What Could RFK Jr. Do As Head of HHS? We Asked Someone Who’s Done the Job

Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode above!

Dan Gorenstein (DG): The U.S. Department of Health and Human Services purview is mission critical. The department oversees Medicare, Medicaid, the Affordable Care Act. HHS regulates the medicines we take, funds groundbreaking research and sets recommendations for the vaccines we give our kids. And last week…

News clip: President-elect Donald Trump promised to shake up Washington and he is doing just that as he staffs up his administration.

DG: …the President-elect tapped a vaccine skeptic who has pushed debunked science to run the department.

News clip: Robert F. Kennedy Jr is Mr. Trump’s for Secretary of the Health and Human Services Department.

DG: Unless the new President can get around it, Kennedy’s nomination is headed to the Senate for a vote. Senators will have to decide whether to give RFK the power to influence the health of the nation.

Kathleen Sebelius (KS): The Secretary is in a position to do a lot of good, but also potentially do a lot of harm.

DG: Today, we talk with former HHS Secretary Kathleen Sebelius about what the country’s top health official can do, what they can’t do, and what RFK would have to do to implement his agenda.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

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KS: I am Kathleen Sebelius. I served as Governor of Kansas from 2002 until 2009, when I was appointed by President Barack Obama to lead the Department of Health and Human Services, and served in that position for five and a half years.

DG: And, Secretary, you know, I was driving my teenage son to school. Actually, he was driving me this morning, and I was telling him that we’re going to interview you today. And I realized that I didn’t know exactly how to describe what the HHS secretary does. Obviously, it’s a hugely important job. From your perspective, what is the job? What is its purpose?

KS: Well, HHS is one of the biggest domestic agencies and really connects with people from birth to death. The HHS budget is about $1.7 trillion. We send more money to states than all the other domestic agencies combined. And they’re about 85,000 employees both in the United States and around the globe. And I’d say the secretary really is making sure that each of the spokes of that wheel are operating well, and also is the public spokesperson for health and wellness, not only in America but around the world, because America has a huge role in global health and in partnering with other countries.

DG: And, Secretary, do you remember a time when your management skills were the difference in how much power you were able to exert in this role?

KS: Well I would say the role of secretary is winning hearts and minds because I can guarantee you nothing gets done in a federal agency unless a lot of the workers in that agency believe that they’re part of the mission. So I spent a good deal of time at the beginning of my tenure literally physically visiting each and every agency. CDC is in Atlanta, so going to Atlanta, being there for two days, wandering around, having lunch with people on the ground. I could never have done the job with any measure of success without learning something from really talented people. Having people come forward and say, you know, you may not have thought about this, but how about this? That kind of management, I think, in any big organization works well. Not that you arrive with the answers, but that you actually learn something about the organization that you’re asked to lead.

DG: Secretary, I’m really curious about the contours of the power that comes with this position. It seems like I’ve heard conflicting descriptions of the power. Like on the one hand, there’s the quote from former Trump HHS Secretary Alex Azar, who said, “The secretary has a shocking amount of power by the stroke of a pen.” And on the other hand, you’ve got these former federal health officials pointing out that the department is made up of 80,000 employees. One even joked it took the FDA 15 years to define peanut butter. You’ve had this job. How powerful is this position?

KS: It can be wildly powerful and unpowerful at the same time. Most of the power in the agency, most of the administrative authority comes from laws that Congress has passed, and the agency is then asked to write rules and regs and implement those laws. What I found out is that there were a lot of areas where the agency had administrative power that they had never used. So for instance, when President Obama no longer had a sympathetic Congress, we were all asked to look at our administrative authority and figure out where we could go on various issues. And one of the areas that, frankly, was identified within HHS was a lot of opportunity to make a difference with LGBTQ citizens in the United States. I mean, across the board, there were rules and regs in place that were very limiting. So we began to redefine what a family member was. This was well before the marriage decision and Supreme Court and others. But we had partners who had been long time living together and were not allowed to visit each other in a critical care unit in a hospital because they weren’t a member of a family. So things like that you could actually move policy, long standing policy. You could rescind what a previous administration had done. You could redefine terms that had a huge impact on people. And that could be done all administratively, not by going back to Congress.

DG: You’ve got, as HHS secretary, a boss. It’s the president of the United States. That’s clearly one of the checks on the power of this position. What are other checks, Secretary, that you discovered once you occupied this position?

