DRA Comments on HHS Strategic Plan

October 27, 2017

Office of the Assistance Secretary for Planning and Evaluation Strategic Planning Team
Department of Health and Human Services 200 Independence Ave. S.W.
Room  415F Washington, D.C. 20201

VIA ELECTRONIC MAIL – HHSPlan@hhs.gov

Attn:  Strategic Plan Comments

Disability Rights Arkansas, Inc. (DRA) is the federally authorized and funded nonprofit organization serving as the Protection and Advocacy System (P&A) for individuals with disabilities in Arkansas. DRA is authorized to advocate for and protect human, civil, and legal rights of all Arkansans with disabilities consistent with federal and state law.

DRA thanks you for the opportunity to comment on HHS’ draft strategic plan. The main areas that we will address are the Strategic Plan’ s implications for people with disabilities and health equity. We also provide additional general comments.

Implications for People with Disabilities
 
HHS’s strategic plan appropriately addresses issues related to individuals with disabilities throughout the entire plan, recognizing that accessibility, community-integration, and self-determination are implicated in almost every aspect of health care. Our comments below seek to clarify and strengthen HHS’ strategies to promote four goals:

1. Expansion of access to services in the context of behavioral and physical health collaborative models.
2. Promotion of community-integration and inclusion.
3. Protection of the right to person-centered services and self-determination.
4. Protection all other individual rights.

We appreciate HHS’ commitment to promoting collaborative models of behavioral and physical health care. Such collaboration has the potential to both address shortages of behavioral health professionals via consultative models, and to address unmet physical health care needs of individuals receiving behavioral health care services. To the extent these models focus on the former by expanding the reach of behavioral health professionals via screening, telemedicine, and/or other consultative models, HHS should ensure that such approaches are coupled with an explicit commitment to expanding and integrating essential community-based behavioral health support services. Essential community-based services include, but are not limited to, Peer Support Services, Assertive Community Treatment, Mobile Crisis Intervention, and various other intensive community-based  services.

We appreciate HHS’ acknowledgment that some of the barriers to treatment pursuant to HIPAA may be “perceived barriers.” As HHS investigates such barriers, we encourage HHS to promote solutions that protect individual privacy while promoting self-direction and advanced planning. Advance directives for behavioral health care (also known as psychiatric advanced directives) are one such legal tool which allow individuals to designate types of treatment and settings in which they want to receive care, and allow them to designate certain individuals or providers that should be notified regarding treatment needs.

Here are additional comments related to these issues:

• We appreciate that HHS has included a section regarding improving Home and Community-Based Services (HCBS), and that HHS makes explicit mention of the well-established and crucial right to community integration and inclusion in numerous sections of the strategic While we encourage the development of additional community supports to enhance community integration, we caution against relying on such supports in place of paid supports.
• Choice of providers for mental health and substance use treatment services is often quite limited. Care must be taken to ensure that all individuals are able to access care free of discrimination.
• HHS’ commitment to protecting individual rights and addressing abuse and neglect should be clarified to ensure it is clearly applicable in all facilities where individuals with disabilities receive services, not just in traditional health care settings.
• Protection from abuse and neglect must be built into emergency planning. People with disabilities and older adults too often bear the brunt of poor disaster planning, and may need additional assistance to safely survive emergencies.
• We object to HHS’ characterization of a lack of “personal responsibility” as the banier to employment for returning citizens, without acknowledgement of discriminatory hiring practices, disability and/or trauma and restrictive conditions of release as major reasons for unemployment. Reentry support should be a long­ tenn investment that addresses both structural and individual barriers to

Implications for Health Equity
 
HHS must continue to undertake activities to identify and address health disparities with the ultimate goal of eliminating them. In activities spanning the Office for Civil Rights, Office of Minority Health, Office of Women’s Health as well as the Centers for Medicare & Medicaid Services, all of HHS’ endeavors must ensure that disparities are not heightened but are prevented. We appreciate recognition of the need to address disparities within the Strategic Plan but believe that HHS must strengthen these sections to ensure all individuals can achieve their health equity.

