Time flies. It has been almost two months since Joe Biden and Kamala Harris were inaugurated. With each passing day, it becomes harder to imagine that we ever elected Donald Trump as prescient. My health has improved. I get more sleep.
During the “Trump Era,” I would stay up late after the 11 o’clock news to hear Steven Colbert rip the president almost every night. We also recorded Trevor Noah on the “Daily Show.” When we had heard all that Colbert had to say, we would switch to hear Trevor’s commentary on the day’s outrageous violation of “norms” by the president. By the time we had had an adequate Trump catharsis, it was well past 1 AM when we finally turned off the TV and stumbled into bed. Lately, I don’t even watch the 11 PM news, without Trump around or on social media, there is not much happening.
Since January 20 I have been going to bed early with a book, and then I fall to sleep knowing that the country is being guided by a responsible individual who is empathetic, experienced, thoughtful, willing to seek advice, and concerned about the underserved and disadvantaged among us. I am confident that he is doing his best to defend the Constitution and approaches every question with an open mind and a concern for the protection of the future of yet unborn Americans and the perpetuation of our advancement toward a more perfect union. Most importantly, I know that he knows that his most important job is to do everything he can to protect the health of every American. Job one is to protect us. I really believe that he cares and that he morns every loss with genuine feelings.
I am confident that he makes up with commitment and a willingness to seek counsel for any deficiencies that he may have. I am confident that he cares about the shabby state of our healthcare system, our deteriorating infrastructure, our loss of leadership in global affairs, and the threats to our planet from global warming caused by our use of carbon-based fuels. I know that the president understands the interconnected nature of these issues and is assembling a leadership team that will take his basic ideas and instincts and develop them into a strategic approach that will move us forward toward a safer, more stable, and more equitable society.
One thing that the Trump years taught us was that cabinet appointments make a big difference. History will likely show that on many occasions a member of Trump’s cabinet was all that stood between him and a national disaster. I have always scratched my head over the inefficiency and the political games associated with the requirement that the president’s choices to assist him in the management of the government must be confirmed by the Senate. It may be a surprise to you to learn that the president appoints over 4000 federal positions and that over 1200 require Senate confirmation. It can take several months of a 48-month term to put together the new government and get it confirmed. This time around the process was further delayed by Trump’s unwillingness to admit defeat for over a month and allow the process of forming a government to begin. Nothing has ever galled me more than the fact that Don Berwick could not win Senate confirmation as the Administrator of CMS while a totally incompetent and eventually disgraced orthopedic surgeon who happened to be a tea party Congressman from Georgia could be easily confirmed as the Secretary of Health and Human Services.
Two months into President Biden’s administration we still have not confirmed all of President Biden’s choices to populate his cabinet. There are 23 cabinet-level positions. At this time 17 have been confirmed and one candidate, Neera Tanden who was imminently qualified to be the Director of the Office of Management and Budget was forced to withdraw from the confirmation process because her Twitter comments about both Republican and Democratic politicians had created animus against her. Considering the Tweet bombs our former president launched against half of the politicians and journalists in Washington the objections to Ms.Tanden seem to be hypocritical.
Biden’s choice to lead the Department of Health and Human Services (HHS) is Xavier Becerra. He has also met with substantial resistance and is not yet confirmed. Currently, Xavier Becerra is the Attorney General of California. Only the Federal Department of Justice is a larger governmental legal department than the organization that he leads. To lead the California Department of Justice is a huge administrative responsibility. Its annual budget is over a billion dollars a year. HHS has $94.5 billion in discretionary budget authority and $1.3 trillion in mandatory funding to manage in 2021. Bacerra has proven that he is an adept administrator during his tenure as the California AG.
One of the reasons that Bacerra is having trouble getting confirmed is that he has been one of the most effective defenders of the ACA during the Trump years. He has initiated over one hundred lawsuits to defend the ACA and block other Trump initiatives over the last four years against the administrative decisions of the Trump administration. I would venture that other than John McCain, no other individual did more to preserve the ACA between 2016 and January 20, 2021, than Xavier Bacerra. Republicans don’t like him because he has vigorously defended issues of women’s health and is an ardent supporter of single-payer healthcare.
To be confirmed in a cabinet position a nominee must appear before the appropriate Senate committee. After the candidate appears before the committee, there is a vote to determine whether the nomination can be voted on by the full Senate. Until recently filibusters could be used to block the confirmation of a candidate. So far, this time around there have been two appointees confirmed with less than the 60 votes that would have been required if the filibuster was still in place. Deb Haaland was confirmed with only fifty-one votes yesterday as the first Native American to head the Department of the Interior which also includes the Bureau of Indian Affairs. Alejandro Mayorkas was confirmed earlier as Secretary of Homeland Security with only 56 votes.
