HHS’s Xavier Becerra, once an ‘invisible’ secretary, is racing to cement a clearer legacy

WASHINGTON — He’s been called the “invisible” secretary. So far removed from the White House sphere of influence that he’s rarely spotted there, even at health care events. Once, officials openly discussed who might be better for the job.

Now, however, health secretary Xavier Becerra is making inroads with the president’s closest advisers. After years on the outs with Susan Rice, Biden’s first domestic policy advisor, Becerra has weekly meetings with her replacement, Neera Tanden, people familiar with their discussions said. He also is speaking regularly with White House Chief of Staff Jeff Zients, according to people who know his schedule.

The looming question is whether, with just a year left in Biden’s first and potentially only term, he’ll have enough time to put his official stamp on what was once considered one of the most consequential Cabinet positions.

It may be too late. Becerra has not been publicly identified with many of the president’s health care accomplishments. He didn’t attend an August event celebrating Medicare’s new power to negotiate drug prices, a packed East Room celebration with Vice President Kamala Harris, Medicare Director Meena Seshamani, and Robert Califf, head of the Food and Drug Administration, all present. He’s ceded the spotlight on Democrats’ politically popular efforts to protect abortion rights to Harris.

Becerra also wasn’t part of White House talks to launch a new phase of Biden’s most personal project, the Cancer Moonshot, three people familiar with the planning said. And when the president touted a new plan to require fair pricing for government-funded medicines this December, Becerra did not issue a statement and was not part of press events.

It’s unclear what legacy Becerra will leave on the nearly $130 billion agency he leads, either, several government officials and outside advocates told STAT. That is confounding to many people who recall that when Becerra was California attorney general, he took a forceful stand on issues like abortion rights. As a member of Congress, he’s credited with helping shape the Affordable Care Act, and then defending it from Republican attacks. Yet as health secretary, several current and former government officials — including many Democrats — said it was hard to point to any obvious wins.

“Certainly from a public profile point of view he’s been a major disappointment,” said Lawrence Gostin, a public health law professor at Georgetown University. “He’s a very prominent Latino leader, and he was well placed to really shine during Covid, monkeypox, and other health crises. He was very silent during those crises and when he did speak, he didn’t seem to have a good, enormous grasp of the medical and scientific and public health issues.”

Gostin tempered his remarks by noting that Becerra’s policymaking behind the scenes as HHS secretary is extensive, especially on reshaping health prices and coverage.

An HHS spokesperson emphasized a string of Becerra’s accomplishments as secretary, including his work to ensure access to Covid vaccines and the launch of the 988 mental health hotline. 

“There’s rhetoric — what people say you’ve done, and then there’s your record — what you’ve actually done. If you look at Secretary Becerra’s robust record, you will see he has accomplished a lot for the American people, including people who are underserved and under-resourced — all while doing national and local interviews in both English and Spanish and traveling across the country to talk with people most impacted by the Department’s work,” said Kamara Jones, the spokesperson.

“Secretary Becerra can either focus on beltway politics or the health and wellbeing of the nation. If you consider his many accomplishments as Secretary and that he is one of the most traveled cabinet secretaries during this Administration, it is clear he is focused on the health and wellbeing of the nation,” Jones added.

It’s not as though he hasn’t done anything, Becerra’s supporters also emphasize. It’s more that he hasn’t been successful at earning or taking credit for his accomplishments, either publicly or with the White House, until recently.

Becerra himself cites record ACA enrollment as one of his biggest wins, and he wants to solidify that coverage even as potential subsidy cuts for many enrollees loom. When asked what he believed his legacy as secretary would be, he pointed to that and spelled out an aspiration for even more solidified health care coverage.

“I would like to see us make it so that everyone equates Obamacare, the Affordable Care Act marketplace, with good health care,” he told STAT, adding that the “ACA becomes like Medicare, Medicaid, and Social Security. They are part of the fabric of life in protecting your health.”

Becerra’s promotion of Obamacare comes against the backdrop of calls from GOP presidential candidates, including former President Trump and Florida Gov. Ron DeSantis, to dismantle the law. Congress has also extended significant ACA subsidies through 2025, but there is no guarantee they will continue, particularly if a Republican wins the White House and congressional control turns over.

His success or failure as health secretary — and his impact on Biden’s broader health care achievements — could be a factor in a 2024 presidential election that will put a spotlight on issues like abortion, high health care costs, and fallout from the Covid-19 pandemic. Whether he has the White House’s ear on these subjects will also determine exactly what legacy he leaves — the latter remains an open question, according to more than a dozen people who spoke with STAT, many of whom worked with Becerra at the Capitol, in California, or in the Biden administration itself.

A quick fade into the background

Almost immediately, Becerra had a stumbling start with the White House.

Within weeks of his confirmation, he landed in a tete-a-tete with White House Domestic Policy Adviser Susan Rice, according to a book published in September and confirmed to STAT by two people. In a phone call with dozens of other officials present, Rice pressed the secretary to loosen certain rules to help Border Control officials deal more effectively with the crush of migrant children at the border. Becerra wanted a written order from Biden before he moved to change anything — an idea Rice sharply shot down.

