Every year since Fiscal Year 2017, Congress has passed an amendment to the National Defense Authorization Act (NDAA) that prohibits reducing the quantity of deployed intercontinental ballistic missiles (ICBMs) below 400. This amendment inhibits progress on adapting the U.S. ICBM force to meet the demands of the new geostrategic environment and restricts military planners to a force structure based on status quo rather than strategic requirements. Congress should ensure that no amendments dictating the size of the ICBM force are included in future NDAAs; this will allow the size of the ICBM force to be determined by strategic military requirements, rather than arbitrary quotas set by Congress. 

Challenge and Opportunity

Congressional offices that represent the districts where ICBMs are located work together on a bipartisan basis to advocate for the indefinite sustainment of their ICBM bases. This group of lawmakers, known as the “Senate ICBM Coalition,” consists of senators from the three ICBM host states – Wyoming, Montana, and North Dakota – plus Utah, where ICBM sustainment and replacement activities are headquartered at Hill Air Force Base. Occasionally, senators from Louisiana – the home state of Air Force Global Strike Command – have also participated in the Coalition’s activities.

Over the past two decades, the members of the coalition have played an outsized role in dictating U.S. nuclear force posture for primarily parochial reasons – occasionally even overriding the guidelines set by U.S. military leaders – in order to prevent any significant ICBM force reductions from taking place. 

In 2006, for example, this congressional coalition successfully reduced the mandated life expectancy for the Minuteman III ICBM from 2040 to 2030, thus accelerating the deployment of a costly new ICBM by effectively shortening the ICBM’s modernization timeline by a decade. As U.S. Air Force historian David N. Spires describes in On Alert: An Operational History of the United States Intercontinental Ballistic Missile Program, 1945-2011, “Although Air Force leaders had asserted that incremental upgrades, as prescribed in the analysis of land-based strategic deterrent alternatives, could extend the Minuteman’s life span to 2040, the congressionally mandated target year of 2030 became the new standard.”

In another notable example, during the Fiscal Year 2014 NDAA negotiations, senators from the ICBM coalition inserted amendments into the bill that explicitly blocked the Obama administration from conducting the environmental assessment that would be legally necessary in order to reduce the number of ICBM silos. In a subsequent statement, coalition members specifically boasted about how they had overruled the Pentagon on the ICBM issue: “the Defense Department tried to find a way around the Hoeven-Tester language, but pressure from the coalition forced the department to back off.” 

By inserting these types of amendments into successive NDAAs, the ICBM coalition has been highly successful in preventing the Department of Defense from fully determining its own nuclear force posture. 

The force posture of the United States’ ICBMs, however, is not – and has never been – sacred or immutable. The current force level of 400 deployed ICBMs is not a magic number; the number of deployed U.S. ICBMs has shifted dramatically since the end of the Cold War, and it could be reduced even further for a variety of reasons, including those related to national security, financial obligations, the United States’ modernization capacity, or a good faith effort to reduce deployed U.S. nuclear forces.

When the Bush administration deactivated the “Odd Squad” at Malmstrom Air Force Base in the mid-2000s, for example – bringing the ICBM force down from 500 to 450 – the main driver was economics, not security: the 564th Missile Squadron used completely different and more expensive communications and launch control systems from the rest of the Minuteman III force. (See: David N. Spires, On Alert: An Operational History of the United States Intercontinental Ballistic Missile Program, 1945-2011, 88 2nd ed., pp. 185.)

By legislating an arbitrary quota for the number of ICBMs that the United States must deploy at all times, Congress is leaving successive presidential administrations and Departments of Defense hamstrung with regards to shaping future force posture. 

Plan of Action

In order to ensure that the Department of Defense is no longer held to arbitrary force posture requirements that have little basis in military strategy, Congress should ensure that no amendments dictating the size of the ICBM force are included in future NDAAs. If such amendments are included, however, they should be based on strategic needs established by presidential and Defense Department guidance documents. 

Conclusion

The stakes of inaction on this front are significant, particularly from a cost perspective, as the maintenance of this arbitrary 400-ICBM quota has served to heavily bias procurement outcomes towards significantly more expensive options. For example, in part due to this arbitrary 400-ICBM quota, the Pentagon’s procurement process for the next-generation ICBM yielded a preference for producing a brand-new missile – the Sentinel – rather than life-extending the current Minuteman III, deploying a smaller number, and cannibalizing the retired missiles for parts that would facilitate the life-extension process. 

While this adapted life-extension could have likely been accomplished at a fraction of the cost of building a completely new missile, the Sentinel acquisition program, in contrast, is now approximately 81 percent over-budget and more than two years behind schedule relative to Pentagon estimates from 2020. This constituted an overrun in “critical” breach of the Nunn-McCurdy Act. 

To that end, it is imperative that Congress take action to ensure that ICBM force posture is shaped by security requirements, rather than parochial and arbitrary metrics that limit the financial and military flexibility of both the Pentagon and the President. 

This action-ready policy memo is part of Day One 2025 — our effort to bring forward bold policy ideas, grounded in science and evidence, that can tackle the country’s biggest challenges and bring us closer to the prosperous, equitable and safe future that we all hope for whoever takes office in 2025 and beyond.

PLEASE NOTE (February 2025): Since publication several government websites have been taken offline. We apologize for any broken links to once accessible public data.

The world is aging. Today, some two thirds of the global population is dying from an age-related condition. Biological aging imposes significant socio-economic costs, increasing health expenses, reducing productivity, and straining social systems. Between 2010 and 2030,  Medicare spending is projected to nearly double – to $1.2 trillion per year. Yet the costly diseases of aging can be therapeutically targeted before they become late-stage conditions like Alzheimer’s. Slowing aging could alleviate these burdens, reducing unpaid caregivers, medical costs, and mortality rates, while enhancing productivity.  But a number of market failures and misaligned incentives stand in the way of extending the healthy lifespan of aging populations worldwide. New solutions are needed to target diseases before they are life-threatening or debilitating, moving from retroactive sick-care towards preventative healthcare.  

The new administration should establish a comprehensive framework to incentivize the discovery, validation, and regulatory approval of biomarkers as surrogate endpoints to accelerate clinical trials and increase the availability of health-extending drugs. Reliable biomarkers or surrogate endpoints could meaningfully reduce clinical trial durations, and enable new classes of therapeutics for non-disease conditions (e.g., biological aging). An example is how LDL (a surrogate marker of heart health) helped enable the development of lipid-lowering drugs. The current lack of validated surrogate endpoints for major late-life conditions is a critical bottleneck in clinical research. Because companies do not capture the majority of the benefit from the (expensive) validation of biomarkers, the private sector under-invests in biomarker and surrogate endpoint validation. This leads to countless lives lost and to trillions of public dollars spent on age-related conditions that could be prevented by better-aligned incentives.  It should be an R&D priority for the new administration to fund the collection and validation of biomarkers and surrogate endpoints, then gain regulatory approval for them. As we explain below, the existing FNIH Biomarkers Consortium does not fill this role.

Currently, companies are understandably hesitant to invest in validation without clear rewards or regulatory pathways. The proposed framework would encourage private companies and laboratories to contribute their biomarker data to a shared repository. This repository would expedite regulatory approval, moving away from the current product-by-product assessment that discourages data sharing and collaboration. Establishing a broader pathway within the FDA for standardized biomarker approval would allow validated biomarkers to be recognized for use across multiple products, reducing the existing incentives to safeguard data while increasing the supply of validated biomarkers and surrogate endpoints. Importantly, this would accelerate the development of drugs which holistically extend the healthspan of aging populations in the U.S. by preventing instead of treating late-stage conditions. (Statins similarly helped prevent millions of heart attacks.)

Key players such as the FDA, NIH, ARPA-H, and BARDA should collaborate to establish a streamlined pathway for the collection and validation of biomarkers and surrogate endpoints, allowing these to be recognized for use across multiple products. This initiative aligns with the administration’s priorities of accelerating medical innovation and improving public health with the potential to add trillions of dollars in economic value by making treatments and preventatives available sooner. This memo outlines a framework applicable to various diseases and conditions, using biological aging as a case study where the validation of predictive and responsive biomarkers may be vital for significant breakthroughs. Other critical areas include Alzheimer’s disease and amyotrophic lateral sclerosis (ALS), where the lack of validated surrogate endpoints significantly hinders the development of life-saving and life-improving therapies. By addressing these bottlenecks, we can unlock new avenues for medical advancements that will profoundly improve public health and mitigate the fast-growing, nearly trillion-dollar Medicare spend on late-life conditions.

Challenge and Opportunity

By 2029, the United States will spend roughly $3 trillion dollars  yearly – half its federal budget – on adults aged 65 and older. A good portion of these funds will go towards Medicare-related expenses that could be prevented. Yet the process of bringing preventative drugs to market is lengthy, costly, and currently lacking in commercial incentives. Even for therapeutics that target late-stage diseases, drug development often takes 10+ years and cost estimates range between $300 million to $2.8 billion. This extensive duration and expense are due, in part, to the reliance on traditional clinical endpoints, which require long-term observation and longitudinal data collection. The burden of chronic diseases is growing, and better biomarkers and surrogate endpoints are needed to accelerate the development of therapeutics that prevent non-communicable diseases and age-related decline. Chronological age, for instance, is a commonly used but inadequate surrogate marker for biological age. This means that, to date, clinical trials on therapeutics designed to improve the biology of aging take decades to validate, rather than years. As a result, pharmaceutical companies find more short-term rewards in treating late-stage diseases, since developing drugs that reduce overall age-related decline requires longer and currently uncertain endpoints.

The validation of reliable biomarkers and surrogate endpoints offers a promising solution to this challenge. Biological measures often correlate with and predict clinical outcomes, and can therefore provide early indications of whether a treatment is effective. If sufficiently predictive, biomarkers can serve as surrogate clinical endpoints, potentially reducing the duration and cost of clinical trials. Validated biomarkers must accurately predict clinical outcomes and be accepted by regulatory authorities, yet the validation process is underfunded due to insufficient commercial incentives for individual agents to share their biomarkers to be used as a public good. (From a purely financial standpoint, companies are better off targeting diseases with known endpoints.) 

The most prominent existing efforts to advance biomarkers and surrogate endpoints are the Foundation for the National Institute of Health’s (FNIH) Biomarkers Consortium and the FDA’s Biomarker Qualification Program. Established in 2006, the Biomarkers Consortium is a public-private partnership aimed at advancing the development and use of biomarkers in medical research. Meanwhile, the FDA’s qualification program was the result of the 21st Century Cures Act, passed in 2016, which underscored the critical role biomarkers play in accelerating medical product development. The Act mandated the FDA to implement a more transparent and efficient process for biomarker qualification. 

Despite the Consortium’s ambitious goals, the rate of biomarker qualification by the FDA has been slow. Since its inception in 2006, only a small number of biomarkers have been successfully qualified. This sluggish progress has been a source of criticism for stakeholders, especially given the high level of resources and collaboration involved. For example, the process of validating biomarkers for osteoarthritis under the Consortium’s “PROGRESS OA” project has been ongoing since Phase 1 and still faces hurdles before full qualification​. We are of the view that this is the result of two issues. Firstly, the qualification process, which involves FDA approval, is seen as overly complex and time-consuming. Despite the 21st Century Cures Act aiming to streamline the process, resulting in the qualification pathway, it remains a significant challenge. The difficulty in navigating the regulatory landscape can limit the impact of Biomarkers Consortium (BC) projects. The Kidney Safety Project, for example, faced substantial regulatory hurdles before finally achieving the first qualification of a clinical safety biomarker​. Secondly, even though the Consortium operates in a precompetitive space, there are ongoing challenges related to data sharing. Companies may still hesitate to share critical data that could advance biomarker validation out of concern for losing a competitive edge, which hampers collaboration​. To address these issues, it is crucial to implement a framework that promotes data sharing in the academic and private sectors, providing strong incentives for the validation and regulatory approval of biomarkers, while improving regulatory certainty with a standardized regulatory process for surrogate endpoint validation.

The current boom in biotechnology underscores the urgency of addressing persisting inefficiencies. Without changes, we face a significant bottleneck in proving the efficacy of new drugs. This is exacerbated by Eroom’s Law—the observation that drug discovery is becoming slower and more expensive over time. This growing inefficiency threatens to hinder the development of new, life-saving treatments at a time when the American population is aging and rapid medical advancements are crucial to deter increasing medical and social costs. In just 11 years—between 2018 and 2029—the U.S. mandatory spending on Social Security and Medicare will more than double, from $1.3 trillion to $2.7 trillion per year. Yet the costly diseases of aging can be therapeutically targeted before they become late-stage conditions like Alzheimer’s.  For federal policymakers, taking immediate action to improve data sharing and biomarker validation processes is vital. Failure to do so will not only stifle innovation but also delay the availability of critical therapies that could save countless lives and accelerate economic growth in the long run. Prompt policy intervention is essential to capitalize on the current advancements in biotechnology and ensure the development of new life-saving tests, tools, and drugs.

Implementing pull-incentives for data sharing now can help the United States adjust to its new demographic structure, where adults in advanced age prevail, while fertility rates decline.  It can also mitigate the escalating costs and timelines of clinical trials, and accelerate the approval of life-saving, health-extending drugs. If our proposed framework is successfully implemented, a robust pool of biomarker data will be established, significantly facilitating the discovery and validation of biomarkers. This will result in several key advancements, including shortened clinical trial durations, increased R&D investment, faster drug approvals, and even increased drug efficacy. Additionally, new drug classes targeting non-disease endpoints, such as biological aging, could be developed. Just as the discovery of LDL as a surrogate marker of heart health was critical in enabling the testing and development of statins, the discovery of clinical-grade biomarkers may unlock new therapeutics designed to target the mechanisms that drive human aging, slowing down the progression of age-related diseases (like cancers) before they become deadly and socio-economically expensive.

Plan of Action

To address the challenge of inefficient data sharing, validation, and approval of biomarkers, we propose implementing a series of pull-incentives aimed at encouraging pharmaceutical companies to contribute their relevant biomarker data to a shared repository and undertake the necessary research and analysis for public validation. These validated biomarkers can then be formally accepted by regulators as surrogate endpoints for drug approval, accelerating the drug development process and reducing late-life costs.

Recommendation 1. An NIH-FDA initiative for Biomarkers and Surrogate Endpoints Within the NIA

Most existing agencies focus on single, often late-stage diseases. This is at odds with a holistic understanding of human biology. A new initiative within the National Institute on Aging (NIA) could be devoted to the discovery, collection, and validation of biomarkers and surrogate endpoints for overall human health and age-related decline. Most National Institutes of Health funds are currently devoted to the diseases of aging (think cancers, Alzheimer’s, heart disease, or Parkinson’s.) Within the NIA, research on Alzheimer’s disease alone receives roughly eight  times more funding than the biology of aging, with few human-relevant results. Every federal agency and U.S. individual would benefit from better biomarkers of long-term health and from an understanding of how to measure the biology of aging. Yet no single agent has the incentives to collect and validate this data, for instance by shouldering the costs of validating predictive and responsive biomarkers of aging.

This new initiative could also be devoted to the development of preclinical, human-relevant methodologies that could broadly facilitate or streamline drug development. In 2022, the FDA Modernization Act 2.0 approved the use of in vitro and in silico New Approach Methodologies (NAMs) like cell-based assays (e.g. organs-on-chips) or computer models (like virtual cells) in preclinical development to reduce or replace animal studies, especially “where no pharmacologically relevant animal species exists.” This may be the case for human aging, where no single animal model reflects the full complex biology of our aging process. 

At present, these technologies cannot accurately represent the multifactorial processes of aging, and they cannot model entire organisms. Much work remains to be done to even understand how to “code” aging into organs-on-chips. Yet if supplemented by approaches like in vivo pooled screening, next generations of human-relevant in vitro or in silico methodologies (like virtual cells) could be infused with the complex data needed to accelerate clinical trial results and increase drug efficacy. For in vitro and in silico models to reproduce key aspects of aging biology, a better understanding of how human aging works in living organisms  — and what markers to include to represent it either virtually or in vitro — may be needed. Yet pharmaceutical companies, startups, health insurance firms, and even research hospitals again lack the incentives to shoulder the costs of collecting and validating this type of data. This means a new office within a federal agency may be needed to supply these incentives.

