HHS in-house think tank sidelines ACA publications


The Office of the Assistant Secretary for Planning and Evaluation (ASPE), part of the Department of Health and Human Services (HHS), has retroactively altered the framing of its previous research on the Affordable Care Act (ACA). The office removed descriptions of reports produced under the previous administration, in some cases seeming to disavow their conclusions, according to the latest report from the Web Integrity Project, co-released today with a Politico report about how ASPE has been “filtering facts” under the Trump administration.

On a page that collects the Obama-era research–125 publications produced between 2011 and 2017–a warning was added that the “conclusions and recommendations may not reflect the official position of the U.S. Department of Health & Human Services today, especially with respect to the consequences of Obamacare.” References touting the benefits of the law were also excised from that page, the title of which was changed from “Affordable Care Act Research” to “Historical Research,” according to snapshots by the Internet Archive’s Wayback Machine, and summary descriptions associated with each report were removed entirely, making it difficult to quickly determine the focus of individual publications.

HHS did not address detailed questions sent to them by WIP, but issued a statement via email. “HHS supports universal access to coverage and the current site is up-to-date with the information needed to advise the Secretary on policy development, legislation development, strategic planning, policy research, evaluation, and economic analysis,” a spokesperson said.

ASPE’s “Affordable Care Act Research” page was altered between May 2017 and October 2017, according to the Internet Archive’s Wayback Machine, and is now titled “Historical Research.”

The changes, which occurred between May and October of 2017, came as a wider controversy at ASPE raised questions about political interference with its output, and brought the normally obscure office into the headlines.

That July, the U.S. Senate was considering a healthcare bill that would effectively repeal the ACA, fulfilling a longtime Republican goal. Amid protracted negotiations among GOP factions, Senator Ted Cruz (R-TX) introduced an amendment to the bill that would have relaxed some of the law’s key provisions, allowing insurance plans with higher deductibles and otherwise noncompliant features onto the market. The amendment was characterized as a gesture to moderate Republicans who worried a previous version of the bill would have left as many as 22 million people newly uninsured, according to the Congressional Budget Office.

As the amendment was circulating, on July 19, 2017, the right-leaning Washington Examiner published a draft of an ASPE analysis of the Cruz amendment, which had not yet been released by ASPE itself, suggesting that it would significantly mitigate the larger bill’s projected coverage losses. (The analysis is currently linked from a new ASPE page, which states that the research “models changes that will create a market that lowers costs, increases quality, and gives more choices than Obamacare does.”)

A range of critics immediately questioned the report’s methodology, with health economists and major insurance trade groups suggesting its assumptions were far too optimistic. In fact, Cruz’s amendment would likely lead to more uninsured, not less, they argued.

A statement released by ASPE on the same day as the Examiner article acknowledged that the analysis was atypical. It “was performed by an HHS contractor on an accelerated timeline,” the agency noted, “and, given the narrow scope of the analysis, made a number of simplifying assumptions in the interest of time.” A few days later, as ASPE’s analysis drew continued criticism, Politico reported that the document had been compiled with help from the consulting firm McKinsey and Company, and added another controversial detail. “McKinsey produced the underlying data and developed the assumptions … The final report was then assembled by the HHS Assistant Secretary for Planning and Evaluation,” the publication wrote, citing unnamed sources at ASPE.

Politico this morning expanded on that reporting, identifying John O’Brien, who served as a de facto deputy to then-acting Assistant Secretary of Planning and Evaluation, John R. Graham, as the appointee responsible. A former longtime ASPE staffer confirmed Politico’s account to WIP, and said the involvement of political personnel in report writing was part of a broader pattern of sidelining career civil servants under Graham’s leadership. Graham also oversaw a shift in priorities at the agency, according to Politico, which deemphasized LGBT issues and led to an exodus of “several dozen” career staffers.

That staffer said that some degree of political influence had always been part of the work at ASPE, which is best described as an in-house think tank for HHS. The office is charged with performing analysis of legislation and always operates with the priorities of political leadership in mind. “But this administration is one of a kind,” the staffer added.

Graham, who has described himself as a “libertarian-conservative,” had a long career as a writer and analyst before arriving at ASPE in April of 2017. In recent years he’s been a vocal critic of the ACA, wondering aloud in Forbes magazine about potential government “death panels,” and predicting that the law would lead to rationing of care. Financial disclosure information released by ProPublica shows that, just before entering government, the bulk of his salary derived from the National Center for Policy Analysis, a now defunct conservative think tank associated with industrialists and conservative activists Charles and David Koch. Additional income came through other organizations with a similar ideological perspective, like the Independent Institute, Mercatus Center and the Pacific Research Institute. He is also a former Vice-President for policy at the Advanced Medical Technology Association, a trade group representing medical device manufacturers.

The former staffer said Graham made his ideological predilections known when he arrived, and once questioned the very premise of health insurance. (An argument along those lines has appeared in his published work.) One should pay for the care they receive, he’d said.

“Usually, when you think like that, you don’t get in charge of an office in HHS that does analysis of health financing issues,” the former staffer said. “I’ve never heard anyone say that kind of thing before.”

As administrations change, there are differences in approach, the staffer added, and Republican administrations may place more emphasis on market-driven programs than their Democratic counterparts. But Graham’s views were well outside of the mainstream, the staffer said, and led to tension with longtime employees. The staffer suggested those tensions had led to Graham’s transfer in April of this year. He is now the Regional Director of HHS Region 10, with headquarters in Washington State. An HHS spokesperson told WIP the agency doesn’t comment on “personnel questions regarding reasons for changes in positions.”

The changes to ASPE’s presentation of ACA-related publications are part of a pattern WIP has documented at other offices within HHS. The Office on Women’s Health, for example, removed information pertaining to ACA coverage of breast cancer screening, detailed in WIP’s report. HHS has also removed portions of the Medicaid and Medicare websites devoted to the ACA.