Gabriel Perna | December 8, 2020
Earlier this week, President-elect Joseph R. Biden Jr. nominated California Attorney General Xavier Becerra to be the Secretary of Health and Human Services (HHS). If confirmed by Congress, Becerra would be the first Hispanic person to take charge of HHS.
Based on his career as a Congressman and actions taken as AG of the most populated state, Becerra’s nomination would have major implications on how the next administration will tackle the deployment and potential expansion of the Affordable Care Act, enforce antitrust law among increasing industry consolidation, aim to lower the price of prescription drugs, and address health disparities for vulnerable populations.
It’s the latter point that excites Elena Rios, MD, President & CEO of the National Hispanic Medical Association, (NHMA). Rios personally knows Becerra and his wife, Carolina Reyes, MD, an obstetrician for Valley Children’s Healthcare in Madera, California. Cut from a similar cloth, both Rios and Becerra were born to Mexican American parents, went to Stanford University in the 1970s, and were the first in their families to go to college.
“A lot of us Latino students from that era have understood the opportunity that was given to us of being the first generation of students to go to college. We were given a real opportunity to have an elite education that not everyone had. And we want to give something back to our community,” Rios says. “[Becerra] has shown that he has the vision and leadership to help his community—and other vulnerable communities.”
For Rios, Becerra’s ascension is perfect timing for her fellow Hispanics. She says his agency can bring together other Hispanic health care leaders and ensure they have a seat at the proverbial table, empower Latino health care workers and provide needed services for disadvantaged Hispanics across the country. “I’m very proud he was nominated, and other Hispanic health care leaders should be proud he is nominated,” she says. “Given how COVID has ravaged our communities, he will be able to help.”
Rios says Becerra’s upbringing means he has a deep understanding of the disparities that have plagued racial minorities. She holds hope that Becerra’s HHS will create programs that address social determinants of health—access to healthy food, better transportation, safe housing, and a more diverse lineup of health care providers in more places of access.
“Many Hispanic and Black Americans are stuck by the cycle of poverty. They can’t they leave the areas where they live, are stuck in low-income jobs, have low education and limited health literacy, and low literacy in general,” she says.
As AG of California, Becerra used the ACA’s impact in reducing disparities to defend it against legal challenges, including the most recent one that was argued to the Supreme Court. He also has held legal challenges aiming to uphold and defend health care and other services for children of undocumented and legal immigrants, Native Americans, low-income Americans, Medicaid beneficiaries and other disadvantaged communities.
In total, Becerra sued the Trump administration 100 times, many times over health care-related policies. He also created an environmental justice bureau that studies the impact climate change and pollution are having on health on vulnerable populations. For some experts, putting an adversary of the Trump administration into this spot represents a clear signal from President-elect Biden.
“I think this nomination is clearly in line with the Biden-Harris administration’s goals to uphold and fortify the Affordable Care Act, overhaul our immigration system, and clearly demonstrates that the Biden-Harris administration is preparing to take on the legal challenges facing these priorities, both in Congress and with the newly configured Supreme Court,” says Robert Hess III, a consultant based in Arizona.
“HHS oversees the Office of Refugee Resettlement, which is in charge of unaccompanied minors – where Becerra’s experience as the son of a Mexican mother may be a strong indication of the Biden-Harris’ plans for immigration reform,” Hess adds.
In a speech made alongside other members of the Biden health team and the President-elect, Becerra inferred his priorities, saying that “the work we do for our children, seniors and disabled. They will all stand in a Biden-Harris HHS.” Joining Becerra on Biden’s health team will be Marcella Nunez-Smith, MD, Founding Director of the Equity Research and Innovation Center (ERIC) at the Yale School of Medicine, who will lead a taskforce on reducing health disparities.
“The same disparities ingrained in our economy are our housing system, food system, our justice system and so many other areas of our society have conspired in this moment to create a grief gap that we cannot ignore,” Nunez-Smith said during the introduction of Biden’s health team.
Elizabeth Mitchell, Pacific Health Group
COVID-19, advancing the ACA and more
If he is confirmed, Becerra’s role at HHS will immediately focus on combatting the COVID-19 pandemic. He would be working alongside Rochelle Walensky, MD, Chief of Infectious Diseases at Mass General Hospital (MGH), who was nominated to lead the Centers for Disease and Control and Prevention (CDC). Walensky, whose post does not require confirmation, has led MGH on the frontlines of the COVID-19 response and spent her career battling infectious diseases, starting in the 1980’s with the AIDS crisis.
The leaders of Biden’s COVID-19 response team also include Vivek Murthy, MD, an advisor to President-elect Biden, who was nominated as Surgeon General, a post he held with the Obama administration; Jeffrey Zients, former director of the National Economic Council, as the COVID-19 coordinator; Natalie Qullian, Deputy Coordinator for the COVID-19 response; and Anthony Fauci, MD, current director of the National Institute of Allergy and Infectious Diseases, as the COVID-19 chief medical advisor.
The coordination required by the HHS Secretary to combat the pandemic, not just within a massive agency that has a budget of more than $1 trillion, but across the government, the private sector and overall public. This will be especially pertinent when the vaccines begin to get distributed on a massive scale. For this reason, Rios is confident in Becerra’s ability to take on this massive job, even though some early critics have questioned his lack of frontline experience.
“It’s going to be a lot of coordination and Xavier Becerra brings that leadership quality to get people to coordinate a massive effort,” Rios says.
Beyond the COVID-19 pandemic response, experts say Becerra has a deep understanding of the ACA through his work as a Congressman and AG of California that could preview how he might advance and protect the law as HHS Secretary. He will work with whoever gets nominated to run CMS to advance value-based care models and roll back Medicaid restrictions.
“After COVID, I’d expect the focus to shift to reversing some of the Trump administration’s conservative policies, such as work requirements for Medicaid populations,” Hess said, who adds that Bidens’ teams would also likely continue some policies of the previous administration. “There has been some indication that the Biden-Harris administration will retain several Trump policies—specifically enhancements and streamlining of the Medicare program, process toward value-based payments, funding for telehealth.”
Another potential agenda item for Becerra is monitoring antitrust activity and prescription drug pricing, something he was known for as AG of California. Of note was his work in filing opposition against large health system Sutter Health, based in Sacramento, for what he described were monopolistic practices. Becerra was able to force the large health system into making a large $575 million settlement. While HHS doesn’t have antitrust oversight, Becerra’s influence could work across agencies with the Department of Justice.
He also secured a nearly $70 million settlement agreement against four pharma companies for collusive “pay-for-delay agreements” that illegally delay affordable prescription drugs from entering the market. Elizabeth Mitchell, CEO of Pacific Health Group, says this may be a signal of the Biden administration’s priorities.
“The nomination of Becerra is a significant indicator that there is going to be a readiness to take on some of the more egregious anti-competitive practices in health care around industry consolidation and drug pricing,” Mitchell said. “There’s no transparency, there’s very little accountability, and pricing is just sort of ridiculous. It’s a pretty interesting opportunity if he is confirmed to really look at some of the market dysfunction.”
Becerra’s nomination will be under review once the new Congress is seated and the President-elect is inaugurated. President Trump’s initial pick for HHS Secretary, Tom Price, MD was confirmed in February while President Obama’s pick, Kathleen Sebelius, was confirmed in April. Republicans have indicated that he may have a tough time getting confirmed based on his past support for Medicare for All.