If you review the list of the Secretaries of HHS, and of HEW before the name was changed, you will see that most have been politicians and have not been people with extensive healthcare experience. They were qualified as politicians or as government administrators. Dr. Congressman Price’s tenure does not add positively to the idea that a Secretary of Health and Human Services be a “medical person.” Xavier Becerra’s resume and personal history position him very well to have the administrative skills and motivations to use the opportunity to lead HHS to move us closer to the Triple Aim which maybe why Mitch McConnell who has willingly supported some pretty inadequate candidates for cabinet positions declared Bacerra to be “…a thoroughly partisan actor with so little subject matter expertise.”
If and when confirmed, Mr. Bacerra will be the first Latinx Secretary of Health and Human Services. Both of his parents were immigrants from Mexico who worked hard to position their children for success as first-generation Americans. Mr. Bacerra is an alum of Standford and Stanford Law School. He was a Congressman from Los Angeles for twenty-five years before becoming the Attorney General of California in 2017 when Kamala Harris was elected to the Senate. While in the House he was an important player in the passage of the ACA. He served for many years on the House Ways and Means Committee. He has been an outspoken and effective advocate on issues of women’s health. He has been an outspoken advocate for single-payer healthcare and for programs to improve the social determinants of health. A skilled, committed, effective advocate for the issues of women and the underserved who effectively defended the ACA against many of the attacks of the Trump administration was likely to encounter resistance from Republicans on the Senate Finance Committee when he presented for confirmation. And, he did.
If you have three hours to watch a Senate committee in action, I would offer the C-Span recording of the confirmation hearing before the Senate Finance Committee of Xavier Becerra. There were actually two days of hearings after which his nomination was not approved by a vote of 14-14. Since the Senate is evenly split the committees are also evenly split in membership with the committee chair being the ranking Democrat. Mr. Bacerra had also appeared before the Senate’s Health, Education, Labor, and Pensions Committee (HELP), where he did not require a vote. Fortunately, Senate Majority Leader Chuck Schumer engineered a floor vote from the Senate to take Bacerra’s nomination out of the committee and move it forward for a potential Senate vote.
I guess it’s true that one man’s partisan actor is another man’s defender of the ACA and the needs of the underserved. I should add that the Senate vote to override the strictly partisan 14-14 vote in the Finance committee was 51-48. One Republican, Susan Collins of Maine did vote to bring Mr. Bacerra’s nomination forward to the Senate floor for debate and vote. She defended her vote in a statement issued by her office:
“I will support the confirmation of Xavier Becerra to serve as Secretary of the Department of Health and Human Services.
“At his hearing before the Health, Education, Labor, and Pensions Committee, I questioned Mr. Becerra about the significant harm school closures are having on students and emphasized the urgent need to reopen schools safely and quickly. Since that exchange, our conversations have continued. I look forward to working with Mr. Becerra, CDC Director Rochelle Walensky, and HHS officials to ensure that existing and emerging science is better reflected as CDC guidance is updated so that children across the nation can resume in-person learning safely.
“During our one-on-one meeting, and in three subsequent conversations, Mr. Becerra and I discussed several shared goals that I hope we can accomplish in the Biden Administration. They include lowering the price of prescription drugs for patients and reducing our dependence on foreign countries for drug manufacturing. I also urged Mr. Becerra to support additional funding for health care providers during the pandemic, particularly in rural areas. While Mr. Becerra is from an urban area, he acknowledged the unique health challenges facing rural America. He committed to making outstanding provider relief payments expeditiously and improving access to care in rural areas, which are major priorities of mine.
“Although there are issues where I strongly disagree with Mr. Becerra, I believe he merits confirmation as HHS Secretary. I look forward to working with the Department to achieve bipartisan results on behalf of the American people.”
If favoring a woman’s right to chose and single-payer healthcare is not enough to make an extremely capable person a danger for Republicans, I should add that Mr. Bacerra gets thin support from Joe Manchin, Democratic Senator from West Virginia, over Second Amendment Issues and his work to limit pollution from fossil fuels like coal which is gold for West Virginia. In the end, Manchin, who may be the most powerful Senator because the other Democrats need him to agree with them on every vote if they get no support from a wayward Republican, issued a statement that he will support Bacerra when the Senate votes on the nomination.
