By Ceci Connolly
Washington Post Staff Writer
Monday, February 16, 2009
When Thomas A. Daschle, embroiled in controversy over failing to pay more than $100,000 in back taxes, stepped down two weeks ago as director of the White House Office on Health Reform and withdrew his nomination to be secretary of health and human services, it left a gaping hole in President Obama's leadership team, one that health-care advocates say has stalled what they hoped would be speedy action on high-priority measures.
"The health agenda isn't being addressed, and the health agenda was certainly a big part of the campaign and a big part of the transition," said Kevin Robert Frost, chief executive of the Foundation for AIDS Research, or Amfar. Noting that Obama and transition officials pledged that AIDS initiatives would get fresh attention, Frost said he fears that "all that stuff is on hold."
Administration advisers are not talking publicly about who might replace Daschle (D-S.D.) or when a nomination might be made. White House Chief of Staff Rahm Emanuel told colleagues, "We are vetting," according to one source who was unwilling to elaborate.
Frost acknowledged what Obama aides are quick to point out: The administration has been focused on passing a $787 billion stimulus package, which includes new money for health and science.
"The problem is the ripple effect," Frost said.
Not only does the department lack a secretary, but Obama has yet to nominate anyone to run critical agencies such as the Food and Drug Administration, the National Institutes of Health, the Centers for Medicare and Medicaid Services, and the Centers for Disease Control and Prevention.
"The department is really starting behind," said Tommy Thompson, who began his tenure as President Bush's HHS secretary on Feb. 2, 2001. "There's a learning curve which is difficult because of the complexities and overall magnitude of the department."
At the moment, career employees named as acting directors are overseeing the department's 65,000-plus employees and $707 billion budget. Two Daschle allies -- William V. Corr and Mark Childress -- had begun work as deputy secretary and chief of staff respectively. But their futures are in doubt; no confirmation hearing has been scheduled for Corr and most Cabinet secretaries prefer to choose their own chiefs of staff.
"The only person with any legal status is the chief of staff to no one," said Paul Jarris, executive director of the Association of State and Territorial Health Officials. "That has got to be a tough position to be in."
Veteran bureaucrats are accustomed to the between-presidents interregnum that occurs every four or eight years. But there are limits to what they can do.
"Career people can keep things running, but there is tremendous eagerness to know what direction they are going in," said Jeffrey Levi, executive director at the nonprofit, nonpartisan Trust for America's Health. Workers at the Centers for Disease Control and Prevention expect to shift course on projects such as sex education and prevention but have not received specific guidance.
"It's remarkable how well the department can continue to function without high-level leadership," said Elizabeth McGlynn, associate director for the independent research outfit Rand Health, but "it's very hard for there to be any directional shift."
White House spokesman Dan Pfeiffer pointed to recent passage of a sweeping economic recovery package and expansion of the State Children's Health Insurance Program as proof that the administration has kept health issues high on the agenda even without a secretary or other key leaders. "We've seen more progress toward expanding access and improving health care in three weeks than we've seen in a long time," he said.
But the stimulus legislation also spotlights the potential gaps and pitfalls to negotiating a major bill without a top-ranking health official.
In earlier versions of the bill, the House set aside $3 billion for prevention, while the Senate version included $5.8 billion. After being eliminated altogether, negotiators settled on $1 billion, "an unfortunate turn of events" that Jarris attributed to the "lack of HHS leadership."
Absent from the package is any money for bioterrorism preparedness, noted Thompson, who had made investing in the pharmaceutical stockpile a top priority.
"A secretary would have recognized that as a weakness and fought to put money in," he said.
At the National Institutes of Health, some wondered how the agency will decide how to spend an additional $10 billion over the next two years.
"It's great to be getting that money, but where is the strategic plan for what to do with it?" asked one longtime scientist there.
And the lack of Republican support for the stimulus package "makes you wonder what's going to happen when they try to change our health-care system," said Douglas Kamerow, a former assistant surgeon general who spent 20 years in the U.S. Public Health Service. "Without a person with Daschle's stature, it really delays and complicates the effort on health reform."
Perhaps nothing highlights the need for leadership more than the recent salmonella outbreak in peanut products, several observers said.
"You need an FDA commissioner more so today than ever before," said Thompson, who criticized Bush for leaving acting chiefs in charge of the agency for much of his eight-year tenure. In addition to gaps in food safety, he worries about the slowdown in drug approvals, "a demoralized staff and a lack of resources."
When Congress called on the agency to testify recently, it fell to a career employee to field lawmakers' angry questions.
"At a minimum it's a missed political opportunity," Levi said. "If there were a commissioner on board, he or she could articulate a reform vision on safety."