What’s it really like to be HHS secretary? Three who’ve done it spill the beans

As the nation's top health official and leader of one of the federal government's largest departments, the secretary of Health and Human Services makes life-or-death decisions every day that affect millions of Americans.

But not all important work is serious.

One former HHS secretary, Kathleen Sebelius, recalled a highlight of her tenure: recording a public service message with "Sesame Street." "The Elmo commercial was to teach kids how to sneeze," she said. "We were trying to spread good health habits."

The script called for Sebelius to ask her co-star to "bend your elbow and sneeze into your arm."

"Elmo has no elbow," the beloved red Muppet replied, veering off script. So, Sebelius said, they swapped roles: "Elmo taught me how to sneeze."

Her story punctuated a rare, intimate conversation Wednesday with three HHS secretaries, past and present — and across party lines. Secretary Xavier Becerra, the agency's current leader, joined Sebelius, who worked under then-President Barack Obama from 2009 to 2014, and Alex Azar, who worked under then-President Donald Trump from 2018 to 2021. Their candid discussion took place at Aspen Ideas: Health, part of the Aspen Ideas Festival, about the job each of them held.

The panel discussion, taped in Aspen, Colorado, before a standing room-only crowd, was hosted as a live episode of KFF Health News' weekly policy news podcast, "What the Health?," and is now available to stream.

Becerra, Azar, and Sebelius spoke not only about the common bullet point on their resumes, but also about their shared understanding of what it means to lead the agency at a time when health is at the front of American minds — and in the crosshairs of American politics. Becerra and Azar have led HHS during the covid-19 pandemic, and Sebelius was in charge during the implementation of the Affordable Care Act.

They offered frank and at times strikingly similar perspectives on leading a department with more than 80,000 employees; a budget of more than $1.5 trillion; and an agenda most often set by outside events or their boss at 1600 Pennsylvania Ave.

Azar, who described fielding "two to five" daily phone calls from Trump, which could come at nearly any hour, said he started his days huddling with senior staff "to discuss what could hit us in the face today."

"The White House is not a patient place," said Becerra, who described losing 11 twin towers' worth of Americans to covid-19 every day when he took the reins. "They want answers quickly."

"It truly is life and death at HHS," Becerra added. "The gravity, it hits you. And it's nonstop."

The panel offered some behind-closed-doors takes on today's top issues, including the bruising fights over skyrocketing drug prices under Trump and ACA contraceptive coverage under Obama.

Deciding which "hills do you die on" was Azar's top challenge as HHS secretary, he said. "When do you fight and when do you not fight with, say, the White House?" He pointed to his push to eliminate drugmaker rebates paid to health plans and pharmacy benefit managers, which drugmakers and others have criticized for driving up drug costs.

"I left a lot of blood on the field of battle just to try to outlaw pharmaceutical rebates," he said.

All three secretaries agreed that one of the least understood but most important aspects of the department's work happens outside the United States, performing what Sebelius called "soft diplomacy." While many countries are loath to welcome officials from the State Department or the military, "they welcome health professionals," she said. "They welcome the opportunity to learn."

Asked what they felt unprepared for when they got the job, Azar — who had worked at HHS previously as general counsel then deputy secretary — replied: "The Trump administration."

Coming from the administration of former President George W. Bush and later a stint as president of the U.S. division of the drugmaker Eli Lilly, Azar said he was "used to certain processes and ways people interact." Working in the Trump administration, "it was different."

The atypical assembly of current and former political appointees also offered a chance for some unusually friendly banter.

Becerra noted that one reason he was familiar with HHS programs was because he had filed numerous lawsuits challenging the agency's actions when he was attorney general of California.

"Oh, he sued me a lot," Azar quipped, as the group laughed. "Becerra v. Azar, all over the place."