Last Friday, Department of Health and Human Services (HHS) secretary Dr. Tom Price sent in his forced resignation to President Donald Trump after a very short 7-month tenure. The health secretary’s departure topped a week in which a last-ditch GOP health care bill failed to advance in the Senate.

Fervor began after a POLITICO investigation revealed that Price had taken more than $400,000 worth of taxpayer-funded charter jets—and at least another half-million dollars’ worth of military flights overseas. Price had offered to reimburse the government $51,887 of the $400,000 spent, which he said represented the cost of his own seat on the trips. However, that wasn’t enough to change the “optics” of the situation.

Was Price’s ultimate demise his fear of riding coach? Doubtful.

His plane scandal landed on a busy week in Washington. Price’s headlines overshadowed a very important week for health care and tax reform. Price also had little sway or influence on Capitol Hill, and was associated with one of Trump’s biggest failures—an inability to repeal Obamacare.

And with that, the former orthopedic surgeon and Congressman was sent packing. Coincidently, I happen to be writing this blog from the back of a small CRJ-900 plane while sitting next to an orthopedic surgeon. Ah, the irony.

The standby list

Immediately following the resignation, a replacement was announced—which leads one to assume this was teed up for a while. The seat upgrade went to Dr. Don J. Wright, a deputy assistant secretary for health and the director of the Office of Disease Prevention and Health Promotion, who will serve as acting secretary. However, it is doubtful he will permanently fill that seat.

Trump said he would decide on a nominee “probably within a month.” This would be the second Cabinet position for Trump to fill. He has yet to pick a secretary for homeland security.

So, who is on the short list of contenders to oversee a $1 trillion department with 80,000 employees?

It’s doubtful that my fellow Acumen bloggers Dr. Terry Ketchersid or Dr. Dugan Maddux would touch that seat with a 10-foot pole. That leaves us with a rumored list that spans from former Louisiana Gov. Bobby Jindal (who was a very vocal critic of Trump during the election) to Dr. Mehmet Oz (a cardio-thoracic surgeon made famous by his daytime talk show).

The most likely candidates from the list include

  • Seema Verma, the administrator of the Centers for Medicare and Medicaid Services
  • Dr. Scott Gottlieb, the commissioner of the Food and Drug Administration, and
  • Dr. David Shulkin, the Veterans Affairs Secretary.

Verma, is probably the most talked about replacement. She is a conservative Republican new to Washington and ironically spent much of her career helping implement and expand the Affordable Care Act (ACA) alongside Vice President Mike Pence in the state of Indiana. Although she plays a leading role in the effort to repeal Obamacare, including the attempt that failed last week, she may not be as much of an enemy of the ACA as Price. She does not seem opposed to try to make Obamacare run as smoothly as possible, especially with open-enrollment season around the corner.

Gottlieb, a physician, is no stranger to politics. He previously served as the FDA’s Deputy Commissioner for Medical and Scientific Affairs, and before that as a senior advisor to the FDA commissioner. However, Gottlieb may prefer to stay where he is and avoid the rollercoaster of health care policy.

Shulkin, also a physician, would most likely be the easiest person to get into the seat, being unanimously confirmed due to his moderate views. However, he has plane scandals of his own. It was revealed he attended Wimbledon and went sightseeing in London with his wife while on official business in Europe.

Trump’s pick will be very telling on how he will proceed with repealing Obamacare, although the likelihood of a new health care bill regaining momentum will be difficult.

I’m sure whoever gets confirmed will be booking a coach seat for their near-term travels.

A short runway

The 2018 MACRA proposed rule was the first draft with Price’s involvement after he emphasized that he wanted to reduce reporting burdens and allow clinicians to focus on patient care. His rhetoric proved true as the proposed rule excluded more clinicians from having to participate while also making it easier to avoid a penalty.

Now that he is gone, what will happen to the final rule that is set to be released in November?

How will clinicians plan for 2018 (which is a few short months away) without a solid MACRA rule in place?

I highly doubt any successor will dial back on the commitment to make MACRA easier. If anything, the agency may tap the brakes on any bolder policies (such as making bundled payment models voluntary).

If Verma takes the seat, we may see the final rule more quickly than from others competing for the HHS secretary spot. Verma is the most familiar with MACRA and would hurry any changes along. She has played a big role in drafting the 2018 MACRA proposed rule alongside Price.

Buckle your seat belts folks, it’s going to be a bumpy ride.

Editor’s Note: The article is based on an Oct. 3 post on the Acumen Nephrology blog.