This article originally appeared in Morning Consult.
Based on my experience as a senior staffer at the Department of Health and Human Services under former Secretary Tommy Thompson, there are a couple of truisms that are important as we evaluate the nomination of Tom Price as HHS secretary and Seema Verma as administrator of the Centers for Medicare and Medicaid Services.
In practical terms, the HHS Secretary is a huge management position that requires the requisite skills. HHS is the largest federal cabinet department with just over $1 trillion in outlays and almost 80,000 employees making its budget larger than the Department of Defense, whose budget is nearly $600 billion. The HHS budget is larger than that of most countries. CMS is the largest among the 11 HHS agencies and centers. Its budget consumes 85 percent of the HHS budget.
This is one reason why four of the last seven HHS Secretaries have been governors (Otis Bowen, Tommy Thompson, Mike Leavitt, Kathleen Sebelius), two have headed up large institutions (Donna Shalala, Louis Sullivan) and one had a reputation as a management guru (Sylvia Mathews Burwell). Tom Price has a very different management profile. He managed his medical practice, was a professor of medicine engaged in training physicians and managed his House office and the House Budget Committee staff — not on a parallel with his predecessors.
While his policy positions and support for Donald Trump make him a logical political choice, what is more likely to define his tenure is how well he manages, maneuvers and uses the HHS bureaucracy to achieve his and the White House’s agenda.
This is important because what goes on at CMS, FDA, NIH, CDC, ACF or HRSA (to name just a few) could quickly become an issue or problem if the Secretary is not engaged in managing the bureaucracy. The same is true for Seema Verma, who is the designated CMS Administrator. Its programs provide health coverage to just over 100 million Americans, promulgates dozens of regulations and makes thousands of decisions affecting that care each year. Verma does have experience working with CMS through her work on the Indiana Medicaid program and should know the agency well and they in turn likely have a familiarity with her. But she has no experience with Medicare, the more politically sensitive program.
Therefore, the administration’s choices for deputy secretary and deputy CMS administrator are critical. Having persons with either direct familiarity or experience with the department/agency or significant management experience will be important to moving their agendas through the sprawling bureaucracies.
The other defining challenge for both Price and Verma relates to the fact that HHS touches nearly every American through one of its programs. The career staff knows this and take it to heart by honoring HHS’ mission “to enhance the health and well-being of Americans by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services.”
In practical terms, this means that staff see its job as seeking to provide people in need with help — be it health care through Medicare, Medicaid of CHIP, or financial and related benefits through the TANF program, or disease prevention through the CDC, or ensuring we have safe foods and effective drugs through FDA. If they believe the incoming secretary and other appointees intend to take away or diminish the help and benefits their agencies provide Americans, the new team will encounter resistance.
And while I am sure the new administration does not see its agenda as being a negative agenda, that point of view may not be shared by the tens of thousands of HHS employees. They do not view the ACA or Medicare and Medicaid as fiscal problems that need to be fixed but rather as programs providing vital human services to millions of people. When they read phrases like “drain the swamp” and pull the ACA out “root and branch,” hear President-elect Trump excoriate the ACA, or read how the new administration intends to reform Medicare and Medicaid, no doubt they feel that their agencies’ work is threatened. In the end, it is the civil servants at HHS and CMS who implement the law and they feel a strong ownership of the programs.
Whenever a Cabinet official, political ambassador or other appointee leaves his or her position earlier than expected to “pursue other challenges” or to “spend more time with their family,” the real cause if often that they alienated, angered or simply mismanaged the career staff to the point they were no longer effective. This is easier to do than most people understand. It will be Tom Price and Seema Verma’s biggest challenge — getting the career staff to buy into their agenda and convince them it will be in the best interests of America.