Building Back Better: the Department of Health and Human Services

From the complexities of the ambitious public-private partnership called Operation Warp Speed, to the problematic early rollout of the COVID-19 vaccines late last year, the U.S. Department of Health and Human Services has been a central player in formulating the United States’ response to the coronavirus.

   But the pandemic isn’t the only issue HHS is asked to manage. Tasked with safeguarding the health and wellbeing of all Americans, HHS oversees a sprawling family of agencies that deal not only with disease research and prevention, but also drug, food and cosmetics safety, and many other services ranging from Head Start to Medicare to refugee resettlement. 

   To support this vast portfolio, HHS commands fully one quarter of the overall federal budget. 

   The United States’ involvement in health care traces all the way back to 1798, when President John Adams signed the Act for the Relief of Sick and Disabled Seamen. This established marine hospitals at America’s major ports to provide medical services for sailors, essential workers whose hard lives at sea and visits to far-flung ports left them susceptible to both injuries and disease. In an additional effort to prevent the spread of foreign contagions, Congress later passed legislation extending this care to immigrants arriving on American shores.

   During the Civil War, when President Abraham Lincoln appointed a chemist to work in the newly established Department of Agriculture, this led to the development of a Bureau of Chemistry. Forty-odd years later, that Bureau was transformed into the Food and Drug Administration with the passage in 1906 of the Pure Food and Drugs Act. 

   Likewise, other agencies were established over time to grapple with various health and safety issues that cropped up as the nation grew. In 1953, under a sweeping reorganization plan, these all coalesced under the newly formed Department of Health, Education and Welfare.

   President Dwight D. Eisenhower appointed a woman as the first Secretary of HEW. Oveta Culp Hobby was a Texan who never graduated from college, but she had distinguished herself from an early age as parliamentarian in the Lone Star State’s House of Representatives. When World War II broke out, Hobby was named the director of the Women’s Army Corps. Over the course of her military service she achieved the rank of colonel and became the first woman in the Army to receive the Distinguished Service Medal. 

   As head of HEW, Hobby oversaw the Public Health Service, the Food and Drug Administration, the Social Security Administration, the Office of Education and a handful of other concerns. She worked on initiatives related to juvenile delinquency, water purification, mental health, polio vaccines, and an early (and unsuccessful) bid to provide government support for low-cost health insurance. 

   Over the next quarter-century, her successors at HEW were confronted with an ever-growing roster of concerns related to public well-being. The Department  funded clinics to serve agricultural workers, published the first Surgeon General’s report on smoking and health, established exhaust emission standards for new cars, oversaw the launch of Medicare and Medicaid, regulated toy safety, and improved access for the handicapped.  HEW also became the home for programs including the Indian Health Service and Office of the Inspector General. 

   The Department was reorganized again during the administration of President Jimmy Carter, when the Education component of HEW split off to become a Cabinet-level department unto itself. The agencies that remained were bunched together under the revised name of Department of Health and Human Services. 

   In the 21st century, some of HHS’s responses to Americans’ health needs have whipsawed depending on the administration in power at the time.

   Under President George W. Bush, initiatives for fighting bioterrorism became a priority following the aftermath of the 9/11 attacks on the World Trade Center and the Pentagon. Bush also created Faith-Based and Community Initiatives in six of his Cabinet Departments, including HHS, and promoted the distribution of grant money to faith-based organizations providing social services. Bush’s HHS Secretary, career politician Tommy Thompson, also played an essential role in the Administration’s commitment to combat the spread of HIV/AIDS worldwide.

   When Barack Obama came into the Oval Office, he successfully pushed for the passage of the Affordable Care Act, and his Secretary of Health and Human Services, Kathleen Sebelius, was tasked with implementing the program. The much-anticipated launch of “Obamacare” health insurance suffered some bad publicity when the government website set up to register applicants crashed due to high demand. Eventually, however, the chaos was resolved, and the ACA helped millions of uninsured Americans, including those with pre-existing conditions, secure affordable health insurance.  But as a result of the initial difficulties, Sebelius bowed to public pressure to resign.

   Republicans remained skeptical about the ACA’s benefits. They filed several court challenges, and GOP members in Congress attempted to water down the act. 

   In 2016, Republican presidential candidate Donald Trump’s “repeal and replace” mantra regarding Obamacare was a major talking point of his campaign.  And after he won the election and was sworn in as 45th President of the United States, one of his very first actions was to sign an executive order to “waive, defer, grant exemption from, or delay” the Affordable Care Act.

   To assist in that regard, Trump appointed Tom Price, an orthopedic surgeon who also represented Georgia in the United States Congress, as his first HHS Director. Prior to becoming politically active, Price had been active in the Association of American Physicians and Surgeons, hardly a mainstream group, but one that was extremely vocal against “socialized medicine.” Certainly Price was in the anti-ACA camp. 

   But his stint at HHS turned out to be brief. In his first few months in office, Price racked up more than a million dollars in travel expenses on charter jets and military funding – and he used taxpayer money to pay for it. This raised a red flag with journalists and ethics experts, and Price’s actions soon became the focus of a bipartisan Congressional probe. He was forced to resign only eight months after he had been sworn in.

