Since taking the helm of the Department of Health and Human Services in February, Secretary Robert F. Kennedy Jr. has moved quickly to shrink the agency, firing thousands of agency staffers. He's canceled billions in grants to universities and public health departments, purged some leadership and shaken up the norms of the scientific review process.
Both the firings and grant cancellations have been challenged in court. A federal judge has temporarily paused the staff cuts for several weeks.
Kennedy heads to Capitol Hill Wednesday to testify before lawmakers for the first time as HHS Secretary.
Former HHS leaders weigh in
"I think some of the cuts are necessary — I wish they'd learn a little bit more about the department before they do it," says one of Kennedy's predecessors, Tommy Thompson, who served as health secretary under President George W. Bush. "I'm not one of those that's going to criticize the administration or Bobby Kennedy for cutting back, because I think it's necessary in government at all levels.
"I hope that they don't cut programs that are absolutely necessary for public health," he adds.
Another former secretary, Donna Shalala, who served under President Bill Clinton, panned Kennedy's approach. "There's no strategy and there's no vision. There's just a bunch of words and an inability to even implement their words," she says.
Kennedy has, at times, seemed unfamiliar with programs and staff that had been cut, and suggested as many as 20% of the people fired could be brought back if they are deemed essential.
HHS did not respond to NPR's repeated requests to interview Kennedy for this story. On Wednesday Kennedy will face the House Appropriations committee in the morning and the Senate's Health, Education, Labor and Pensions committee in the afternoon. The purpose is to discuss President Trump's proposed budget for the agency, which would make the restructuring of the agency and dramatic cuts to staff and the budget permanent.
"The reorganization has been put forward without a lot of explanation," says Dr. Joshua Sharfstein, who served as principal deputy commissioner at the FDA in the Obama administration and is now a professor at Johns Hopkins University. "In a time when the slogan of HHS is 'radical transparency,' the department and the secretary really should be more transparent about what's happening and be able to answer these legitimate questions that are coming up about their plans."
Wednesday's hearings could answer some of the big questions about the future of HHS as Kennedy tries to fundamentally reshape it.
Government as a protector of health goes way back
The U.S. public health service got its start in the 1700s caring for seamen who were sick or injured. The corps of uniformed physicians grew, helping to prevent the spread of yellow fever and smallpox in the 1800s, and eventually doing disease research and work on sanitation.
Another foundational function of the federal government in health is making sure the food and medicine Americans consume are safe. Around 1900, someone who bought milk might have been actually buying milk thinned with pond water. "It was noticed when the family found worms wiggling in the bottom," science writer Deborah Blum told NPR in 2020. Dairies thinned milk to stretch their profits and then reconstituted it with things like plaster dust, yellow lead for color, and formaldehyde as a preservative, she said.
The federal government stepped into this free-for-all to regulate it, says Edward Berkowitz, emeritus professor of history at George Washington University. "At the beginning of the 20th century there were pure food and drug laws that were passed when Teddy Roosevelt was president," he explains.
Both the public health corps and food regulation existed in different parts of the federal government, Berkowitz says, until President Dwight Eisenhower created the Department of Health, Education and Welfare in 1953. "That's our modern department that we still have, but there have been a few little changes along the way," Berkowitz says, including the spinning out of both Social Security and Education into their own agencies. The name Health and Human Services dates back to President Jimmy Carter.
America's largest health insurer
Today's HHS does a lot more than those original functions. It runs Medicare and helps states run Medicaid — along with Healthcare.gov, the marketplace for health insurance created by the Affordable Care Act. Through those three entities, the federal government helps insure about half of Americans. (These divisions of HHS also account for more than 60% of the agency's budget.)
HHS encompasses the National Institutes of Health, the Centers for Disease Control and Prevention, FDA, and smaller divisions, including an agency for mental health and one that enables elderly and disabled people to have support they need to live at home, and another that supports domestic violence shelters.
When the year began, HHS had a staff of 82,000 and a budget of nearly $2 trillion. Kennedy has described the agency's structure as "incomprehensible," arguing it had too many administrative departments. "HHS has more than 100 communications offices and more than 40 I.T. departments and dozens of procurement offices and nine H.R. departments," he explained in a social media video announcing the restructuring plan.
"We're going to eliminate an entire alphabet soup of departments and agencies while preserving their core functions by merging them into a new organization called the Administration for a Healthy America or AHA," he added.
But Congress was deeply involved in the creation of that "alphabet soup" and lawmakers may object to Kennedy's sweeping, sudden restructuring. "There has always been bipartisan support for HHS programs, that's how they survived," says Shalala, who served in Congress after her term as secretary. During the COVID-19 pandemic, Republican support for agencies like NIH and CDC began to fracture, although it's unclear if lawmakers will uphold all of the changes Kennedy is now trying to make at HHS.