Becerra seemed to fade into the background from there, three sources said. He wasn’t a major figure in the Biden administration’s Covid-19 response, yielding frequently to top infectious disease official Anthony Fauci, then-Covid-19 coordinator Jeff Zients and then-Centers for Disease Control and Prevention Director Rochelle Walensky.

His first appearance at a White House press briefing was a full year into his tenure — so late, compared to other cabinet secretaries, that reporters were asking when they might see him there.

“The White House really paid no attention to him,” for the first two years, said a former senior Biden official.

In fact, some White House officials seem to have a closer relationship with Becerra’s deputy, Admiral Rachel Levine. Her official remit is mental health issues but she became integral to shifting budgets so that federal programs like free Covid tests can continue, one person familiar with the dynamics said. Her intricate knowledge of the budget details was vital as congressional relief funds dried up, the person said.

Becerra, in an interview with STAT, said his relationship with White House officials has “evolved” over the past two and a half years. “We try to make sure that we’re doing what the president asked. The White House gets to propose, it’s our job at HHS to execute.”

Jones, the HHS spokesperson, added that Becerra is “a team player who prioritizes staying in sync with the White House and playing whatever position the President needs him to play. If furthering the President’s agenda means he needs to be on TV, he’s on TV. If it means he needs to be on the road, he’s on the road. If it means he needs to meet with an agency to ensure they’re implementing a policy as intended, he’s meeting with the agency.”

When it comes to media and outreach, the secretary largely stuck to constant travel around the country to champion Biden priorities. He traveled to more than half the U.S. states and India in 2023 alone, heading from Wisconsin to Arizona, South Dakota, and California to champion Biden’s efforts on drug price negotiation, mental health care access, and other policies.

Democratic lawmakers praised that travel as an important effort to highlight Biden priorities and reach out to communities about federal health programs. But others question if it is the best use of a Cabinet member’s time, considering that polls show the president had not made substantial public inroads with his health policies.

For instance, despite the administration’s moves to cap insulin costs and negotiate drug prices through the Medicare program — two crowning accomplishments under Becerra’s tenure and focal points in his travel events — only 30% of Americans said last year that the president has made progress lowering costs.

“Basically, the majority of Americans do not believe that Biden’s done anything about drug prices,” said Robert Blendon, a Harvard T.H. Chan School of Public Health professor who tracks voters’ sentiment on health care and other policies. “The president has not been seen as a great communicator of what they’ve accomplished.”

That’s where someone like the highest-ranking health official could be key.

“It’s not getting him slightly more likable or knowable. It’s having somebody … repeat over and over again, ‘You said drug prices were really a problem — we’ve lowered them,’” Blendon said.

He’s not playing that role on abortion, either — though he could have. Before President Biden tapped him for the Cabinet, Becerra was known as something of a fighter. He took on anti-abortion activists, high drug costs, and then-President Trump’s agenda as California’s attorney general, suing the federal government 110 times.

“We’re not looking to pick a fight, but we’re ready for one,” he said during his California confirmation hearing for the AG role.

But as the Biden administration has sought to frame itself as a protector of abortion rights, the face of that fight has almost entirely been Harris, who has held campaign rallies and White House roundtables and made the issue a cornerstone of her 2024 election message. Harris was California attorney general before Becerra and initiated several of the suits and complaints he pursued.

That doesn’t mean the secretary has been inactive, abortion advocates argue. His agency issued guidance shortly after Roe v. Wade fell, underscoring physicians’ obligation to treat people in emergency situations including abortion. HHS is also barreling toward a U.S. Supreme Court battle this summer over whether the abortion pill mifepristone, which accounts for more than half of the country’s abortions, can remain on the market.

“Anyone who holds that office has to bring so many different skill sets to it,” said Amy Friedrich-Karnik, director of federal policy at the Guttmacher Institute, a research and advocacy group focused on reproductive rights. Becerra brings the legal chops, but communicating progress, even for advocates, has always been a “challenge,” Friedrich-Karnik said.

“The details matter and the specifics matter … translating that to the public can be hard,” she said. “It behooves the administration to continue to prioritize and work really hard to explain to the public what it is they’re doing.”

At HHS, a hazy legacy

Becerra’s generally low profile means he has not been in Washington much. For at least the first few years of the administration, he was not in the room with White House officials shaping the president’s signature policies, multiple people familiar with the dynamic said. That makes it hard to claim any of Biden’s accomplishments as his own, they said.

In contrast, other health secretaries have planted their legacies on signature issues. Trump’s HHS secretary, Alex Azar, made rules dismantling the pharmacy benefit manager system — in a bid to lower drug prices — a top priority, regardless of Congress’ freeze on the issue. Obama HHS Secretary Katherine Sebelius became the face of ACA implementation and the eventual rollout chaos.

“Azar, he’s probably the most parallel figure to Becerra in the sense that he’s a lawyer. He’s also a cultural warrior, on the other side. But he had absolute command from the start,” said Gostin.