KS: Well certainly what the president wants and needs and wants to drive is one, as you say. I would say there is a congressional check where lots of committees in the House and the Senate have jurisdiction over pieces of the Department of Health and Human Services, in fact, to the point that the secretary has to go through two Senate confirmation hearings, one with the Finance Committee and one with the HELP committee. That’s gobbledygook to a lot of people, but it just means that there are lots of congressional committees — there are three in the House and two in the Senate — with big interest in what’s going on at HHS. And so they can have hearings on a regular basis. They do what’s called oversight, calling the secretary in, calling the department in. Why are you doing this or that? Challenging authority. And then there’s a whole legal system that can sue the department. The FDA is very used to that. I mean, any time they would issue, for instance, a tobacco regulation, tobacco companies would immediately file a lawsuit and slow that down or stop it. When there’s any kind of cut suggested to the hospital system, the hospital association immediately goes to court. So I would say court, Congress and the president operate as guardrails around the secretary’s power.

DG: When we come back, Secretary Sebelius explains the barriers RFK could face to implementing his agenda, and what could happen if he is confirmed by the Senate.

MIDROLL

DG: Welcome back. We’re talking with former HHS Secretary Kathleen Sebelius about the power of the job she did for 5 years under President Obama. A job that President-elect Trump has now picked Robert Kennedy Jr. for. 

Kennedy has mentioned a lot of things that he would like to do at HHS. So, Secretary Sebelius, I’d like to walk through a few of those ideas and get a sense from you of how easy it would be for him to accomplish some of these goals. For example, he said that staffers at the FDA should be ready to “pack their bags” and that he wants to slash 600 jobs at the NIH, the National Institutes of Health. How much discretion does the secretary have to fire people?

KS: Well at this point, I would say the discretion is limited by civil service protection. You really can’t just fire people who are in a protected position. But I think just suggesting that you want to fire people before he knows anything about what those folks are doing, who they are, what the expertise is. The likelihood that you lose the best talent right away because they walk out the door. The FDA scientists are well sought out by industry across the board. So just the suggestion that a secretary comes in and says at the outset, I’m going to get rid of this division, what that does is send a chilling effect throughout the department saying, we have somebody coming in here who doesn’t value us, doesn’t like what we do. And I can tell you right now, there are likely to be lots of people already having conversations about their next job.

DG: So Bobby Kennedy has spread known falsehoods about the debunked idea that vaccines can cause autism. At the same time, as you know, the U.S. has seen a dip in measles vaccination rates, for example, among kindergartners, according to the CDC. As of the beginning of this month, we’ve seen 266 measles cases, with 16 outbreaks. In 2022, New York had its first case of polio in more than 30 years after vaccination in some communities have dropped. Now you’ve got Kennedy, who’s vowed to tell NIH scientists, “we’re going to give infectious disease a break for about eight years.” If you have a secretary who is hell-bent on limiting vaccine take up, what can the secretary do?

KS: Well, those are two different issues. Okay. So NIH does the research, and that research is done in research universities across the country. Bobby Kennedy said, let’s give infectious diseases a break and focus on obesity. What he clearly doesn’t understand is that within the National Institutes of Health, those are going on simultaneously. You can’t pick and choose when an infectious disease is going to break out. And in fact, he’s clearly not reading the news because we are, I think, a year or so away from a major outbreak of avian flu in humans. We’ve seen avian flu jump from birds to farm animals and from farm animals to farm workers. That’s just a step away from a major outbreak of avian flu, which right now has no vaccine. 

Vaccines are recommended for children going either to school or to daycare centers, and come from recommendations of scientists at the Centers for Disease Control and Prevention. And then state governments adopt their own vaccine list based on CDC recommendations. Some have a more robust list, some have a narrow list. So in terms of vaccine take up, a secretary could do a couple of things. He could make very strong recommendations to states that they grant far more exemptions to parents, so greatly increase the number of children who could qualify to go to school without vaccines. He could encourage states to just make it optional.

And to me, this is really personal. I have an 11 month old grandson. He is too young to qualify for the full measles vaccination set. We live in a red state. He is susceptible to getting measles because he can’t get vaccinated. And so this is real life consequences that, I mean, kids could die from this kind of policy change. And I think the secretary could have a lot of influence. He can’t change the rules, but he could recommend very strongly that people who believe in Donald Trump should change the rules.

DG: Right. He’s talked about how he’s not actually anti-vaccine, but he is a proponent of sort of vaccine choice. And this is just making me think about what we talked about at the top of the conversation, you said a part of the job is to be a spokesperson. And I think what you’re saying is that if Kennedy became secretary, he would be able to put out information that is ultimately harmful to public health.

KS: He’d not only be able to put it out, but because this is coming from the Secretary of Health and Human Services, he’d be able to deliver it in a way that people would think it was legitimate. And I remember clearly when we were dealing with this early outbreak in the Obama administration of H1n1, which, thank God, turned out to be less virulent than people had feared. 