Further, the Strategic Plan should ensure that all of HHS’ activities are undertaken in a culturally competent manner. Providing culturally competent services is critical to ensure that services are client/patient centered and are appropriate for not just the particular program at issue but also for the clients/enrollees served. We urge HHS to include more specific and measurable goals and strategies to address cultural competency in a holistic manner including disability, race, ethnicity, language, immigration status, age,  sex, gender identity, and sexual orientation.

Here are additional comments related to these issues:

• We support HHS’ recognition of the need for health literacy tools. We suggest HHS specifically recognize the need to provide culturally competent tools such that all individuals, regardless of their background, can benefit from these tools.
• We recommend additional requirements to specifically address collecting, analyzing and applying demographic data.
• We appreciate HHS’s mention of the need to reduce disparities. We believe this includes not merely racial and ethnic health disparities but also disparities based on disability, language, age, sex, sexual orientation, and gender We recommend HHS include a broad definition of health care disparities in its strategic plan.
• We note that alternative payment models must not be implemented in such a way that they create incentives to skimp on needed care or avoid costlier patients, such as those with severe disabilities. We believe that HHS should focus on models that prioritize  primary  care  (for  example,   those  that  include  strong PCMH requirements). Furthermore, we recommend that if HHS uses financial incentives, those incentives should be focused on improving outcomes and not on reducing costs.
• We appreciate the recognition of the need to provide programs that improve the quality of care and increase access.  To that end, we recommend that such programs be developed and implemented in a culturally competent manner.
• We strongly support the inclusion of the strategy “Reduce disparities in quality and safety” as it is critical to ensure that our health care system is accessible to all individuals, regardless of disability, race, ethnicity, language, immigration status, sex, gender identity, sexual orientation, and age.
• To the extent HHS recognizes the need for providing materials in non-English languages; HHS should also recognize the need for providing materials in formats that will be accessible to individuals with disabilities who have communication This would include large print format and audio or video recordings for those who cannot access written materials. All websites should also be designed, or redesigned, with accessibility in mind.
• We are concerned that the plan fails to mention other federal civil rights laws and Executive Orders which are relevant to providing healthcare options that are responsive to consumer demands. These include Executive Order 13166, Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act, the Americans with Disabilities Act, the Age Discrimination Act, and Section 1557 of the Affordable Care All of these laws must be fully implemented and enforced by HHS to ensure that HHS’ programs and activities, and those it supports with federal funds, are responsive to consumer demands.
• We do not agree with HHS’ statement that removing barriers to and promoting participation in HHS programs by persons and organizations with religious beliefs or moral convictions is a solution to assisting targeted populations. Rather, HHS should remain religiously and morally neutral in its funding and activities to ensure that individuals do not feel proselytized to by providers or receive access to a limited scope of services due the moral or religious nature of an organization.

General Comments

We believe HHS’ strategic plan must specifically mention and address HHS’ legal responsibility to uphold the laws of the United States, including the Affordable Care Act and Medicaid. Without adherence to Medicaid’s governing statute and regulations, many of the goals and strategies outlined in this plan will be unobtainable. Further, we appreciate the recognition that consumers and enrollees should have choice but that choice must come with sufficient knowledge and information to make informed choices. The  recent   actions  by  the  Administration  to  cut  funding  for  navigators   and  open enrollment outreach are contrary to the stated ability to provide consumers with choices that they actually can understand. Navigators in particular play a critical role in informing consumers about their eligibility for health insurance, helping them enroll, explaining how to use health insurance, and connecting them with health care.

We thus suggest adding a new “strategy” bullet that would ensure compliance with all current statutory and regulatory requirements regarding the Affordable Care Act and Medicaid.

Thank  you for your attention to our comments.

Tom Masseau
Executive Director