A resolution honoring the life of Nebraska community leader Howard L. Hawks.

— 486 — Mandate for Leadership: The Conservative Promise 1. Investigate state medical school compliance with the Coats–Snowe Amendment,71 which prohibits discrimination against health care entities that do not provide or undergo training for abortion. 2. Ensure that the Accreditation Council for Graduate Medical Education (ACGME) complies with all relevant conscience statutes and regulations and that states have taken the affirmative steps (for example, by issuing regulations) to assure compliance with Coats–Snowe. 3. Communicate to medical schools that any abortion-related training must be on an opt-in rather than opt-out basis. 4. Require states that receive HHS funds to issue regulations or enter into arrangements with accrediting bodies to comply with the Coats–Snowe Amendment’s prohibition of mandatory abortion training by individuals or institutions. The Coats–Snowe Amendment specifically requires such state regulations or arrangements. l Prioritize funding for home-based childcare, not universal day care. As HRSA’s Early Childhood Health page outlines, “Currently, only about half of U.S. preschoolers are on-track with their development and ready for school. And more than one in four of children (28%) who experience abuse or neglect are under 3 years old.”72 Concurrently, children who spend significant time in day care experience higher rates of anxiety, depression, and neglect as well as poor educational and developmental outcomes. Instead of providing universal day care, funding should go to parents either to offset the cost of staying home with a child or to pay for familial, in-home childcare. l Provide education and resources on early childhood health. By partnering with new organizations like the Center on Child and Family Poverty, HRSA should provide resources and information on the importance of the mother–child relationship in child well-being. This should include relationship education curricula that equip mothers and caregivers to connect with and improve their understanding of their infants, toddlers, and young children. Maternal and Child Health. Currently, the HRSA Maternal and Child Health program is collecting data on the benefits of doulas in improving the health, safety, and emotional well-being of mothers at birth. Doulas provide a patient-focused, nonmedical support system for single or married mothers that “decreases the — 487 — Department of Health and Human Services overall cesarean rate by 50%, the length of labor by 25%, the use of oxytocin by 40%, and requests for an epidural by 60%. Doulas often use the power of touch and massage to reduce stress and anxiety during labor.”73 Given concerns about maternal mortality or postpartum depression that is worsened by poor birth experiences, doulas should be an active option for all women whether they are giving birth in a traditional hospital, through midwifery, or at home. Additionally, since most Doulas’ services are not covered by traditional insurance programs, the Maternal and Child Health program should work to pro- vide funding for low-income mothers. INDIAN HEALTH SERVICE (IHS) The Indian Health Service serves our American Indian and Alaska Native popu- lations. Reforms are needed to improve America’s ability to deliver on its promises to these important populations and must take account of cultural preferences and lifestyles, limitations due to geography (such as challenging terrain), and limited Internet access. For example, contacting individuals within some of these com- munities and tribes during the COVID-19 pandemic proved to be difficult because many had transient addresses and unreliable cell service. During the transition to the Biden Administration, IHS abandoned tribes as their sources of COVID-19 tests and vaccine supplies disappeared. It is important to guard against such situations in order to preserve these tribes’ access to health resources during public health emergencies (PHEs). Even before the pandemic, services available to these populations through federal resources and personnel (such as vision care) were often scarce or nonexistent. Patients in these populations should be empowered to rely on alternatives to IHS through better access to private health care providers. Exploring positive reforms contained in the VA MISSION Act74 could reveal similar opportunities for increased options and access for American Indians and Alaska Natives. RURAL HEALTH A growing concern is the decreasing access to health care services for Americans living in rural, less populated areas. Many find themselves in regions that were not previously as rural as industries move away, taking with them economic prosperity and often medical providers. Others are in essential professions such as farming that by nature necessitate living in regions with fewer city accommodations and economic opportunities. Seeking space for one’s family and cultivating the land are valued goals that are deeply rooted in America’s fabric. Both Congress and an Administration must continually keep in mind how health care policies uniquely affect these regions because their market trends and populations are different from those of more populous regions. Often, rural patients face an hour’s drive to the nearest medical provider or facility or have

