RFK Jr. at HHS? Former health secretary Kathleen Sebelius explains the limits of the role : Shots

Robert F. Kennedy Jr. is on Capitol Hill this week, trying to convince senators that they should greenlight him to lead the Department of Health and Human Services, ahead of expected confirmation hearings.

Kennedy — who initially ran for president as a Democrat in the primary and an Independent in the general election before dropping out and endorsing Trump — is perhaps best known for his vaccine skepticism and for spreading misinformation about the safety of vaccines. He’s also a fierce critic of the pharmaceutical industry, processed foods and water fluoridation.

Kennedy has never worked in health care or the federal government, but he’s become outspoken on a wide range of health care issues that have now coalesced under the banner of the “Make America Healthy Again” movement. He has said he wants to fire hundreds of career staffers at the Food and Drug Administration and at the National Institutes of Health, and shift federal research funding from infectious disease to chronic disease and obesity.

If confirmed, Kennedy would be in charge of a $1.7 trillion agency with power over regulating food and drugs, funding groundbreaking research and setting vaccine recommendations. He would also oversee Medicare, Medicaid and the Affordable Care Act, which account for nearly 90% of the department’s budget and provide health insurance to nearly 170 million Americans.

Kennedy’s views have led to a mixed reaction across the political spectrum. Colorado’s Democratic Gov. Jared Polis praised the pick, and New Jersey’s Democratic Sen. Cory Booker acknowledged his common ground with Kennedy on the unhealthy U.S. food system. In contrast, Oregon Sen. Ron Wyden said Kennedy’s “outlandish views … should worry all parents,” and former New York City mayor Michael R. Bloomberg says Kennedy would be “beyond dangerous” as health secretary.

On the other side of the aisle, Wisconsin Republican Sen. Ron Johnson called Kennedy a “brilliant, courageous truth-teller,” while former Republican Vice President Mike Pence urged senators to reject Kennedy’s nomination over his support for abortion rights.

Kathleen Sebelius, who led HHS under President Barack Obama from 2009 to 2014 talked with the health policy podcast Tradeoffs about the power of the position, and the checks and balances Kennedy may face in enacting some of his priorities.

“The [HHS] secretary is in a position to do a lot of good, but also potentially do a lot of harm,” she said.

Kathleen Sebelius on May 6, 2014 in National Harbor, Md.

Patrick Smith/Getty Images/Getty Images North America

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Patrick Smith/Getty Images/Getty Images North America

Here are highlights from that conversation, edited for length and clarity:

On the role of the HHS secretary

[The secretary] is the [federal government’s] 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.

A lot of 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. I spent a good deal of time at the beginning of my tenure literally physically visiting each and every agency … 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.

On how much power the HHS secretary wields

[The job] 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 [regulations] 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.

One of the areas that [we] 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. 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. You could actually move 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.

On the limits of the HHS secretary’s power

Certainly what the president wants and needs is one [limit]. 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. 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 — 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, challenging authority: Why are you doing this or that?

And then there’s a whole legal system that can sue the department. The FDA is very used to that. Any time they would issue, for instance, a tobacco regulation, tobacco companies would immediately file a lawsuit and slow that down or stop it. That can be done. When there’s any kind of cut suggested to the hospital system, the hospital association immediately goes to court. So I would say the court, Congress and the president operate as guardrails around the secretary’s power.

On how much discretion Robert F. Kennedy Jr. would have to fire hundreds of career staffers, as he has promised to

At this point, I would say the discretion is limited by civil service protection. In the waning days of the last Trump administration, there was an executive order issued that would have removed civil service protection from a host of federal employees. I can’t remember how many. The Biden incoming administration immediately rescinded that executive order, so it’s never been carried out. [So, absent that] 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, [there’s a] 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, I’m going to fire researchers at NIH, I’m going to get rid of these folks. What that does is send really 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.

On Kennedy’s interest in moving research priorities at the National Institutes of Health away from infectious diseases

NIH 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. Do I want people to stop researching what could be an effective counter to an avian flu outbreak? Absolutely not. Because it’s coming. And it’s coming on a timetable that Bobby Kennedy cannot control.

On the impact that Kennedy’s anti-vaccine views could have on vaccine uptake nationwide

[The CDC has] a list of known childhood vaccines and makes recommendations to states. And then state governments adopt their own vaccine list based on CDC recommendations. Some [states] have a more robust list, some have a narrow list. So in terms of vaccine take-up … 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 [vaccines] optional.

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 these are real life consequences. 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.

On how she thinks senators should think about the power they’d be giving Kennedy if they confirmed him to lead HHS

I think they should think long and hard about it. 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 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.

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 [Kennedy] 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.

Dan Gorenstein is the executive editor of Tradeoffs, a nonprofit health policy news organization. Reporter Ryan Levi produced this story for the Tradeoffs podcast, and adapted it for the web. You can listen to the full interview here: