HHS in a second Trump term

With the GOP platform offering little guidance on where a second Trump administration will take health care, one must look to his potential appointees and Project 2025.

This is the first of two articles on government health care under a second Trump administration. The second will be posted tomorrow.

“Personnel is policy,” proclaimed Scot Faulkner, Ronald Reagan’s director of personnel. Faulkner led the internal insurrection by hard-right conservatives that seized control of hiring during Reagan’s first term.

They succeeded in placing deregulatory, anti-environment and anti-labor zealots, most with ties to rightwing think tanks, atop key agencies throughout the U.S. government. Their enduring legacy is a society whose maldistribution of wealth and income rivals the Gilded Age.

The importance of personnel was underscored last Friday after weeks of GOP presidential candidate Donald Trump disclaiming any knowledge of Project 2025. He was the top speaker at a Washington conference run by Moms for Liberty and sponsored by the Heritage Foundation.

The Heritage Foundation is the chief architect of Project 2025, which Democratic vice presidential candidate Tim Walz accurately described as the playbook for the next Republican president. It calls for sharply reducing the role of government in the economy while using its regulatory power to advance a Christian Nationalist agenda.

Moms for Liberty came to national prominence in 2021 through its efforts to elect its members to local school boards and ban schoolbooks that mention LGBTQ+ people or structural racism. The organization served as a member of Project 2025’s advisory board. In the past year, it also entered the national political arena by raising millions of dollars from conservative billionaire Richard Uihlein and others to run ads in swing states encouraging its supporters to get out to vote. 

While 78-year-old Trump has repeatedly disavowed Project 2025, his appearance at a Heritage-sponsored event was a reminder that, should he win the election, he will turn to Heritage, Moms for Liberty and similar groups for staffing dozens of agencies after he takes office. Why? He has nowhere else to go.

“Trump has entangled himself in that faction. There is no third set of Republican policy professionals — between the ‘Never Trump’ and MAGA factions — for him to attach himself to,” E.J. Fagan, a political science professor at the University of Illinois Chicago, told the Washington Post for its report on the Moms for Liberty conference. “I find it implausible that Donald Trump could actually distance himself from that because there would be no one to staff his government.”

Naming Robert Kennedy Jr., an anti-vaxxer, and Tulsi Gabbard, a former Democrat turned Republican culture warrior, to head his transition team only assures that Heritage and like-minded groups will take control of the hiring process. Neither attention-seeker has experience running anything larger than a small office, while an incoming president gets to name over 4,000 key people to run hundreds of agencies and their sub-offices, only 1,200 of whom require Senate confirmation.

Bare bones platform

These appointees will have free rein to pursue their own agendas, especially when it comes to health care in general and reproductive health and abortion rights in particular. While the GOP platform adopted by the Trump-controlled Republican National Committee at its July convention provides no specifics on where a second Trump term would take HHS, a $1.8 trillion agency whose budget would rank it as the 12^th largest economy in the world, it does provide a few clues.

Let’s start by noting how it dissembles on the question of abortion. First it says it should be left to the states. Then it says that a Trump administration will back a late-term abortion ban, which, if passed by a Republican-controlled Congress and signed by the president, would affect every state in the union and open the door to a national ban on all abortions. It makes no mention of rape, incest or preserving the life and health of the mother.

The platform also signals endorsement of efforts in conservative states to pass so-called fetal personhood laws. “We believe that the 14th Amendment to the Constitution of the United States guarantees that no person can be denied life or liberty without due process, and that the states are, therefore, free to pass laws protecting those rights,” the 16-page document says.

Beyond its central focus on the “right to life” agenda, the RNC platform promises to protect Medicare’s finances by severely restricting immigration. “Medicare’s finances are being financially crushed by the Democrat plan to add tens of millions of new illegal immigrants to the rolls of Medicare,” the platform said.

The Democratic platform says no such thing. It calls for creating a legal path to citizenship for undocumented immigrants, who only then would qualify for government programs. But even if Medicare, Medicaid and Social Security were opened to undocumented workers while on the path to citizenship, would that “financially crush” those programs?

