President Donald Trump’s appointees in the health department have deleted positive references to Obamacare, altered a report that undermined the administration’s positions on refugees and added anti-abortion language to the strategic plan — part of an ideological overhaul of the agency’s research office.
While every administration puts its imprint on the executive branch and promotes ideas that advance its own agenda, this one has ventured several steps further — from scrubbing links to climate change studies from an Environmental Protection Agency website to canceling an Interior Department study on coal mining risks and suppressing reports on water contamination and the dangers of formaldehyde.
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Inside the Health and Human Services policy research shop, staffers say the political pressures to tailor facts to fit Trump’s message have been unprecedented.
Several pointed to embarrassments such as PolitiFact grading a lawmaker’s statement, based on the agency’s May 2017 report on Obamacare premium hikes, as “false,” and concluding the study had serious methodological problems.
Another report suggesting that millions more people would get health coverage if Obamacare were rolled back — a finding at odds with nearly every independent analysis — was widely mocked and produced over the objections of career staff at the office of the assistant secretary for planning and evaluation, known as ASPE, say several sources.
The office has been especially vulnerable to political pressure because its leadership remains in flux. The University of Minnesota health economist tapped to lead the office by Trump has been dogged by questions about his financial entanglements, leaving his nomination in limbo for more than a year. The acting head of ASPE was recently reassigned to a regional office, and the top deputy altered McKinsey-produced data to make it more favorable to the Trump administration, according to multiple sources with knowledge of the changes.
“I find the attack on the integrity and the culture of the office to be disturbing,” said Richard Frank, a Harvard health economist who ran ASPE as an Obama administration political appointee. “This is really a departure to an office that has a 50-year history to it.”
HHS officials vigorously disputed portrayals of the office as ideologically driven.
“I reject the premise of your question and allegation,” said spokeswoman Caitlin Oakley. “Secretary [Alex] Azar has made very clear that HHS is a science- and evidence-based organization and it will operate accordingly.”
Oakley said the 120-person office has been refocused to work on Trump administration priorities like drug pricing and the opioid epidemic. Two staffers say those topics are regarded as safer ground because they are not part of the health care culture wars. Under Azar, who assumed leadership of the agency about six months ago — after most of these incidents occurred — the office has produced a six-page research brief on drug pricing, which published this week, and two studies on the opioid epidemic. Oakley said more reports are coming.
Republican health policy analyst Lanhee Chen, who served as an HHS senior counselor in the George W. Bush administration, scoffed at the notion that this policy shop is more partisan than the one that preceded it.
“I don’t believe the Trump administration ASPE has put out reports that are any less analytically or methodologically rigorous than those of the Obama administration ASPE,” Chen said. “Those who express concerns regarding the quality of reports ‘falling off’ are probably using that argument as a cover for the fact that they disagree with the findings of the reports.”
Chen said he regards the policy shop as a vehicle to advance administration policy, “so in that sense, methodological rigor has not necessarily been a metric I have used to evaluate their reports. That’s why we have studies from academics and analysts outside of government.”
This story is drawn from interviews with nine individuals with knowledge of ASPE operations, most of whom asked for confidentiality to speak freely, as well as with outside observers.
Shift in office’s focus
ASPE historically has been used to investigate the impact of HHS policies and help shape future strategy, and under the Obama administration, it focused closely on the expansion of health insurance coverage and the Affordable Care Act — issues on which Barack Obama had campaigned heavily and made central to his presidency. The office published 43 reports on the ACA’s effects on rural hospitals, women’s health and other discrete corners of health care between January 2015 and January 2017 alone, generally extolling the effects and sometimes overlooking the drawbacks.
For instance, one 2016 study on choosing health plans in the ACA market was criticized for slanting its findings.
“The analysis was solid, and the numbers were all in there,” said Larry Levitt of the Kaiser Family Foundation. “But there was a heavy emphasis on affordability for consumers receiving subsidies, and the fact that premium increases were quite large was somewhat buried.”
Frank, who led the office at that time, said he was trying to balance several goals.
“One was to implement the policies of President Obama and produce analyses that would support implementation of the president’s goals,” Frank said. “But second was to be a steward of the organization [and] produce analysis that was pretty transparent, so if the press or others wanted to figure out how we did things, it was easy to do.”
Frank also defended ASPE’s Obama-era studies, which he says were broadly accepted as methodologically sound. “When I was preparing to be confirmed, I had the staff pull up fact checks on every one of our reports because I wanted to know the number of Pinocchios,” he said, referencing The Washington Post’s rating system for truthfulness. “There weren’t many.”
ASPE’s output dramatically slowed and changed under the Trump administration, producing just three reports that investigated health coverage despite the president’s repeated promise to explore and create alternatives to Obamacare.
The reports also have been widely questioned: One touted by Sen. Ted Cruz last year suggested that 4 million more people could get health coverage if his legislation to roll back Obamacare took effect — a conclusion at odds with the Congressional Budget Office and criticized by numerous independent analysts.
That also wasn’t the conclusion of ASPE’s career staff. Instead, the report drew on findings by consultants at McKinsey & Co. and was altered by a Trump political appointee named John O’Brien, a deputy assistant secretary who previously worked as a vice president at CareFirst BlueCross BlueShield, according to three individuals. The published version identifies O’Brien as the author within the document’s metadata.
