I. Introduction

Because of the unusual nature of this year, Congress has done almost nothing in the arena of health policy development since the planes crashed into the Pentagon and the World Trade Center on September 11^th. While that event certainly demanded the full attention of Congress, it is likely that they would have returned to dealing with some of the nation's health policy problems had it not been for the introduction of anthrax-laced mail into the halls of the Senate in October. These two events together have literally stopped the US Congress in its tracks from dealing with all non-security, non-essential legislation.

The Administration, however, must deal with the ongoing responsibilities of running the government and, although, much of its attention is devoted to its war against terrorism the daily process of governance goes on. The Department of Health and Human Services (HHS) has full responsibility for administering many health and social welfare programs but it also has the responsibility to develop policy proposals for both the President and the Congress. One of the most important offices in HHS for purposes of policy review and development is the Office of the Assistant Secretary for Planning and Evaluation (ASPE).

II. Assistant Secretary for Planning and Evaluation

The Assistant Secretary for Planning and Evaluation serves as policy advisor to the Secretary of Health and Human Services on every issue. His responsibilities include analysis and policy formulation, development and review of regulations and legislation, budget analysis, strategic planning, policy research, and program evaluation.

The new Assistant Secretary for Planning and Evaluation is Bobby P. Jindal. I had the pleasure of working with Bobby when he was the executive director of the National Bipartisan Commission on the Future of Medicare in 1998. He came to the Commission from the Department of Health and Hospitals in Louisiana where he was responsible for a $4 billion budget and in the space of two years managed to eliminate a $400 million deficit. He has served as the President of the University of Louisiana System and he has a stellar academic record. He is uniquely qualified to think about the challenges facing our country today and, since many of the other actors in health policy are diverted right now, his role will be unusually strong this year. Because of this fact, I asked my staff to interview him and find out what we can expect from the Administration in the health policy arena next year.

The primary role of ASPE is to be a non-partisan evaluation staff for the Secretary. It was designed not to be an operating division but rather staff to the secretary so it could provide objective analysis of various issues and proposals. It funds research on a variety of healthcare and welfare topics. It has a staff of 140 including contractors. Some of these people work inside the department but the majority work elsewhere in academia or other public policy research organizations.

It is organized into several offices. The major offices are:

-- the Office of Disability, Aging and Long-Term Care Policy,

-- the Office of Health Policy,

-- the Office of Human Services Policy/HHS' Chief Economist,

-- the Office of Program Systems, and

-- the Office of Science Policy.

The people in these offices are responsible for extensive research and evaluation of HHS programs. They also play a critical role in the development of health policy regulations and are currently working on the finalization of new privacy regulations that I discussed in this newsletter a year and a half ago.

In recent years ASPE has done 175 research projects in the Office of Disability, Aging and Long-Term Care Policy and 56 research projects in the Office of Health Policy. These studies range from a National Study of Assisted Living for the Frail Elderly to a look at the Effects of Welfare Reform on the Health status of Immigrants. While there are many other parts of HHS which do analysis and research this is the place where much of the work done to develop new policies and evaluate existing policies comes together.

We asked Mr. Jindal what he sees as the future of his operation and health policy development in these unusual times.

He told us that this Secretary, Tommy Thompson, believes in having his department speak with one voice on policy matters. Since this is a very large and wide-ranging department including agencies as diverse as the Centers for Disease Control, the Food and Drug Administration, the Centers for Medicare and Medicaid Services, the National Institutes of Health, the Indian Health Service, and many others, one can see how difficult that may be to accomplish. Other Secretaries have had different philosophies and at times each individual agency within the department has had great freedom to make and advocate its own policies even if they did not always fit in with positions of other agencies within the department. This year Secretary Thompson would like these views to be more coordinated.

Because of Mr. Thompson's approach to policy, Mr. Jindal's office will have a great deal of work to do in the development of the HHS budget and policy proposals for the next year. While ASPE does not have control over the agencies' recommendations, it is staff to the Secretary for legislative and regulatory review and as such represents him in discussions with the various agencies as they prepare their policy agendas.

This becomes a very challenging process because each agency has its own mission and they all have very significant interests in policy. Mr. Jindal tells us that proposals are usually developed through a dynamic process of meetings and conversations that arrive at consensus within the department before they get to the Secretary. He says that Mr. Thompson is very concerned that the process does not get bogged down so affected agencies get a chance to see each other's proposals and comment on them but there are very strict timelines so something can't be "talked to death". Although it doesn't have veto power, it is the job of ASPE to see all these proposals and coordinate the package that goes to Mr. Thompson.

III. Policy Priorities

Secretary Thompson has a number of high priority issues that the agency will be devoting its time to. Although he couldn't give us too much detail because of upcoming negotiations inside the department and the administration, Mr. Jindal did list several issues that are of high priority to the Secretary.

