Kaiser Daily Health Policy Report Examines Remaining Vacancies at HHS, Nominations to Date

As the Bush administration begins its second year in office, there are several top positions in HHS left open, raising concerns among some lawmakers and policy experts. Some of President Bush's nominations are awaiting Senate confirmation, but candidates have not been formally nominated for the heads of the FDA, the NIH and the Administration for Native Americans. In addition, Bush has yet to name a replacement for David Satcher, whose four-year term as surgeon general expires in February (Brookings Institution Presidential Appointee Initiative). With HHS "short-handed," lawmakers have started pressing Bush to fill the empty slots, particularly since the Sept. 11 attacks on the World Trade Center and the Pentagon and the anthrax attacks. Paul Light, a senior adviser for the Presidential Appointee Initiative, which tracks and studies the nomination process for the Brookings Institution, said, "The policy makers at the top are there, but there are pretty significant gaps in the delivery corps" (Washington Post, 10/17/01). In a November interview with the Dallas Morning News, Sen. Ron Wyden (D-Ore.) said, "The nation needs an infusion of expertise and leadership at NIH, [National Cancer Institute] and FDA. ... At a time when considerable attention is focused on the threat of anthrax and smallpox and the necessity of biological detectors, it is essential that scientists are in place to lead important work in this field" (Morris, Dallas Morning News, 11/4/01). In addition, without a full staff of agency heads, the task of relaying important health information often falls to the secretary of the department, Tommy Thompson, even though many agency heads with expertise in their given fields might be better suited for such a responsibility. Given that it takes an average of three months from the time the White House announces a nomination until the time a nominee is confirmed, it may be some time until the open slots at HHS are completely filled (Washington Post, 10/17/01).

Making the Cut
In total, there are 17 positions at HHS for which Bush must put forward nominees and the Senate must confirm. Eleven have been confirmed so far. Typically, the White House Office of Presidential Personnel oversees the appointment process and screens potential nominees. When the OPP determines a candidate has the credentials for the position, the name is sent to the president's chief of staff. The chief of staff reviews the potential nominee, and then the process shifts from OPP to the Office of the Counsel to the President, which verifies that a candidate meets legal and ethical requirements. If the White House counsel clears a candidate, the FBI will conduct a background check. Once this process is completed, the White House will publicly announce a nomination. The formal nomination of a candidate starts the Senate confirmation process, which is dominated by the committee that has jurisdiction over the nomination. For HHS, the Senate Health, Education, Labor and Pensions Committee oversees the process. Typically, the nominee will meet informally with the committee chair while the committee members review the nomination. If the committee members are unhappy with the nominee, members may hold more interviews or request additional information from the White House. After a confirmation hearing is scheduled and the committee votes, a floor vote is scheduled. If the full Senate approves the nomination, the appointee is commissioned and sworn into office.

Confirmed Nominees
The following briefly describes HHS nominees who have been nominated by Bush and confirmed by the Senate:

• Secretary of Health and Human Services, Tommy Thompson: Before becoming HHS secretary, Thompson served as governor of Wisconsin for 14 years, where he focused on welfare reform and the state's health and child care programs. Thompson, who as governor frequently said that HHS was slow to approve waiver requests, has said he will work to speed the waiver approval process as secretary. President Bush announced Thompson's nomination on Dec. 29, 2000; Thompson was confirmed by the Senate Jan. 24, 2001, and sworn into office Feb. 2, 2001 (HHS bio, 6/21/01).
• Deputy Secretary of Health and Human Services, Claude Allen: Allen served as secretary of Virginia's Department of Health and Human Resources, where he worked on children's health care programs and patients' rights. Allen also played a role in reforming Virginia's welfare system and mental health services. With his current position, Allen acts as the department's chief operating officer and works closely with members of Congress to push Thompson's agenda. Allen was nominated April 25, 2001, and confirmed May 25, 2001.
• Assistant Secretary of Legislation, Scott Whitaker: Whitaker previously worked in various capacities for Assistant Senate Minority Leader Don Nickles (R-Okla.). Most recently, Whitaker worked as policy adviser and concentrated on health care issues such as Medicare and Medicaid policy. In his position with HHS, Whitaker is tasked with pushing Bush's proposals to increase coverage for the uninsured and reform Medicare. Whitaker was nominated April 6, 2001, and confirmed May 1, 2001.
• Assistant Secretary for Children and Families, Wade Horn: With his confirmation to HHS, Horn rejoins the agency he worked at during the first Bush administration. After serving as commissioner of the HHS Division of Child, Youth and Families, Horn was a presidential appointee to the National Commission on Children and served on the National Commission on Childhood Disability. Most recently, Horn was president of the National Fatherhood Initiative. Horn was nominated April 6, 2001, and confirmed July 25, 2001.
• Assistant Secretary for Public Affairs, Kevin Keane: Keane previously worked on Thompson's gubernatorial staff as press secretary, communications director and executive assistant. Before joining Thompson's staff, Keane worked in journalism. Keane was nominated April 30, 2001, and confirmed July 19, 2001 (Serafini/Fenoglio, National Journal, 6/23/01).
• Assistant Secretary for Planning and Evaluation, Bobby Jindal: Jindal previously served as president of the University of Louisiana system. In 1998, at age 26, Jindal was selected to head the National Bipartisan Commission on the Future of Medicare, where he helped develop the commission's proposals for reforming the program. At HHS, Jindal is responsible for evaluating and developing policies and regulations for the agency. Jindal was nominated April 6, 2001, and confirmed May 25, 2001 (HHS bio, 7/25/01).
• Assistant Secretary for Aging, Josefina Carbonell: From 1972 until her appointment, Carbonell was president and CEO of the Miami-based Little Havana Activities and Nutrition Centers, which provide health, nutrition and social services to senior citizens. She also worked to implement a pilot program in Florida that provides primary care and preventive screening to the elderly. Carbonell was nominated June 8, 2001, and confirmed Aug. 1, 2001 (HHS bio, 8/20/01).
• General Counsel, Alex Azar: Before joining HHS, Azar handled labor, employment and commercial litigation as a partner at a Washington, D.C.-based law firm. After receiving his law degree from Yale, Azar clerked for Supreme Court Justice Antonin Scalia and then joined Kenneth Starr's independent counsel team for the Whitewater investigation. Azar was nominated June 7, 2001, and confirmed Aug. 3, 2001.
• Inspector General, Janet Rehnquist: Rehnquist, the daughter of Supreme Court Chief Justice William Rehnquist, worked as an assistant U.S. attorney in Virginia, where she defended federal agencies in civil litigation. She also investigated Medicare fraud and abuse while working as counsel for the Senate's Permanent Subcommittee on Investigations. Rehnquist served in the previous Bush administration as an associate counsel in the White House. Rehnquist was nominated June 5, 2001, and confirmed Aug. 3, 2001 (National Journal, 6/23/01).
• Centers for Medicare and Medicaid Services Administrator, Tom Scully: From 1995 until his confirmation by the Senate, Scully was the president and CEO of the Federation of American Hospitals, which represents 1,700 hospitals and health systems. Before his tenure at the hospital association, Scully handled health care regulation and legislation as a partner in a Washington, D.C., law firm. Like other members of the new administration, Scully worked in the previous Bush administration, serving as counselor to the director of the Office of Management and Budget, deputy assistant to the president and associate director of OMB for Human Resources, Veterans and Labor. Scully was nominated April 30, 2001, and confirmed May 25, 2001 (HHS bio, 6/25/01).
• Administrator of the Substance Abuse and Mental Health Services Administration, Charles Curie: Curie was the deputy secretary for Mental Health and Substance Abuse Services at the Pennsylvania Department of Public Welfare (White House release, 7/11/01). He was nominated Oct. 2, 2001, and confirmed Oct. 25, 2001.