“They used numbers and graphs from McKinsey and slapped their own labels on it” to help Congressional Republicans achieve a political victory, said one person with knowledge of the alteration. The episode drew scrutiny from Congress and raised concerns from ASPE career staff and inside McKinsey.
“ASPE was never intended to get involved” in analysis of one party’s legislation, said one staffer. “That’s just not what we do.”
O’Brien, who was tapped to advise Azar this year, referred questions to the HHS press office. McKinsey declined to comment.
“We pay contractors for various projects at the agency, and it’s no surprise that when we pay for and develop a product, it has HHS’ name on it,” said an individual with knowledge of the report. “And HHS did not change the content of the report.”
Other reports also have run into political interference. Researchers last year concluded that the net financial benefit of refugees to the United States government was $63 billion over 10 years, because of the taxes they pay and other economic contributions. However, the 55-page report was quashed out of concerns that it would bolster the case for admitting refugees as the Trump administration prepared to reduce admissions, The New York Times first reported.
HHS instead issued a three-page report that focused on refugees’ costs, finding that they used more of the health department’s services than the average American.
“We do not comment on allegedly leaked documents,” said John Graham, then the acting secretary of the office, adding the office’s focus was solely on health department costs and to “provide anything more would be beyond the scope of HHS’s response.”
Changing language and websites
ASPE civil servants also were pressured to alter the agency’s strategic plan, which POLITICO first reported in February.
“Political leadership were adamant that all the references to LGBT health issues should be taken out,” said one staffer.
The prior plan, published in 2014, made seven references to LGBT health. “Support the safety, well-being, and healthy development of children and youth … including lesbian, gay, bisexual, and transgender (LGBT) youth and other vulnerable populations,” read one objective under the Obama administration.
Meanwhile, language sought by anti-abortion advocates was added into the draft plan and included in the final version posted this spring after Azar took the reins. “A core component of the HHS mission is the dedication to serve all Americans from conception to natural death,” the plan now reads — the first time that the health department formally said that life begins at conception.
“In our strategic plan we actually affirmed life from conception to natural death,” Shannon Royce, the HHS liaison with religious leaders who pushed for the new language, said at an Evangelicals for Life conference in January, touting the change as “very significant.”
Meanwhile, a new report from the Sunlight Foundation’s Web Integrity Project tracked how the policy shop retroactively altered the descriptions of reports that found positive effects from Obamacare.
“Millions of Americans have already [benefitted] from many of the law’s provisions including coverage for preventive health services, ban on lifetime limits, and insurance coverage for young adults,” the office’s website read until mid-2017. “The expansion of Medicaid coverage and launch of Affordable Insurance Exchanges will help millions more in 2014.”
Under the Trump administration, those descriptions and a research section on “the Affordable Care Act” were removed from ASPE’s site. The reports were relocated to a new section called “Historical Research,” while a new section of the site — “Health Coverage Research” — was added.
“Since January 20, 2017, ASPE has been developing research that analyzes the impact of Obamacare (the Affordable Care Act) and models changes that will create a market that lowers costs, increases quality, and gives more choices than Obamacare does,” the section’s description now reads.
One reason that ASPE has been especially vulnerable to pressure is because it has lacked a full-time assistant secretary, staff say.
Trump in early April 2017 nominated Stephen Parente, a University of Minnesota economist who had performed analyses for then-Rep. Tom Price, among his many consulting engagements.
However, Parente’s nomination has stalled, and other top officials who were chosen weeks or months after, including assistant secretary of legislation Matthew Bassett and general counsel Robert Charrow, have since joined HHS.
POLITICO in October first reported on Parente’s history of working with the insurance industry, one of several financial entanglements that has hindered his confirmation, according to two individuals with knowledge of the discussions.
Parente continues to pursue the position and has been on the Hill this summer meeting with lawmakers. He also attended Azar’s speech at The Heritage Foundation on Thursday, and HHS leadership still supports his candidacy, a spokesperson said.
In Parente’s absence, Graham was made acting secretary overseeing ASPE, and O’Brien was essentially his top deputy, according to four staffers.
The office also leaned on inexperienced leaders. Kara Townsend, then a 29-year-old GOP health care policy adviser to the Senate health committee, was appointed to lead the research division on disability, aging and long-term care — inheriting a position that had previously been filled by seasoned researchers like Linda Elam, who had served as Medicaid director for Washington, D.C., and Peter Kemper, who had led decades of studies into long-term care.
Graham was reassigned in April to be director of HHS’ regional office in Seattle, about the same time that O’Brien began to focus on advising Azar. Brenda Destro, another deputy assistant secretary, currently runs the office, which staff say has stabilized somewhat since Graham and O’Brien’s effective departures. All told, several dozen career staff have departed the agency or switched to other divisions since the end of the Obama administration.
“Just look at the [decline] in reports and the staffing,” said Frank, the former director. “ASPE is not being made use of in the same way.”
“ASPE is not considered an analytic and research powerhouse right now as it has been in the past, and some of what it has put out has had a heavy dose of spin,” said Kaiser Family Foundation’s Levitt.
HHS leadership strongly disagrees.
“ASPE has played an integral and successful role leading research and planning on a number of the department’s priorities, including combating the opioid crisis and bringing down prescription drug costs,” spokeswoman Oakley said. “ASPE staff have been critical to supporting the secretary’s senior advisers on these issues, as they support leadership across the department.”
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