Analysis of the HHS Draft Strategic Plan, FY 2018-2022

Update: Please note that after the comment period closed, the U.S. Department of Health and Human Services removed all of the documents from their site that are linked below. The links are all now broken, but the content is still relevant.

On September 27, 2017, the Department of Health and Human Services (HHS) released their Draft Strategic Plan for the 2018-2022 period. The biggest shift from the current HHS Strategic Plan, FY 2014-2018, is from the focus on getting Americans covered (current) to the emphasis on free-market solutions and personal responsibility (in the new/draft). Otherwise, largely, there are a lot of similarities.

The HHS Draft Strategic Plan, FY 2018-2022 was released just two days before former HHS Secretary Tom Price resigned from office. HHS confirmed that they expected this Draft Strategic Plan process to continue, regardless of the leadership changes.

All federal agencies are required to have a four-year strategic plan to comply with the Government Performance and Results Act (GPRA) of 1993, which ensures that agencies are creating measurable performance goals that are publicly available and tracked. The Trump Administration is not only setting their new philosophical goals for HHS, but also complying with the GPRA mandate.

HHS’ most recent published four-year Strategic Plan was for 2014-2018 and can be found here. It was weighted by the Obama Administration’s efforts at the time to implement the Affordable Care Act and the emphasis on coverage is clear, but otherwise focuses on similar priorities as this draft because the HHS department priorities then, and now, are far reaching.

Nuts and bolts of the strategic plan

The new HHS Draft Strategic Plan, FY 2018-2022 is organized as follows:

• Introduction
  • Key info about the department, the document, its purpose
• Five strategic goals
  • Each with four accompanying objectives
  • Strategies for accomplishing each
• Appendices

The five strategic goals and accompanying objectives are as follows:

• Strategic Goal 1: Reform, Strengthen, and Modernize the Nation’s Health Care System
  • Objective 1.1: Promote affordable health care, while balancing spending on premiums, deductibles, and out-of-pocket costs
  • Objective 1.2: Expand safe, high-quality healthcare options, and encourage innovation and competition
  • Objective 1.3: Improve Americans’ access to health care and expand choices of care and service options
  • Objective 1.4: Strengthen and expand the healthcare workforce to meet America’s diverse needs
• Strategic Goal 2: Protect the Health of Americans Where They Live, Learn, Work, and Play
  • Objective 2.1: Empower people to make informed choices for healthier living
  • Objective 2.2: Prevent, treat, and control communicable diseases and chronic conditions
  • Objective 2.3: Reduce the impact of mental and substance use disorders through prevention, early intervention, treatment, and recovery support
  • Objective 2.4: Prepare for and respond to public health emergencies
• Strategic Goal 3: Strengthen the Economic and Social Well-Being of Americans across the Lifespan
  • Objective 3.1: Encourage self-sufficiency and personal responsibility, and eliminate barriers to economic opportunity
  • Objective 3.2: Safeguard the public against preventable injuries and violence
  • Objective 3.3: Support strong families and healthy marriage, and prepare children and youth for healthy, productive lives
  • Objective 3.4: Maximize the independence, well-being, and health of older adults, people with disabilities, and their families and caregivers
• Strategic Goal 4: Foster Sound, Sustained Advances in the Sciences
  • Objective 4.1: Improve surveillance, epidemiology, and laboratory services
  • Objective 4.2: Expand the capacity of the scientific workforce and infrastructure to support innovative research
  • Objective 4.3: Advance basic science knowledge and conduct applied prevention and treatment research to improve health and development
  • Objective 4.4: Leverage translational research, dissemination and implementation science, and evaluation investments to support adoption of evidence informed practices
• Strategic Goal 5: Promote Effective and Efficient Management and Stewardship
  • Objective 5.1: Ensure responsible financial management
  • Objective 5.2: Manage human capital to achieve the HHS mission
  • Objective 5.3: Optimize information technology investments to improve process efficiency and enable innovation to advance program mission goals
  • Objective 5.4: Protect the safety and integrity of our human, physical, and digital assets

The format changed from the current 2014-2018 version, which is waterfall-aligned by: Goals, objectives, strategies, and performance indicators. This new draft version has no performance indicators. I will discuss that more below. The current 2014-2018 version was easier to read, as there was a lot of context and narrative.

Analysis

What was the same from the previous plan?

The new 2018-2022 Draft Strategic Plan largely continues a number of goals from the previous strategic plan and work that was ongoing through the goals of the Center for Medicare and Medicaid Services Innovation Center. The Innovation Center was established under the ACA to develop, test, and implement new payment models for Medicare and Medicaid. The Innovation Center has been testing market-based solutions for healthcare payment models since its inception.

Additionally, many HHS goals for public health, disaster preparedness, science, research, transparency, accountability, and disparities

 

What was conspicuously different from the previous plan?

