Shah S, Forman H. The Case for Independent Centers for Disease Control and Prevention—Protecting Public Health from Politics. JAMA Health Forum. Published online September 25, 2020. doi:10.1001/jamahealthforum.2020.1139
Recent polling shows that Americans trust the US Centers for Disease Control and Prevention (CDC) more than the White House to handle coronavirus disease 2019 (COVID-19) and accurately report data on the pandemic.1 Despite this finding, the White House has frequently curbed the ability of the CDC to function at its full potential. Over the past 6 months, the administration has revised evidence-based CDC guidelines, blocked CDC officials from appearing on television, cut off CDC communication with a newly commissioned Department of Health and Human Services (DHHS) working group focused on reopening schools, and ordered hospitals to bypass the CDC and send information on patients with COVID-19 to a central database.
A relevant question is not whether the public trusts the CDC to make public health policy decisions, but whether the CDC can autonomously make these decisions in the first place. As it stands, the CDC, which falls under DHHS in the executive branch, is subject to political pressures that may influence its decision-making process. Furthermore, the composition of the CDC itself changes with each new administration, and its director does not require Senate confirmation. These characteristics risk dissolving public trust by enabling the CDC to be treated as a political arm of the party in power rather than as an apolitical agency. To carry out its mission effectively, the CDC must remain depoliticized, trusted, and able to respond to public health disasters swiftly, without restrictive political pressures. For these reasons, we believe the CDC should become an independent federal agency.
There are multiple examples of existing independent federal agencies, including the Federal Reserve System and the Federal Trade Commission, that can make decisions swiftly during national crises without Presidential or Congressional approval. A framework of essential attributes shared across these agencies has previously been described in a proposal to make the US Food and Drug Administration (FDA) independent,2 including the following key attributes: (1) a single director appointed by the President and confirmed by the Senate (akin to that of the Federal Reserve), (2) rule-making authority in accordance with Congressional enabling legislation and intent, (3) oversight by the Office of Management and Budget limited to significant regulations and policy development, and (4) independent litigation authority through the Department of Justice.
In 1994, the Social Security Administration was moved out of DHHS and reconfigured as an independent federal agency.3 A similar process should be applied to the CDC. As an independent federal agency, the CDC could be governed by a single director and include a governing board with diverse lifetime experiences in public health. Additionally, to prevent politicization of the board, each member could require Senate confirmation to be appointed, serve staggered terms that span multiple presidential and congressional terms, and receive protections from budgetary cuts. Many independent agencies are not subject to regular congressional appropriation and authorization processes for funding. Some agencies, including the Consumer Financial Protection Bureau, determine their own budgets, with some limitations enforced by Congress, and are not required to submit their request for review by the Office of Management and Budget.4 A similar degree of autonomy for the CDC could help ensure it maintains funding required to protect public health regardless of the political climate.
To ensure accountability, CDC board members could be removed for cause and reappointed via congressional approval. The CDC could also have some rule-making (eg, nationwide mandates, emergency declarations) supervised by the Office of Management and Budget. Importantly, to counterbalance federal oversight, the CDC could have independent litigation authority through the Department of Justice to challenge excessive oversight. This balancing of authority would safeguard against politicization from those acting in bad faith who belong to either entity.
Although there are various degrees and combinations of rules that can be imposed on any independent federal agency, the benefits include the agency’s abilities to avoid significant politicization and react swiftly to national and local events. Throughout the COVID-19 pandemic, these benefits would have enabled the CDC to respond more effectively to COVID-19, rather than adhering to the political interests of the presidential administration.
A reasonable concern is that an independent CDC could still be politicized. There is precedent for this counterpoint. For example, the Federal Communications Commission has been viewed as highly politicized in the wake of its net-neutrality decision. However, although an independent CDC may face pressures from the presidential administration, these nonobligatory pressures are not equivalent to the current legal requirement for executive branch approvals before responding to public health disasters. Furthermore, because CDC appointments would span multiple presidential terms, CDC board members can function more independently from the incumbent presidential administration’s political interests.
Another counterpoint is that the intended goals of independence—including less federal oversight and greater decision-making autonomy—could reasonably be established under the status quo. In other words, why overhaul the system when incremental reforms may suffice? Additionally, the CDC’s existing position within the DHHS provides benefits of its own. These include enabling collaborative initiatives, streamlined data sharing, and overlapping responsibilities with other DHHS agencies, including the National Institutes of Health and FDA. Similar points have been made against the FDA becoming an independent federal agency.5 Although these counterarguments are worth considering, independence should not be conflated with isolation: an independent CDC could still be configured to ensure effective collaboration and data sharing with other relevant agencies. This attribute may become more crucial if pressure builds for other public health agencies, including the FDA, to become independent from DHHS.
Given the saga of the nation’s response to COVID-19, the CDC needs to be freed from its politicized governance. Without the capacity to act autonomously, the CDC will continue to be constrained by politics—undermining the public’s trust in the agency and risking the nation’s health.
Corresponding Author: Soleil Shah, MSc, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305-5450 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
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