Recommendation 2. New Data-sharing Incentives 

The specific incentives used would need to be developed in collaboration with policymakers and industry stakeholders, but a few are outlined below: 

Pull-incentives 

One possibility is offering transferable Priority Review Vouchers (PRVs) or similar pull incentives to companies that share their biomarker data. PRVs are currently awarded by the FDA to companies developing drugs for neglected tropical diseases, rare pediatric diseases, or medical countermeasures. A PRV allows the holder to expedite the FDA review of another drug from 10 months to 6 months, and holds significant financial value. Offering transferable PRVs for drugs designed to target biological aging, for instance, could create the incentives needed for pharmaceutical companies to target early-stage age-related conditions before they turn into diseases.  

The creation of a new PRV category would require legislative action. Our proposed NIH-FDA initiative would be well positioned to oversee the issuance of PRVs, working with government agencies and think tanks to determine, for instance, what an “aging therapeutic” means, and what a company needs to achieve to gain a PRV for a longevity drug. The Alliance for Longevity Initiatives, for instance, has developed an advanced approval pathway for health-extending drugs that directly target the biology of aging. Another possible strategy would be for the FDA to encourage drugs that target multiple disease indications at once, perhaps offering discounts or incentives for every extra biomarker or surrogate endpoint validated. This could effectively encourage the development of drugs that do more than marginally improve on existing interventions. 

We acknowledge that an overabundance of PRVs can saturate the market, decreasing their value and weakening the intended pull-incentive for pharmaceutical innovation. A response would be to demand that proposals to issue additional PRVs include a comprehensive market impact analysis to mitigate unintended economic consequences. Expanding the number of PRVs can also place extra demands on the FDA’s limited resources, potentially leading to longer approval times for other essential medications, even though PRV holders often delay redemption, preventing an immediate influx of priority review applications. The PRV system may inadvertently favor larger, well-established pharmaceutical companies that have the means to acquire and leverage PRVs effectively, creating barriers for smaller firms and startups. These are all spill-over problems worth solving for the potential upshot of mitigating late-life disease costs and encouraging drugs that holistically improve the human healthspan.  

Biomarker Data Sharing as a Condition of Federal Funding

Federal funding recipients are legally obligated to make their research publicly accessible through agency-specific policies aimed at advancing open science. This mandate was strengthened by the 2022 OSTP Memorandum. Despite this clear mandate, the implementation of public access policies has been uneven across federal agencies, with progress varying due to differences in resources, technical infrastructure, and agency-specific priorities. The 2022 OSTP Public Access Memorandum aims to accelerate agency efforts to enhance public access infrastructure and policies. This updated guidance presents an opportunity for agencies to not only meet immediate data-sharing requirements but also to expand policy scopes to include essential clinical data, such as biomarker data from clinical trials. To meet these goals, agencies should ensure that funding agreements explicitly require the publication of comprehensive biomarker data and that suitable repositories are available to store and share these critical datasets effectively.

Case Study: Project NextGen

A prime example of the potential success of such initiatives is Project NextGen, a program led by BARDA in collaboration with the NIH to advance the next generation of COVID-19 vaccines and treatments. As part of its vaccine program, Project NextGen includes centralized immunogenicity assays with the overarching goal of establishing correlates of protection, which could serve as surrogate biomarkers for next-gen vaccines. These assays are collected during Phase 2b vaccine studies sponsored by Project NextGen, which have been designed to measure a number of secondary immunogenicity endpoints including systemic and mucosal immune responses. Developers share their assays so that they can be used as a public good, in return for federal funding. This effort demonstrates the feasibility and benefits of a federally led effort to share assay data to advance biomarker validation and drug development. 

Recommendation 3. Create and Manage a Data Repository 

To enhance collaborative research and ensure the efficient use of publicly funded clinical data, we recommend establishing a secure data repository. This repository will serve as a centralized platform for data submission, storage, and access. Management of the repository could be undertaken by a federal agency, such as the NIH, leveraging their experience with the Biomarkers Consortium, perhaps in partnership with non-governmental organizations like the Biomarkers of Aging Consortium. Drawing from existing models, such as Project NextGen’s assay data management, can provide valuable insights into the implementation and operationalization of the repository. 

The cost of establishing and maintaining this repository, including data storage, management, and access controls, would be dwarfed by the socio-economic returns it could provide. This repository can facilitate data sharing, protect sensitive information, and promote a collaborative environment that accelerates biomarker validation and approval, while ensuring pharmaceutical companies that their hard-earned data is safely stored. 

The securely stored data in the repository would primarily be accessible to qualified researchers, clinicians, and policymakers involved in biomarker research and development, including academic researchers, pharmaceutical companies, and public health agencies. Access would be granted through an application and review process. The benefits of this repository are multifaceted: it accelerates research by providing a centralized database, enhances collaboration among scientists and institutions, increases efficiency by reducing redundancy and improving data management, ensures data security through robust access controls, offers cost-effectiveness with long-term socio-economic returns, and supports regulatory bodies with comprehensive data sets for more informed decision-making.

Recommendation 4. Create A Regulatory Pathway with Broader Application 

To accelerate the adoption of validated biomarkers and surrogate endpoints in drug development, we propose the creation of a streamlined regulatory approval process within the FDA. This new pathway would establish clear criteria and standardized procedures for biomarker evaluation and approval, facilitating their recognition for use across multiple products and therapeutic areas.

Currently, the FDA’s Center for Drug Evaluation and Research (CDER) operates the Biomarker Qualification Program (BQP), which allows drug developers to seek regulatory qualification for specific contexts of use. While this program fosters collaboration between the FDA and external stakeholders, biomarkers are qualified on a case-by-case basis, limiting their broader applicability across different drug development programs.

Additionally, the FDA maintains a Table of Surrogate Endpoints that have been used as the basis for drug approvals under the accelerated approval pathway. However, this table primarily serves as a reference and does not comprehensively address the need for a streamlined approval process for biomarkers and surrogate endpoints.

By developing a framework that moves away from traditional product-by-product assessments, the FDA could reduce existing barriers to biomarker and surrogate endpoint discovery and approval. This approach would encourage data sharing and collaboration among pharmaceutical companies and research institutions, leading to faster validation and broader acceptance of these critical tools in drug development.

This proposal builds upon existing legislative efforts, such as the 21st Century Cures Act of 2016, which includes provisions to accelerate medical product development and supports the use of biomarkers and surrogate endpoints in the regulatory process. Furthermore, it aligns with the FDA’s ongoing efforts to provide clarity on evidentiary criteria for biomarker qualification, as outlined in the 2018 guidance document “Biomarker Qualification: Evidentiary Framework.”

Inspiration for this approach can be drawn from the Advanced Approval Pathway for Longevity Medicines (AAPLM) proposed by the Alliance for Longevity Initiatives (See AAPLM-Whitepaper)​. The AAPLM includes provisions such as a special approval track, a priority review voucher system, and indication-by-indication patent term extensions, which align economic incentives with the transformative health improvements that longevity medicines can provide. These measures offer a valuable template for facilitating the recognition and approval of biomarkers. Adding to the existing FDA table of surrogate endpoints that can serve as the basis for drug approval or licensure, and referencing existing collaborations between the NIH and FDA, such as the Biomarkers Consortium, can provide a robust foundation for new biomarker evaluations. Ultimately, this regulatory innovation will support the development of life-saving drugs, enhance public health outcomes, and meaningfully contribute to economic growth by bringing effective treatments to market more quickly.

Conclusion

Today, over two thirds of all deaths in the United States are the result of an age-related condition. The burden of non-communicable diseases is growing, and better biomarkers and surrogate endpoints are needed to target diseases before they are life-threatening or debilitating. The next administration should implement a comprehensive framework to promote data sharing and incentivize the validation and regulatory approval of biomarkers and surrogate endpoints. This aligns directly with the administration’s goal to make Americans healthy. These solutions can substantially reduce the duration and cost of clinical trials, accelerate the development of life-saving drugs, and improve public health outcomes. It is possible and necessary to create an environment that encourages and rewards pharmaceutical companies to share crucial data that accelerates medical innovation. By discovering and validating predictive and responsive biomarkers of health and disease, new therapeutic classes can be developed to directly target biological aging and prevent most forms of cancers, heart disease, frailty, vulnerability to severe infection, and Alzheimer’s. This will enable the United States to remain at the forefront of medical research, and to respond to the growing demographic crisis of aging populations in declining health.

This action-ready policy memo is part of Day One 2025 — our effort to bring forward bold policy ideas, grounded in science and evidence, that can tackle the country’s biggest challenges and bring us closer to the prosperous, equitable and safe future that we all hope for whoever takes office in 2025 and beyond.

PLEASE NOTE (February 2025): Since publication several government websites have been taken offline. We apologize for any broken links to once accessible public data.

In order to help all American workers and strengthen the national economy, the next administration should establish a Sector-Focused Employment Training Initiative (SETI) to coordinate and expand evidence-based sectoral employment training programs across the U.S. workforce. SETI would help address persistent wage inequality and limited career advancement for low-income workers, equipping millions of Americans to contribute to and prosper alongside critical U.S. industries.

Sectoral employment training programs offer a proven, evidence-based way to generate substantial and long-term employment and earnings gains for participants. These programs provide low-income and non-traditional workers (i.e., workers without a high school or college degree) with access to higher-wage jobs in better paying sectors with opportunities for advancement. There has been encouraging movement towards integrating sectoral approaches into federal job training programs, but without coordination and firm grounding in evidence, these programs risk being fragmented and ineffective. SETI would work closely with federal programs, local workforce development systems, and key industries to coordinate and expand sectoral employment programs in direct response to local workforce needs. Sectoral employment programs target in-demand, high-wage occupations and focus on breaking down barriers to employment through training, mentorship, and comprehensive supports. 

SETI would ultimately create pathways for millions of Americans to enter in-demand careers with long-term growth trajectories, strengthening both the competitiveness and prosperity of U.S. industries. 

Challenge and Opportunity

The state of wage inequality and economic mobility in the United States

Workers in the U.S. have experienced decades of skyrocketing wage inequality, with the highest earners increasingly pulling away from middle- and low-wage workers. From 1979 to 2018, the top 0.1 percent of earners saw their earnings grow fifteen times faster than the bottom ninety percent. In 2022, the median weekly earnings of Black full-time workers was approximately 83 percent that of all full-time workers. These disparities often stem from structural barriers to opportunities faced by people of color in the American job market. Despite the historically fast wage growth that low-wage workers experienced from 2019 to 2023, large racial, educational, and gender wage gaps persist. These gaps are especially pernicious as American workers are encountering major affordability challenges, including meeting basic needs such as housing and healthcare. 

It is increasingly difficult for non-college-educated workers to gain employment in high-paying occupations with career advancement opportunities. Opportunities for upward mobility in many industries with a high concentration of low-wage workers are limited, and though some pathways exist, access to them is unequal. Black, Hispanic, and female workers disproportionately experience low wage mobility. The downsizing of once prosperous industries has also left many Americans, especially those without college degrees with fewer opportunities for jobs with meaningful career advancement. For example, from 1979 to 2019 America lost 6.7 million manufacturing jobs (a 35 percent decrease), which previously gave adults with a high school education a path into the middle class. Many of these jobs were replaced by lower-wage service jobs, but a resurgence of manufacturing jobs are now at risk of being unfilled due to skills gaps. 

As rapid advancements in automation and artificial intelligence are projected to shift the types of jobs Americans hold, policymakers must act now to ensure that workers can obtain the skills needed to thrive in a changing labor market and to meaningfully shrink wage inequities. Historically, technological change in labor markets has unequally benefitted college-educated workers to the detriment of non-college-educated workers, but it does not have to in the future. AI has the potential to restore middle wage jobs, but only if it is implemented thoughtfully. Policymakers must urgently invest in evidence-based sector-focused employment training programs to ensure workers benefit from, rather than are displaced by, emerging technologies. These targeted training programs will provide workers with in-demand skills for careers with long-term potential for upward mobility. 

Creating competitive career pathways through sector-focused employment programs

Sectoral employment programs train job seekers, typically low-income adults and those with non-traditional backgrounds (i.e. those whose educational and/or training background is different from traditional expectations for their role) for high-quality, in-demand employment with opportunities for longer-term career advancement. In contrast to traditional job training programs, sectoral employment programs target in-demand occupations and focus on breaking down barriers to employment through training, mentorship, and additional supports.  Programs work with local employers to identify in-demand jobs with high starting wages and opportunities for advancement, and equip participants with the technical and general career readiness skills and credentials to succeed in both the targeted jobs and in the labor market more broadly. Sectors typically include healthcare, IT, and manufacturing.

Among many workforce development models, sectoral employment training programs stand out for their proven ability to produce and sustain significant wage gains. A review of four randomized evaluations of several sectoral employment programs highlights their effectiveness in consistently boosting employment and earnings. These programs lead to substantial and lasting earnings gains  (a 12–34 percent increase) primarily by helping workers access better-paying, higher-quality industries and occupations. Additionally, these programs provide training in certifiable and transferable skills which can enable job mobility. 

Sectoral employment programs can also be cost-effective by increasing employee income, which in turn generates additional tax revenue for the government to help offset some of the program costs. Preliminary, ongoing research by Nathan Hendren and co-authors, suggests the returns from this increased tax revenue can be substantial. For example, initial analyses of three key sectoral employment programs (Project QUEST, Year Up, and WorkAdvance) suggest that just using estimated incomes over the observed follow-up time frames, the benefits they provide to participants exceeds the net cost to the government—meaning that the marginal value of public funds (MVPF) is greater than one. What is more, if the increase in earnings observed over the study period persisted for 20 years or more, the increase in tax revenue would offset the program costs entirely. 

Meeting a moment for American workers

SETI would build on recent federal investments and a strong bipartisan movement to support the American worker. There is significant bipartisan support for strengthening national infrastructure and technological advancement by investing in workforce development, as evidenced by the passage of the Bipartisan Infrastructure Law (BIL) and the Creating Helpful Incentives to Produce Semiconductors Act (CHIPS). Nine regional Workforce Hubs help implement federal investments to ensure Americans get connected to the quality jobs created through these significant federal investments. Importantly, additional key infrastructure for advancing workforce development programs already exists through the Workforce Innovation and Opportunity Act (WIOA), which has a goal of bringing about increased federal coordination for workforce development programs. WIOA workforce development programs are provided and coordinated through approximately 3,000 One-Stop centers (also known as American Job Centers) nationwide, governed through local Workforce Development Boards and coordinated through the Department of Labor’s Employment and Training Administration (ETA). 

Furthermore, the U.S. Department of Commerce (DOC) has made a suite of recent investments in workforce development. Through a $500 million allocation from the American Rescue Plan, the DOC’s Economic Development Administration (EDA)’s Good Jobs Challenge awarded 32 industry-led, workforce training partnerships funds to develop workforce training systems in 2022. As of December 2023, 11,000 workers have been trained and 3,000 participants have secured jobs through the Good Jobs Challenge. In FY24, EDA will be providing an additional 5-8 awards to regional workforce training systems that establish sectoral partnerships, though this is still not sufficient to meet the clear demand of Good Jobs Challenge funding, which initially received $6.4 billion in funding requests from over 500 applicants. 

In 2023, the DOL’s Chief Evaluation Office and the ETA funded the Sectoral Strategies and Employer Engagement Portfolio (SSEEP), which includes three grant programs totalling approximately $188 million in funding to workforce development strategies that build relationships with employers in specific sectors to provide tailored training and good jobs to participants. Targeted sectors include renewable energy, transportation, broadband infrastructure, healthcare, climate resiliency, and hospitality. Importantly, evidence and evaluation are embedded within SSEEP. The portfolio includes a formative study, implementation studies, and assessments to identify sites for impact evaluation. The DOL continues to push for increased investment in sectoral employment strategies, putting forth a Sectoral Employment through Career Training for Occupational Readiness (SECTOR) program to seed and scale industry-led and worker-centered sectoral training partnerships in its FY25 budget proposal. SECTOR was included in the FY25 Presidential Budget, but did not make it into either the House or Senate FY25 Labor-HHS-Education appropriations bills.

These significant investments and proposals for expansion of sectoral workforce development approaches are encouraging, but they risk being uncoordinated in a federal employment and training program ecosystem that spans 43 programs across 9 agencies. Since the Government Accountability Office (GAO) recommended reducing overlap and fragmentation between these programs in 2019, DOL has taken several steps to increase coordination. The DOL should build upon this progress and establish a SETI to coordinate and broaden sectoral employment strategies across programs. 

