Federal agencies must recalibrate to fight today’s health challenges

It is vital for any reforms to prioritize enhancing leadership and coordination across the federal bureaucracy while not eliminating critical missions and roles. 

COVID-19, monkeypox and infant formula shortages are just a few of the public health challenges the federal government has faced over the last several months and years. Despite the federal response to these challenges, criticism of agencies such as the Centers for Disease Control and Prevention and the Food and Drug Administration have come from both sides of the aisle during both the Trump and Biden administrations.

Recently, several recommendations have been proposed to optimize the role of federal agencies; however, many of these may carry unintended consequences. It is vital for any reforms to prioritize enhancing leadership and coordination across the federal bureaucracy while not eliminating critical missions and roles. 

First, reports of an internal review at the CDC, prompted by its response to COVID-19, have brought to light a number of concerns such as a rigid financial structure, lack of authority to collect public health data and excessively lengthy review processes for scientific guidance. The CDC has also been criticized during the pandemic for falling short in communicating its scientific guidance in a way that considers real-world implications. Potential solutions to address these issues include requiring Senate confirmation of the CDC director to increase accountability, providing the CDC with authority to collect core public health data and identifying ways to quickly reallocate funding in an emergency.

One idea that should not be considered, however, is to drop “prevention” from the CDC’s name and to jettison its focus on noninfectious diseases in order to make it solely an infectious diseases response agency. As we know, the vast majority of deaths in America stem from preventable chronic diseases and 90 percent of the nation’s $4.1 trillion in annual health care expenditures are for people with chronic and mental health conditions. Not only is the CDC’s mission central to promote health and prevent illness broadly, but its work also ensures Americans are more resilient to emergencies such as COVID-19. A recent study estimated that two-thirds of COVID-19 hospitalizations were attributable to obesity, hypertension, diabetes and heart failure — all preventable chronic diseases.

Second, the FDA is reportedly reorganizing its food safety program after the nationwide infant formula shortage and investigations into its inability to ensure the safety of produce, baby food and water. Solutions voiced at a recent U.S. Senate hearing include a new leadership structure unifying food programs, new models for public-private sector collaborations and additional resources to hire and retain staff.

An idea that should not be considered is taking “food” out of the FDA’s mission, which for nearly a century has included the monitoring of food safety, to create a new agency (and thereby likely a new silo). Instead, ensuring the FDA begins to prioritize not only food safety but also healthier food is a better choice. With respect to the latter, aggressively tackling excessive sodium and added sugars while defining the term “healthy” on food labeling should be top priorities for the agency, as poor diet is now the nation’s leading risk factor for mortality, having surpassed smoking. Along with tobacco, which the FDA also regulates, the agency needs to fulfill its mission first and foremost as a public health agency regulating these two leading risk factors of disease.

Third, Congress created the position and office of the Assistant Secretary of Preparedness and Response (ASPR) at the Department of Health & Human Services (HHS) over 15 years ago to support the nation’s response to public health threats. However, HHS secretaries have not always empowered the ASPR to act on their behalf nor provide clear direction to HHS agencies. The Biden administration has proposed to transition ASPR from an office supporting the secretary to an agency on par with the CDC, FDA, and others but this doesn’t solve the lack of coordination, and alternatively, risks creating yet another silo.

A better idea would be for Congress and the HHS secretary to clarify and strengthen ASPR’s leadership roles and responsibilities during a federal response to a pandemic, a recommendation recently put forth by the Bipartisan Policy Center’s (BPC) Future of Health Task Force. Enhancing the office’s hiring and contracting authorities should also be included. BPC’s task force also recommended coupling ASPR’s leadership within HHS with the creation of a new White House deputy national security advisor for pandemic and biothreats preparedness to coordinate, direct and hold all federal departments and agencies accountable for all biodefense preparedness and operational response efforts.

Finally, one policy objective that should be pursued, particularly given our experience with COVID-19, is to strengthen our nation’s public health infrastructure such that it has the capabilities to respond to a broad range of challenges. This requires sustainable long-term investments in states and localities in addition to renewed federal leadership.

To this point, a recommendation by the Commonwealth Fund Commission on a National Public Health System to establish a position at HHS, such as an undersecretary for Public Health, should be favorably considered. This position would help oversee and coordinate the development of a national public health system with federal agencies, states, localities, tribes and territories. Given the urgency of ensuring programmatic alignment and budgetary transparency, the commission recommended that HHS, under existing statutory authority, could reconfigure and support the position of the assistant secretary for health to serve in this role right now.

As we approach midterm elections and the 118th Congress in 2023, it is likely that there will be increasing calls for reform and government oversight of the nation’s federal public health structure. It is important that proposals be scrutinized, not only on their merits but also for unintended consequences. While considering reorganization or reallocation of duties, the federal government should focus on strengthening its leadership ability to respond to all public health challenges, emergent and long-standing, so that we can achieve a healthier nation.

Anand Parekh, M.D., M.P.H., is chief medical advisor at the Bipartisan Policy Center and former deputy assistant secretary of health at the Department of Health and Human Services.