A recent move by the Trump administration could further politicize HHS, severely disrupt the agency's decision-making and cause sizable policy swings each time there's a new president. Those changes would create significant uncertainty for providers, payers and the public, according to experts.
President Donald Trump last month signed an executive order that would make it easier for federal agencies to hire and fire career officials "in positions of a confidential, policy-determining, policymaking or policy-advocating character … not normally subject to change as a result of a presidential transition" by reclassifying them under a new category of federal workers called Schedule F. It would let agencies sack attorneys, public health experts, regulators, scientists and other officials without cause, according to Donald Kettl, a professor at the University of Texas at Austin's Lyndon B. Johnson School of Public Affairs.
The White House claimed the order was necessary to ensure agencies could get rid of "poor performers," pointing to a 2016 survey that found less than a quarter of federal employees believe their agency effectively addresses poor performers. Agencies have until Jan. 19—the day before the next presidential inauguratio—to decide which employees they could reclassify but have another four months to make their final decisions.
Experts said the policy could allow Trump to replace all federal employees in policy-related positions with people who are effectively political appointees.
"It's the most dangerous attack on the civil service ever. We'd be taking nonpartisan positions and turning them into partisan positions," said former HHS Secretary and current Rep. Donna Shalala (D-Fla.).
HHS could be more affected by the order than other federal departments because it's responsible for a wide range of policymaking activities, Kettl said. The Centers for Disease Control and Prevention, CMS, the Food and Drug Administration, the Health Resources and Services Administration and the National Institutes for Health could be significantly affected because there have been several policy disputes among career officials and Trump appointees.
HHS officials serving in supervisory roles are most likely to be affected by the order since they often have the most technical knowledge of their programs. But it could also impact lower-level officials involved in carrying out policies or gathering and analyzing evidence. For example, the CDC might fire a low-level researcher for writing a background paper about how mask-wearing affects the spread of COVID-19 because it could influence policy.
"You would not be able to trust the policymaking in those agencies because the evidence could be politicized," Shalala said.
Experts said HHS' Assistant Secretary for Planning and Evaluation could be most at risk because nearly all its career officials directly influence policy advice—the agency is responsible for policy coordination, legislation development, strategic planning, policy research, evaluation and economic analysis.
"The fact that (the agency's advice) often isn't taken doesn't change the fact that they fit into this category. Every single one of them," said Joe Antos, a health policy researcher at the American Enterprise Institute who has held several policy-related positions in government.
Still, it's unclear how many of HHS' more than 80,000 employees would be tossed out if Trump gets reelected because HHS has just seven months to decide which employees to reclassify, a task that could prove impossible given that thousands of its employees would require review. It's more likely HHS would automatically reclassify supervisory positions because the department doesn't have enough resources to review employees on a case-by-case basis, Antos said.
Experts said the order aims to punish career employees that didn't quickly produce the results political appointees wanted. Newcomers often don't understand HHS' programs and policies because "the level of technical complexity is mind-boggling," which leads them to mistrust civil servants, Antos said.
But if Trump were to get rid of HHS' most knowledgeable people, it could cause problems down the road since their replacements would be more likely to make mistakes—like issue conflicting regulations—due to a lack of institutional and technical knowledge, experts said.
The policy's fate is unclear if former Vice President Joe Biden wins the presidency. Though Biden's political appointees would probably have a more favorable view of civil servants, they might want to keep the order in place to root out Trump loyalists that "burrowed into" the civil service during the end of Trump's term, experts said. It's common for political appointees to convert to civil servants before a president leaves office, although federal rules limit those transitions.
But "it's not in the interest of either political party (to politicize the civil service because) it destroys the integrity of the decision-making process in government," Shalala said.
Trump's order is part of a long-running debate on reforming the civil service, Kettl said. There's consensus that it must be improved to help it achieve its mission. But there's widespread disagreement among civil servants, politicians and outside experts about how to fix the federal workforce.
"The current system has very few friends," Kettl said.
Public employee unions want to protect federal jobs and increase protections for current employees, while conservatives want to make it easier to fire federal employees, shrink the federal workforce and make more government employees at-will.
"Folks from the left have been looking to put more professionals into some of the key positions," Kettl said. "This is round five of what's going to be a 15-round fight."
The White House budget office did not respond to a request for comment.