“As our nation faces deep divides and a healthcare crisis that has taken the lives of far too many Americans, we must commit to working together to heal our nation. While Attorney General Xavier Becerra and I have very different records on issues like abortion and the Second Amendment, he has affirmed to me his dedication to working with Members on both sides of the aisle to address the impacts of the COVID-19 pandemic and the numerous needs of our nation in a bipartisan way. He is committed to working with me to stabilize rural healthcare across America and combat the drug epidemic that has ravaged my home state of West Virginia. He has a proven record of defending the Affordable Care Act and fighting to protect the 800,000 West Virginians and millions of Americans with preexisting conditions. He understands the need to expand telehealth infrastructure – especially in rural communities – and implement the Defense Production Act (DPA) to improve domestic supply chains. He committed to me that he will uphold the law in regards to the Hyde Amendment. For these reasons, I believe Attorney General Becerra will be a leader for every American and West Virginian, and I will vote to confirm him as Secretary of Health and Human Services. I look forward to working with Attorney General Becerra to expand healthcare for rural communities and address the issues facing our nation.”
Yogi Berra taught us that “It ain’t over till it’s over” so maybe it is premature to say that it is highly likely that those 51 votes will also give Mr. Bacerra his victory and his seat at the table on the Biden Cabinet in the next few days or weeks. If Susan Collins changes her mind and votes against him, Kamala Harris’ vote will break the tie. Either way, Mr. Bacerra becomes the next Secretary of Health and Human Services by a very thin margin in the toughest of times.
Now is a good time to ask what things Bacerra will try to do as Secretary of HHS. If you remember my recent six posts detailing the recommendations of the Commonwealth Fund Task Force On Payment and Delivery System Reform that began on February 9, you will also remember that many of the recommendations begin with “Congress and HHS should…” There is some possibility that Congress might produce some kind of bill that could marginally lower the cost of drugs, especially those that the government purchases. It is true that both Joe Manchin and Susan Collins mention the special concerns about access to adequate care for rural communities. Going forward telehealth offers great advantages to rural communities and it is quite possible that some sort of bipartisan bill might be passed that provides resources to rural communities for telehealth. Telehealth requires Internet resources so it is conceivable that an infrastructure bill may indirectly enable better healthcare in the same way that the recently signed COVID relief bill has provided healthcare benefits and expanded access to care. An article published by the Pew Research Center before the bill was passed described the healthcare benefits in the law.
The package of health measures is in line with Biden’s campaign pledge not to replace the Affordable Care Act—arguably the signature piece of legislation signed by President Barack Obama—but to extend its reach.
“This is a down payment on the type of more comprehensive reform that [Biden] talked about during the campaign,” said Linda Blumberg, an expert in health policy and insurance at the Urban Institute, a nonpartisan think tank in Washington, D.C.
The increased health care subsidies and other changes related to private health insurance could increase the number of Americans with health insurance by 1.3 million, according to a Congressional Budget Office analysis.
One thing will not happen. Joe Biden is not going to try to impose Medicare For All. He is committed to the difficult task of moving America to full coverage through the expansion of the ACA. It is my opinion that Xavier Bacerra is likely to be one of the most capable people to maximize the benefits and reach of the ACA. I also believe that as long as there is an individual expense to coverage that there are those who will pass no matter how much help they get on the exchanges. The same Pew paper quoted above goes on to report that the goal is that no one pays more than 8.5% of their income for their healthcare. The COVID relief bill expands subsidies on the exchanges with that concept for two years:
The subsidy changes would be in effect for two years, although advocates hope they would eventually be made permanent.
“This is a safety net for everyone,” said Frederick Isasi, executive director of Families USA, which advocates for affordable health care. “It says that no matter who you are or where you live, if you haven’t got employer health insurance you should not have to pay more than 8.5% of income for a good plan.”
That is good, but there will still be people who are healthy who will say no to purchasing care at any price. Someday we will have true Universal Coverage, but not yet, although with Bacerra as Secretary of HHS there is the possibility that some state might get a Medicaid waiver to try it. But, we must not forget that job one on The soon to be Secretary’s first day is ending the COVID-19 pandemic and building an infrastructure to protect us from the next pandemic.
I am looking forward to seeing how Secretary Bacerra will move us toward a public option. He has made it clear that although he might advocate for a single-payer system his job as Joe Biden’s Secretary of HHS will be to work to implement Joe Biden’s healthcare objectives, and for the time being the prime strategy is to build on the foundation created by the ACA. It will be very interesting to see how this plays out over the next few years with Joe Biden and Xavier Bacerra working together.