President Obama: We are closely monitoring the emerging cases of swine flu in the United States.

KS: We had no vaccine. It was a strain of the flu that had never been seen before, and it was killing children and young adults. 

News clip: The government now believes that roughly 8 million children have come down with the virus.

KS: A very different population than usually dies from the flu. And that was terrifying to folks. We had some news outlets who were at that point doing sort of a point-counterpoint with scientists on one hand and with vaccine skeptics on the other, and presenting them as if it was a debate. And I remember very clearly going to talk to the heads of various news organizations in New York and elsewhere saying, this is really dangerous stuff. If you give that information as a choice to the American public, you’re putting them in a very precarious situation because they believe that somehow this is a legitimate debate. That’s really dangerous in this situation where people can die.

DG: Kennedy has talked a lot about vaccines, raw milk, ultra processed foods. What we’ve heard him really not talk about is Medicare, Medicaid, the Affordable Care Act. And to put this in perspective for a minute, if he were to become secretary, he’d be overseeing, as you know, the Centers for Medicare and Medicaid Services, which makes up nearly 90% of the department’s budget and serves more than half of the country’s population, 170 million people. I’m curious, is it possible for someone to run HHS and effectively ignore that part of the job?

KS: Yeah, probably. And that could be the best thing that could happen because there’s some really talented folks who know how to run those programs. I think the secretary is in a position to do a lot of good, but also potentially do a lot of harm to all sorts of care. Could we be more healthy in the United States? You bet. Would I like Bobby Kennedy to tackle processed foods and food ingredients and go to battle with the corporate interests who are promoting products that make us a lot less healthy? You bet. A lot of that jurisdiction is not within HHS. The school lunch programs, all within the Department of Ag. The food stamp program that he talks about, SNAP? All within the Department of AG. So I think unfortunately, he really doesn’t even understand what’s within the jurisdiction of the department or what kind of impact he could have. But ignoring CMS might be a really good idea.

DG: Just to be clear, you say “Department of Ag,” you are talking about the Department of Agriculture. 

So as the Senate sets up potentially to vote on RFK Jr.’s nomination, how should the senators think about the amount of power they’re potentially handing over to RFK?

KS: Well, I think they should think long and hard about it. You know, think about Bobby Kennedy as secretary during COVID, when there’s an opportunity to stand up Operation Warp Speed and a COVID vaccine, which clearly saved lives. My guess is he would not have participated in that robust effort. He would have tried to throw barriers and roadblocks and suggest to people that they shouldn’t get the vaccine. That’s a real life example that we just had, and I think, you see, what was a remarkable scientific breakthrough and accomplishment and then contrast it with this point of view, that’s a really dangerous place to be when you’re looking at the safety and security of U.S. citizens, and you’re looking at health issues that can topple our economy. In again, my experience, I worked for a president who had a pretty clear health agenda. And there were times that I would sit with our leadership team and say, I think we’re going to do this initiative. And somebody would kindly remind me, maybe you should talk to the white House about doing that initiative. And I’d be like, oh, yeah, oh, yeah, there’s that guy down the street. I have no idea what Donald Trump’s health policy is, so it’s a little confusing for me to know what to tell the senators. If he is allowed to, as Donald Trump has said, “go wild on health,” what does that mean? And I would, if I were a senator, try to understand that because it’s likely within HHS to have a huge impact on that senator’s constituents.

DG: Secretary, thank you very much for taking the time to talk to us on Tradeoffs.

KS: Sure. Good to be with you.

DG: After we talked with Secretary Sebelius, another major health care nomination was announced.

News clip: President-elect Donald Trump has just picked Mehmet Oz to serve as the Administrator for the Centers for Medicare and Medicaid Services.

DG: We’ll have more coverage in the weeks to come on what could happen to Medicare, Medicaid and Obamacare under a Republican administration and Congress.

But the announcement made me think of something we heard from several people when we asked them about RFK: They told us that Kennedy’s ability to implement his agenda will be shaped in large part by his relationship with the people leading top HHS agencies like CMS. Here’s how Tom Scully put it. Tom ran CMS for the first few years of the George W. Bush administration.

Tom Scully: The secretary on his own can’t do anything unless he has support of the White House and the rest of the administration. And if you have that support and the other people running your agencies, you can do a lot of stuff.

DG: Tom likes the Oz pick — says the president-elect could’ve done a lot worse. It’s too soon to know how Kennedy and Oz will get along. But Tom adds he doubts RFK will be in the weeds on CMS policy.

I’m Dan Gorenstein, this is Tradeoffs.