Biden’s health picks signal a bottom-up approach to the Covid-19 pandemic

President-elect Biden’s pandemic-response strategy took clearer shape this week with the rollout of several surprising appointments — a list that underscores that his Covid-19 response will be led far more by career government scientists and lower-level health agency deputies than has been the case during the Trump administration.

For his highest-profile health care positions, Biden tapped longtime Washington insiders, Xavier Becerra, a congressman of two decades and California’s attorney general, and Jeffrey Zients, an Obama administration economist. They are Biden’s health secretary nominee and coronavirus coordinator, respectively.

But the mechanics of the government’s response, pandemic experts told STAT, will likely fall increasingly to health agency deputies focused on pandemic response as well as longtime agency scientists at the Centers for Disease Control and Prevention. The strategy would represent a marked contrast from Trump-era pandemic response, where career scientists at several health agencies, especially the CDC, quickly fell out of favor with the White House and played little public role in the federal Covid-19 effort.


Biden also named three figures who will serve under Becerra and Zients but be central to his administration’s pandemic response: Rochelle Walensky, who will lead the Centers for Disease Control and Prevention; past and, if confirmed, future surgeon general Vivek Murthy; and Yale professor Marcella Nunez-Smith, who will have an advisory role focused on health disparities.

Walensky, in particular, is likely to play an early and aggressive role in the pandemic response. Her position as CDC director does not require Senate confirmation, which means she can start at the agency as early as Jan. 20, when Biden takes office.


The new slate of appointments, according to interviews with Democratic congressional aides and pandemic-response experts, underscores how Biden has based his highest-profile health selections more on leadership and managerial ability than on health care expertise. And amid a devastating global pandemic, Biden may be taking the long view on health care, tapping a health secretary capable of seeing past the pandemic to address issues like Affordable Care Act protections or even high drug prices.

“There was an element of surprise that they went to a lawyer, but he’s reputed to be an extremely inspiring leader who gets people to follow him,” said Irwin Redlener, a Columbia University professor and pandemic-response expert. “Even putting aside the pandemic, the actual mechanics of running an agency of that size are daunting.”

Redlener and others pointed instead to other key positions like CDC director and the assistant health secretary for preparedness, a role filled during the Obama administration by Nicole Lurie, one of Biden’s top pandemic advisers during the presidential campaign. The president-elect also hasn’t announced nominees to lead the Food and Drug Administration or the Centers for Medicare and Medicaid Services, both of which are likely to play a substantial role in the pandemic response.

Elevating the officials who fill those positions to leading pandemic-response roles would fulfill Biden’s campaign pledge to “listen to the scientists” and bolster the roles of longtime federal officials who are not political appointees but career civil servants.

Throughout the pandemic, many health agency officials in career roles have seen diminished public roles: Namely CDC deputies like Nancy Messonnier and Anne Schuchat, who made few public appearances after the first months of 2020.

If confirmed, Becerra, given his lack of experience managing government health efforts, is likely to lean heavily on those agency experts in the early days of the Biden administration’s pandemic response. But though he has never managed a health care agency or worked in health care delivery, Becerra is no stranger to health issues in general.

While in Congress, Becerra authored a handful of health care bills largely pertaining to services covered by Medicare, which he helped oversee as a member of the House Ways and Means Committee. In 2017, he attracted attention by voicing support for “Medicare for All,” the single-payer health care proposal that the president-elect does not support.

As California attorney general, he led a coalition of blue-state governments that fought in court to protect conservative challenges that sought to invalidate the Affordable Care Act. He also launched myriad lawsuits against wayward health industry players like the opioid manufacturers Purdue Pharma and Mallinckrodt, and extracted a half-billion dollar fee to settle an antitrust case against Sutter Health, a major Northern California health provider and hospital chain.

During Covid-19, Becerra has also put his health policy chops to use, demanding to no avail that the federal government exercise its controversial “march-in rights” authority to seize Gilead’s exclusive license for remdesivir, the pricy antiviral that emerged early in the pandemic as a promising coronavirus treatment.

The legal experience is likely “ancillary” to his ability to manage a pandemic, said Marian Moser-Jones, a University of Maryland professor who studies public health and U.S. health care delivery during crises.

“We have tunnel vision right now, we’re thinking about the pandemic, and he’s not really an emergency preparedness kind of guy,” she said. “But just because somebody doesn’t have experience running a huge agency doesn’t mean they can’t do it.”

Becerra’s appointment, in itself, is not unusual. Past health secretaries have often come from management backgrounds as opposed to medical ones: Donna Shalala, President Clinton’s health secretary, was previously a government official and university president; Kathleen Sebelius, President Obama’s first health secretary, was previously the governor of Kansas and the state’s insurance commissioner; and Sylvia Matthews Burwell, who succeeded Sebelius, was previously the Clinton administration’s budget director.

Zients, similarly, is an Obama-era economist with expertise in managing government initiatives but none in health or science — a résumé strikingly similar to that of Ron Klain, Biden’s incoming chief of staff who served as the Obama administration’s “Ebola czar” in 2014 and 2015.

Walensky, the infectious diseases chief at Massachusetts General Hospital, represents the opposite mold: While she’s a renowned physician, she has little experience in government, which experts said would make the role of longtime agency deputies all the more crucial.

“I don’t think we should automatically assume things about a selection’s lack of health-specific experience without also considering a few things: The Biden-Harris administration has been exceedingly science-focused, and often we have leaders with more policy experience to help navigate the field and allow them to listen more closely to the scientists,” said Saskia Popescu, a biodefense expert with appointments at George Mason University and the University of Arizona.

Source: STAT