Let’s triple our health spending, and put it in the hands of a new Cabinet-level Secretary

There’s an old joke that, judging by its budget, the United States is an insurance company with an army. The “army” is the Department of Defense, with a 2020 budget of $713 billion. The “insurance company” is Medicare, Medicaid, and Social Security, with a 2020 budget of $2.5 trillion. Everything else the US did in 2020 ran on a budget of $3.4 trillion. In a usual year, that “everything else” slice would be even smaller, because last year COVID triggered a wave of disaster response spending.

Our federal insurance company is mostly run by the US Department of Health and Human Services. As its name suggests, its activities are in two buckets. The first is Human Services, which is essentially the insurance outfit. The second bucket is Health:

That last one may be unfamiliar, but you’ll recognize one of the offices it houses: the Biomedical Advanced Research and Development Authority, or BARDA. Thanks to COVID, BARDA got an additional $15 billion in 2020, over and above its regular budget allocation. Add in other COVID-specific appropriations like NIH’s RAD-x program, and the 2020 total was about $70 billion. In a normal year, though, “Health” accounts for about $50 billion in spending.

That’s $50 billion for health, $720 billion for defense, and $2.5 trillion for human services.

Knowing now what we know about the threat of pandemic disease, this is not a sensible balance.

It is a national shame that we have become so resigned to the human cost of SARS-CoV-2, which as I write exceeds half a million lives in the U.S. alone.

The economic costs, meanwhile, are still being tallied. Back in the fall, Cutler and Summers put together a relatively conservative projection that assumed a total of 625,000 deaths and a definitive end to the outbreak by 2022. Both assumptions now seem optimistic. They tallied the cost of lost GDP, death (via QALYs), long COVID, and mental health impairment. They did not account for excess deaths outside of the official COVID-19 tally. They ignored the cost of the stimulus/bailout/disaster relief bills. Like I said, it was a conservative projection, and it estimated the cost of COVID-19 as $16 trillion.

The last pandemic to achieve this scale of death and damage was almost exactly one century ago. Let’s assume that the next will be one century in the future. If we could spend $16 trillion over the next century to avoid it, we’d come out ahead.

$16 trillion over one hundred years. $160 billion per year. We could more than triple our spending on health if it gave us the tools to defend against pandemic disease.

I have plenty of opinions on how we could spend that money. We could double NIH’s budget. We could build an operational medicine army—MediCorps. We could build a global disease surveillance infrastructure. We could constantly fund development of new vaccines, drugs, and diagnostics for all of the diseases.

Less obvious is who should be in charge of where and how it’s spent. It should not be funneled through HHS.

We need a new federal Department of Health run by a Cabinet-level Secretary. Today, the leader of HHS is really the Secretary of Human Services; his portfolio happens to include all of our health spending, too. But the Secretary of Human Services runs our national insurance company, which deserves a leader with the vision and background to that job well. To oversimplify, the Secretary of Human Services needs to focus on deciding what healthcare we’re willing to deliver, and how much we’re going to pay for it.

The Secretary of Health would focus on what healthcare we’re able to deliver, and how much we're going to pay to be able to deliver new kinds of healthcare in the future. This encompasses the missions of CDC, FDA, NIH, and BARDA. But the true potential of a Department of Health spans far beyond these agencies.

It's clarifying to think about a new Department in terms of who would lead it. The obvious candidates for an inaugural Secretary of Health would probably be a former FDA Commissioner or BARDA Director, or perhaps a Scientist/Advisor in the mold of Anthony Fauci. But the ideal Secretary would be a leader with the power, portfolio, and authority to go toe-to-toe with the Secretaries of Defense and State.

The Department I’m describing would be a globe-spanning operation with an enormous budget spread among interlocking bureaus. NIH and BARDA fund different types of new technologies and platforms, at different stages of development, and have different—often competing—cultures. CDC has a communications mission but also stations health officials around the world. MediCorps would extend this footprint further. The whole operation would have to coordinate variously with the military, foreign service, and FEMA.

Procurement of new health technologies is an opportunity all its own. Consider how the Defense Department funds development of weapons and systems that it hopes it will never need to use against adversaries it hopes will never materialize. The Department of Health would do the same, but for vaccines and therapies it hopes it will never need to use against diseases it hopes will never spread. This ongoing investment would require a stable of commercial partners and a strategy to keep them honest.

It’s worth considering, too, how the formation of a dedicated Department of Health would attract and nurture talent and expertise, especially at the highest levels. The framers of the U.S. Constitution explicitly designed our system to leverage and channel the personal ambition of individual politicians. A Cabinet position demands a geopolitical point of view that, say, Directorship of NIH or BARDA does not. The pat term for this is “vision,” but it refers to the kind of perspective and persuasiveness that can earn the President’s confidence. It tends to come from those who nurse their own political ambitions and desire to wield power on the global stage.

It is an under-appreciated feature of our political system that it invites the participation of the politically ambitious, but forces them to strive for just one of many potential roles, each of which demands different expertise. One Senator’s committee assignments might demand specific skill in writing legislation, another’s might focus on investigation and oversight. One Secretary focuses on war, another on diplomacy. Yet true domain experts do not typically occupy these high offices. Instead, they usually ends up in the hands of political professionals who at best have a working familiarity with the technical details. The Secretary of State, for example, is usually a politician with an interest in foreign policy, not a career foreign service professional.

The creation of a Secretary of Health role would create a market for life science expertise among those who hope to exercise power at the highest levels. Given how central the life sciences will be to the politics and policy of this century, that seems like a good investment for us to make.