Improve Population Health and Efficiency Through Internal Competition Within Public Agencies

Against the backdrop of rising federal debt and sweeping workforce reductions across U.S. health agencies under the Trump administration, this commentary proposes a potential principled alternative to arbitrary budget cuts: an intra-agency competition framework to foster internal competition within public health agencies. Drawing on economic theories, the authors argue that splitting agencies into two or more autonomous, competing subunits could help reduce costs, increase efficiency, and improve population health outcomes by channeling competitive incentives toward the public interest. The framework is potentially applicable across three broad functional domains of government: direct service delivery (e.g., the fee-for-service Medicare program), where competing subunits can be evaluated on return on investment weighted by beneficiary satisfaction; regulatory oversight (e.g., the Food and Drug Administration), where competition can reduce bottlenecks and improve decision quality by subjecting each subunit's performance to comparative scrutiny; and public health practice (the Centers for Disease Control and Prevention), where regional subunits can compete on a cost-effectiveness metric such as the ratio of health gains over subunit operating costs. Financial incentive structures permitted under U.S. federal employment law and civil service regulations are discussed. Potential applications in other countries were also explored, especially countries with publicly funded healthcare delivery systems. A potential implementation roadmap is proposed, along with key implementation challenges, including the complexity of measuring outcomes, legal uncertainties regarding executive reorganization authority, political barriers, risks of fragmentation and inequality, and short-term administrative overhead. The paper concludes that rigorous cost-benefit analysis and phased pilot programs are essential before broad adoption.