Plan of Action

The next administration should establish a Sector-Focused Employment Training Initiative (SETI), an inter-agency initiative based jointly within the Department of Labor’s Employment and Training Administration and the Department of Commerce’s Economic Development Administration. SETI would work closely with various federal intermediaries, including local Workforce Development Boards and regional Workforce Hubs, to coordinate and expand sector-focused training programs within American Job Centers, Workforce Hubs, DOL’s Sectoral Strategies and Employer Engagement Portfolio (SSEEP) and other federal initiatives, trade associations, community colleges, and local and national nonprofits. SETI would support the expansion of existing evidence-based programs like Per Scholas and Year Up as well as the establishment of new evidence-based sector-focused job training programs. Additionally, SETI would provide technical assistance to local workforce development systems on how to implement these programs and match job seekers with evidence-based training providers. It would also promote continuous improvement by supporting rigorous evaluations of promising new models. To establish SETI, the next administration should take the following specific steps:

Recommendation 1. The President should call upon Congress to direct federal funding to SETI through the annual Labor-HHS-Education appropriations bill.

This could be achieved by securing new funding through the federal budget and/or proposing tax incentives for employers that participate in the initiative. Broadly, the goal of SETI is to fund, coordinate, and expand sector-focused training programs across American Job Centers, federal workforce development initiatives, trade associations, community colleges, and local and national nonprofits. SETI would coordinate existing sector-focused training approaches across agencies to maximize current investments and expand sector-focused approaches through programs including SECTOR (which would be funded as part of SETI). SETI will ensure that the sectoral employment programming is evidence-based, effective, and coordinated. It will also include mechanisms for monitoring and evaluation for continuous program improvement. To help fund this initiative in the future, the federal government could commission an assessment (through GAO) of the array of workforce development programs across the country to identify opportunities to redistribute funding away from less effective models. 

Recommendation 2. Establish the structure of SETI, which will include a guiding task force, an Executive Director, and personnel:

• The SETI task force will oversee the design and implementation of SETI. The task force should be chaired by the Executive Director and should include representatives from: the National Association of Workforce Development Boards; representatives from high-growth industries, including green energy and semiconductor industries; state and local governments, including staff from state labor offices; DOL and DOC  staff overseeing the Good Jobs Challenge, Workforce Hubs, and other federal initiatives; union representatives; representatives from trade organizations, community colleges, and established sectoral job training nonprofits such as Year Up and Per Scholas. The task force should conduct consultations with industry leaders, educational institutions, labor organizations, and community groups to gather input and build support for SETI. This will help tailor the initiative to the specific needs of various regions and sectors.
• The Executive Director will chair the task force, manage the day-to-day operations of SETI, oversee hiring of personnel, and will be responsible for ensuring that the directives of the task force are carried out, reporting back regularly to the task force.
• SETI personnel will carry out the directives of the task force as delegated by the Executive Director, which will include disbursement of funds to local sectoral employment training programs and providing technical assistance. 

Recommendation 3. Beginning with implementation pilots, SETI should provide technical assistance and funding to local Workforce Development Boards, national Workforce Hubs, and other intermediaries implementing federal workforce development initiatives to launch and scale sectoral employment programming.

• Implementation pilot of SETI: SETI personnel, under the direction of the Executive Director and the guidance of the task force, will work with intermediaries in select localities (e.g., local Workforce Development Boards, Workforce Hubs, etc.) to identify promising opportunities to launch or scale up sectoral employment programs. Together, local intermediaries and SETI personnel will identify industries with strong labor demand and potential for career growth, such as healthcare, IT, manufacturing, and green energy. SETI will support local intermediaries  to develop and strengthen industry partnerships and generate industry buy-in for sectoral employment programs. SETI will provide technical assistance and funding to local intermediaries to leverage existing infrastructure to set up and deliver programming in partnership with industry. For example, a local intermediary such as a Workforce Development Board would receive SETI funding and technical assistance to launch and scale sectoral employment programs through  local American Job Centers, trade associations, community colleges, and/or local and national nonprofits, in alignment with community needs and resources. These implementation pilots can serve as a proof of concept for SETI, providing valuable insights into the best practices for training, employer collaboration, and participant support.
• Standards of quality and best practices: Following insights gained from the implementation pilots, the existing rigorous evidence base on sectoral employment programs, and learnings from SSEEP and other federal initiatives, the SETI task force will publish standards of quality for sectoral employment programs and best practices for how local intermediaries  can integrate them into existing workforce development infrastructure. Additionally, the task force will make recommendations to local intermediaries  on which less effective workforce programs to scale back and how.
• Technical assistance: SETI personnel will provide technical assistance to local intermediaries to develop, grow, and strengthen sectoral employment programs that meet high quality standards and best practices. Technical assistance may include guidance on program design (ensuring key components are included), employer engagement, and participant recruitment, as well as support for building the capacity of local training providers.
• Funding: SETI will provide funding to local intermediaries to disburse to sectoral employment programs that follow standards of quality and best practices.
• Community of practice: SETI will establish and lead a community of practice of local intermediaries launching and scaling sectoral employment programs to sustain coordination and collective learning. This will build upon and implement best practices learned from the  Good Jobs Challenge Community of Practice. 

Recommendation 4. SETI should encourage and fund rigorous evaluations, including randomized evaluations, in partnership with research labs and consulting firms  to continuously assess and improve SETI’s sectoral employment programs.

Evidence from these evaluations can help policymakers and practitioners identify effective models that should be scaled up. During the technical assistance phase, SETI personnel should embed monitoring and evaluation practices into the setup of sectoral employment programs. SETI should share successful strategies and practices identified through evaluations with states, localities, and training providers to ensure continuous improvement and widespread adoption of effective models. 

Conclusion 

The next administration should establish a Sector-Focused Employment Training Initiative (SETI) to expand access to quality, evidence-based sectoral employment training programs to help millions of American workers prosper. A SETI would coordinate various government job training investments and efforts by setting best practices, providing technical assistance, and delivering further funding to expand sectoral employment programs. An effective, coordinated approach to sectoral employment training programs is critical to reduce wage inequality and ensure the long-term prosperity of workers and in-demand industries during a time of rapid technological advancement.

This action-ready policy memo is part of Day One 2025 — our effort to bring forward bold policy ideas, grounded in science and evidence, that can tackle the country’s biggest challenges and bring us closer to the prosperous, equitable and safe future that we all hope for whoever takes office in 2025 and beyond.

PLEASE NOTE (February 2025): Since publication several government websites have been taken offline. We apologize for any broken links to once accessible public data.

The federal government is dramatically inefficient, duplicative, wasteful, and costly in executing the common services required to operate. However, the new Administration has an opportunity to transform government operations to save money, improve customer experience, be more efficient and effective, consolidate, reduce the number of technology platforms across government, and have significantly improved decision-making power. This should be accomplished by adopting and transforming to a government-wide shared service business model involving the collective efforts of Congress, the Office of Management and Budget (OMB), General Services Administration (GSA), and oversight agencies, and be supported by the President Management Agenda (PMA). In fact, this is a real opportunity for the newly created Department of Government Efficiency (DOGE) to realize a true systemic transformation to a better and more streamlined government. 

Challenge and Opportunity

The federal government is the largest employer in the world with many disparate mission-centric functions to serve the American people. To execute mission objectives, varied mission support functions are necessary, yet costly with many disconnected and inefficient layers added over many years. For example, a hiring action costs over $10,000 in the federal government vs. $4,000 in the private sector, and transactions such as paying an invoice cost hundreds of dollars compared to $1–2 in other sectors. Many support functions—such as travel management, FOIA management, background investigations, human resources, financial management, facilities management, and more — are equally costly and inefficient.

While these functions are critical to helping government programs achieve their mission, over many years they have grown costly and inefficient through high staffing ratios, duplication of technology platforms, disparate data systems, lack of standardization, and poor modernization. Congress focuses on individual agencies independently and not holistically on the opportunity for government-wide efficiency. Because improving operations has no mandate and GSA serves only in a coordinating role, agencies are free to approach operations any way they wish, resulting in a lack of standardization and the interoperability of systems. Many systems are still operating on extremely old software code, and the Administration and Congress lack government-wide data capacity to have the facts they need to govern. With a burdening national debt, we need to streamline government. To illustrate this opportunity, the federal government operates hundreds of human resources functions, whereas Walmart, the second largest U.S. employer with two million employees, operates just two, one for American and one for Europe.  

There are several small examples in government demonstrating the ability to realize large cost savings and improved services. When the NASA shared services operations were established, it saved over $200 million through consolidation in their first several years. The consolidation of federal payroll services from 24 to 4 functions saved over $3.2 billion. The Technology CEO Council report “The Government We Need” estimated savings of over $1 trillion by the federal government moving to shared services. Commercial sector entities such as Johnson & Johnson saved approximately $2 billion in just two years. 

Plan of Action

Over 85% of Fortune 500 companies and growing numbers of public sector governments around the world have committed to shared services as a mainstream business model. Australia, Canada, the United Kingdom, Singapore, and others have realized significant reduction in cost and improved delivery. While shared services have been attempted in many forms since the 1980s in the federal government, implementation has been inconsistent and incomplete due to Congressional and Administration inattention.  As part of past PMAs, a GSA Office of Shared Solutions and Performance (OSSPI) was established, along with a Technology Management Fund (TMF) to support modernization, yet little action has been taken to set goals and achieve results. Most government shared service centers operate on antiquated technology platforms, are at high risk of failure, and are in critical need of modernization. 

Immediate legislative and executive action are necessary to enable robust, cross-government benefits. Transforming government into an efficient and effective operation will take time, measurement, and accountability. It’s important that this be done correctly and begin by building the requisite capacity to realize success and regularly report to the Administration and Congress. To ensure success, the following initial actions should be taken:

1. Congress should make the consolidation of common service operating and business models statutorily mandatory and provide resources for GSA to conduct the appropriate analysis, design, and transformation to consolidated common services.
2. The Administration should install the leadership with the responsibility, authority, and accountability for transforming government operations. This would be a Senate-confirmed Commissioner of Government Operations at GSA directing operations with policy authority resting with the OPM Deputy Director for Management (DDM).  
3. The Administration should enhance GSA/OSSPI to create an effective governance structure and increase their capacity and role. Governance would be structured through the DDM, the GSA Commissioner for government operations, the establishment of a Shared Services Advisory Board (SSAB) made up of agency Deputy Secretaries, and the inclusion of the existing chief operating councils. OSSPI would take on the lead role for transformation and operations oversight and have the staff resources and authority necessary to execute.
4. Congress should direct and the Administration should conduct a deep analysis and design the most effective operating and business models. It is necessary to identify current resources, cost, and performance as well as benchmarks against other entities. This would be led by GSA and conducted by an independent, non-conflicted entity. Based on this analysis GSA would design optimized models, provide a clear business case, and prepare a transformation/modernization plan. The Commission would then approve and recommend further Congressional and/or executive action required to implement the transformation. In parallel, GSA would develop selected government staff and managers to participate in the analysis and transformation process.
5. The Administration, through OMB and GSA, should implement the multi–year transformation and modernization effort and implement, measure, report results, and realize the requisite Return on Investment (ROI). 

These initial activities should cost approximately $80 million and be cost-neutral by allocating funding from existing redundant operational and modernization efforts. This would fund cross-government analysis, GSA operations, government staff training, and transformation planning with an ROI to the taxpayer. Impacted federal staff would be retrained in new associated shared services roles and/or other mission support functions where needed.

Conclusion

The time to act boldly is now. The Administration needs to immediately begin reducing costs and improving services to taxpayers and government programs through the implementation of a shared services business model with strong leadership, a proven approach, and accountability to demonstrate results. Trillions of dollars fed back into supporting governments financial needs are necessary and attainable.

It often takes the federal government months to hire for critical science and technology (STEM) roles, far too slow to respond effectively to the demands of emerging technologies (e.g., artificial intelligence), disasters (COVID), and implementing complex legislation (CHIPS). One solution is for the Federal Government to create a pool of pre-vetted STEM talent to address these needs. This memo outlines how the federal government can leverage existing authorities and hiring mechanisms to achieve this goal, making it easier to respond to staffing needs for emerging policies, technologies, and crises in near-real time.

To lead the effort, the White House should appoint a STEM talent lead (or empower the current Tech Talent Task Force Coordinator or Senior Advisor for Talent Strategy). The STEM talent lead should make a national call to action for scientists and technologists to join the government. They should establish a team in the Executive Office of the President (EOP) to proactively recruit and vet candidates from underrepresented groups, and establish a pool of talent that is available to every agency on-demand.

Challenge and Opportunity

In general, agencies are lagging in adopting best practices for government hiring. This includes  the Subject Matter Expert Qualifications Assessment (SMEQA, a hiring process that replaces simple hiring questionnaires with efficient subject-matter-expert-led interviews), shared certificate hiring (which allow qualified but unsuccessful candidates to be hired into similar roles without having to reapply or re-interview), flexible hiring authorities (which allow the government to recruit talent for critical roles (e.g. cybersecurity) more efficiently and allow for alternative work arrangements, such as remote work), proactive sourcing (individual identification and relationship building), and continuous recruiting.

Failure to effectively leverage these hiring tools leads to significant delays in federal hiring, which in turn makes it difficult or impossible for the federal government to nimbly handle rapidly emerging and evolving STEM issue areas (e.g., AI, cybersecurity, extreme weather, quantum computing) and to execute on complex implementation demands.

There is an opportunity to correct this failure by empowering a STEM talent lead in the White House. The talent lead would work with agencies to build a national pool of pre-vetted STEM talent, with the goal of making it possible for federal agencies to fill critical roles in a matter of days – especially when crises strike. This will save the government time, effort, and money while delivering a better candidate experience, which is critical when hiring for in-demand roles.

Plan of Action 

The federal government should adopt a four-part plan of action to realize the opportunity described above.

Recommendation 1. Hire and empower a STEM talent lead for critical hiring needs

The next administration should recruit, hire, and empower a STEM talent lead in the Executive Office of the President. The STEM lead should be offered a senior role, either political (Special Assistant to the President) or a senior-level civil service role. The role should sit in the White House Office of Science and Technology Policy  (OSTP) and report to the OSTP director. The STEM talent lead would be tasked with coordinating hiring for critical STEM roles throughout the government. Similar roles currently exist, but are limited to specific subject areas. For instance, the Tech Talent Task Force Coordinator coordinates tech talent policy in an effort to scale hiring and manages a task force that seeks to align agency talent needs. The Senior Advisor for Talent Strategy serves a similar function. The Senior Advisor leads a “tech surge” at the Office of Management and Budget, pulling together workforce and technology policy implementation, including efforts to speed up hiring. Either of these roles could be elevated to the STEM lead, or a new position could be created.

The STEM talent lead would also coordinate government units that have already been established to help deliver STEM talent to federal agencies efficiently. Such units include the United States Digital Service, 18F, Presidential Innovation Fellows, the Lab at the Office of Personnel Management (OPM), the Department of Homeland Security’s Artificial Intelligence Corps, and the Digital Corps at the General Services Administration. The STEM talent lead should be empowered to pull experts from these teams into OSTP for short details to define critical hiring needs. The talent lead should also be responsible for coordinating efforts among the various groups. The goal would not be to supplant the operations of these individual groups, rather to learn from and streamline government-wide efforts in critical fields.

Recommendation 2. Proactive, continuous hiring for key roles across the government

The STEM talent lead should work with the administration and agencies to define the most critical and underrepresented scientific and technical skill sets and identify the highest impact placement for them in the federal government. This is currently being done under the Executive Order on Artificial Intelligence which could be expanded to include all STEM needs. The STEM Lead should establish sourcing strategies and identify prospective hires, possibly building on OPM’s Talent Network goals.

The lead should also collaborate with public and private subject matter experts and use approved and tested hiring processes, such as SMEQA and shared certificates, to pre-vet candidates. These experts would then be placed on a government-wide hiring certificate so that every federal agency could make them a job offer. Once vetted and placed on a government-wide hiring certificate, experts would be available for agencies to onboard within days.