Pending Confirmation
The following nominations formally have been sent to the Senate and are currently awaiting action:

• Assistant Secretary for Management and Budget, Janet Hale: During the Reagan administration and previous Bush administration, Hale held a variety of positions at the departments of Housing and Urban Development and Transportation, as well as OMB. After the elder Bush left office, Hale worked as the executive vice president of the University of Pennsylvania. In addition, she was the top lobbyist for the U.S. Telephone Association. Hale was nominated May 22, 2001 (National Journal, 6/23/01).
• Commissioner of Children, Youth and Families, Joan Ohl: Ohl previously served as secretary of the West Virginia Department of Health and Human Resources. During her tenure in Charleston, W.Va., Ohl focused on welfare reform and decreased the number of welfare recipients in the state by two-thirds. If confirmed, Ohl will oversee the welfare program (Associated Press, 7/10/01). Ohl was nominated July 10, 2001.
• Assistant Secretary for Health, Eve Slater: Slater currently works in the pharmaceutical industry as senior vice president for clinical and regulatory development at Merck Research Laboratories. In her position at Merck, Slater oversees late phase clinical trials and over-the-counter drug development. A medical doctor by profession, Slater was chief of the hypertension unit at Massachusetts General Hospital from 1977 to 1983 (White House release, 10/16/01). Slater was nominated Oct. 16 (Washington Post, 10/17/01).

Academia vs. Professionals
Thus far, the Bush administration has completed the nomination and confirmation process for senior positions at HHS in nearly the same time frame as did the Clinton administration in its first year. However, some positions were staffed at different times under the two administrations. For example, Bush's nomination for SAMHSA was confirmed in late October, while former President Clinton's nominee was confirmed in June. In addition, Clinton's pick for commissioner of the Administration on Aging was confirmed in April, while Bush's choice passed the Senate in August. However, in other cases, Bush's nominations were confirmed before Clinton's -- Bush's nomination for assistant secretary for legislation was confirmed about one month before Clinton's choice was. The professional experience of the Bush nominees also differs greatly from that of the individuals Clinton selected during his first term. Clinton, for instance, relied heavily on those with experience in government and academia. Bush's selections, however, show a preference for individuals with experience working in the private sector, particularly in industry and trade associations. For example, Clinton selected Fernando Torres-Gil, a professor at the School of Social Welfare at the University of California-Los Angeles, as assistant secretary for aging. By contrast, Carbonell, Bush's choice, has worked as president of a not-for-profit organization that assists the elderly. To head CMS (then known as HCFA), Clinton named Bruce Vladeck, who was the president of the United Hospital Fund of New York, a philanthropic organization, and a member of the New York State Council on Health Care Financing, a state government panel. Bush, however, selected Scully, the head of a trade association. Of the 14 positions for which Bush has either announced or formally submitted a name to the Senate, only one was involved in higher education -- Jindal, who was president of the University of Louisiana system and a professor there. Clinton, however, selected seven people with experience in academia for positions within HHS during his first term (Brookings Institution Presidential Appointee Initiative/Congressional Research Service, "Presidential Appointments to Full-Time Positions in Executive Departments During the 103rd Congress," 2/10/95).
This story was written by staff writer Darryl Drevna.