BOX 7-1

The Secretary-Designate—A Scenario

The phone rings, and a senior leader in U.S. domestic or health policy, relaxing at home on the Saturday evening after Thanksgiving, answers. The President-elect is calling to ask this widely respected individual to serve as the twenty-first secretary of the U.S. Department of Health and Human Services. The request elicits an enthusiastic, “I will be honored to serve.”

Even though this call was not a surprise, the new secretary-designate feels a mix of excitement and trepidation. The excitement comes from having the opportunity to bring direction and transformative ideas to the $2 trillion health sector. The trepidation lies in the challenge of bringing order to a department with a $737 billion budget and 300 programs.

Soon the briefing process is under way. The appointee must simultaneously prepare to lead the department and for confirmation hearings:

  • The appointee listens carefully to current agency heads and many others, learning innumerable details about the current organization and leadership of the 65,000-person department.

  • Courtesy visits to Capitol Hill are arranged, and it feels as if the political aspects of the job are building to hurricane force. The appointee hears from many interest groups voicing suggestions about changing programs and operations and warnings against creating new levels of bureaucracy and splitting up or combining agencies.

  • Mounds of reports, memoranda, budgets, organizational charts, and academic papers shape the topography of the secretary-designate’s temporary Washington office.

  • The appointee focuses on developing the department’s budget for the next fiscal year—the largest budget of any agency in the history of the United States or, for that matter, any other country.

  • The appointee interviews candidates for the team that will run the department. Some current executives want to stay—not always the most effective ones; interest groups recommend various candidates; congressional committee chairs propose their top aides; and the President-elect’s transition team and others put forward individuals, some with little familiarity with the substance of health policy or the health sciences.

By January 19, the next secretary has barely had time to think. But that day, the Senate recognizes the appointee’s round-the-clock preparations with a vote in favor of confirmation—a signal of confidence in the nominee’s ability to make a positive difference.

The next day, as the new chief architect of U.S. health policy, the appointee attends the inaugural ceremony, and somberly takes the oath of office in the presence of immediate family. Then the real work begins.

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