Recommendation 3. Implement a “shared-certificate-by-default” policy

Traditionally, more than one qualified applicant will apply to a federal job opening. In most cases, one applicant will be chosen and the rest rejected, even if the government (even the same agency) has another open role for the same job class. This creates an unnecessary burden on qualified applicants and the government. Qualified applicants should only have to apply once when multiple opportunities exist for the same or similar jobs. This exists, to a limited extent, for excepted service applicants but not for everyone. To achieve this, all critical, scientific, and national security roles should default to shared hiring certificates. Sharing hiring certificates is an approved federal policy but is not the default. The Office of Management and Budget (OMB) could issue a policy memo making shared certificates the default, and then work with the OPM to implement it. 

Furthermore, the STEM talent lead should coordinate a centralized list of qualified applicants who were not chosen off of shared certificates if they opt-in to receiving job offers from other agencies. This functionality, called “Talent Programs,” has been piloted through USAJobs but has had limited success due to a lack of centralized support.

Recommendation 4. Let departing employees remain available for rapid re-hire into federal roles

Departing staff in critical roles (as determined by the STEM talent lead; see Recommendation 2) with good performance reviews should be offered an opportunity to join a central pool of experts that are available for rehire. The government invests heavily in hiring, training, and providing security clearances to employees with an expectation that they will serve long careers. 20+ year careers, however, are no longer the norm for most applicants. Increasingly, talent is lost to burnout, lack of opportunity inside government, or a desire to do something different. Current policy offers only “reinstatement” benefits, which allow former federal employees to apply for jobs without competing with the broader public. Reinstatement job seekers are still required to apply from scratch to individual positions.

Former employees are a critical group when staffing up quickly. Immediate access to staff with approved security clearances is particularly critical in national emergencies. Former employees also bring their prior training and cultural awareness, making them more effective, quicker than new hires. To incentivize participation from departing employees, the government could offer to maintain their security clearance, give them access to their Thrift Savings Plan and/or medical insurance, and other benefits. This could be piloted through existing authorities (e.g., as intermittent consultants) and OMB and/or OPM could develop a new retention policy based on the outcomes of that pilot.

Conclusion 

The federal government needs to establish processes to proactively recruit for key roles, help every qualified candidate get a job, and rapidly respond to STEM staffing needs for critical and complex policies, technologies, and crises. A central pool of science and technology experts can be called upon to fill permanent roles, respond to emergencies, and provide advisory services. Talent can enter and exit the pool as needed, providing the government access to a broad set of skills and experience to pull from immediately.

This action-ready policy memo is part of Day One 2025 — our effort to bring forward bold policy ideas, grounded in science and evidence, that can tackle the country’s biggest challenges and bring us closer to the prosperous, equitable and safe future that we all hope for whoever takes office in 2025 and beyond.

PLEASE NOTE (February 2025): Since publication several government websites have been taken offline. We apologize for any broken links to once accessible public data.

The next administration should establish a National Water Technology (Pipeline) to spur the innovation and commercialization of water technologies. The Pipeline should be designed to:

1. Proactively deploy broad-spectrum monitoring and treatment technologies nationwide to avoid the devastating societal impacts of water contaminants.
2. End significant sanitary sewer overflows that pose risks to human and environmental health.
3. Ensure that every community in America has access to affordable and safe drinking water.

A National Water Technology Pipeline would mobilize American entrepreneurs and manufacturers to lead on research and development of the next generation of solutions in water treatment, monitoring, and data management. The Pipeline would facilitate commercialization of later-stage water technologies by identifying innovative next-to-market solutions, proving technology through competitive demonstration projects, and deploying market-ready technology at full scale with federal funding support. An underlying objective of the Pipeline would be to improve water quality and access in the United States while addressing mounting infrastructure and maintenance costs. The Pipeline would also place an emphasis on training the next generation of technology-focused water professionals and strengthening community engagement and customer service.

Modernizing the water sector will require the federal government to renew its commitment to investing in water. In recent years, the water sector received only 4% of its funding from the federal government: a far lower fraction than other infrastructure sectors, such as highways (25%), mass transit and rail (23%), and aviation (45%). The funding injection from the Bipartisan Infrastructure Law (BIL) has provided a temporary step-change in federal investment, but the substantial gap in funding is still anticipated to grow. Increasing federal funding for water technology advancement even by a percentage point would have hugely beneficial impacts. By dedicating 1% of projected water infrastructure costs for a “good state of repair”—an estimated $12 billion over the next 10 years—the next administration can build a robust National Water Technology Pipeline, ushering in a new era of water and sanitation technologies. A similar scale of investment, $25 billion over 10 years for clean energy demonstrations, was authorized through BIL for the Department of Energy (DOE). 

Challenge and Opportunity 

The next administration will inherit water and wastewater infrastructure that the American Society of Civil Engineers has given a C- and D+ rating, respectively in 2021, which is essentially unchanged from the prior D and D+ rating in 2017. Much of the water and wastewater infrastructure across the United States is more than half a century old. These infrastructure assets are showing signs of significant deterioration and displaying strong risks of failure as they approach the end of their service lives. Put simply, many U.S. water systems are not equipped to handle emerging treatment requirements and increasing severe weather challenges.

We cannot address our nation’s water infrastructure crisis without addressing water infrastructure funding for modern systems. One problem is that federal water infrastructure funding has simply dried up. In the 1970s and early 1980s, federal funding accounted for 15–30% of water infrastructure funding nationwide. This fraction has recently declined to a baseline of only 4%, far lower than other infrastructure sectors. Municipalities have been forced to raise local water rates to cover the funding gap. Access to adequate supplies of clean water is quickly becoming unaffordable for many Americans as a result, and recent polls show that the percentage of voters who find their water service unaffordable is on the rise. The inadequacy of current investment in water is both perception and reality.  

A second problem is the growing cost of operating and maintaining water infrastructure. Nearly three-quarters of the public spending in the water sector supports operations and maintenance water systems, often legacy facilities. EPA conservatively estimates expenditures of $1.2 trillion over the next 20 years are needed just to maintain legacy drinking water ($625B) and wastewater ($630B) systems at current levels of service, without any modernization. Moreover, the U.S. water sector is large and complex, including over 50,000 community water systems and 16,000 sanitary sewer systems nationwide. Such a balkanized system makes it difficult to transfer innovative experiences and funding strategies across jurisdictional boundaries.

These challenges were exacerbated by the financial stresses and widespread supply chain challenges that the COVID-19 pandemic placed on municipalities. COVID-19 highlighted water treatment as an essential service. Serving as one of the most important tools we have for reducing the spread of infectious disease, clean water merits robust federal investment. COVID-19 also highlighted the usefulness of wastewater collection systems as early warning detection systems via wastewater-based epidemiology. Had there been investment in these wastewater based monitoring systems over the previous decade, the tracking of COVID-19 would have been significantly improved. The water industry is also vital to operations of other sectors essential to human health, environmental health, energy production, and transportation. Every dollar invested in drinking water and wastewater infrastructure increases GDP by $6.35, creates 1.6 new jobs, and provides $23 in public health-related benefits. Investing in the water sector is investing in the U.S. economy. The United States is lagging behind many other countries in dealing with issues as wide ranging as water-loss reduction, asset management, customer engagement, and customer service. It is past time to catch up.

The next administration should view these challenges as opportunities. Much has changed for the water sector in the last four years including the rise to prominence of artificial intelligence and machine learning capabilities, increased availability of low-cost sensors, widespread use of wastewater-based epidemiology as an early warning system for health risks, and rising challenge of malevolent cybersecurity threats from bad actors. Instead of propping up aging facilities, the next administration can incentivize investment into—and demonstration of—the most advanced and efficient water systems. Moreover, the next administration can incentivize the deployment of advanced monitoring and analytic technologies to proactively evaluate equipment health and develop a data-driven schedule for infrastructure replacement instead of ad hoc upgrades. The recent BIL funding provides an example of a historic $15B water infrastructure investment to replace lead pipes nationwide. While some innovative construction methods are being utilized, the water sector still lacks a suitable technology solution for the non-invasive identification of buried lead pipes, this is exactly the type of challenge a Technology Pipeline could address. Establishing a National Water Technology Pipeline will help unify our nation’s water sector and create pathways to expedite the installation of modern systems instead of maintaining outdated legacy technologies.

The next administration should empower the National Institute of Standards and Technology (NIST) in the Department of Commerce to lead this Pipeline development. (Isn’t the Environmental Protection Agency (EPA) in charge of water quality for the United States? See FAQs.) With the recent expansion of capabilities afforded by the CHIPS and Science Act, NIST is better positioned now more than ever to facilitate validation of new breakthroughs in low-cost sensors, data management and analytics, internet of things (IOT), predictive analysis, and machine learning and other technologies that are proving capable of significant productivity gains for water utilities and can prevent catastrophic system failures. As an example, modern sensor and data solutions have been demonstrated to reduce the historical challenge of sanitary sewer overflows by optimizing existing sewer networks. Further advances could even enable real-time monitoring of lead, per- and polyfluoroalkyl substances (PFAS), and other contaminants. Operational and maintenance savings realized from these technological solutions can be directly reinvested into infrastructure needs and/or used to subsidize water costs for low-income customers. The growth of the semiconductor manufacturing sector and water-intensive microchip facilities are also closely linked to water and wastewater infrastructure and NIST can play a part in driving those solutions. NIST can also engage in interagency initiatives with the DOE to address specific water-energy nexus challenges

Plan of Action

The next administration should set the United States on a path to build the most advanced water systems in the world by launching a new National Water Technology Pipeline initiative. The Pipeline would accelerate adoption of existing “market-ready” solutions from around the world while also fostering the development of next-generation technologies by American innovators. The Pipeline should be structured around three main goals:

1. Proactively deploying broad-spectrum monitoring and treatment technologies nationwide to avoid the devastating societal impacts of water contaminants.
2. Ending significant sanitary sewer overflows that pose risks to human and environmental health.
3. Ensuring that every community in America has access to affordable and safe drinking water.

Achieving these goals will require a multi-pronged approach, as described below.

New Public-Private Frameworks to Enable Innovation

NIST should lead a new collaborative effort aligned with the Department of Commerce’s mission to “promote U.S. innovation and industrial competitiveness” in the water sector. Specifically, NIST should partner with industry leaders from utilities, vendors, equipment manufacturers, and system designers to develop a unified framework for deploying new technologies in the water sector. The framework would include verification and provisional standards to allow utilities to more easily adopt new technologies and to open the market for private investment in public water infrastructure. These efforts could be modeled after NIST efforts on the Manufacturing USA program or DOE’s Office of Clean Energy Demonstrations (OCED). 

Technology Demonstration and Deployment Network

Congress should appropriate 1% of the projected total water infrastructure costs each year for the next 10 years to support water innovation. Specifically, these monies would be used for competitive grants (administered by NIST) to assist “early adopter” water utilities in deploying improved technologies, to fund state-based water innovation councils, and to support small manufacturers innovating in the water sector. NIST would coordinate with state, county, and local utilities, industry associations and professionals, and manufacturers to facilitate identification, testing, validation, and adoption of viable technology solutions. A similar development and dissemination strategy has successfully accelerated innovation in the transportation sector. NIST can also help lower risk associated with technology piloting by borrowing from the emerging piloting models in the water sector including the Isle Utilities “Trial Reservoirs” and WaterStart “CHANNELS” programs 

Education, Workforce, and Community Engagement

Innovation in theory cannot become innovation in practice without a well-trained, certified workforce to implement new solutions. Now more than ever, Americans are in need of well-paying jobs. A new water workforce will provide job opportunities in every county in the nation. The next administration can begin retraining workers into tech-savvy water professionals immediately through programs like the National Science Foundation’s Advanced Technological Education program and the Department of Defense’s SkillBridge program. 

Over the last three decades, the federal government has abdicated its responsibility for funding the water sector, leaving states and local utilities to tackle new treatment challenges, deal with the impacts of climate change, and overcome catastrophic events  like the COVID-19 pandemic. The next Administration can reinvest in U.S. water systems and bolster our economy by empowering NIST to spearhead a Pipeline to deliver modern solutions for modern water obstacles.

This action-ready policy memo is part of Day One 2025 — our effort to bring forward bold policy ideas, grounded in science and evidence, that can tackle the country’s biggest challenges and bring us closer to the prosperous, equitable and safe future that we all hope for whoever takes office in 2025 and beyond.

PLEASE NOTE (February 2025): Since publication several government websites have been taken offline. We apologize for any broken links to once accessible public data.

After a 50-year population boom, migration to the Sun Belt is skidding to a halt. Instead, the scorching heat and devastating storms increasingly common across the southern (and coastal) United States are prompting Americans to consider moving to more geographically resilient regions. New America estimates that 20 million Americans will relocate in the coming decades to escape extreme heat, drought, sea-level rise and natural disasters such as tropical storms, flooding, and wildfires. Many of them are likely to end up in “Receiving Cities” in the Midwest, Northeast, and the northern Great Plains.

Many anticipated “Receiving Cities” – places like Cincinnati, Duluth, Buffalo and Detroit – could benefit from the economic stimulus and revitalization that often accompany population inflows. These cities have a large carrying capacity but have suffered from deindustrialization, disinvestment, and population outflows in the last half century.

Yet at present, many Receiving Cities aren’t positioned to support an influx of residents. The rapid and unplanned arrival of transplants could overwhelm housing supply (which is already in shortfall across much of the country), increase housing insecurity and displacement, and place additional stress on federal and local rental and homeowner assistance programs, legal aid clinics, and other housing-related services. 

Because weather-related migration is not presently occurring en masse, the new administration has an opportunity to (i) increase the preparedness and socioeconomic appeal of Receiving Cities, in large part through production and preservation of housing for all income levels; and then (ii) encourage and support American households in relocating to these communities. The federal government should designate “Receiving Cities” to which it will allocate funds and tax incentives aimed at producing and preserving affordable housing, in anticipation of population inflows. 

Challenge and Opportunity

How will the Sun Belt Exodus Unfold?

Over the last 50 years, Florida, Texas, Arizona, and other Sun Belt states have experienced a boom of residents seeking affordable housing, low taxes, and balmy weather. These population inflows have had a significant positive impact on local economies by creating jobs, boosting housing markets, and stimulating small businesses. 

Yet extreme weather and natural disasters are starting to reverse this trend. A study published in July 2024 by the Federal Reserve Bank of San Francisco shows that the U.S. population is starting to migrate away from areas increasingly exposed to extreme heat toward historically colder areas, which are becoming more attractive as extreme cold days become increasingly rare. Meanwhile, analysis from First Street Foundation suggests that 3.2 million Americans have already relocated from areas with high flood risk. As extreme weather events become more frequent and severe, and as Southern cities become hotter, New America estimates that 20 million Americans will relocate by 2100. 

As Americans move, however, many are relocating to nearby communities that are often no less vulnerable than the ones they had left. A report from Rice University on government buyouts of flood-prone houses, for example, found that 58 percent of participating homeowners relocated within a 10-mile drive of their previous property. And, even as some Americans are leaving the Sun Belt, others are continuing to move there. Census Bureau data from 2023 shows that 11 of the 15 fastest-growing cities in the U.S. are located in Arizona, Texas, and Florida: states at increasing risk of various natural hazards, including sea-level rise, extreme heat, drought, flooding, and tropical storms.

Alongside negative effects on physical safety and quality of life, decisions to remain in geographically vulnerable areas have major economic consequences for residents, local and state governments, and the federal government. Residents and local governments risk hundreds of billions of dollars in financial losses from property damage and lost local tax revenues. State and regional actors increase the fallout of an all-but-certain collapse of real estate, mortgage lending, and homeowners insurance markets. Additionally, the federal government faces multi-billion dollar losses each year from post-disaster assistance payouts and from administering the already-insolvent National Flood Insurance Program. 

In order to minimize these losses, the U.S. must support the steady relocation of American households to more geographically resilient regions, including the Midwest, Northeast, and the northern Great Plains. And it must ensure that “Receiving Cities” in these regions have the housing and infrastructure to support and benefit from population inflows – just as Sun Belt metros have over the last half century – without displacing existing residents.

An Opportunity for Receiving Cities 

For many Receiving Cities, transplants from the Sun Belt and elsewhere offer a chance for socioeconomic revitalization and growth. Population increases can boost demand for goods and services, fill gaps in the local labor market, and increase the municipal tax base. Transplants will bring a diverse range of professional experience, skills, and educational backgrounds that can complement the existing workforce within their new community.