Most experts and economists say the opposite. Immigrants on the path to citizenship are overwhelmingly young. They contribute payroll taxes immediately, which helps fund current retirees' benefits. Unauthorized immigrants also pay into Medicare (often by using someone else’s Social Security number) while remaining ineligible for benefits, further bolstering Medicare finances. One study found unauthorized immigrants contributed a $35 billion surplus for Medicare during the first decade of this century. Immigrants also make up a significant share of the health care workforce and are crucial to staffing thousands of nursing homes, hospice centers and hospitals across the country.   

The GOP platform promises to focus on chronic disease prevention and expand access to primary care. Yet it offers no programs. It promises help for long-term care through tax credits for family caregivers but never addresses how to prevent tax credits from leading to lower family incomes for two-earner households. Tax credits can never make up for the lost wages when someone has to stay home to take care of a loved one.

The only other health care-related plank in the GOP/Trump platform is its promise to increase “choice and competition” to lower health insurance and prescription drug costs. But how? Nothing is offered. For that, one must turn to Project 2025’s long section on HHS. Its primary author, Roger Severino, who ran the HHS Office of Civil Rights during Trump’s presidency, has drafted a plan that would radically transform the agency.

A minister for unending culture wars

Severino, who turned 50 this year, grew up in southern California, the son of working-class Columbian immigrants. His father worked in a bulk-mail warehouse, his mother on an electronics assembly line. For a 2017 Atlantic profile, he recalled being called a wetback in school and how his teachers discouraged him from taking honors classes. It didn’t stop him from earning his bachelor’s degree from the University of Southern California, a master’s degree in public policy from Carnegie Mellon University and a law degree from Harvard.

Image courtesy C-span.

While in law school, he “came into his Catholicism,” according to the profile. He also met his wife Carrie, who now runs the Judicial Crisis Network, which pushes for the appointment of conservative judges. Her one book is an “insider’s account” of the fight to get Brett Kavanaugh appointed to the Supreme Court.

Severino left the Justice Department in 2013 to join the Heritage Foundation’s newly created DeVos Center for Religion and Civil Society, funded by Betsy DeVos, the wife of a Michigan billionaire who later became Trump’s Secretary of Education. Two years later, DeVos’ protégé brought his religion-based antipathy to abortion, contraceptives, and gay and transgender rights to his new job running HHS’ civil rights office.

While the new justices on the Supreme Court his wife helped elevate took care of abortion, Severino’s greatest victory came from rolling back the Obama administration’s rules implementing Section 1557 of the Affordable Care Act, which for the first time prohibited sex discrimination in government-funded health care programs or at “covered entities” (hospitals, physician practices, clinics, etc.) that receive federal funds. The Obama rule on nondiscrimination included gender identify and sex stereotyping. It equivocates on sexual orientation discrimination by saying the civil rights office should evaluate complaints on a case-by-case basis. The preamble of the Trump-era rule, which didn’t become final until 2020, suggested his administration would interpret sex to mean only biological sex assigned at birth, according to a Kaiser Family Foundation brief.

But that victory was short-lived. In a rule released in 2022 and made final earlier this year, the Biden administration returned non-discrimination enforcement policies to what they had been under Obama. It added protections for transgender people and access to gender affirming care and stated specifically that Section 1557 preempted any state law contrary to those protections. It attempted to mollify religious opponents by creating a streamlined process for seeking an exemption.

After leaving HHS, Severino rejoined Heritage as head of a new HHS Accountability Project. Over the three-year span that led up to publication of Project 2025 “Mandate for Leadership,” he familiarized himself with almost every aspect of the sprawling agency’s operations.

The Project 2025 section on HHS calls for a dramatic overhaul of every major center within the agency, including Centers for Medicare and Medicaid Services, the Centers for Disease Control and Prevention, the Food and Drug Administration, and the National Institutes Health. He has positioned himself as the logical choice for HHS Secretary should Trump win the White House for a second time.

Tomorrow, I’ll review Project 2025’s plan for the Health and Human Services Department.