HHS idles as top jobs go unfilled

The leadership void at the top of the Department of Health and Human Services (HHS) is affecting more than President Obama’s health reform agenda.

Though the department is capable of fulfilling its day-to-day responsibilities as guardian of the nation’s public health, pharmaceuticals, foods, medical research and other areas, the continued lack of a secretary and of leaders at key agencies will delay the Obama administration from putting its stamp on the massive bureaucracy.

As illustrated by the Food and Drug Administration’s (FDA) active role responding to the salmonella outbreak from contaminated peanut butter, HHS does not grind to a halt without its senior leadership team in place.

But while the senior civil servants and Bush administration holdovers overseeing the department’s 67,000 employees have the know-how and experience to keep the engines at HHS running, they lack the clout to set new policy. Charles Johnson, a Bush appointee as assistant secretary for budget, is acting HHS secretary.

The administration has installed a handful of political appointees, but they also lack the clout to make big changes to departmental policy without explicit direction from the highest levels of the administration.

The White House, meanwhile, has too full an agenda to get involved in all but the biggest items of departmental business.

Until Sen. Judd Gregg (R-N.H.) unexpectedly gave up his Commerce nomination Thursday, HHS was the last Cabinet-level entity without a nominee for secretary after the sudden departure of Obama’s first choice, former Sen. Tom Daschle (D-S.D.), last week amid controversy about unpaid taxes. All but two of Obama’s other nominees have been confirmed and the remainders are nearing confirmation.

The White House admits it had no second choice behind Daschle, which likely means HHS will go without a secretary in place for longer than is typical for a new administration.

Transitions always bring uncertainty to federal agencies, but the surprise exit of Daschle, who had been part of the Obama team since early in the president’s campaign and was seen as an integral part of the new administration, intensified that uncertainty at the same time it prolonged the absence of leaders within the department.

Though the White House began its search for an HHS secretary almost immediately after Daschle stepped aside, the process will take time as the administration carefully vets its favored candidates, then submits the nominee for a thorough going-over by the Senate.

Tradition also strongly suggests that the president will not nominate people for important jobs such as FDA commissioner, Centers for Disease Control and Prevention (CDC) director, Centers for Medicare and Medicaid Services (CMS) administrator or Nationals Institutes of Health (NIH) director until a secretary is nominated.

“There’s always the secretary appointed first,” said former Wisconsin Gov. Tommy Thompson (R), who was HHS secretary during President George W. Bush’s first term.

The department is capable of carrying out its basic responsibilities without a secretary or agency heads in place for a time, Thompson emphasized. But leadership at the top matters, he said, starting with the secretary’s role advising the president on whom to choose to fill the upper echelons of the department’s staff and to lead its big agencies.

Thompson illustrated the shortcomings of a leadership vacuum by saying that the FDA suffered from not having a confirmed commissioner for nearly half of Bush’s eight years in office. “They don’t want to make the same mistake George W. Bush did,” Thompson said of the Obama administration.

The delay in getting that leadership in place will not end when an HHS secretary is confirmed, Thompson said. A new secretary has a lot to learn about the department, he said. “It’s an awesome educational process that any new secretary is going to go through,” he said.

“For all purposes, there is no Obama administration” within HHS, remarked William Hubbard, who was the FDA’s associate commissioner for policy and planning from 1991 to 2005.

Adjustment periods are always difficult for new administrations, Hubbard stressed. But, he added, “The Daschle problem has complicated all of that.”

Those Obama appointees in place at HHS — several of whom are Daschle associates who may not stay — are nearly as limited in their authority as the civil servants and the leftover Bush appointees, Hubbard said.

“They don’t have much of a portfolio. For instance, they don’t have a boss,” said Hubbard, who currently is a consultant with the Coalition for a Stronger FDA, a group that supports boosting the agency’s budget.

The FDA will still review new drug applications, CMS will still pay medical providers for treating beneficiaries, the NIH will keep issuing research grants and CDC will maintain its vigilance of the public health, the officials agreed.

“The bulk of that work just continues apace,” said Alex Azar, who served as both HHS general counsel and as deputy secretary during the previous administration.

But those agencies will not be able to set new priorities without leaders, Hubbard said. “You get no guidance from above in terms of priorities.”

During a crisis such as the salmonella outbreak, the FDA can respond to the immediate problem but cannot promote new food safety policies, for example, Hubbard said. “It’s very difficult for the Obama people to do that, because they don’t exist.”

A new administration needs to reshape the department to fit the president’s priorities, said Azar, who currently is senior vice president of corporate affairs and communications at the drug maker Eli Lilly & Co. “You do lose the initiative on transformation and change activities,” he said. “That does get stalled.”

Obama, for example, is expected to adopt a more stringent regulatory approach to pharmaceutical companies, health insurers and other sectors the department oversees. In the meantime, the agencies are “handicapped,” Hubbard noted.