Having worked on reorganizing both nonprofit and public sector organizations, I have a few reflections on Secretary Robert F. Kennedy Jr.’s restructuring of the Department of Health and Human Services (HHS). With my early career experience at HHS, I have a solid understanding of the department and its history of transformation.
A History of Change at HHS
Reorganization is nothing new for HHS. The department itself was formed through restructuring when the Department of Health, Education, and Welfare split, giving birth to a separate cabinet-level Department of Education. The Centers for Medicare & Medicaid Services (CMS) was also a product of significant reorganization, consolidating agencies that previously managed Medicare and Medicaid separately. These changes, executed under Secretary Joe Califano during the Carter administration, expanded the federal role in healthcare. Califano’s tenure ended abruptly when President Carter removed him for taking a strong stance against the tobacco industry—one of the last HHS secretaries to pursue such an independent agenda, until now.
A Shift in Priorities
Unlike past reorganizations that built new capabilities, Secretary Kennedy’s efforts appear to focus on reducing the department’s size and scope, aligning with the administration’s broader push to limit federal involvement in healthcare. The most striking aspect of the restructuring is not just the organizational chart changes but the drastic reduction in staffing—from 82,000 employees down to 62,000. While some cuts may streamline operations, reductions of this magnitude will inevitably impact the department’s effectiveness. It remains unclear whether these staffing cuts are primarily driven by the Department of the Office of Government Efficiency (DOGE), Secretary Kennedy, or both.
Structural Changes and Their Implications
One major element of the reorganization is the consolidation of Public Health Service agencies into a new entity, the Administration for a Healthy America. This includes the Office of the Assistant Secretary for Health, the Health Resources and Services Administration, and the Substance Abuse and Mental Health Services Administration, among others. While these agencies share a common focus on health, renaming and restructuring alone will not address chronic diseases like obesity and diabetes without substantive new initiatives. Secretary Kennedy’s unconventional views on substance use treatment may also shape the direction of this new administration.
The Untouched Giants: Medicare, Medicaid, and the ACA
Interestingly, the reorganization does not significantly impact HHS’s largest programs—Medicare, Medicaid, and the Affordable Care Act (ACA). Any major shifts in these areas will likely come from Congress and the White House’s Office of Management and Budget. However, significant cuts to Medicaid and ACA coverage could have far greater consequences for public health than any changes enacted through the new Administration for a Healthy America.
Internal Power Struggles
CMS has historically been the dominant player within HHS, often operating with a degree of independence and engaging in power struggles with other agencies and even White House officials. Meanwhile, agencies like the Food and Drug Administration and the Centers for Disease Control and Prevention have maintained their own scientific and regulatory identities, sometimes creating friction with political leadership. These internal dynamics will likely continue under Kennedy’s leadership.
The Importance of Prioritization
One lesson I’ve learned in public service is that time in office is limited, and prioritization is essential. While Secretary Kennedy may aim to reshape the entire bureaucracy, he will eventually recognize the need to establish new units led by allies who share his vision. Key examples include the newly created Office of Vaccine Injury within the CDC and the new Assistant Secretary for Strategy—both of which could advance non-mainstream or even anti-science agendas.
Disappearing Offices and Equity Concerns
Notably, some offices are being eliminated altogether, including the Office of Infectious Diseases and HIV/AIDS Policy, the Office of Minority Health, and the Administration for Community Living. These offices have historically played a critical role in addressing health disparities. Yet, tackling chronic illness in America inherently requires addressing inequities—whether or not the administration explicitly acknowledges them.
The Road Ahead
A future Democratic HHS Secretary will likely face a difficult choice: focus on rebuilding HHS agency by agency or prioritize advancing a select few policy goals within a limited tenure. Realistically, they will need to do both. While rebuilding HHS will require congressional approval and funding, dismantling it under the Trump administration has required neither—a stark and unprecedented shift in governance.
The long-term consequences of Kennedy’s restructuring remain to be seen, but one thing is certain: the landscape of federal health policy is undergoing a profound transformation.