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The Swedish Social Insurance Agency is an important part of the Swedish welfare state. The Agency has recently made a number of major changes, such as establishing a new internal organization and reforming processes for decision making. Many of these changes have been controversial. Critics have complained that the Agency shows a lack of efficiency, has failed to make payments on time, and has been too harsh in its application of eligibility rules. The changes have put the agency at a number of crossroads, many of them recurring from earlier reforms, in dealing with problems such as regional differences in the application of rules. In this article, some of these choices are discussed. The discussion departs from four dichotomies: uniformity-local adaptation; centralization-decentralization; specialization-generalist approaches; and closeness-distance. These dichotomies are illustrated with examples from the agency. The general conclusion is that although the change process has taken a rocky road, there has been a great deal of internal consistency in the combination of measures taken.