But without additional investment, many of these cities are unprepared to absorb population inflows. Post-industrial cities in the Midwest and Northeast theoretically possess the urban carrying capacity to accommodate new residents, but have persistently underinvested in housing, along with other community needs. For instance, Detroit, with its thousands of vacant and abandoned buildings, was actually short 24,000 habitable homes after blight was taken into account, according to a 2020 study from the University of Michigan. Similarly, a 2022 report from Duluth, Minnesota, often cited as the most geographically resilient city in the U.S., shows that the community requires 2,400 additional units to keep pace with its current rate of growth.

Consequently, the rapid and unplanned arrival of transplants in receiving cities could possibly overwhelm a local housing sector, exacerbate unaffordability, displacement, and homelessness, and place additional stress on rental and homeowner assistance programs, legal aid clinics, and other housing-related services. Recent experience in Chico, California is emblematic: following sudden population growth due to the 2018 Camp Fire, housing prices in Chico increased 21 percent while many Housing Choice Voucher beneficiaries struggled to find rentals. Smaller and mid-sized municipalities can especially struggle with the abrupt arrival of many displaced persons or transplants. A shortfall of financial and technical resources creates barriers to preparedness, and many local governments do not possess the staffing and expertise to access the federal funding and professional assistance that is crucial for planning.

Access to affordable and quality housing will be foundational for any successful revitalization or growth. Through a Receiving Cities Housing Program, the U.S. government can support future receiving cities to prepare local housing markets for expected population increases due to weather change. As this population movement is not presently occurring en masse, there is opportunity for the incoming administration to (i) help increase the preparedness and socioeconomic appeal of future receiving cities, in large part through production and preservation of affordable housing; and then (ii) encourage and support American households in relocating in the near future to receiving cities, in order to increase individual, community, and national resilience.

Burdens for unprepared communities

Although out of scope for this memo, it is worth mentioning that without proper planning, large population inflows could also place increased strain on existing infrastructure and public services in receiving communities, including health care, transportation, education, water and sanitation, electricity, and waste management. Unprepared localities may experience new or additional challenges in basic amenity provision, service disruptions, and/or increased cost of living for both newcomers and long-time residents as a result.

Plan of Action

Upon taking office, the President should sign an Executive Order to boost housing supply nationwide, with a focus on housing supply in Receiving Cities via a Receiving Cities Housing Program. The Executive Order will establish an Interagency Policy Committee (IPC) focused on housing risk reduction in Receiving Cities, stewarded by the Domestic Policy Council or the National Economic Council.

In parallel, the new administration must work to frame domestic relocation and the Receiving Cities Housing Program as an opportunity instead of a crisis or burden. American viewpoints are evolving on weather and disaster-related relocation, previously a political and social “third rail.” A 2021 survey found that 57 percent of participants believed climate change will force them to consider a move in the next decade. According to a similar survey from the real estate firm Redfin in 2021, nearly half of respondents that planned to relocate in the next year cited climate change as a deciding factor. 

To further depoliticize weather-related migration, the President should publicly position extreme weather as a risk to be managed similar to cyber risk and national security risk. He could do so in a speech to the American people and to Congress, such as the 2025 State of the Union. The President can also direct their Communications Director and Press Secretary, along with relevant agencies such as the Federal Emergency Management Agency (FEMA) and the Department of Housing and Urban Development (HUD), to communicate on the risks to households of remaining in vulnerable regions, and of the Receiving Cities Housing Program as a tool for revitalization and economic growth.

Overall, the Receiving Cities Housing Program should be guided by the following recommendations:

Recommendation 1. Expand federally supported research and data collection on geographic resilience, weather-related migration projections, and urban carrying capacity to inform designation of “Receiving Cities.”

Improved understanding of (i) geographic resilience; (ii) likely domestic weather-related relocation patterns; and (iii) urban carrying capacity is essential for informed and data-driven decision-making regarding the designation of “Receiving Cities.” The Executive Order should: 

• Direct relevant federal departments, agencies, and offices, including FEMA, HUD, and the U.S. Department of Agriculture (USDA), to expand research and data collection on the future geographic resilience of U.S. cities, with the goal of better understanding each city’s geographic resilience, based on its long-term exposure to extreme weather and related natural hazards. If possible, analysis should integrate or otherwise leverage existing research, datasets, and toolkits, including FEMA’s National Risk Index; the Environmental Protection Agency (EPA)’s Climate Change Indicators; the National Oceanic and Atmospheric Administration (NOAA)’s Climate Explorer Toolkits; the most recent iteration of the National Climate Assessment; and projections by vetted private firms and non-governmental organizations such as the Rhodium Group and First Street Foundation.
• Direct the U.S. Census Bureau to expand research and data collection on domestic weather-related relocation patterns now and in the future. In particular, the Census Bureau should conduct a feasibility study on the collection of comprehensive, standardized, and up-to-date data on migration flows, ideally leveraging existing instruments such as the American Community Survey or the Household Pulse Survey. If feasible, data collection processes should be implemented.
• Direct the Department of Labor (DOL)’s Bureau of Labor Statistics (BLS), HUD’s Office of Policy Development and Research (PD&R), and other relevant federal departments, agencies, and offices to expand research and data collection on the urban carrying capacity of U.S. cities. BLS, for example, should build on its Employment Projections Program and the Projections Managing Partnership to project industry growth regionally, while PD&R should leverage data from the American Housing Survey, Comprehensive Housing Affordability Strategy, and the U.S. Housing Market Conditions platform, among other resources, to assess the availability of quality and affordable housing stock in U.S. cities.

Recommendation 2. Designate a set of “Receiving Cities” based on clearly articulated criteria and in consultation with prospective Receiving Cities.

The Receiving Cities Housing Program must consider geographic resilience, projected demographic growth, and urban carrying capacity (including potential carrying capacity of adjacent federal lands) during its selection process. Criteria should include a desire from the Receiving City to be included in the program. In order to ensure buy-in, potential Receiving Cities should also tangibly demonstrate a long-term commitment to affordable housing development, resilient urban planning, and socioeconomic equity amid weather-related migration. The IPC should develop and announce a set of measurable housing-related preconditions for designation of a city as a “Receiving City.” Program requirements could include, but is not limited to:

• An annual municipal earmark for the production and preservation of affordable housing. 
• Demonstrable inclusion of natural hazards and weather-related migration considerations in housing and community development plans, with an emphasis on historically marginalized populations and other groups disproportionately vulnerable to negative environmental impacts.
• Consideration and implementation of innovation measures to increase production and/or preservation of affordable housing, such as “smart zoning” reform, community land trusts, and a local housing fund.

Recommendation 3. Develop a Receiving Cities Housing Program that supports production and preservation of affordable housing in designated “Receiving Cities.”

Once the Receiving Cities Housing Program selects participant cities, it must support these communities to (a) build new units, via a New Home Program, and (b) rehabilitate and preserve existing units, via a Home Restoration Program.

The Receiving Cities New Homes Program will include the following assistance:

• IPC member agencies should provide technical assistance and funding for cities to amend zoning and land use policies to accommodate the production of affordable housing, including through the Pathways to Removing Obstacles to Housing program. 
• HUD should allocate increased HOME program funds for Receiving Cities. 
• FEMA should similarly consider “Receiving City” designation within its funding allocation decisions for a number of existing housing-related programs, including the Building Resilient Infrastructure and Communities program; the Hazard Mitigation Grant program; the Flood Mitigation Assistance program; and the Pre-Disaster Mitigation program to support the production and/or preservation of resilient and affordable housing in future receiving communities.
• A number of additional relevant departments, agencies, and offices should prioritize implementation of housing-related initiatives in designated “Receiving Cities.” This includes, but is not limited to:

• The Thriving Communities Network, a federal interagency initiative that provides place-based technical assistance and capacity building for historically marginalized communities. In particular, HUD’s Thriving Communities Technical Assistance Program, which is part of the network, can help local governments ensure that housing needs are considered as part of larger infrastructure investment plans.
• The General Service Administration’s Good Neighbor Program, which promotes the sale of surplus federal properties that buyers can potentially redevelop for residential use.
• The Department of Energy’s Better Buildings Initiative, which supports the construction of more energy-efficient homes.
• Make changes to the Department of Transportation’s Transportation Infrastructure Finance and Innovation Act Program and Railroad Rehabilitation and Improvement Financing Program, to make it more accessible to developers in Receiving Cities. 

The Receiving Cities Home Restoration Program will be responsible for making older and vacant homes market-ready, and will include the following assistance:

• HUD and Congress should increase lender uptake to the FHA 203(k) Rehabilitation Mortgage Insurance Program by introducing a preferred vendor approach and lifting other bureaucratic hurdles. For example, the program could allow for new detached properties to be constructed on a lot, allowing for further proliferation of Accessory Dwelling Units and duplexes.
• Appropriate IPC members should provide local lenders with incentives and technical assistance to expand purchase-rehabilitation financing options for buyers. Examples of programs that can be scaled or replicated include U.S. Bank’s American Dream home loan program, a fixed-rate mortgage loan program with flexible underwriting criteria targeted to lower-income buyers (less than 80% AMI) that includes rehabilitation funding. Another example is the Detroit Home Mortgage program, through which eligible buyers can obtain a first mortgage for the appraised value of the home, and a second mortgage of up to $75,000 to fill the gap between the appraised value and the sale price plus any renovation costs.
• Congress should expand tax credits like the Historic Rehabilitation Tax Credit to include additional homes in Receiving Cities, and streamline requirements for taking advantage of these tax credits. 
• Expand the pool of grant funds, including Community Development Block Grants (CDBG), to support rehabilitation of homes in Receiving Cities. 

Recommendation 4. Secure long-term federal financing for the Receiving Cities Housing Program.

Major legislation such as the American Rescue Plan Act, the Infrastructure Investment and Jobs Act (IIJA), and the Inflation Reduction Act (IRA) demonstrate that the federal government can direct significant and flexible resources towards adaptation and resilience. Prioritization of these needs must continue via the Receiving Cities Housing Program, as effective preparation in receiving cities for weather-related migration is a long-term effort.

Concurrently, IPC member agencies should coordinate with relevant federal financing departments, agencies, and offices to increase funding for the production and preservation of affordable housing in designated “Receiving Cities,” with the following actions:

• The Treasury should study the feasibility of issuing green bonds, direct grants, and low-interest loans for the production and preservation of affordable housing in “Receiving Cities.” The Department should further consider state- and local-level partnerships to provide tax-exempt municipal bonds, as well as tax incentives and other support for public-private partnerships, to fund affordable housing development as part of the Receiving Cities Housing Program.
• The Federal Housing Finance Agency, and more specifically the government-sponsored enterprises (GSEs) Fannie Mae and Freddie Mac, could offer lower-interest loans to private developers, nonprofit organizations, and local governments for the production and preservation of affordable homes in designated “Receiving Cities.” Additionally, the GSEs should issue “green bonds” to fund housing production and rehabilitation in participating communities, and can also securitize mortgages from properties in “Receiving Cities,” to increase liquidity for lenders and incentivize additional investments.

Recommendation 5. Create a pilot program that offers incentives for American households to relocate from high-risk areas to “Receiving Cities.”

As a supplement to the Receiving Cities Housing Program, HUD, in collaboration with FEMA and DOT, should pilot a resilient relocation program that provides tax breaks, housing vouchers, and/or direct payouts for households to relocate to Receiving Cities. The pilot could also incorporate workforce training or reskilling programs. 

At the local, state, and federal level, there are existing programs that provide incentives or support for people to relocate, such as Tulsa Remote; the ThinkVermont Innovation Initiative; and the Biden Administration’s recently established WelcomeCorps. A similar federal initiative for weather-related migration should leverage knowledge and expertise from existing programs. 

Conclusion

Led by the incoming administration, a new Receiving Cities Housing Program should incorporate a whole-of-government approach and emphasize coordination with local leaders, civil society, and the private sector. Implementation of this program will help provide projected receiving cities with increased resources to plan for and receive new arrivals, and also ensure that relocation to geographically resilient regions is a logical and appealing choice for Americans voluntarily relocating in part or whole due to weather.

Ultimately, with sufficient planning, technical assistance, resource allocation, and communications, the federal government can shape weather-related migration into an opportunity for economic revitalization and growth in geographically resilient communities, and also ensure equitable and high quality-of-life for both new arrival and long-time residents.

This action-ready policy memo is part of Day One 2025 — our effort to bring forward bold policy ideas, grounded in science and evidence, that can tackle the country’s biggest challenges and bring us closer to the prosperous, equitable and safe future that we all hope for whoever takes office in 2025 and beyond.

PLEASE NOTE (February 2025): Since publication several government websites have been taken offline. We apologize for any broken links to once accessible public data.

Securing America’s Energy Independence through Solar Energy while Keeping America’s Ranching Industry Intact

Through the new Western Solar Plan (official name: Final Utility-Scale Solar Energy Development Programmatic Environmental Impact Statement and Proposed Resource Management Plan Amendments), the Bureau of Land Management (BLM) designated over 31 million acres of federal land across 11 states as priority zones for future solar development. About 30 million acres of this land will overlap with current livestock grazing allotments. Building conventional solar developments replaces traditional livestock grazing lands, decreasing economic opportunities for American ranchers. It doesn’t have to be this way. Practices like agrivoltaics are a win-win-win for America’s energy industry, American ranchers, and our rural American economies. To accomplish this, BLM’s right-of-way application materials should require applicants to address how solar arrays will be planned, designed, and operated to support traditional ranching practices and surrounding rural economies.

Challenge and Opportunity

Due to the decreasing cost of solar energy, the United States is undergoing a surge in large-scale solar photovoltaic developments. Over the past decade, 121 GW of solar capacity was added with continued growth projected through 2050. The BLM has the potential to significantly increase federal income from solar land leases while simultaneously preserving traditional American ranching operations. The BLM simply needs to request such solutions when selecting the companies that will develop solar projects on public land. The August 2024 Western Solar Plan makes progress on identifying lands eligible for solar developments that are close to transmission lines and on degraded lands, but does not go far enough to ensure the access and viability of grazing operations within them.

Constructing large-scale solar farms generally requires clearing and grading large areas of land, which destroys vegetation, erodes topsoil, and makes land unsuitable for grazing livestock. But alternative approaches exist. Small changes in construction practices, improved wire management, and minor alterations to the solar array racking system allow for agrivoltaics where land is simultaneously used for agriculture and solar energy production. Agrivoltaics can improve forage production outcomes in dry years and reduce livestock heat related mortality. Both benefits support rural ranching families, enabling them to produce more beef and lamb for American markets. There are already market solutions that eliminate the need for grading lands and support integrating large animals in solar arrays without decreasing solar energy output. 

However, BLM’s application materials do not require solar developers to plan for long-term grazing and land management practices within solar arrays that could facilitate traditional ranching operations. Solar energy projects on BLM lands are often not authorized through competitive leases, but by BLM granting a right-of-way (ROW). The ROW application materials address “likely environmental effects” and “probable effects on” various plants and wildlife but do not address how to keep current grazing or ranching businesses on the same land. The lack of long term agriculture considerations in ROW application materials negatively impacts rural ranching communities. BLM can lead the way in ensuring U.S. solar array design and management plans integrate traditional ranching and grazing operations. 

Plan of Action 

The following recommendations are listed in order of priority from easiest to more challenging.

Recommendation 1. Require Right of Way applicants to address how they will maintain current ranching and grazing activities.

At a minimum, BLM should update its ROW application materials to add questions about how proposed projects will 1) preserve current ranching and grazing leases, and 2) economically affect nearby communities. BLM should prefer solar projects that maintain current land uses and deliver substantial economic benefits to local ranching families or conservation land trusts. 

Recommendation 2. Create a separate Right of Way  application for solar projects to better address their particular impacts.

BLM’s ROW application does not specifically address the impacts of solar arrays. Currently,  ROWs are used for many different purposes like transportation, utility systems, telecommunications and other facilities. Given that utility-scale solar arrays occupy thousands of acres—significantly more than the small footprint of other ROW uses—BLM should pay special attention to the stewardship of public lands used for solar developments. Creating a dedicated ROW application for solar energy systems will help BLM select the best projects to provide the most value to rural Americans.

Recommendation 3. Make the selection process for solar companies to lease BLM land competitive.

BLM’s ROW application is not a competitive process. It is simply an application to use land. This leaves land lease revenue on the table that the federal government could use. By making a Request for Proposal (RFP) competitive bid process, BLM could select between solar companies based on land lease rates and a list of evaluation criteria for how the project will satisfy Recommendations 1 and 2. Using a competitive process will allow the federal government to generate more revenue and select solar projects with the most local benefits.

