“Black Man Given Nation's Worst Job,” The Onion quipped after Barack Obama won the 2008 presidential election. If so, his Health and Human Services Secretary, Kathleen Sebelius, got the runner-up. As the public face of the Affordable Care Act, the former Kansas governor has taken enough abuse to kill a zombie bug during her five-year tenure as a cabinet member. She’ll be remembered mainly for the ill-fated rollout of healthcare.gov last fall—a debacle that nearly destroyed Obama's presidency—but her legacy is richer than that.
As a cabinet member, Sebelius oversaw the most sweeping expansion of the health care system in a half century. The passage of the Affordable Care Act set the stage for reform, but the task of implementation was, as one official put it, like constructing a complicated building in a war zone. Against a backdrop of rabid partisan resistance, HHS and the Treasury Department wrote the rules and built the systems to translate a labyrinthine law into a fairer, more inclusive, more effective health care system. The Congressional Budget Office projects that 24 million people will be insured through the new insurance exchanges by 2017. Millions more will gain access to Medicaid, and the number of uninsured Americans will decline by a third — from 45 million to 30 million.
Sebelius wasn’t Obama’s first choice to run HHS, a massive bureaucracy that encompasses not only the Office of Health Reform and the Centers for Medicare & Medicaid Services but also the NIH, the FDA and the CDC. But when the president’s first nominee, former Senator Tom Daschle, flamed out over tax irregularities, she was an easy pick. She had endorsed him early, when Hillary Clinton was a safer bet, and was widely respected for her record of crossing the aisle to get things done. She’d served as an insurance commissioner as well as a legislator and a governor, and was often mentioned as a prospect for vice president.
Loyal to a flaw, she was bold and progressive when the White House leaned that way. She dazzled women’s health advocates in 2011 by listing prescription birth control among the preventive health services (such as immunizations and screening tests) that insurers must cover without copays or deductibles. The administration has since granted exemptions to mollify religious conservatives, but it has gone to the mat to keep overzealous employers from controlling women’s reproductive lives. And while Sebelius has helped the president delay some of the law’s controversial features (e.g., the employer mandate and the ban on low-value insurance plans) until after the 2014 elections, she hasn’t budged on the founding principle that anyone with access to health coverage has a responsibility to secure it.
For all her determined efforts to improve health, ease disparities and defend women’s rights, Sebelius has also ditched principle for politics when called upon. In December 2011, just hours after the FDA cleared the emergency contraceptive “Plan B One-Step” for unrestricted over-the-counter sale, she brazenly overruled her own agency. After an exhaustive review of the evidence, the FDA’s scientific advisors had concluded that the morning-after pill was “safe and effective for adolescent females” and could be used properly “without the intervention of a healthcare provider.” Sebelius baldly countered that “the data … do not conclusively establish that Plan B One-Step should be made available over the counter for all girls of reproductive age.”
The motive was obvious—demagogues would accuse the administration of promoting child sex if it let the approval stand—but Sebelius and the president spent the next year-and-a-half vainly defending their unprecedented meddling in the drug-approval process. Only after a scorching 2013 court decision did they finally relent, allowing the FDA to act on the medical evidence.
The secretary’s good-soldier impulse may have even helped undermine the development of healthcare.gov. As The Washington Post recounted in exquisite detail last fall, she consented when the White House decided to move the project from her office to the bowels of the Centers for Medicare & Medicaid Services, where it would be less visible to political opponents. The CMS functionaries charged with building the exchanges ended up at the mercy of skittish White House political handlers, who forbade them from sharing needed technical specifications with outside partners.
But whatever her role in the stillbirth of healthcare.gov, Kathleen Sebelius has surely served her sentence for it. Since last October, she has quietly endured public humiliation by everyone from Jon Stewart to Lamar Alexander. This week, prominent Republicans greeted the news of her resignation with a fresh round of vitriol. “Kathleen Sebelius’s tenure in the Obama administration has come to an end just as it began,” wrote Representative Rennee Ellmers, the North Carolina representative who heads the Republican Women’s Policy Committee—“with a total lack of responsibility.”
By any objective measure, that's a bum rap. As the president noted in a Friday-morning farewell ceremony, healthcare.gov has not only survived its disastrous rollout but exceeded expectations for the first enrollment period. “Under Kathleen’s leadership, her team at HHS turned the corner, got it fixed, got the job done, and the final score speaks for itself,” he said. “There are seven-and-a-half million people across the country who have the security of health insurance ... and that’s because of the woman standing next to me today. We’re proud of her for that.”
For what may have been the first time in five years, the lock-jawed Kansan looked jubilant.