There are dozens of references to leveraging faith-based organizations as part of the various objectives. These institutions certainly were not necessarily excluded from doing so, when appropriate, under previous HHS leadership, but there is clearly an overt effort to partner with faith-based organizations as often as possible on as many objectives as possible. There are many high quality healthcare organizations, which are also faith-based organizations. However, issuing a call, writ-large, to faith-based organizations seems to suggest that they may somehow fill the role of healthcare provider organizations, which would not be appropriate in many cases.

Additionally, there were several references to improving or protecting Americans’ health throughout the lifespan, including “from conception” or including “the unborn.” While the current 2014-2018 version also has an objective focused on prenatal care, using this terminology is clearly intended to appease certain audiences. However, the policy didn’t change: Just the conspicuous wording. In order to guarantee the best pregnancy-related outcomes, the Obama Administration ensured that coverage began as early as possible, which is at the states’ discretion.

There is also a big emphasis on patient or consumer personal responsibility throughout. HHS has governance of numerous anti-poverty programs: Medicaid, TANF, SNAP, child-support, and LIHEAP (collectively, these programs are colloquially referred to as: health care, cash assistance, food stamps, child-support, heat assistance), to name a few. “Personal responsibility,” or what is sometimes called “skin in the game” usually means people want the consumer to have some consequences associated with their utilization trends.

Even outside of public programs, there is an emphasis on giving patients or consumers more information to drive healthcare decision-making. This is not how the medical system works and giving consumers more information will not change the reality of the market.

Related to the theme of personal responsibility was the theme of “removing barriers” to work and other obstacles. These barriers should be clearly identified so HHS can discuss strategies for removing them more clearly, as well as the associated performance metrics.

 

What was missing or deficient?

As mentioned above in the structure section, this Draft Strategic Plan has no section for performance indicators to align to each goal’s objectives. HHS should consider where they draw a baseline, considering many goals are a continuation of work done under the previous Administration and they will want to properly benchmark progress. Additionally, the strategies are not operationalized as well one might expect and they could be more actionable if it was clear how they would be measurable. While HHS may intend to publish this draft and then have the appropriate agencies develop metrics, they should make that clear — perhaps even by proposing operational metrics.

Antimicrobial resistance is a serious public health threat and this Draft Strategic Plan handles it as a strategy for meeting a few different objectives, but primarily under Objective 2.2. It should be called out under its own objective, or at least separated out from chronic conditions. (See: Objective 2.2: Prevent, treat, and control communicable diseases and chronic conditions.) It is too critical to short and long term global health to be handled casually.

As previously mentioned, most references to accessing coverage and care were modified from the current FY 2014-2018 version. The current version focuses on achieving universal, high quality care, but conversations around access were focused in his draft on affordability and consumer responsibility. This is expected, given differing Administration priorities.

The new version also takes pain to avoid discussing disparities in connection to race or ethnicity, but rather just all disparities. There are strategies linked to “culturally competent care” but that does not begin to scratch the surface of this problem.

A lot of these initiatives proposed in the Draft Strategic Plan cost money. At a time when the overall goal seems to be to cut the operating budget of the department and agencies, as well as the mandatory and discretionary spending of the federal government, it is not clear how these expenses will be offset.

There is an emphasis on “Serious Mental Illness,” (SMI) rather than just “mental health.” SMI is a clinical term that connotes a specific subset of mental health diagnoses. It is surely this Administration’s prerogative to focus on those diagnoses over others, but the lay-public does not understand these terms and use of nomenclature like “serious” may be off-putting to getting more people screened for common and pervasive, yet serious, conditions like depression and anxiety.

 

What was good?

Goal 4, centered around scientific advancement and evidence-based practices, was really well-designed. If all of the other goals and strategies flowed from this approach, then this effort would be on more solid footing. However, knowing that many of the selected objectives may not supported by sound science or evidence, the connections between this goal and the other goals and objectives was unclear. In other words, without research or studies, if allowed to proceed, some of the strategies, particularly for Goal 1, are not well-founded. As mentioned above, there were specious assumptions about consumer directed spending, or “personal responsibility,” but no clear provider responsibility for patient spending patterns.

Otherwise, largely, these goals are bipartisan, and despite wording, most (indeed, not all) of the objectives are consensus-driven approaches to widely-acknowledged U.S. healthcare problems. Most of these issues will be able to strategically drive the HHS workforce of over 80,000 people and almost 30 agencies without distracting politics for the next four years.

 

Conclusions

Overall, HHS may consider a structure change and tie goals, objectives, and strategies to performance metrics. That is critical for a successful strategic plan. It would be ideal for the public to be able to comment on the metrics before finalizing.

If the Administration can tie most of their efforts to Goal 4 and truly operate in a science and evidence-based decision-making capacity for policy and program decisions, then that will increase confidence in the other philosophically-driven goals as well. Many of their conservative, free-market solutions to healthcare, particularly in the safety net programs, have yet to be evaluated properly. Based on the statements in Goal 4, it appears that the Administration might plan to do that, in scientific earnest prior to bringing them to scale. Clarification of this would be enormously helpful.