-- Access to care -- It is a very high priority of Mr. Thompson to decrease the number of people in this country who are uninsured. The department has already made and aggressive and creative use of its waiver authority to help more people get insurance and it will continue to try new ways to reduce the number of uninsured. In this year alone the department has added 1.5 million people to the Medicaid and SCHIP rolls through the use of waivers and it has expanded benefits for an additional 3.5 million people. The Secretary's goal is to make the waiver process as easy and quick as possible and he has promised his former colleagues in governor's offices around the country expeditious responses to their waiver requests.

-- Improve Medicare -- Secretary Thompson wants to modernize the Medicare program. He wants to focus more on quality of care and reduce some of the serious problems we see in health care for the elderly. He would like to add some form of catastrophic coverage and prescription drug coverage and make the program more like the Federal Employees Health Benefit Plan.

-- Improve Quality -- In addition to improving the quality of care in Medicare, Secretary Thompson wants to improve quality in all care. He particularly would like the department to help think about ways for people to use technology to improve the quality of care and reduce errors at all levels. Mr. Jindal notes, the Secretary keeps saying, "We have better technology in our grocery stores than in our health care settings." He wants to encourage adoption of electronic prescribing methods, electronic patient records, and the use of other tools to decrease errors and improve quality.

-- Improve Public Health -- The department has ongoing efforts to improve public health and ASPE, in particular, is involved in significant research efforts on the prevention and avoidance of Asthma and Diabetes.

-- Organ transplantation -- The Secretary is concerned that more work be done on organ transplants. He wants to increase the number of organ transplants and organ donations.

-- Workforce -- There is a serious concern in the department and throughout the federal government about the workforce problems in health care. These are becoming more important as the population ages and in the present as we deal with ongoing bioterrorism threats.

-- Bioterrorism - No Secretary of HHS today can ignore the problem of bioterrorism and this Secretary has been particularly active on the issue. Even before the events of September 11 and the October anthrax attacks, Secretary Thompson and his staff were working very aggressively on this problem. Obviously, they will be very involved as Congress deals with the problems posed in this arena during the next budget cycle.

-- Welfare Reform -- Last, but not least, the department has major work to do on the subject of welfare reform as the reauthorization of that program comes up next year. Secretary Thompson has a very strong interest in preventing teen pregnancy and developing a strong "healthy families" policy. While this is not limited to the area of welfare reform, it will necessarily be a part of any welfare reform efforts. It remains to be seen what this means for health care programs. While welfare reform itself is not a health program, there are so many interrelationships between welfare and health care that the manner in which a new program develops will be of interest to all those who are concerned about our health care system.

Obviously, ASPE will not be the major initiator of proposals in these areas but it will be the office that tries to pull all the pieces together for the Secretary and the Administration. As they work on these problems the leadership in that office brings to the table a unique sensitivity to state and local concerns. Both Mr. Jindal with his wide-reaching experience at the state level and Secretary Thompson with his experience in the Wisconsin governorship have a strong interest in developing federal policies that work in cooperation with the states. The Department is actively working on "tool kits" to share with the states on best practices based on information they have learned from their evaluations. They also want to work closely with states and localities on evaluating programs that show particular strength and success to see if they can be replicated elsewhere.

IV. Supporting Activities

One of the most important responsibilities Mr. Jindal has as the Assistant Secretary for Planning and Evaluation is to chair the HHS Research Council. This is a new group that has been set up by the Secretary to coordinate research across all operating divisions within the Agency and evaluate programs as a precursor to policy development. Its mission is twofold, to evaluate short term policies and work with the operating agencies to look at the longer term impact of their policies on people and organizations.

Mr Jindal also serves as co-chair, along with a designated operating agency director, of the Data Council. The Data Council coordinates all health and non-health data collection and analysis activities of the Department of Health and Human Services. In this capacity it serves as the HHS liaison to the National Committee on Vital and Health Statistics.

The council does a limited amount of modeling but its primary focus is on keeping the basic health care data consistent. ASPE does most of the staff work of the data council and shares its information with other government agencies and private contractors who try to answer various questions about the future of health care in this country. ASPE also works closely in partnership with the Office of the Actuary in determining the long-range cost of a variety of programs including Medicare.

The Secretary has placed the Data Council in charge of implementing the administrative simplification provisions of the Health Insurance and Portability and Accountability Act of 1996 (HIPAA). They have been very instrumental in the release of the regulations on privacy that were required by HIPAA.

IV. Conclusion

Clearly ASPE is an invaluable office to the Secretary of Health and Human Services as he deals with the competing pressures that come before him in the policy making process. It will be interesting to see how health policy unfolds next year as the pressures to deal with domestic social problems grow in a difficult economy and the pressures to expand resources for national security grow as our new efforts to combat international terrorism place increasing stress on the national budget. For more information on ASPE you can visit their web site at http://aspe.hhs.gov/

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