United States President-elect Joe Biden’s choices for his healthcare team point to a stronger federal role in the nation’s COVID-19 strategy, restoration of a guiding focus on science and an emphasis on equitable distribution of vaccines and treatments.
It is a shift from President Donald Trump’s strategy where states were largely left to marshal resources, acquire protective equipment, build a strategy and implement restrictions often without clear direction from the federal government.
With Monday’s announcement of California Attorney General Xavier Becerra as his health secretary and half a dozen other key appointments, Biden aims to leave behind the personality dramas that sometimes flourished under Trump. He hopes to return the federal response to a more methodical approach, seeking results by applying scientific knowledge in what he says will be a transparent and disciplined manner.
“We are still going to have a federal, state and local partnership,” said Dr Georges Benjamin, executive director of the nonprofit American Public Health Association. “I just think there is going to be better guidance from the federal government and they are going to work more collaboratively with the states.”
In a sense, what Biden has is not quite yet a team, but a collection of players drafted for key positions. Some have already been working together as members of Biden’s coronavirus advisory board. Others will have to suit up quickly.
By announcing most of the key positions in one package, Biden is signalling that he expects his appointees to work together, and not as lords of their own bureaucratic fiefdoms.
“These are not turf-conscious people,” said Drew Altman, CEO of the nonpartisan Kaiser Family Foundation, a clearinghouse for healthcare information and analysis. But, “it’s up to the (Biden) administration to make it an effective team.”
A Washington saying, sometimes attributed to late President Ronald Reagan, holds that “personnel is policy”.
Here is what Biden’s healthcare picks say about the policies his administration is likely to follow:
Stronger federal management
The selection of Becerra as health secretary and businessman Jeff Zients as White House coronavirus coordinator point to a more assertive federal coronavirus role.
Under Trump, states were sometimes left to figure things out themselves, as when the White House initially called on states to test all nursing home residents without providing an infrastructure, only to have to rectify that omission later.
Zients has made a name for himself rescuing government programmes that went off course, such as the Affordable Care Act – also known as Obamacare – website HealthCare.gov. Becerra has experience managing California’s attorney general’s office, which is bigger than some state governments.
Former Health and Human Services Secretary Kathleen Sebelius knows both men from her service in the Obama administration and says she does not see them working at cross purposes.
A Secretary Becerra “can’t get up every morning and think only COVID,” she said. He will “work on COVID and coordinate the assets of the FDA, CDC and NIH, but he’ll have lots of other things to do”. Meanwhile, “Zients will be the railroad engineer making sure the trains run on time.”
States are ready for the feds to take on a more assertive role, she said. “Governors – Republicans and Democrats – are eager to finally have a federal partner,” she said. “They have felt not only on their own but unclear about what was coming out of the White House.”
Science at the forefront
Biden’s selection of infectious disease expert Dr Rochelle Walensky to head the Centers for Disease Control and Prevention, the elevation of Dr Anthony Fauci to medical adviser, and the return of Dr Vivek Murthy as surgeon general are being read in the medical community as a restoration of the traditionally important role of science in public health emergencies.
“It means that the response plan will be grounded in health science,” said Dr Nadine Gracia, executive vice president of the Trust for America’s Health, a nonprofit that works to promote public health.
Under Trump, “those of us who practice in medicine today have been dismayed,” said Dr Wendy Armstrong, an infectious disease specialist at Emory University medical school. “The individuals with the greatest expertise have not had the voice many of us wish they would have had … This to me signals that the government is ready to put expertise in place that can guide its plan.”
Walensky, a widely recognised HIV/AIDS expert, got her coronavirus experience first hand as chief of infectious diseases at Massachusetts General Hospital in Boston during the first wave this spring.
“She was a real leader when it came to COVID,” said Dr Rajesh Gandhi, an infectious disease physician at Mass General. “She organised infection control policies within the hospital, she organised treatment studies, she was organising testing and leading testing.”
Focus on equity
Even more than the nomination of a Latino politician for health secretary, Biden’s selection of Yale University’s Dr Marcella Nunez-Smith is being read as a sign that his administration will work for equitable distribution of vaccines and treatments among racial and ethnic minorities, who have suffered a disproportionately high toll of COVID-19 deaths.
That challenge faces widespread scepticism among minorities that the healthcare system has their best interests in mind.
Early indications are that the vaccines are highly effective, said Altman of the Kaiser Foundation. But polling indicates a strong undertow of doubts, especially among African Americans.
“While states will be able to make the final decisions on who gets the vaccine, there has to be guidance around those decisions so that they are fair and equitable across the country,” Altman said. “You don’t want to have the kind of variations that people will look and say, ‘This just wasn’t fair.’ ”