   Trump turned to Alex Azar as his replacement. Azar came with government experience – he had served at HHS during the George W. Bush administration. But more recently he had spent a decade as a top executive at the pharmaceutical giant  Eli Lilly and Company. During his tenure there, the company’s drug pricing rose significantly, with their top-selling insulin more than doubling in price in the American market.

   As HHS Secretary, Azar also worked to dismantle the Affordable Care Act, but his biggest test of loyalty to his boss in the Oval Office came when COVID-19 reached America’s shores last year. In January, 2020, there was a struggle within the White House over how to deal with the virus. Trump, wanting to project an attitude of calm and control, repeatedly dismissed the threat to Americans and promised “like a miracle, it will disappear.” 

   But Azar saw the handwriting on the wall, and on January 31, the Secretary declared a public health emergency. Less than a month later, however, his Department failed to abide by basic health protocols when HHS personnel were working at California quarantine sites that had been set up to receive travelers arriving from Asia. 

   With contradictory messaging emerging from the White House about the need for wearing masks and practicing social distancing, and with Trump promising throughout the spring that – “like a miracle, [the virus] will disappear,” instead, COVID-19 quickly spread out of control. By the end of May, 2020, more than 100,000 Americans had died of coronavirus. 

   Azar was able to exert his leadership in the initiative that became known as Operation Warp Speed, a moniker that likely appealed to his brand-savvy boss. This brought together top health and defense department officials who planned to stake Big Pharma with the R&D funding needed to create and test COVID-19 vaccines at an unprecedented pace and, when the vaccines passed muster, to get them into the arms of Americans as quickly as possible.

   Indeed, vaccines by Pfizer and Moderna were successfully developed, tested and approved before the end of 2020. But distribution of the vaccine was a logistical mess.

   Largely due to his incompetent handling of the pandemic, Trump lost his bid last year to be re-elected for another four-year term. Instead, by the time that Joseph R. Biden was sworn in as President two months ago, there had been over 19 million coronavirus cases reported in the United States in the past year and over 400,000 Americans had died of COVID-19. And Azar, who as a political appointee had left when Trump’s term expired, did so without replenishing the federal stockpile of vaccine doses.

   Since then, the infections have continued to rise and the death toll has topped 500,000. New leadership at the Department of Health and Human Services will be crucial in stanching this trend.

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   By the time this piece is published, a new HHS Secretary already may have been confirmed. Biden’s nominee, Xavier Becerra, would be the first Latino ever to serve in the position. As such, his background looks somewhat different from those who have held the position previously – Becerra is the son of migrant workers and he was the first person in his family to go to college. He earned undergraduate and law degrees from Stanford University, which is where he met his wife, who has her own career as a perinatologist. 

   Becerra represented the State of California in the U.S. House of Representatives for twelve terms. During his time in Congress, he became known as a policy wonk and consensus builder as he worked for passage of the Affordable Care Act. 

   Four years ago, Becerra went back to his home state and became Attorney General, where he has presided over the second largest Department of Justice in the land (the only one bigger is the federal Department of Justice), managing thousands of employees and a billion-plus dollar budget. As California’s AG, he filed several lawsuits in defense of the Affordable Care Act, he went after big hospital chains and pharmaceutical giants who were engaged in price gouging, and he developed a reputation for supporting women’s reproductive rights. 

   In late January, during Becerra’s Senate confirmation hearings for the HHS post, some Senators raised questions about his lack of a medical degree, although it’s worth noting that many previous HHS Secretaries had not been medical doctors, and Becerra is widely recognized as being an expert in health policy.

   Also at the hearings, a handful of Republican Senators – all of them male, it should be noted – chose to use their five minutes of questioning to grill Becerra about his opinions on women’s reproductive rights. But even when confronted with a particularly combative performance by Nebraska Senator Ben Sasse, the nominee retained his equanimity.

   “I understand Americans have different, deeply held beliefs… and I absolutely respect that,” Becerra reiterated several times over the course of two days of questioning. “Here is where I think there’s an opportunity… to try to see if we could find that common cause on how we move forward.”

   Other Senators brought up issues that were of top concern for their constituents. These included the Medicare funding cliff, the high cost of prescription drugs, the opioid epidemic, access to telehealth expansion, the lack of health services in rural communities, and the inequities in health services available to urban populations.

   As the ranking law officer of a large and highly diverse state, both in terms of race and ethnicity, but also in terms of rural/urban divides, Becerra has seen how those issues have played out for Californians, and in his responses to the Senators he frequently expressed empathy for their concerns. Many of the Senators asked for his help, should he be confirmed, in passing the health-related bills they were sponsoring. Repeatedly, he assured them that he’d want to work with them on those issues. But in this mistrustful era, not all of the Senators seemed to put store in his sincerity.

   The Department of Health and Human Services is expected to do the crucial work of ensuring that the health care systems for this nation serve the public, yet as was made clear this past year, that infrastructure was woefully insufficient.

   Once the Senators got past their partisan grandstanding at Becerra’s confirmation hearings, the substantive questions they posed suggested that there is plenty of room for finding common ground. To Build Back Better, the Biden administration is going to need to listen carefully to the ideas that are coming in from Alaska, Mississippi, Kansas and elsewhere, and undertake the multi-faceted work that will allow every American access to quality, affordable health care.

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Barbara Lloyd McMichael is a freelance writer living in the Pacific Northwest.