HHS confirmation delay could set back reform efforts

Washington -- While President Obama's new Health and Human Services secretary says she's looking forward to tackling the challenges ahead, the long delay in confirming her might mean the department is already behind.

On April 28, the Senate confirmed by a 65-31 vote the nomination of Democratic Kansas Gov. Kathleen Sebelius to be HHS chief, filling the last vacancy in Obama's cabinet. The process was delayed because Sebelius was the president's second choice to fill the position. Some Republican lawmakers also held up the nomination because of Sebelius' tax history as well as her stances on issues such as abortion and comparative-effectiveness research.

Sebelius is now tasked with getting HHS up to speed in what is shaping up to be a busy year.

"With the confirmation of Gov. Sebelius, the commitment of the administration and Congress to passing health care reform this year now moves into high gear," said Sen. Edward Kennedy (D, Mass.), chair of the Health, Education, Labor and Pensions Committee.

But besides deciding how to dole out billions in federal stimulus dollars and help reform the Medicare physician payment system, among other major responsibilities, Sebelius also must work to address the latest outbreak of influenza A(H1N1) virus that has many fearful of a pandemic.

"I come to the department as our nation confronts a serious public health challenge," Sebelius said. "I will work closely with President Obama and officials from across the government as we address this threat."

Filling in the gaps

With nobody at the helm at HHS, the Obama administration also has been slow to fill other key positions within the department that will figure heavily into any reform efforts this year. This includes an official administrator for the Centers for Medicare & Medicaid Services, which has been managed since the beginning of Obama's term by acting administrator Charlene Frizzera.

"CMS has got to be part of the reform debate," said Robert Helms, PhD, resident scholar at the American Enterprise Institute for Public Policy Research, a conservative government and economics research institution based in Washington, D.C.

Dennis G. Smith, formerly the director of the CMS Center for Medicaid and State Operations, agreed that the agency will be in a holding pattern until a permanent leader is nominated and approved by the Senate.

"It is the nature of bureaucracy to continue policy, not to make new policy," said Smith, now a senior fellow in health care reform at the Heritage Foundation's Center for Health Policy Studies, a conservative public policy research institute based in Washington, D.C.

Smith said the Obama administration might face some fallout over the amount of time it took to have the HHS secretary confirmed, suggesting that the White House did not recover quickly enough from the derailment of its first nominee, former Senate Majority Leader Tom Daschle (D, S.D.). Daschle withdrew his name from consideration Feb. 3 amid controversy over tens of thousands of dollars in federal income taxes that he failed to pay on time.

"They most certainly were not prepared for what happened," Smith said. "That's part of being able to govern -- you've got to have a contingency plan in place and not get caught flat-footed. But that seems to be what happened."

Helms suggested that the need for Obama to pursue his second choice for the job could have consequences of its own. "Daschle was expected to be not only knowledgeable, but also very powerful when it came to dealing with Congress, and particularly the Senate. She's not going to have that same experience."

If he had been confirmed, Daschle would have worn two hats -- as HHS secretary and also as head of the newly minted White House Office for Health Reform. When the nominee removed himself from consideration, however, Obama decided to appoint someone outside of HHS to manage the new reform office. The job has since been given to Nancy-Ann DeParle, former director of the Health Care Financing Administration, the predecessor to CMS.

Smith expressed concern that DeParle and Sebelius potentially could slow health system reform if the two experience philosophical or managerial policy differences. "When you set up dual power tracks, you are setting up a struggle. The White House cannot run an agency day-to-day."

Support for Sebelius

Despite the misgivings voiced by some Republican lawmakers that helped slow the nomination process, numerous health care organizations, including the American Medical Association, came out in support of Sebelius, who served as Kansas insurance commissioner prior to being elected governor.

"In Gov. Sebelius' roles as insurance commissioner and governor, she demonstrated the leadership skills required to direct HHS and help implement health system reform," said AMA President Nancy H. Nielsen, MD, PhD. "In these tough economic times, the need for health system reform that provides coverage and high quality, affordable health care for all Americans is clear. It's time to strengthen the public-private mix of health insurance and achieve greater value from the nation's health care spending."

The American Academy of Family Physicians also congratulated Sebelius on her confirmation and applauded her previous work on health care issues in her state. "As the Kansas insurance commissioner, Sebelius developed a comprehensive knowledge of the needs of patients, the insurance industry and employers who purchase health care for workers," said Ted Epperly, MD, AAFP's president. The academy "looks forward to working with Sebelius in shaping health care reform, ensuring access to high quality primary care for all Americans and strengthening the fiscal foundation on which that care is provided."