rewrite this title Who Decides Who Leads U.S. Health Agencies?

There has been a lot of back and forth over actions that President-elect Trump will take in his second term, not least of which involve health. As the president who oversaw the COVID-19 response—which public-health experts say was lacking in many ways, aside from the development of vaccines—Trump has made sweeping statements about what the future of the American health care system will look like under his leadership.

He’s promised to “make America healthy again,” and allow long-time vaccine critic Robert F. Kennedy, Jr. “to go wild on health. I’m going to let him go wild on the food. I’m going to let him go wild on the medicines,” Trump said in the weeks leading up to the election.

Trump has criticized what he perceives as corruption in major government health agencies: from the U.S. Centers for Disease Control and Prevention (CDC), one of the most globally respected infectious disease agencies; to the U.S. Food and Drug Administration (FDA), which oversees drug approvals and food safety; to the National Institutes of Health (NIH), the largest public biomedical research institute in the world.

And as he did in his first administration, Trump has considerable power to appoint leaders who share his views, and potentially change policies and practices in health. Here are the agencies and positions to watch as Trump assumes power for a second time.

Secretary of Health and Human Services (HHS)

This cabinet-level position is a critical one, as HHS oversees the FDA and CDC. HHS is in charge of many programs, including social programs for child care, childhood wellness and prevention efforts including vaccinations, maternal health programs, mental health and substance abuse programs, and those focused on older people and people with disabilities.

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In 2022, President Biden signed into law the Inflation Reduction Act, which allows the Secretary to negotiate lower drug prices directly with pharmaceutical companies for certain drugs beginning in 2026.

The Secretary is appointed by the president and must be confirmed by the Senate, which is currently ruled by a Republican majority. Cabinet members are appointed and released at the discretion of the President, and most incoming presidents appoint new Secretaries to join their administration.

Director of the NIH

The NIH director is appointed by the president and confirmed by the Senate, but has not always changed whenever administrations do. Dr. Francis Collins, for example, served as director under three presidents before retiring in 2021. Prior to 1971, the NIH director was appointed by the Surgeon General.

The NIH manages the largest public biomedical research budget in the world, at $47 billion. The NIH includes 27 institutes or centers focused on conducting research and making discoveries in areas such as aging, cancer, substance abuse, and infectious diseases. Many important treatments were born in NIH labs or in academic labs funded by NIH grants, and then further developed by the pharmaceutical industry (including the fundamental discoveries that contributed to the COVID-19 vaccine.)

Commissioner of the FDA

The FDA commissioner is appointed by the president and must be confirmed by the Senate. The agency is responsible for approving new drugs including vaccines and medical devices, as well as overseeing food safety, which involves conducting inspections and regulating imported food. During the COVID-19 pandemic, the FDA took a central role in reviewing data and balancing the risks and benefits of a new vaccine technology, mRNA, against the new SARS-CoV-2 virus.

While the position does not have a term limit, most new presidents appoint their own commissioner.

Director of the CDC

The CDC director is appointed by the president, and for the first time in 2025, the appointee will need to be confirmed by the Senate, after a Congressional law passed in 2022.

Read More: Did the Pandemic Break Our Brains?

Many Trump supporters have criticized the CDC’s handling of the COVID-19 pandemic, particularly the mask and vaccination mandates. They also believe that the agency’s current responsibilities, which extend to workplace safety and climate’s effects on health, are too broad.

Administrator of the Centers for Medicare and Medicaid Services (CMS)

The CMS Administrator has a crucial role in making decisions about which drugs and treatments to reimburse for Medicare- and Medicaid-eligible populations, which cover nearly 140 million Americans. CMS reimbursements are precedent-setting, as private insurers often follow CMS decisions when deciding what to cover.

As part of the Inflation Reduction Act, CMS is responsible for implementing any negotiated reduced drug prices by the HHS Secretary for Medicare beneficiaries.

The administrator is also nominated by the president and confirmed by the Senate.