Becerra wasn’t part of the discussion about relaunching Biden’s Cancer Moonshot, three people familiar with discussions told STAT. Instead, it was White House aides and outside advisers who took on the effort to reframe one of Biden’s most personal missions, almost entirely channeling reworked projects and goals to a new agency that the president pushed to found, the Advanced Research Projects Agency for Health.

He also has been missing from Biden’s latest push for the National Institutes of Health to license patents for government-funded research to generic drugmakers, an attempt at cheaper medicine that the pharmaceutical industry and even some NIH alums have questioned. When Biden himself made a rare appearance at the NIH campus in December to champion the initiative, Domestic Policy Advisor Neera Tanden and new NIH director Monica Bertagnolli were by his side. Becerra was not.

Yet the agency under Becerra has lodged a series of accomplishments on health cost and coverage fronts, even if they are not translating to the broader public, said Judy Baker, an Obama HHS official and NYU policy professor.

“HHS has traditionally had less success with communicating to the public what they’re doing,” Baker said. “A good communication plan to the public would be a thing they should prioritize.”

Even on Covid-19, the secretary can count some wins: He met with Pfizer officials last year to strike a deal for Covid-19 treatment Paxlovid that resulted in a buyout agreement that would let officials return unused doses for new ones, assuring free coverage for government insured Americans through 2024.

Becerra, for his part, sees himself as a “manager” or “steward” of these myriad issues handled by the farm of subagencies under his purview, several people told STAT. That oftentimes means letting Medicare and Medicaid officials take the lead on defending major drug price reforms and explaining coverage changes, or tapping other high-ranking officials like Levine to be the public face of efforts to boost mental health care and protect transgender Americans’ rights.

“Obviously the fact that today there are still more Americans who have insurance than before than any other previous administration — more than 300 million people — that’s an accomplishment,” Becerra told STAT.

Yet he acknowledged that many Americans won’t see the effects of one of his agency’s biggest efforts — lowering drug costs — just yet.

“We want them to know because we want them to be able to take advantage of it. And so we’re gonna get out there and talk about all of those very important things,” he said.

Becerra also does maintain influence on Capitol Hill, even if not with the White House. He has strong relationships with the Congressional Hispanic Caucus, a powerful base of influence particularly as Biden and other presidential candidates head into the 2024 election.

“It’s really helpful when you have someone there [as HHS secretary] who understands the impacts, especially the negative impacts to our communities, of policies like people getting kicked off of Medicaid. It makes a huge difference, having a seat at the table,” said Rep. Nanette Barragán (D-Calif.), chairwoman of the caucus.

Asked about whether the White House has leveraged Becerra well as one of the most prominent cabinet members, Barragán sidestepped the question, replying, “We’re really proud that he is a former colleague of ours and representing our communities.”

Much of Becerra’s work has also been accomplished behind the scenes, supporters say. Becerra met with Pfizer officials to strike a deal for Covid-19 treatment Paxlovid that resulted in a buyout agreement that would let officials return unused doses for new ones, assuring free coverage for government insured Americans through 2024.

“Whenever I ask for a phone call, or he asks for a phone call, it’s quickly done,” said Richard Neal (D-Mass.), Becerra’s former colleague on the Ways and Means Committee and the current highest-ranking Democrat. “If you move from the legislative branch to the executive branch, there’s gonna be differences. You also work for the President.”

Becerra has visited Democratic Rep. Adriano Espaillat’s New York district “a bunch of times,” the congressman told STAT. “He’s someone that brings not just the budgetary regulatory experience to the job, but brings a level of empathy for health care that I think was much needed in the department.”

The door wedges open — but is it enough?

There has been a shift in Becerra’s favor in recent months, multiple people familiar with HHS and White House discussions told STAT. There are new people in the White House and at HHS, including a new assistant secretary for public affairs, seasoned communications expert Jeff Nesbit.

And Becerra meets at least once a week with Rice’s replacement, Tanden, he said. There are formal weekly meetings and touching base “every week on a less formal basis.”

The secretary “has a big heart and has been an incredible partner to improve health care for all Americans,” Tanden said in a statement. “I am proud to work alongside him as he continues to advance President Biden’s key priorities” including health care coverage, mental health access and the opioid crisis response, she said.

He also is speaking regularly with White House Chief of Staff Jeff Zients, a returnee to the administration from his Covid-19 task force days, according to two people familiar with their discussions. Zients’ relationship with Becerra started out much like Rice’s, with neither corresponding regularly with the HHS secretary in the early months of the crisis, one of those people said. The dynamics changed after Zients returned in a different role, they added.

“He often invites us to lunch,” said Becerra. “The communication is fluid, but it’s constant … it’s a good ebb and flow. It’s a relationship that evolves given the situation.”

That’s helped change his presence and visibility with the White House. Becerra spoke with Tanden at a December event heralding community health workers and applauding American Rescue Plan funding for their support. He also appeared beside the president at a Nov. 14 event on women’s health and attended a state dinner with the Australian president in October. The president applauded his work on insuring Americans during a September reception for Hispanic Heritage Month.

“At the end of the day, if we can say at the same time that we have lowered costs [while providing] better care for more Americans, that means we will have delivered on the president’s promise,” said Becerra. “And that’s our job to execute.”