— 515 — Department of Housing and Urban Development 25. Process must prioritize where political leadership can implement administrative reforms through regulatory action and subregulatory guidance reforms. 26. China and other foreign nations should not be able to disrupt our nation’s housing markets, including by artificially driving up prices and reducing affordability and access to housing for Americans who are crowded out of the market by such market participation. 27. These initiatives are maintained under such designations as diversity, equity, and inclusion (DEI); critical race theory (CRT); black, indigenous, Pacific Islander, and other people of color (BIPOC); and environmental, social, and governance (ESG). 28. At a minimum, these efforts duplicate what the federal government already collects and assesses; at worst, they institute arbitrary procedures in real estate appraisal practices that undermine integrity and perversely introduce arbitrary biases into what should be an unbiased system for determining financial value. 29. Revise regulatory and subregulatory guidance, where applicable within statutory authorities, that adds unnecessary delay and costs to the construction and development of new housing and has been estimated to account for about 40 percent of new housing unit costs in multifamily housing. 30. The Biden Administration has issued a proposed rule to replace the Trump Administration’s “Preserving Community and Neighborhood Choice” rule that had repealed earlier rules expanding AFFH enforcement. See U.S. Department of Housing and Urban Development, Office of Fair Housing, “Preserving Community and Neighborhood Choice,” Final Rule, Federal Register, Vol. 85, No. 153 (August 7, 2020), pp. 47899–47912, https://www.govinfo.gov/content/pkg/FR-2020-08-07/pdf/2020-16320.pdf (accessed March 5, 2023), and U.S. Department of Housing and Urban Development, Office of the Secretary, “Affirmatively Furthering Fair Housing,” Proposed Rule, Federal Register, Vol. 88, No. 27 (February 9, 2023), pp. 8516–8590, https://www. govinfo.gov/content/pkg/FR-2015-07-16/pdf/2015-17032.pdf (accessed March 5, 2023). 31. Certain pilot initiatives may encourage greater take-up of loan products designed for faster equity accumulation, including loans with shorter terms and accelerated amortization schedules. In concept, the FHA’s Home Equity Accelerator Loan (HEAL) and Good Neighbor Next Door (GNND) pilot initiatives might lead to meaningful wealth generation for first-time buyers, but they should be available to all eligible households only when they do not arbitrarily discriminate based on race or other characteristics. 32. Housing supply does remain a problem in the U.S., but constructing more units at the low end of the market will not solve the problem. Investors and developers can deliver at more efficient cost new units that will allow for greater upward mobility of rental and ownership housing stock and better target increased construction of mid-tier rental units. Further, and more fundamental to the housing supply challenge in markets across the U.S., localities can consider revising land use, zoning, and building regulations that constrict new housing development, adding time delays and costs that impede construction. Federal housing policy should get out of the way where possible and minimize the distortive impact that stimulating greater demand through loose lending can have in driving up housing prices for households that are looking for affordable entry into the housing market. 33. U.S. Department of Housing and Urban Development, Office of the Secretary, “Housing and Community Development Act of 1980: Verification of Eligible Status,” Proposed Rule, Federal Register, Vol. 84, No. 91 (May 10, 2019), pp. 20589–20595, https://www.govinfo.gov/content/pkg/FR-2019-05-10/pdf/2019-09566.pdf (accessed March 5, 2023). 34. Reforms should contemplate rent payment flexibilities, allow escrow savings, and set maximum term limits that can reduce implicit penalties for increasing household incomes over eligibility terms for housing assistance and reweight waiting-list prioritization for two-parent households. 35. Some PHAs have been able to implement work requirements and term limit policies in various congressionally authorized demonstration programs, notably the Moving to Work (MTW) demonstration program established in 1996 for 39 PHAs (Congress has since authorized another 100 PHAs) in which participating MTW PHAs were given authority to implement rent reforms, work requirements and other experimental policies in rental assistance programs along with flexibilities in the use of capital and operating appropriations. 