Recommendation 4. Integrate land stewardship into evaluation criteria for selecting solar projects.

Once the BLM begins selecting solar companies through a competitive process, it is important to select appropriate evaluation criteria. Independent research by the Colorado Agrivoltaic Learning Center, found that most solar development RFPs by utilities and municipalities attribute the vast majority of the selection criteria to the price of the energy and a company’s history and financial capabilities. Very rarely does the evaluation criteria of a solar development RFP specify any land stewardship or local partnerships. BLM could place 20-30% of a project’s evaluation on how the public’s land will continue to be stewarded by rural communities and legacy ranching families for decades to come. This change will encourage companies to compete on how to support rural ranching families without requiring the government to add any financial incentives.

Conclusion 

BLM has the opportunity to increase the federal government’s income from solar land leases while simultaneously keeping rural economies and ranching families thriving. Revising the ROW application process or creating new processes to select solar projects that design for and practice agrivoltaics will maximize positive outcomes for rural America. BLM can keep traditional ranching communities on its lands within solar arrays and still provide the beef and lamb our country wants. By advancing agrivoltaics, BLM will continue its tradition of working hand-in-hand with rural communities while generating increased revenue from solar energy deployments.

This action-ready policy memo is part of Day One 2025 — our effort to bring forward bold policy ideas, grounded in science and evidence, that can tackle the country’s biggest challenges and bring us closer to the prosperous, equitable and safe future that we all hope for whoever takes office in 2025 and beyond.

PLEASE NOTE (February 2025): Since publication several government websites have been taken offline. We apologize for any broken links to once accessible public data.

The United States Air Force is replacing its current arsenal of Minuteman III intercontinental ballistic missiles (ICBMs) with an entirely new type of ICBM, known as Sentinel (previously known as the Ground-Based Strategic Deterrent or GBSD). Sentinel’s price tag continues to grow beyond initial expectations, with the program on track to become one of the country’s most expensive nuclear modernization projects ever. 

As it stands, the Sentinel program is risky, draws funding away from more urgent priorities, and will exacerbate the Pentagon’s budget crisis. A better approach would be to life-extend a portion of the current ICBM force (the Minuteman III) in the near term in order to spread the costs of nuclear modernization out over the longer term. This approach will ensure that the United States can field a capable ICBM force on a continuous basis without compromising other critical security priorities. 

Challenge and Opportunity

The Sentinel ICBM program involves (1) a like-for-like replacement of the 400 Minuteman III ICBMs currently deployed across Colorado, Montana, Nebraska, North Dakota, and Wyoming, (2) the creation of a full set of test-launch missiles, and (3) upgrades to launch facilities, launch control centers, and other supporting infrastructure. Sentinel would keep ICBMs in the United States’ nuclear arsenal until at least 2075.

Unfortunately, the Sentinel program is riddled with challenges and flawed assumptions that have significantly increased both its cost and risk, and that will continue to do so over the coming years, as described below.

Sentinel’s price tag continues to grow beyond initial expectations

The Sentinel program’s ever-increasing price tag indicates that the program is not nearly as cost-effective as initially projected. In 2015, the Air Force issued a preliminary estimate that Sentinel (then “GBSD”) would cost $62.3 billion to acquire. One year later, the Pentagon’s Cost Analysis & Program Evaluation (CAPE) office projected that Sentinel could more realistically cost $85 billion, a 37% increase from the Air Force’s estimate. In August 2020, CAPE’s projected Sentinel acquisition cost jumped again to $95.8 billion, with total life-cycle costs reaching as high as $263.9 billion¹. In October 2020, the Pentagon reported that CAPE’s latest life-cycle estimate was $1.9 billion greater than its 2016 estimate, but did not explain why the estimate had grown. In January 2024, the Air Force notified Congress that the Sentinel program would cost 37 percent more than projected and take at least two years longer than estimated–an overrun in “critical” breach of Congress’ Nunn-McCurdy Act. The overrun put Sentinel’s anticipated cost at approximately $130 billion. In July 2024, upon certifying the Sentinel program to continue after its Nunn-McCurdy breach, the Pentagon announced a new CAPE estimate of $140.9 billion, constituting an 81% increase compared to the 2020 estimate.

As Sentinel matures over the coming years and schedule delays compound these cost issues, it will likely incur further cost increases. Sentinel is on track to become one of the country’s most expensive nuclear-related line items over the next decade.

Sentinel draws funding away from more urgent priorities

By its own admission, the Pentagon cannot afford all the weapons it wants to buy. In July 2020, the then-Air Force Chief of Staff, General Dave Goldfein, remarked that the Sentinel program represents “the first time that the nation has tried to simultaneously modernize the nuclear enterprise while it’s trying to modernize an aging conventional enterprise,” and added that “[t]he current budget does not allow you to do both.”

Funding tradeoffs at the Pentagon have already become apparent. In early 2020, for example, a decision to dramatically increase the budget of the National Nuclear Security Administration directly led to a Virginia-class submarine being cut from the Navy’s budget plan. Compounding the problem is the fact that the Pentagon is currently facing a “bow wave” of major expenditures. The bills for several big-ticket procurement projects—including Sentinel, the Long-Range Standoff Weapon, the F-35 fighter, the B-21 bomber, the Columbia-class ballistic missile submarine, and the KC-46A tanker—will all come due over the next decade. With growing recognition that the Pentagon simply cannot afford to foot so many major bills simultaneously, these large procurement projects have been characterized as “fiscal time bombs”^,

The Sentinel program is already impacting funding of other defense programs with its latest batch of cost overruns. The Pentagon admitted in a July 2024 press release that they certified the Sentinel program to continue despite its critical cost and schedule overruns, partly because Sentinel “is a higher priority than programs whose funding must be reduced to accommodate the growth in cost of the program.” In reality, however, the Air Force does not yet know which programs will face funding reductions to offset Sentinel’s increase. General James Slife, Vice Chief of Staff of the Air Force, stated in July 2024 that because Sentinel’s cost growth will be realized several years from now, “it is a decision for down the road to decide what trade-offs we’re going to need to make in order to be able to continue to pursue the Sentinel program.” 

With these funding issues in mind, it is imperative to think carefully about whether spending $141 billion to acquire the Sentinel right now makes sense. It may well be a better use of funds to focus on pressing security objectives––such as hardening U.S. command-and-control systems against cyber threats.

Life-extending part or all of the Minuteman III ICBM force—instead of moving to acquire Sentinel as quickly as possible—would constitute a cheaper and less risky option for the United States to field a viable ICBM force at New START levels for at least the next two decades. The Pentagon’s primary justification for pursuing the Sentinel program was the assumption that building an entirely new missile force from scratch would be cheaper than life-extending the Minuteman III force. This assumption stands in stark contrast to an Air Force-sponsored analysis that “[a]ny new ICBM alternative will very likely cost almost two times—and perhaps even three times—more than incremental modernization of the current Minuteman III system.”  

The Pentagon’s assumption also does not match historical precedent. In 2012, after the completion of a comprehensive round of Minuteman III life-extension programs, the Air Force admitted that it cost only $7 billion to turn the Minuteman III ICBMs into “basically new missiles except for the shell.” There is little public evidence to suggest that a similar round of life-extension programs would cost significantly more. Even if the programs were more expensive, the added expense is unlikely to come anywhere close to Sentinel’s projected $141 billion acquisition fee; tripling the previous $7 billion price tag for Minuteman III upgrades would still amount to less than one-sixth of the acquisition price of Sentinel.

If a life-extension option were pursued in lieu of Sentinel, it is likely that the Minuteman III’s critical subsystems would eventually need to be replaced. Replacement appears to be technologically feasible. Lieutenant General Richard Clark, the Air Force’s deputy chief of staff for strategic deterrence and nuclear integration, testified to the House Armed Services Committee in March 2019 that it would be possible to extend the lives of the Minuteman III’s propulsion and guidance systems one more time, despite his stated preference for proceeding with the GBSD. Furthermore, a 2014 RAND report commissioned by Air Force Global Strike Command found “no evidence that would necessarily preclude the possibility of long-term sustainment.” In fact, the report noted, “we found many who believed the default approach for the future is incremental modernization, that is, updating the sustainability and capability of the Minuteman III system as needed and in perpetuity.” 

Plan of Action

The next administration should revise its nuclear employment guidance to accept a slightly higher threshold for risk with regard to its ICBM force. This action is critical for enabling a life-extended Minuteman III force because the Pentagon’s interest in pursuing Sentinel is largely driven by its own interpretation of presidential nuclear-employment guidance. If the Air Force believes that the Minuteman III might dip below a preset reliability threshold, then the service will push for Sentinel in order to meet the current nuclear-employment guidance.

Revising the guidance to accept a slightly higher threshold for risk would reduce the need to pursue Sentinel immediately. This revision would first be publicly reflected in the next administration’s Nuclear Posture Review, and would then be translated into policy by the Pentagon. 

It is important to emphasize that (1) presidential revisions to the nuclear-employment guidance are not unusual, and (2) revising the nuclear-employment guidance would have little bearing on strategic stability. In a nuclear first strike, an adversary would still be forced to target every silo. This means that a life-extended Minuteman III force would theoretically produce the same deterrence effect as a brand-new Sentinel force. 

To provide additional support for the guidance revision, the next administration could launch a National Security Council-led review of the role of ICBMs in U.S. nuclear strategy. In particular, this review would assess the feasibility and cost of a Minuteman III life-extension program. The review would also consider whether such a program could be further enabled by reducing the number of deployed ICBMs or the number of annual flight tests, or by pursuing new forms of nondestructive booster reliability testing (see FAQ for more details). 

Conclusion

Life-extending the nation’s existing arsenal of Minuteman III missiles instead of immediately pursuing the Sentinel program is the best way to ensure that the United States can continue to field a capable ICBM force without sacrificing funding other critical national-security priorities. 

This course of action could buy the United States as much as twenty years of additional time to decide whether to pursue or cancel a follow-on Sentinel program, thus allowing the United States to further spread out costs and reconsider the future role of ICBMs in U.S. nuclear posture. 

This action-ready policy memo is part of Day One 2025 — our effort to bring forward bold policy ideas, grounded in science and evidence, that can tackle the country’s biggest challenges and bring us closer to the prosperous, equitable and safe future that we all hope for whoever takes office in 2025 and beyond.

PLEASE NOTE (February 2025): Since publication several government websites have been taken offline. We apologize for any broken links to once accessible public data.

The 2018 Foundations for Evidence-Based Policymaking Act (Evidence Act) promotes a culture of evidence within federal agencies. A central part of that culture entails new collaboration between decision-makers and those with diverse forms of expertise inside and outside of the federal government. The challenge, however, is that new cross-agency and cross-sector collaborative relationships don’t always arise on their own. To overcome these challenges, federal evaluation staff can use “unmet desire surveys,” an outreach tool that prompts agency staff to reflect on how the success of their programs relates to what is happening in other agencies and outside government and how engaging with these other programs and organizations would help their work be more effective. It also prompts them to consider the situation from the perspective of potential collaborators—why should they want to engage?

The unmet desire survey is an important data-gathering mechanism that provides actionable information to create new connections between agency staff and people—such as those in other federal agencies, along with researchers, community stakeholders, and others outside the federal government—who have the information they desire. Then, armed with that information, evaluation staff can use the new Evidence Project Portal on Evaluation.gov (to connect with outside researchers) and/or other mechanisms (to connect with other potential collaborators) to conduct matchmaking that will foster new collaborative relationships. Using existing authorities and resources, agencies can pilot unmet desire surveys as a concrete mechanism for advancing federal learning agendas in a way that builds buy-in by directly meeting the needs of agency staff.

Challenge and Opportunity

A core mission of the Evidence Act is to foster a culture of evidence-based decision-making within federal agencies. Since the problems agencies tackle are often complex and multidimensional, new collaborative relationships between decision-makers in the federal government and those in other agencies and in organizations outside the federal government are essential to realizing the Evidence Act’s vision. Along these lines, Office of Management and Budget (OMB) implementation guidance stresses that learning agendas are “an opportunity to align efforts and promote interagency collaboration in areas of joint focus or shared populations or goals” (OMB M-19-23), and that more generally a culture of evidence “cannot happen solely at the top or in isolated analytical offices, but rather must be embedded throughout each agency…and adopted by the hardworking civil servants who serve on behalf of the American people” (OMB M-21-27).

New cross-agency and cross-sector collaborative relationships rarely arise on their own. They are voluntary, and between people who often start off as strangers to one another. Limited resources, lack of explicit permission, poor prior experiences, differing incentives, and stereotypes are all challenges to persuading strangers to engage with each other. In addition, agency staff may not previously have spent much time thinking about how new collaborative relationships could help answer questions posed by their learning agenda, or even that accessible mechanisms exist to form new relationships.  This presents an opportunity for new outreach by evaluation staff, to expand a sense of what kinds of collaborative relationships would be both valuable and possible. 

For instance, the Department of the Interior (DOI)’s 2024 Learning Agenda asks: What are the primary challenges to training a diverse, highly skilled workforce capable of delivering the department’s mission? The DOI itself has vital historical and other contextual information for answering this question. Yet officials from other departments likely have faced (or currently face) a similar challenge, and are in a position to share what they’ve tried so far, what has worked well, and what has fallen short. In addition, researchers who study human resource development could share insights from literature, as well as possibly partner on a new study to help answer this question in the DOI context. 

Each department and agency is different, with its own learning agenda, decision-making processes, capacity constraints, and personnel needs. And so what is needed are new forms of informal collaboration (knowledge exchange) and/or formal collaboration (projects with shared ownership, decision-making authority, and accountability) that foster back-and-forth interaction. The challenge, however, is that agency staff may not consider such possibilities without being prompted to do so or may be uncertain how to communicate the opportunity to potential collaborators in a way that resonates with their goals.

This memo proposes a flexible tool that evaluation staff (e.g., evaluation officers at federal agencies) can use to generate buy-in among agency staff and leadership while also promoting collaboration as emphasized in OMB guidance and in the Evidence Act. The tool, which has already proven valuable in the federal government (see FAQs) , local government, and in the nonprofit sector, is called an “unmet desire survey.” The survey measures unmet desires for collaboration by prompting staff to consider the following types of questions: 

• Which learning agenda question(s) are you focused on? Is there information about other programs within the government and/or information that outside researchers and other stakeholders have that would help answer it? What kinds of people would be helpful to connect with?
• Are you looking for informal collaboration (oriented toward knowledge exchange) or formal collaboration (oriented toward projects with shared ownership, decision-making authority, and accountability)? 
• What hesitations (perhaps due to prior experiences, lack of explicit permission, stereotypes, and so on) do you have about interacting with other stakeholders? What hesitations do you think they might have about interacting with you? 
• Why should they want to connect with you?
• Why do you think these connections don’t already exist?

These questions elicit critical insights about why agency staff value new connection and are highly flexible. For instance, in the first question posed above, evaluation staff can choose to ask about new information that would be helpful for any program or only about information relevant to programs that are top priorities for their agency. In other words, unmet desire surveys need not add one more thing to the plate; rather, they can be used to accelerate collaboration directly tied to current learning priorities. 

Unmet desire surveys also legitimize informal collaborative relationships. Too often, calls for new collaboration in the policy sphere immediately segue into overly structured meetings that fail to uncover promising areas for joint learning and problem-solving. Meetings across government agencies are often scripted presentations about each organization’s activities, providing little insight on ways they could collaborate to achieve better results. Policy discussions with outside research experts tend to focus on formal evaluations and long-term research projects that don’t surface opportunities to accelerate learning in the near term. In contrast, unmet desire surveys explicitly legitimize the idea that diverse thinkers may want to connect only for informal knowledge exchange rather than formal events or partnerships. Indeed, even single conversations can greatly impact decision-makers, and, of course, so can more intensive relationships.

Whether the goal is informal or formal collaboration, the problem that needs to be solved is both factual and relational. In other words, the issue isn’t simply that strangers do not know each other—it’s also that strangers do not always know how to talk to one another. People care about how others relate to them and whether they can successfully relate to others. Uncertainty about relationality prevents people from interacting with others they do not know. This is why unmet desire surveys also include questions that directly measure hesitations about interacting with people from other agencies and organizations, and encourage agency staff to think about interactions from others’ perspectives.

