strong proponent of . . . 'TQM', total quality management, letting employees in more on decision-making."
Mr. Vladeck, whose annual salary is $115,700, sees his mission as even bigger than the very big challenge of running two programs that serve 67 million elderly and poor people and will cost $230 billion this year. He wants to help rekindle popular belief in government.
Referring to the Bush and Reagan administrations, he says there have been "12 years or more of a systematic effort to undercut the legitimacy of government intervention in important aspects of important life." Now that Mr. Clinton has taken over, there is a "very narrow window . . . to attempt to show the public what good government is."
His activist philosophy has familial roots. His father's father, born in Russia, was a leading socialist who participated in the revolution of 1905 and soon after left for the United States. His maternal grandfather was executive secretary of the International Ladies Garment Workers Union.
Mr. Vladeck's mother, sister and brother are all lawyers, as was his late father, who also was chairman of a health insurance organization that grew out of the labor movement.
"I suspect Bruce's real interest in health care stems from my father's passionate involvement in trying to make sure low-income working people had access to high-caliber, affordable . . . health care," says his brother, David, an attorney in the Public Citizen Litigation Group, a nonprofit public interest law firm.
Mr. Vladeck obtained a bachelor's degree from Harvard University and master's and doctoral degrees in political science from the University of Michigan. In 1974 he began teaching public health, as well as political science, at Columbia University.
Later, he served as assistant commissioner in New Jersey for health planning, where he helped design a hospital rate-setting system that become a model for federal Medicare regulators. He wrote a book on the dismal conditions in many nursing homes in the 1970s, "Unloving Care: The Nursing Home Tragedy."
From 1983 until Mr. Clinton named him to head the Health Care Financing Administration, he was president of the United Hospital Fund of New York, a health policy think tank. While there, he rose to national prominence as a theoretican on health issues and an advocate of programs for the poor.
Admirers describe a man of high intellect, discipline and wide-ranging interests.
Sally Rogers, acting president of the United Hospital Fund of New York, says, "He has an incredible capacity for work, and he probably reads faster than anybody I've ever been associated with. He remembers everything he has read and can cite things back to his college years."
"He's not a technocrat," says his brother, David. "It is true that he's developed the expertise you need to sort of wind your way through the complex formulas that apply to hospital reimbursement and so forth. But if you look at his writings, they're always on a broader plane."
"At the hospital fund, his work focused on how do you get high-quality care to people with AIDS. What do you do about the emerging TB epidemic in New York? What do you do about teen-agers who are really out of the health care system? What do you do about prenatal care? Those are the issues that captured his attention," David Vladeck says.
But the activism that marks his career raises concerns in some quarters that he is too eager to regulate.
Gail Wilensky, who headed the Health Care Financing Administration for two years in the Bush administration, says there are two directions a HCFA chief can go.
"Any time you are in a regulatory agency, you can do the minimum amount of regulation consistent with the law," a more conservative approach she espouses, "or you can . . . expand the amount of regulations because you think that's the best way to get things done," the tack she thinks he'll take.
Mr. Vladeck responds: "There's an awful lot of taxpayer dollars that flow out of this place. And we have some real legal and moral responsibilities to be damn careful about how we spend that money. That's not a question of being a regulator or not being a regulator. That's a question of being a prudent and thrifty public administrator."
Whatever the philosophical differences, no one disputes his credentials. He's "well-liked, smart, knowledgeable," Ms. Wilensky says.
"Bruce was one of those people who brings to government the capacity for academic excellence and insight, with a real practical feel for the world around him," says James R. Tallon Jr., majority leader of the New York State Assembly and chairman of the Kaiser Commission on the Future of Medicaid.
Though he works long hours, say those who know him, Mr. Vladeck takes out time for his wife and three children. Once, Ms. Rogers recalls, he spurned a White House invitation to watch his son play baseball.
Baseball is one of his passions. Careful in his choice of words, Mr. Vladeck terms himself a "connoisseur" of the game.
His interest in language carries over to his use of verse -- at birthdays, dinners and speeches, his brother says -- and underlies his discomfort with the agency's name. "It lacks a certain euphony," he says. "The acronym," HCFA, "doesn't win any prizes, either."