36. The FSS program has a general five-year term with a possible two-year extension, which could be applied at the term limit for overall benefits, and certain PHAs have imposed five-year to seven-year term limits. Families in these programs build escrow savings during their term eligibility that helps to facilitate successful transitions to family self-sufficiency and unassisted housing. — 516 — Mandate for Leadership: The Conservative Promise 37. HUD should implement administrative changes in regulation and guidance and seek statutory authority to end all Housing First directives of Continuum of Care (CoC) grantees and contract homelessness providers in addition to establishing restrictions on local Housing First policies where HUD grant funds are used. 38. The U.S. Interagency Council on Homelessness (USICH) was established in the 1990s, and numerous Administrations have devoted enormous resources to the Housing First model, experimenting with various ways to provide federally financed rapid rehousing and permanent housing opportunities. Housing First is a far-left idea premised on the belief that homelessness is primarily circumstantial rather than behavioral. The Housing First answer to homelessness is to give someone a house instead of attempting to understand the underlying causes of homelessness. Federal intervention centered on Housing First has failed to acknowledge that resolving the issue of homelessness is often a matter of resolving mental health and substance abuse challenges. Instead of the permanent supportive housing proffered by Housing First, a conservative Administration should shift to transitional housing with a focus on addressing the underlying issues that cause homelessness in the first place. 39. The Senate Low-Income First-Time Homebuyers (LIFT) Act would address this policy goal. See S. 2797, Low-Income First-Time Homebuyers Act of 2021 (LIFT Homebuyers Act of 2021), 117th Congress, introduced September 22, 2021, https://www.congress.gov/117/bills/s2797/BILLS-117s2797is.pdf (accessed March 5, 2023). 40. FHA did not facilitate the widespread use of 30-year mortgages until the 1950s when, interacting with Federal Reserve policies, federal agencies began broader adoption of the mortgages, which, despite lowering the monthly repayment terms, result in slow equity accumulation and wealth-building opportunities. 41. The Housing and Economic Recovery Act of 2008 fundamentally revised the scope of federal regulation in the nation’s housing finance system, placing Fannie Mae and Freddie Mac under the purview of a newly established Federal Housing Finance Agency (FHFA) and establishing a Housing Trust Fund (HTF) that is administered in the HUD Office of Community Planning and Development. See H.R. 3221, Housing and Economic Recovery Act of 2008, Public Law No. 110-289, 110th Congress, July 30, 2008, https://www.congress. gov/110/plaws/publ289/PLAW-110publ289.pdf (accessed March 5, 2023). 42. Guiding questions: What reforms should be proposed that could be accomplished within five years? What reforms can be done administratively, and what reforms would need legislative authorization? Are there functions that HUD administers that could be achieved more effectively at another department or agency? What big-picture reforms should be proposed that might take more than five years that would reorganize HUD and its programs to meet the objectives in the vision or mission? What would occur in the absence of these public finance subsidies? How much crowd-out do these subsidies create in the market? Would America be a seriously underhoused nation without these subsidies? Who are the policies intended to benefit? What organizational changes must be made? 43. The Faircloth Amendment (Quality Housing and Work Responsibility Act of 1998) amended the Housing Act of 1937 to maintain public housing units at 1999 levels, preventing housing authorities from maintaining more public housing than they did then. H.R. 4194, Departments of Veterans Affairs and Housing and Urban Development, and Independent Agencies Appropriations Act, 1999, Public Law No. 105-276, 105th Congress, October 21, 1998, Title V, https://www.congress.gov/105/plaws/publ276/PLAW-105publ276.pdf (accessed March 5, 2023). In recent years, the statutory restriction on new construction of public housing units has been circumvented through some narrow uses of preservation programs such as the Rental Assistance Demonstration (RAD) program, initially authorized in 2012 and reauthorized several times since under higher program unit conversion caps. Congress also provided paths for renewal and continuation of a portion of existing public housing; project/site-based housing stock (refinancing with long-term HAP contract commitments); and Section 8 units through the Multifamily Assisted Housing Reform and Affordability Act of 1997 (MAHRA). H.R. 2158, Departments of Veterans Affairs and Housing and Urban Development, and Independent Agencies Appropriations Act, 1998, Public Law No. 105-65, 105th Congress, October 27, 1997, Title V, https://www.congress.gov/105/plaws/publ65/PLAW-105publ65.pdf (accessed March 5, 2023). 44. As the evolution of HUD rental assistance transitions away from the public housing model toward housing choice vouchers, there should be adequate landlord participation to ensure that the supply of housing units for rent in these programs meets the demand for rent among eligible tenants. This issue has been addressed in various ways, including by a task force instituted at the department during the Trump Administration, but could likely remain a challenge in the administration of the program.