The fact that the barriers to new collaborative relationships are both factual as well as relational underscores why people may not initiate them on their own. That’s why measuring unmet desire is only half the battle—it’s also important to ensure that evaluation staff have a plan in place to conduct matchmaking using the data gathered from the survey. One way is to create a new posting on the Evidence Project Portal (especially if the goal is to engage with outside researchers). A second way is to field the survey as part of a convening, which already has as one of its goals the development of new collaborative relationships. A third option is to directly broker connections. Regardless of which option is pursued, note that large amounts of extra capacity are likely unnecessary, at least at first. The key point is simply to ensure that matchmaking is a valued part of the process.

In sum, by deliberately inquiring about connections with others who have diverse forms of relevant expertise—and then making those connections anew—evaluation staff can generate greater enthusiasm and ownership among people who may not consider evaluation and evidence-building as part of their core responsibilities.

Plan of Action

Using existing authorities and resources, evaluation staff (such as evaluation officers at federal agencies) can take three steps to position unmet desire surveys as a standard component of the government’s evidence toolbox. 

Step 1. Design and implement pilot unmet desire surveys. 

Evaluation staff are well positioned to conduct outreach to assess unmet desire for new collaborative relationships within their agencies. While individual staff can work independently to design unmet desire surveys, it may be more fruitful to work together, via the Evaluation Officer Council, to design a baseline survey template. Individuals could then work with their teams to adapt the baseline template as needed for each agency, including identifying which agency staff to prioritize as well as the best way to phrase particular questions (e.g., regarding the types of connections that employees want in order to improve the effectiveness of their work or the types of hesitancies to ask about). Given that the question content is highly flexible, unmet desire surveys can directly accelerate learning agendas and build buy-in at the same time. Thus, they can yield tangible, concrete benefits with very little upfront cost.

Step 2. Meet unmet desires by matchmaking. 

After the pilot surveys are administered, evaluation staff should act on their results. There are several ways to do this without new appropriations. One way is to create a posting for the Evidence Project Portal, which is explicitly designed to advertise opportunities for new collaborative relationships, especially with researchers outside the federal government. Another way is to field unmet desire surveys in advance of already-planned convenings, which themselves are natural places for matchmaking (e.g., the Agency for Healthcare Research and Quality experience described in the FAQs). Lastly, for new cross-agency collaborative relationships along with other situations, evaluation staff may wish to engage in other low-lift matchmaking on their own. Depending upon the number of people they choose to survey, and the prevalence of unmet desire they uncover, they may also wish to bring on short-term matchmakers through flexible hiring mechanisms (e.g., through the Intergovernmental Personnel Act). Regardless of which option is pursued, the key point is that matchmaking itself must be a valued part of this process. Documenting successes and lessons learned then set the stage for using agency-specific discretionary funds to hire one or more in-house matchmakers as longer-term or staff appointments.

Step 3. Collect information on successes and lessons learned from the pilot.

Unmet desire surveys can be tricky to field because they entail asking employees about topics they may not be used to thinking about. It often takes some trial and error to figure out the best ways to ask about employees’ substantive goals and their hesitations about interacting with people they do not know. Piloting unmet desire surveys and follow-on matchmaking can not only demonstrate value (e.g., the impact of new collaborative relationships fostered through these combined efforts) to justify further investment but also suggest how evaluation leads might best structure future unmet desire surveys and subsequent matchmaking.

Conclusion

An unmet desire survey is an adaptable tool that can reveal fruitful pathways for connection and collaboration. Indeed, unmet desire surveys leverage the science of collaboration by ensuring that efforts to broker connections among strangers consider both substantive goals and uncertainty about relationality. Evaluation staff can pilot unmet desire surveys using existing authorities and resources, and then use the information gathered to identify opportunities for productive matchmaking via the Evidence Project Portal or other methods. Ultimately, positioning the survey as a standard component of the government’s evidence toolbox has great potential to support agency staff in advancing federal learning agendas and building a robust culture of evidence across the U.S. government.

This action-ready policy memo is part of Day One 2025 — our effort to bring forward bold policy ideas, grounded in science and evidence, that can tackle the country’s biggest challenges and bring us closer to the prosperous, equitable and safe future that we all hope for whoever takes office in 2025 and beyond.

PLEASE NOTE (February 2025): Since publication several government websites have been taken offline. We apologize for any broken links to once accessible public data.

A federal agency takes over 100 days on average to hire a new employee — with significantly longer time frames for some positions — compared to 36 days in the private sector. Factors contributing to extended timelines for federal hiring include (1) difficulties in quickly aligning position descriptions with workforce needs, and (2) opaque and poor processes for screening applicants.

Fortunately, federal hiring managers and HR staffing specialists already have many tools at their disposal to accelerate the hiring process and improve quality outcomes – to achieve better hires faster. Inside and outside their organizations, agencies are already starting to share position descriptions, job opportunity announcements (JOAs), assessment tools, and certificates of eligibles from which they can select candidates. However, these efforts are largely piecemeal and dependent on individual initiative, not a coordinated approach that can overcome the pervasive federal hiring challenges.

The Office of Personnel Management (OPM), Office of Management and Budget (OMB) and the Chief Human Capital Officers (CHCO) Council should integrate these tools into a technology platform that makes it easy to access and implement effective hiring practices. Such a platform would alleviate unnecessary burdens on federal hiring staff, transform the speed and quality of federal hiring, and bring trust back into the federal hiring system.

Challenge and Opportunity 

This memo focuses on opportunities to improve two stages in the federal hiring process: (1) developing and posting a position description (PD), and (2) conducting a hiring assessment.

Position Descriptions. Though many agencies require managers to review and revise PDs annually, during performance review time, this requirement often goes unheeded. Furthermore, volatile occupations for which job skills change rapidly – think IT or scientific disciplines with frequent changes to how they practice (e.g., meteorology) or new technologies that upend how analytical skills (e.g., data analytics) are practiced – can result in yet more changes to job skills and competencies embedded in PDs.

When a hiring manager has an open position, a current PD for that job is necessary to proceed with the Job Opportunity Announcement (JOA)/posting. When the PD is not current, the hiring manager must work with an HR staffing specialist to determine the necessary revisions. If the revisions are significant, an agency classification specialist is engaged. The specialist conducts interviews with hiring managers and subject-matter experts and/or performs deeper desk audits, job task analyses, or other evaluations to determine the additional or changed job duties. Because classifiers may apply standards in different ways and rate the complexity of a position differently, a hiring manager can rarely predict how long the revision process will take or what the outcome will be. All this delays and complicates the rest of the hiring process.

Hiring Assessments. Despite a 2020 Executive Order and other directives requiring agencies to engage in skills-based hiring, agencies too often still use applicant self-certification on job skills as a primary screening method. This frequently results in certification lists of candidates who do not meet the qualifications to do the job in the eyes of hiring managers. Indeed, a federal hiring manager cannot find a qualified candidate from a certified list approximately 50% of the time when only a self-assessment questionnaire is used for screening. There are alternatives to self-certification, such as writing samples, multiple-choice questions, exercises that test for particular problem-solving or decision-making skills, and simulated job tryouts. Yet hiring managers and even some HR staffing specialists often don’t understand how assessment specialists decide what methods are best for which positions – or even what assessment options exist.

Both of these stages involve a foundation of occupation- and grade-level competencies – that is, the knowledge, skills, abilities, behaviors, and experiences it takes to do the job. When a classifier recommends PD updates, they apply pre-set classification standards comprising job duties for each position or grade. These job duties are built in turn around competencies. Similarly, an assessment specialist considers competencies when deciding how to evaluate a candidate for a job.

Each agency – and sometimes sub-agency unit – has its own authority to determine job competencies. This has caused different competency analyses, PDs, and assessment methods across agencies to proliferate. Though the job of a marine biologist, Grade 9, at the National Oceanic and Atmospheric Administration (NOAA) is unlikely to be considerably different from the job of a marine biologist, Grade 9 at the Fish and Wildlife Service (FWS), the respective competencies associated with the two positions are unlikely to be aligned. Competency diffusion across agencies is costly, time-consuming, and duplicative. 

Plan of Action

An Intergovernmental Platform for Competencies, PDs, Classifications, and Assessment Tools to Accelerate and Improve Hiring

To address the challenges outlined above, the Office of Personnel Management (OPM), Office of Management and Budget (OMB) and the Chief Human Capital Officers (CHCO) should create a web platform that makes it easy for federal agencies to align and exchange competencies, position descriptions, and assessment strategies for common occupations. This platform would help federal hiring managers and staffing specialists quickly compile a unified package that they can use from PD development up to candidate selection when hiring for occupations included on the platform.

To build this platform, the next administration should:

• Invest in creating Position Description libraries starting with the unitary agencies (e.g. the Environmental Protection Agency) then broadening out to the larger, disaggregated ones (e.g., the Department of Health and Human Services).  Each agency should assign individuals responsible for keeping PDs in the libraries current at those agencies. Agencies and OPM would look for opportunities to merge common PDs. OPM would then aggregate these libraries into a “master” PD library for use within and across agencies. OPM should also share examples of best-in-class JOAs associated with each PD. This effort could be piloted with the most common occupations by agency.
  Adopt competency frameworks and assessment tools already developed by industry associations, professional societies and unions for their professions. These organizations have completed the job task analyses and have developed competency frameworks, definitions, and assessments for the occupations they cover. For example, IEEE has developed competency models and assessment instruments for electrical and computer engineering. Again, this effort could be piloted by starting with the most common occupations by agency, and the occupations for which external organizations have already developed effective competency frameworks and assessment tools.
• Create a clearinghouse for assessments at OPM indexed to each occupation associated in the PD Library. Assign responsibility to lead agencies for those occupations responsible for the PDs to keep the assessments current and/or test banks robust to meet the needs of the agencies. Expand USA Hire and funding to provide open access by agencies, hiring managers, HR professionals and program leaders.
• Standardize classification determinations for occupations/grade levels included in the master PD library. This will reduce interagency variation in classification changes by occupation and grade level, increase transparency for hiring managers, and reduce burden on staffing specialists and classifiers.
• Delegate authority to CHCOs to mandate use of shared, common PDs, assessments, competencies, and classification determinations. This means cleaning up the many regulatory mandates that do not already designate the agency-level CHCOs with this delegated authority. The workforce policy and oversight agencies (OPM, OMB, Merit Systems Protection Board (MSPB), Equal Employment Opportunity Commission (EEOC)) need to change the regulations, policies, and practices to reduce duplication, delegate decision making, and lower variation (For example, allow the classifiers and assessment professionals to default to external, standardized occupation and grade-level competencies instead of creating/re-creating them in each instance.)
• Share decision frameworks that determine assessment strategy/tool selection. Clear, public, transparent, and shared decision criteria for determining the best fit assessment strategy will help hiring managers and HR staffing specialists participate more effectively in executing assessments.
• Agree to and implement common data elements for interoperability. Many agencies will need to integrate this platform into their own talent acquisition systems such as ServiceNow, Monster, and USA Staffing. To be able to transfer data between them, the agencies will need to accelerate their work on common HR data elements in these areas of position descriptions, competencies, and assessments.

Data analytics from this platform and other HR talent acquisition systems will provide insights on the effectiveness of competency development, classification determinations, effectiveness of common PDs and joint JOAs, assessment quality, and effectiveness of shared certification of eligible lists. This will help HR leaders and program managers improve how agency staff are using common PDs, shared certs, classification consistency, assessment tool effectiveness, and other insights.

Finally, hiring managers, HR specialists, and applicants need to collaborate and share information better to implement any of these ideas well. Too often, siloed responsibilities and opaque specialization set back mutual accountability, effective communications, and trust.  These actions entail a significant cultural and behavior change on the part of hiring managers, HR specialists, Industrial/Organizational psychologists, classifiers, and leaders. OPM and the agencies need to support hiring managers and HR specialists in finding assessments, easing the processes that can support adoption of skills-based assessments, agreeing to common PDs, and accelerating an effective hiring process.

Conclusion

The Executive Order on skills-based hiring, recent training from OPM, OMB and the CHCO Council on the federal hiring experience, and potential legislative action (e.g. Chance to Compete Act) are drivers that can improve the hiring process. Though some agencies are using PD libraries, joint postings, and shared referral certificates to improve hiring, these are far from common practice. A common platform for competencies, classifications, PDs, JOAs, and assessment tools, will make it easier for HR specialists, hiring managers and others to adopt these actions – to make hiring better and faster.

Opportunities to move promising hiring practices to habit abound. Position management, predictive workforce planning, workload modeling, hiring flexibilities and authorities, engaging candidates before, during, and after the hiring process are just some of these. Making these practices everyday habits throughout agency regions, states and programs rather than the exception will improve hiring. Looking to the future, greater delegation of human capital authorities to agencies, streamlining the regulations that support merit systems principles, and stronger commitments to customer experience in hiring, will help remove systemic barriers to an effective customer-/and user-oriented federal hiring process.

Taking the above actions on a common platform for competency development, position descriptions, and assessments will make hiring faster and better. With some of these other actions, this can change the relationship of the federal workforce to their jobs and change how the American people feel about opportunities in their government.

This action-ready policy memo is part of Day One 2025 — our effort to bring forward bold policy ideas, grounded in science and evidence, that can tackle the country’s biggest challenges and bring us closer to the prosperous, equitable and safe future that we all hope for whoever takes office in 2025 and beyond.

PLEASE NOTE (February 2025): Since publication several government websites have been taken offline. We apologize for any broken links to once accessible public data.

Taking time to plan and document a loved one’s preferences for medical treatment and end-of-life care helps respect and communicate their wishes to doctors while reducing unnecessary costs and anxiety. There is currently no federal policy requiring anyone, including Medicare beneficiaries, to complete an Advance Healthcare Directive (AHCD), which documents an individual’s preferences for medical treatment and end-of-life care. At least 40% of Medicare beneficiaries do not have a documented AHCD. In the absence of one, medical professionals may perform major and costly interventions unknowingly against a patient’s wishes. 

To address this gap, the Centers for Medicare and Medicaid Services (CMS) should launch the Medicare Advance Healthcare Directive Enrollment (MAHDE) Initiative to support all adults over age 65 who are enrolled in Medicare or Medicare Advantage plans to complete and annually renew, at no extra cost, an electronic AHCD made available and stored on Medicare.gov or an alternative secure digital platform. MAHDE would streamline the process and make it easier for Medicare enrollees to complete and store directives and for healthcare providers to access them when needed. CMS could also work with the National Committee for Quality Assurance (NCQA) to expand Advance Care Planning (ACP) Healthcare Effectiveness Data and Information Set (HEDIS) measures to include all Medicare Advantage plans caring for beneficiaries aged 65 and older. 

AHCDs save families unnecessary heartache and confusion at times of great pain and vulnerability. They also aim to improve healthcare decision-making, patient autonomy, and function as a long-term cost-saving strategy by limiting undesired medical interventions among older adults. 

Challenge and Opportunity

Advance healthcare directives document an individual’s preferences for medical treatment in medical emergencies or at the end of life. 

AHCDs typically include two parts: 

1. Identifying a healthcare proxy or durable power of attorney, who will make decisions about an individual’s health when they are unable to.
2. A living will, which describes the treatments an individual wants to receive in emergencies—such as CPR, breathing machines, and dialysis—as well as decisions on organ and tissue donation. 

Other documents complement AHCDs and help communicate treatment wishes during emergencies or at the end of life. These include do-not-resuscitate orders, do-not-hospitalize  orders, and Physician (or Medical) Orders for Life-Sustaining Treatment forms, along with similar portable medical order forms for seriously ill or frail individuals (e.g., Medical Orders for Scope of Treatment, Physician Orders for Scope of Treatment, and Transportable Physician Orders for Patient Preferences). These forms are all designed to honor an individual’s healthcare preferences in a future medical emergency.

With the U.S. aging population projected to reach more than 20% of the total population by 2030, addressing end-of-life care challenges is increasingly urgent. As people age, their healthcare needs become more complex and expensive. Notably, 25% of all Medicare spending goes toward treating people in the last 12 months of their life. However, despite commonly receiving more aggressive treatments, many older adults prefer less intensive medical interventions and prioritize quality of life over prolonging life. This discrepancy between care received and a patient’s wishes is common, highlighting the need for clear and proactive communication and planning around medical preferences. Research shows patients with ACPs are less likely to receive unwanted and aggressive treatments in their last weeks of life, are more likely to enroll in hospice for comfort-focused care, and are less likely to die in hospitals or intensive care units.  