Kennedy's new vision — and view of past 'failures'
At times, Kennedy has praised the staff of HHS. In a social media video from his first week on the job, he says he was "bowled over" by the enthusiastic reception he received from personnel at HHS headquarters. "My main vision at HHS, which I hope that you will all join me, is to reverse the chronic disease epidemic in America," he tells staff in the video.
At other times, Kennedy has accused HHS staff of being "sock puppets" of industries like Big Food and Big Pharma. He also draws a direct line between failures of HHS staff and Americans' health. "The rate of chronic disease and cancer increased dramatically as our department has grown," he said in the restructuring video announcement.
"You know how bureaucracies work — every time a new issue arises, they tack on another committee. This leads to tremendous waste and duplication and, worst of all, a loss of any unified sense of mission," he added. "The resulting pandemonium has injured American health and damaged department morale."
His overhaul cuts the size of the staff by 20,000, between people being fired and those who chose early retirement or buyouts. While thousands of employees losing their jobs is "heartbreaking," Kennedy told CBS in April, "it's something that has to be done if we're going to save our country and restore it."
The way staff was fired this spring created its own pandemonium. After the "reduction in force" notices were sent on April 1, it was difficult to ascertain who had been cut, let alone why. Some supervisors resorted to emailing their teams to find out who remained. Others found out they had been fired when they arrived at work to find their badge had been deactivated, or when they were told by email to leave the building because they were expected to be fired soon.
Adding to the confusion was Kennedy's assertion in interviews that several thousand of the people who were fired might later be brought back. "There are going to be casualties and there's going to be mistakes, and what our job is as we reconstitute this agency to make sure that those mistakes are rectified," Kennedy told CBS. He said going through each person's job to ensure they weren't needed before the notices went out "takes too long and you lose political momentum."
In prioritizing speed over precision, the overhaul seems to be affecting some of the foundational functions of HHS. FDA labs that monitor the food supply have lost staff, and some inspections have already been delayed or canceled. Scientists working on some of Kennedy's stated priorities were fired as well, including those focused on chronic diseases. Grants canceled to states have kept them from holding vaccination clinics, even as measles continues to spread.
Staff fulfilling tasks required by Congress were also cut, including statisticians working on an ongoing national survey on drug use and epidemiologists that work on rape prevention.
HHS spokesperson Emily Hilliard wrote to NPR in a statement in April: "All statutorily required positions and offices will remain intact, and as a result of the reorganization, will be better positioned to execute on Congress's statutory intent."
HHS has been reorganized before
Former HHS secretaries interviewed by NPR agreed that making changes is an expected and appropriate part of leading the agency, although they did not agree with Kennedy's criticism of HHS scientists.
"It's been quite a while since I was there, so things have changed I'm sure, but I was always impressed by the vast majority of scientists at the department," says Thompson, the secretary under Bush.
Which is not to say that he was hands-off in running HHS. "I wanted to streamline everything," he says. "The biggest change since the start of Medicare was under my leadership." Thompson says he also overhauled the organ transplant system, food security services and obesity and childhood diabetes programs.
He says he made these changes after studying the department and moving his office to each division for a week to see how they worked from the inside. "I don't think anybody's ever done that except me. That's my style. I wanted to learn."
Kathleen Sebelius, who served as Health Secretary under President Barack Obama, oversaw several restructuring efforts as well, including combining two agencies into a single one after months of input from Congress, advocates and patients. She says she's "alarmed" by the process and scope of Kennedy's overhaul.
"I always thought that dismissing people was a last resort once your budget is cut, not the first thing that you do as part of a reorganization," she says. "With agencies that touch people from birth to death and everything in between, there is absolutely no way that reductions made in such an arbitrary fashion won't impact the services that people rely on every day."
Shalala says she thinks restructuring just "sucks up time and it gets you unfocused on outcomes." She says firing talented people is the wrong way to streamline the agency. "Look, they want to go after waste, fraud and abuse — that's what we did. We brought billions back, we extended the life of Medicare, with a beefed up [inspector general] and with an FBI that beefed up the unit that went after health care fraud. They've decimated those units," Shalala says. "There's no evidence that, when they're breaking down the government with a hammer and bludgeoning these agencies, they know how to put them back together with a new strategy."
Roger Severino, a fellow at the conservative Heritage Foundation who directed the HHS Office for Civil Rights in the first Trump administration, thinks Kennedy is right about the problems in the department and his approach to the overhaul. "HHS lost its way, it lost its vision from making sure the outcomes were there of improving longevity and quality of life, and instead, it turned into a money-dispensing machine," he says. "Why? Because special interests have captured HHS, and RFK Jr. is committed to ending it."
Sharfstein gives Kennedy credit for asking big picture questions about America's health, but questions his approach. "Even as the department can be improved and its focus can move to major solutions to outstanding problems, you don't want to lose all the advantages of science for the health of the American people," he says.
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