Democrats ask of Biden’s health team: Who’s in charge?

Democrats ask of Biden’s health team: Who’s in charge?December 18, 2020

President-elect Joe Biden vowed to assemble a world-class team capable of ending the pandemic and securing sweeping health care gains.

But in the days since he rolled out his health leadership, Democrats have been occupied by a simpler challenge: figuring out who among Biden’s health team is actually in charge.

The president-elect’s half-dozen initial appointments range from public health specialists to politicians, most of whom come from different professional backgrounds, and few of whom have worked together extensively before.

Xavier Becerra, for instance, is in line to run the Health and Human Services Department at the center of the Covid-19 crisis — though he has little public health background. Jeff Zients, an economic policy expert, will coordinate the pandemic response out of the White House. And Vivek Murthy, who spent three years as the Obama administration’s surgeon general, is reprising his role at HHS — yet with the promise he’ll also wield outsize influence in the West Wing.

That mix has left Democrats questioning who will ultimately shape Biden’s health agenda – and harboring lingering concerns about how his team will mesh in the midst of the high-stakes pandemic fight.

“I don’t know who’s going to be driving the policy,” said Rep. Pramila Jayapal (D-Wash.), who chairs the Congressional Progressive Caucus. “I want to know how these things are actually going to happen.”

The rising angst over the structure of Biden’s health team follows a post-election period during which the transition scrambled to build out its Covid-19 leadership and lock in an HHS nominee.

Despite campaigning on his preparedness to run the crisis response, Biden spent weeks sorting out his health care hierarchy — surprising Democrats who expected he would have long ago decided on the team responsible for managing the incoming administration’s most urgent priority.

The search for an HHS chief turned particularly frenetic, with multiple candidates rising and falling in the space of days before Biden settled on Becerra, a former congressman and current California attorney general.

Since then, several Democrats have privately questioned how Becerra — a progressive who has expressed support for “Medicare for all” — will fit within Biden’s more moderate administration, and how much authority he’ll have among a pandemic leadership team that he played little apparent role in helping choose.

In addition to selecting Zients as Covid czar, Biden last week named Marcella Nunez-Smith — a public health expert with no political experience — to head the White House’s Covid-19 Equity Task Force.

He also appointed a new director of the Centers for Disease Control – Rochelle Walensky, a physician with no prior political experience — depriving Becerra of the ability to search for his own public health chief. And Biden brought back Murthy, a close adviser who was also a contender for the HHS nomination.

As surgeon general, Murthy would be one of several senior officials working under Becerra at HHS. Yet Biden has also signaled he’ll play a central role in leading the administration’s coronavirus work out of the White House.

“Dr. Murthy will be one of my most trusted public health and medical advisers,” Biden said last week, touting the benefits of his “expanded responsibilities.”

In a statement, transition spokesperson Andrew Bates said the incoming administration is taking an “all-of-government approach to overcome the coronavirus outbreak” that would be “grounded in historical best practices, cutting-edge new strategies and — always — science.”

Becerra, he added, would be an “empowered leader at the forefront of this effort.”

But Murthy’s envisioned role as both a subordinate to Becerra and close adviser to Biden has concerned some Democrats inside and outside of the transition, who worried it could muddy decision-making and give rise to the kinds of competing power centers that could complicate the Biden administration’s health ambitions.

“What you don’t want is a White House where everyone’s just chasing the ball,” said one official working with the transition. “It feels like a very crowded West Wing.”

Added another Democrat close to the transition: “Seems like a recipe for disaster.”

The responsibility for averting those pitfalls will rest largely with Zients, a skilled manager credited with turning around the Affordable Care Act’s HealthCare.gov website after its botched launch in 2013.

That crisis role won him praise across the government for his willingness to make difficult decisions, and yet still keep the peace between teams across the White House and HHS that were working under emergency conditions. And while Zients has no significant health policy experience, those who interacted with him at the time described his recognition early on that what the effort lacked was not expertise, but guidance.

“I remember him being a very precise leader on clarity and direction, but also really listening to the subject matter experts,” said one former Obama official who worked on the HealthCare.gov rescue team. “The person we need right now is someone who knows how to coordinate the entire-of-government response, and a lot of that isn’t necessarily public health.”

In the Biden White House, Zients will play a similarly high-profile role modeled on the Obama administration’s 2014 Ebola response, charging him with managing the Covid-19 work across the entire government and serving as the pandemic point person for the president and his chief of staff, Ron Klain.

In addition to keeping tabs on agency-specific initiatives, Zients may also build out his own White House team of specialists focused on specific elements of the response.

“I’ll be totally blunt: If they hadn’t put Jeff in that chair then I would say this is all going to fall on Ron, and he’s got too much to do,” said Andy Slavitt, a former Obama administration acting Medicare and Medicaid chief. “But Zients is the kind of person who people will be talking to him on the phone seven, eight, nine times a day.”

In the Biden administration’s first months, Murthy is expected to work closely with the White House on pandemic messaging — serving as one of the most visible faces of the push to sell Biden’s Covid-19 response and encourage hundreds of millions of Americans to get vaccinated.

That effort will also feature Anthony Fauci, the top infectious disease expert who will be Biden’s chief medical officer alongside his existing role at the National Institutes of Health. And at the CDC, Walensky — a well-known infectious disease expert — will be charged chiefly with restoring trust and morale at an agency that was sidelined and subjected to months of political pressure by the Trump White House.

In theory, Democrats said that should leave the broader health agenda to Becerra, whose pursuit of dozens of legal challenges to the Trump administration’s most divisive policies puts him in a position to immediately begin unraveling much of Trump’s health legacy.

Prior to taking California’s attorney general post, Becerra as a House lawmaker sat on the Ways and Means health subcommittee and aided the ACA’s passage in 2010 – credentials that allies have wielded against suggestions he lacks the experience to run Biden’s expansive health department.

“He won’t be able, as HHS secretary, to work full time on Covid,” said former Obama administration HHS chief Kathleen Sebelius. “You can’t put everything else on pause while you deal with Covid, because there’s too much else in that department that’s absolutely essential.”

The transition team has also resisted calls to elevate Murthy to a Cabinet-level position, despite criticism that Biden’s Cabinet lacks a public health expert — a decision seen at least in part as an attempt to further delineate top officials’ roles.

Still, Murthy is likely to retain significant clout simply by virtue of his close relationship with a president-elect who relies heavily on a small circle of confidants. Becerra’s backers have also taken note of Biden’s nomination of Neera Tanden to run the Office of Management and Budget — a choice that would grant the former Obama HHS senior adviser broad power over the administration’s policy agenda.

“There are a lot of very experienced and talented cooks in the pandemic kitchen,” said Larry Levitt, the Kaiser Family Foundation’s executive vice president for health policy and a former Clinton White House official. “The Biden transition team may have a very clear idea of how the responsibilities shake out, but it will also likely take some working out.”

Any honeymoon period for Biden’s health leadership won’t last long, if it exists at all. The U.S. is likely to be in the middle of both the deadliest stage of the pandemic and the largest mass immunization campaign in decades by the time Biden is sworn in, requiring the administration to work at full speed and under intense scrutiny from its first day.

It’s a challenge that Democrats say will immediately test the Biden team, and its ability to balance the competing urgencies of curbing the pandemic and putting its stamp on the broader health landscape.

“What most people are hoping for is confidence and a willingness for ambitious health care policy, and there are some big moves in that direction,” said Adam Green, a co-founder of the Progressive Change Campaign Committee. “The question is who on the team is charged with the theory of that [political] fight.”

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