— 449 — 14 DEPARTMENT OF HEALTH AND HUMAN SERVICES Roger Severino If the U.S. Department of Health and Human Services (HHS) were a separate coun- try, its approximately $1.6 trillion budget would rank as the world’s fifth-largest national budget. For good or ill, HHS activities personally impact the lives of more Americans than do those of any other federal agency. Under President Trump, HHS was dedicated to serving “all Americans from conception to natural death, including those individuals and families who face…economic and social well-being challenges.”1 Under President Biden, the mission has shifted to “promoting equity in everything we do” for the sake of “populations sharing a particular characteristic” including race, sexuality, gender identification, ethnicity, and a host of other categories.2 As a result of HHS’s having lost its way, U.S. life expectancy, instead of return- ing to normal after the COVID-19 pandemic, continued to drop precipitously to levels not seen since 1996 with white populations alone losing 7 percent of their expected life span in just one year.3 Nothing less than America’s long-term survival is at stake. Accordingly, HHS must return to serving the health and well-being of all Americans at all stages of life instead of using social engineering that leaves us sicker, poorer, and more divided. OVERVIEW HHS consists of 11 operating divisions that have varying degrees of practical independence from the Secretary of Health and Human Services and 15 staff divisions that are directly under the Office of the Secretary. This chapter’s rec- ommendations are limited to those divisions that most need reform and address, wherever possible, five cross-cutting goals. — 450 — Mandate for Leadership: The Conservative Promise Goal #1: Protecting Life, Conscience, and Bodily Integrity. The Secretary should pursue a robust agenda to protect the fundamental right to life, protect con- science rights, and uphold bodily integrity rooted in biological realities, not ideology. From the moment of conception, every human being possesses inherent dignity and worth, and our humanity does not depend on our age, stage of development, race, or abilities. The Secretary must ensure that all HHS programs and activities are rooted in a deep respect for innocent human life from day one until natural death: Abortion and euthanasia are not health care. A robust respect for the sacred rights of conscience, both at HHS and among gov- ernments and institutions funded by it, increases choices for patients and program beneficiaries and furthers pluralism and tolerance. The Secretary must protect Americans’ civil rights by ensuring that HHS programs and activities follow the letter and spirit of religious freedom and conscience-protection laws. Radical actors inside and outside government are promoting harmful identity politics that replaces biological sex with subjective notions of “gender identity” and bases a person’s worth on his or her race, sex, or other identities. This destructive dogma, under the guise of “equity,” threatens American’s fundamental liberties as well as the health and well-being of children and adults alike. The next Secretary must ensure that HHS programs protect children’s minds and bodies and that HHS programs respect parents’ basic right to direct the upbringing, education, and care of their children. Goal #2: Empowering Patient Choices and Provider Autonomy. Basic eco- nomics holds that costs tend to decrease and quality and options tend to increase when there is robust and free competition in the provision of goods and services. Health care is no exception. Health care reform should be patient-centered and market-based and should empower individuals to control their health care–related dollars and decisions. Of course, providers who deliver health care also need the freedom to address the unique needs of their patients. States should be the primary regulators of the medical profession, and the federal government should not restrict providers’ abil- ity to discharge their responsibilities or limit their ability to innovate through government pricing controls or irrational Medicare and Medicaid reimburse- ment schemes. Finally, America’s broken insurance system, run largely through confusing pro- vider networks and third-party payers (employers), induces overconsumption of health care, limits consumer shopping, and hides true costs from patients. The federal government should focus reform on reducing burdens of regulatory compliance, unleashing innovation in health care delivery, ceasing interference in the daily lives of patients and providers, allowing alternative insurance coverage options, and returning control of health care dollars to patients making decisions with their providers about their health care treatments and services.