Established ACP Policies and Support Mechanisms

Historically, some federal policies have underscored the importance of patient decision-making rights and the role of AHCDs in helping patients receive their desired care. These policies reflect the ongoing effort to empower patients to make informed decisions about their healthcare, particularly in end-of-life situations. 

The Patient Self-Determination Act (PSDA), a federal law introduced in 1990 as a part of the Omnibus Budget Reconciliation Act, was created to ensure that patients are informed of their rights regarding medical care and their ability to make decisions about that care, especially in situations where they are no longer able to make decisions for themselves. 

The Act requires hospitals, skilled nursing facilities (SNFs), home health agencies, hospice programs, and health maintenance organizations to: 

1. Inform patients of their rights to make decisions under state law about their medical care, including accepting or refusing treatment.
2. Periodically inquire whether a patient has completed a legally valid AHCD and make note in their medical record.  
3. Not discriminate against patients who do or do not have an advance directive. 
4. Ensure AHCDs and other documented care wishes are carried out, as permitted by state law. 
5. Provide education to staff, patients, and the community about AHCDs and the right to make their own medical decisions. 

It also directs the Secretary of Health and Human Services to research and assess the implementation of this law and its impact on health decision-making. Additionally, to encourage physicians and qualified health professionals to facilitate ACP conversations and complete AHCDs, CMS introduced and approved two new billing codes in 2016, allowing qualified health providers to bill CMS for advance care planning as a separate service regardless of diagnosis, place of service, or how often services are needed (Figure 1). These codes were expanded in 2017 with the temporary Healthcare Common Procedure Coding System code G0505, followed by CPT code 99483, to offer care planning and cognitive assessment services that include advance care planning for Medicare beneficiaries with cognitive impairment.

Figure 1. Two primary CPT codes and billing descriptors for advance care planning reimbursement. (Source: CMS Medicare Learning Network Fact Sheet)

In 2022, ACP was introduced as one of four key components of the Care for Older Adults (COA) initiative within the Healthcare Effectiveness Data and Information Set measures. HEDIS is a proprietary set of clinical care performance measures developed by the National Committee for Quality Assurance (NCQA), a private, nonprofit accreditation organization that creates standardized measures to help health plans assess and report on the quality of care and services. HEDIS evaluates areas such as chronic disease management, preventive care, and care utilization, enabling reliable comparisons of health plan performance and identifying areas for improvement. It is reported that 235 million Americans are enrolled in plans that report HEDIS results, and reporting HEDIS measures is mandatory for Medicare Advantage plans.

The COA initiative includes the ACP measure as a reporting requirement for Medicare Special Needs Plans (SNPs), which are plans designed for individuals who have complex care needs, are eligible for Medicare and Medicaid, have disabling or chronic conditions, and/or live in an institution. The report includes the percentage of Medicare Advantage members within a specified population who participate in ACP discussions each year. This population currently includes:

• Adults aged 65–80 with advanced illness, signs of frailty, or those receiving palliative care.
• All adults aged 81 and older.

HEDIS measures contribute to the overall STAR rating of Medicare Advantage and other health plans, which helps beneficiaries choose high-quality plans, enables highly rated plans to attract more members, and influences the funding and bonuses CMS provides to these plans.

Despite the PSDA, CMS provider reimbursement codes that incentivize physicians and qualified health professionals to facilitate advance care planning, and its recent inclusion in HEDIS measures for Medicare Special Needs Plans, there remain many barriers to completing AHCDs.

Barriers to AHCD Completion 

Although Medicare provides health and financial security to nearly all Americans aged 65 and older, completing a comprehensive AHCD is not universally expected within this population. Conversations about treatment decisions in future emergencies and end-of-life care are often avoided for various cultural, religious, financial, and mental health reasons. When they do happen, preferences are more often shared with loved ones but not documented or communicated to healthcare professionals. It is perhaps unsurprising, then, that only about half of Medicare beneficiaries have completed an AHCD. Studies show that of those who have, most do so in conjunction with estate planning, which may explain increasing cultural and socioeconomic disparities in the completion of AHCDs. 

For Medicare beneficiaries who wish to complete an AHCD with a physician or qualified health professional, Medicare only covers planning as part of the annual wellness visit. If ACP is provided outside of this visit, the beneficiary must meet the Medicare Part B deductible, which is $240 in 2024, before coverage begins. If the deductible has not been met through other Part B services (such as doctor visits, preventive care, mental health services, or outpatient procedures), the beneficiary is responsible for the deductible and a 20% coinsurance payment. Additionally, some states may require attorney services or notarization to legally validate an AHCD, which could incur extra costs.

These additional costs can make it challenging for many Medicare beneficiaries to complete an AHCD when they want to. Furthermore, depending on the complexity of their situation and readiness to make decisions, many patients may need more than one visit with their clinical provider to make decisions about critical illness and end of life care, creating more out-of-pocket expenses. 

AHCDs can also vary widely, are not uniform across states, and are often stored in paper formats that can be easily lost or damaged, or are embedded in bulky, multipage estate plans. Efforts to centralize AHCDs have been made through state-based AHCD registries, but their availability and management vary significantly and there is limited data on their use and effectiveness. Additionally, private ACP programs through initiatives like the Uniform Health-Care Decisions Act (UHCDA), the Five Wishes program, MyDirectives, and the U.S. Advance Care Plan Registry (USACPR), among others, have contributed to broadening ACP accessibility and awareness. However, data from private ACP programs are not widely published or have shown variable results. The UHCDA, first drafted and approved in 1993 by the Uniform Law Commission—a nonprofit organization focused on promoting consistency in state laws—was updated in 2023 and aims to address these variations in state AHCD policies, however with varying degrees of success. The Five Wishes program reports 40 million copies of their paper and digital advance directives in circulation nationwide, and their digital program recently launched a partnership with MyDirectives, a leader in digital advance care planning, to facilitate electronic access to legally recognized ACP documents. Unfortunately, data on completion and storage of these directives is not consistently reported across all users. 

Despite efforts by numerous organizations to improve ACP completion, access, and usability, the lack of updated federal policy supporting advance care planning makes it difficult for patients to complete them and healthcare providers to quickly locate and interpret them in critical situations. When AHCDs are not available, incomplete, or hard to find, medical professionals may be unaware of patients’ care preferences during urgent moments, leading to treatment decisions that may not align with the patients’ wishes.

Plan of Action

To support all Medicare beneficiaries aged 65 and older in documenting their end-of-life care preferences, encourage the completion of AHCDs, and improve accessibility of AHCDs for healthcare professionals, CMS should launch the Medicare Advance Healthcare Directive Enrollment Initiative to focus on the following four interventions.

Recommendation 1. Streamline the process of AHCD completion and electronic storage during open enrollment through Medicare.gov or an alternative CMS-approved secure ACP digital platform. 

To provide more clarity and support to fulfill patients’ wishes in their end-of-life care, CMS should empower all adults over the age of 65 enrolled in Medicare and Medicare Advantage plans to complete an electronic AHCD and renew it annually, at no extra cost, during Medicare’s designated open enrollment period. Though electronic completion is preferred, paper options will continue to be available and can be submitted for electronic upload and storage. 

Supporting the completion of an AHCD during open enrollment presents a strategic opportunity to integrate AHCD completion into overall discussions about healthcare options. New open enrollment tools can be made easily available on Medicare.gov or in partnership with an existing digital ACP platform such as the USACPR, the newly established Five Wishes and MyDirectives partnership, or a centralized repository of state registries, enabling beneficiaries to complete and safely store their directives electronically. User-friendly tools and resources should be tailored to guide beneficiaries through the process and should be age-appropriate and culturally sensitive. 

Building on this approach, some states are also taking steps to integrate electronic ACP completion and storage into healthcare enrollment processes. For example, in 2022, Maryland unanimously passed legislation that mandates payers to offer ACP options to all members during open enrollment and at regular intervals thereafter. It also requires payers to receive notifications on the completion and updates of ACP documents. Additionally, providers are required to use an electronic platform to create, upload, and store AHCDs.

An annual electronic renewal process during open enrollment would allow Medicare beneficiaries to review their own selections and make appropriate changes to ensure their choices are up to date. The annual review will also allow for educational opportunities around the risks and benefits of life-extending efforts through the secure Medicare enrollment portal and is a time interval that accounts for the abrupt changes in health status as individuals age. The electronic enhancements also provide a better fit with the modern technological healthcare landscape and can be completed in person or via a telehealth ACP visit with a physician or qualified health professional. Updates to AHCDs can also be made at any time outside of the open enrollment period. 

CMS could also work across state lines and in collaboration with private ACP organizations, the UHCDA, and state-appointed AHCD representatives to develop a universal template for advance directives that would be acceptable nationwide. Alternatively, Medicare.gov could provide tailored, state-specific electronic forms to meet state legal requirements, like the downloadable forms provided by organizations such as AARP, a nonprofit, nonpartisan organization for Americans over 50, and CaringInfo, a program of the National Hospice and Palliative Care Organization. Either approach would ensure AHCDs are legally compliant while centralizing access to the correct forms for easy completion and secure electronic storage.

Recommendation 2. Remove barriers to access advance care planning services. 

CMS should remove the deductible and 20% coinsurance when beneficiaries engage in voluntary ACP services with a physician or other qualified health professional outside of their yearly wellness visit. 

The current deductible and coinsurance requirements may discourage participants from completing their AHCDs with the guidance of a medical provider, as these costs can be prohibitive. This is similar to how higher cost-sharing and out-of-pocket health expenses often result in cost-related nonadherence, reducing healthcare engagement and prescription medication adherence. When individuals face higher out-of-pocket costs for care, they are more likely to delay treatments, avoid doctor visits, and fill fewer prescriptions, even if they have insurance coverage. Removing deductibles and coinsurance for ACP visits would allow individuals to complete or update their AHCDs as needed, without financial strain and with support from their clinical team, like preventive services.

Additionally, CMS could consider continued health provider education on facilitating ACPs and partnership with organizations like Institute of Healthcare Improvement’s The Conversation Project, which encourages open discussions about end-of-life care preferences. Partnering with Evolent (formerly Vital Decisions) could also support ongoing telehealth discussions between behavioral health specialists and older adults, focusing on late-life and end-of-life care preferences to encourage formal AHCD completion. Internal studies of the Evolent program, aimed at Medicare Advantage beneficiaries, demonstrated an average savings of $13,956 in the final six months of life and projected a potential Medicare spending reduction of up to $8.3 billion.

These enhancements recognize advance care planning as an ongoing process of discussion  and documentation that ensures a patient’s care and interventions reflect their values, beliefs, and preferences when unable to make decisions for themselves. It also emphasizes that goals of care are dynamic, and as they evolve, beneficiaries should feel supported and empowered to update their AHCDs affordably and with guidance from educational tools and trained professionals when needed.

Recommendation 3. Ensure electronic accessibility for healthcare providers.

CMS should also integrate the Medicare.gov AHCD storage system or a CMS-approved alternative with existing electronic health records (EHRs).

EHR systems in the United States currently lack full interoperability, meaning that when patients move through the continuum of care—from preventive services to medical treatment, rehabilitation, ongoing care maintenance—and between healthcare systems, their medical records, including AHCDs, may not transfer with them. This makes it challenging for healthcare providers to efficiently access these directives and deliver care that aligns with a patient’s wishes when the patient is incapacitated. To address this, CMS could encourage the integration of the Medicare.gov AHCD storage system or an alternative CMS-approved secure ACP digital platform to interface with all EHRs.

This storage platform could operate as an external add-on feature, allowing AHCDs to be accessible through any EHR, regardless of the healthcare system. Such external add-ons are typically third-party tools or modules that integrate with existing EHR systems to extend functionality, often addressing needs not covered by the core system. These add-ons are commonly used to connect EHRs with tools like clinical decision support systems, telehealth platforms, health information exchanges, and patient communication tools.

Such a universal, electronic system would prevent AHCDs from being misplaced, make them easily accessible across different states and health systems, and allow for easy updates. This would ensure that Medicare beneficiaries’ end-of-life care preferences are consistently honored, regardless of where they receive care. 

Recommendation 4. Provide financial incentives for AHCD completion.

CMS should offer financial incentives for completing an AHCD, including options like tax credits, reduced or waived copayments and deductibles, prescription rebates, or other health-related subsidies.

Medicare’s increasing monthly premiums and cost-sharing requirements are often a substantial burden, especially for beneficiaries on fixed incomes. Nearly one in four Medicare enrollees age 65 and older report difficulty affording premiums, and almost 40% of those with incomes below twice the federal poverty level struggle to cover these costs. Additional financial burdens arise from extended care beyond standard coverage limits.

For example, in 2024, Medicare requires beneficiaries to pay $408 per day for inpatient, rehabilitation, inpatient psychiatric, and long-term acute care between days 61–90 of a hospital stay, totaling $11,832. Beyond 90 days, beneficiaries incur $816 per day for up to 60 lifetime reserve days, amounting to $48,720. Once these lifetime reserve days are exhausted, patients bear all inpatient costs, and these reserve days are never replenished again once they are used. Although the average hospital length of stay is typically shorter, inpatient days under Medicare do not need to be consecutive. This means if a patient is discharged and readmitted within a 60-day period, these patient payment responsibilities still apply and will not reset until there has been at least a 60-day break in care. 

Medicare coverage for skilled nursing facilities is similarly limited: While Medicare fully covers the first 20 days when transferred from a qualified inpatient stay (at least three consecutive inpatient days, excluding the day of discharge), days 21–100 require a copayment of $204 per day, totaling $16,116. After 100 days, all SNF costs fall to the beneficiary. These costs are significant, and without out-of-pocket maximums, they can create financial hardship.

Some of these costs can be subsidized with Medicare Supplemental Insurance, or Medigap plans, but they come with additional premiums. By regularly educating patients and families of these costs—and offering tax credits, waived or reduced copayments and deductibles, prescription rebates, or account credits—CMS could provide substantial financial relief while encouraging the completion of AHCDs.

Encourage Expansion of the NCQA’s ACP HEDIS Measure

Finally, the MAHDE Initiative can be coupled with the expansion of the HEDIS measure to establish a comprehensive strategy for advancing proactive healthcare planning among Medicare beneficiaries. By encouraging both the accessibility and completion of AHCDs, while also integrating ACP as a quality measure for all Medicare Advantage enrollees aged 65 and older, CMS would embed ACP into standard patient care. This approach would incentivize health plans to prioritize ACP and help align patients’ care goals with the services they receive, fostering a more patient-centered, value-driven model of care within Medicare.

Figure 2. Four key features of the Medicare Advance Healthcare Directive Enrollment (MAHDE) Initiative. This initiative should also work in tandem with efforts to encourage the NCQA to expand ACP HEDIS measures to include all Medicare Advantage beneficiaries aged 65 and older. (Source: Dr. Tiffany Chioma Anaebere)

Conclusion

When patients and their families are clear on their goals of care, it is much less challenging for medical staff to navigate crises and stressful clinical situations. In unfortunate cases when these decisions have not been discussed and documented before a patient becomes incapacitated, doctors witness families struggle deeply with these choices, often leading to intense disagreements, conflict, and guilt. This uncertainty can also result in care that may not align with the patient’s goals. 

Physicians and other qualified health professionals should continue to be trained on best practices to facilitate ACP with patients, and more importantly, the system should be redesigned to support these conversations early and often for all older Americans. The MAHDE Initiative is feasible, empowers patients to engage in ACP, and will reduce medical costs nationwide by allowing patients to be educated about their options and choose the care they want in future emergencies and at the end of life. 

Starting an AHCD enrollment initiative with the Medicare population older than age 65 and achieving success in this group can pave the way for expanding ACP efforts to other high-need groups and, eventually, the general population. This approach fosters a healthcare environment where, as a nation, we become more comfortable discussing and managing healthcare decisions during emergencies and at the end of life.

This action-ready policy memo is part of Day One 2025 — our effort to bring forward bold policy ideas, grounded in science and evidence, that can tackle the country’s biggest challenges and bring us closer to the prosperous, equitable and safe future that we all hope for whoever takes office in 2025 and beyond.

PLEASE NOTE (February 2025): Since publication several government websites have been taken offline. We apologize for any broken links to once accessible public data.