What RFK Jr. can — and can’t — actually do as Trump’s health secretary

Donald Trump announced Thursday that Robert F. Kennedy Jr. would be his nominee to lead the Department of Health and Human Services (HHS), setting the stage for a potentially radical remaking of the nation’s health care.

Kennedy’s nomination was not a surprise. Last month, Kennedy said Trump had promised him control of the department and its many subagencies, which include the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the Centers for Medicare and Medicaid (CMS), and others. Trump himself pledged during the campaign to let Kennedy “go wild on health.”

It’s a perplexing pick. Kennedy has spent decades spreading anti-vaccination pseudoscience, and the organization he leads, Children’s Health Defense, has been one of the foremost anti-vaccine advocacy groups in the US and abroad. His work in support of a Samoan anti-vaccine group helped fuel a wave of vaccine hesitancy in the island nation, leading to a 2019 measles epidemic that killed 83 people, most of them children.

He’s expressed a range of other conspiracy-laden ideas about health: He says fluoride is industrial waste linked to a range of diseases, and suggested it should be removed from all US water systems. He has speculated that gender dysphoria may result from herbicide exposure and implied mass shootings are linked to antidepressants.

Kennedy does hold other views that align with many scientists: He traces America’s high levels of chronic disease to the widespread availability of highly processed, non-nutritious food, which he and nutrition policy experts blame in part on broken agriculture policy. He’s railed against corruption and conflicts of interest in the FDA’s drug approval process that favor big pharmaceutical companies over the interests of individuals — something economists, scientists, and consumer advocates agree on.

HHS secretaries are usually seasoned bureaucrats with a lot of experience moving policy through government agencies — a state insurance commissioner in Barack Obama’s case or a tenured pharma executive in Donald Trump’s first term. They typically understand how science is done and what it means for a health intervention to be grounded in evidence.

Kennedy doesn’t have that résumé — far from it. Now he’ll be in charge of much of US health care, which raises the question: How much damage can he actually do in this role?

The answer will depend on a few things. First, he has to be confirmed by the Senate (unless the White House attempts to circumvent that chamber’s constitutional “advise and consent” powers) and Republicans have only a narrow majority. Even if Kennedy is confirmed, Trump has other important health care appointments to make — particularly for CMS, NIH, FDA, and CDC — and those people will hold sway over the administration’s health care agenda too. They could be in the Kennedy vein or, as we have seen with Trump’s foreign policy picks, a mix of the conventional and the iconoclastic.

For now, however, Kennedy’s appointment is a watershed moment that could portend enormous changes to the American health system. Republicans in Congress will control the HHS budget, and Kennedy, if confirmed, could have broad discretion to pursue his “Make America Healthy Again” agenda with Trump’s blessing. If the Trump administration attempts to remove civil servants across the government, including the health agencies, decades of public health knowledge could be lost at the CDC, FDA, and elsewhere. It is uncertain if the Republican-dominated judiciary would step in to stop any of it.

Here’s what we know about the Trump health department’s plans — and what hurdles may await them.

Over the last 30 years, vaccines have saved the lives of more than 1.1 million children in the US alone. Over the same period, they’ve also saved Americans $540 billion in direct health care costs and trillions in social costs. Routine vaccines protect American children from 16 diseases.

Trump himself suggested blocking funding for local schools with vaccine requirements during the campaign, though the federal government has limited authority to do so. Despite Kennedy’s long history of anti-vaccine rhetoric, he said in early November he wasn’t planning to take anyone’s vaccines away.

“People ought to have choice, and that choice ought to be informed by the best information,” Kennedy said in an NBC News interview. “So I’m going to make sure scientific safety studies and efficacy are out there, and people can make individual assessments about whether that product is going to be good for them.”

However, a co-chair of Trump’s transition team recently said Kennedy hoped to access federal health data with the goal of proving vaccines are unsafe and pulling them from the US market.

That’s not as easy to do as it sounds.

Undoing the approval of an already approved vaccine would require submitting evidence of harm that meets the FDA’s standards to prove harm, which simply doesn’t exist. Although a Trump-installed loyalist could theoretically rewrite the FDA’s standards, that would likely lead to opposition from the pharmaceutical companies that produce these vaccines. There would be a wave of expensive and prolonged lawsuits for the federal government.

Drugmakers also wield influence in Congress, which writes the law that sets pharmaceutical industry fees that cover nearly half of the FDA’s budget. That law will need to be reauthorized before the end of Trump’s term, setting up a potentially vicious fight if the two sides are at odds over vaccines.

There is a more realistic move Kennedy could take to address his concern about vaccine side effects: He could resuscitate the National Vaccine Program Office, which monitored vaccine safety with particular rigor but was shuttered under the first Trump presidency.

Although it would be difficult to pull vaccines from the American market, and Kennedy says he won’t, there are other ways he could exert influence to reduce vaccine uptake.

Kennedy could try to influence the CDC. That agency has two important roles in promoting vaccines in the US: It convenes an Advisory Committee on Immunization Practices to provide expert recommendations on who should get which vaccines and at what age, and it administers the Vaccines for Children program, which provides free vaccines for children in low-income families.

The advisory committee is not mandated by federal law — it is convened only if the CDC wants it to be. A vaccine skeptic appointed to run the CDC under Kennedy could either staff the committee with anti-vaccination activists or dissolve it entirely. That would mean the agency would no longer provide widely accepted guidelines for vaccination that state health departments and hundreds of thousands of clinicians nationwide now rely on.

The Vaccines for Children program is funded by a pot of money that Congress sets aside for the CDC every year. Kennedy could press Congress and the White House to simply cut that funding, ending the program entirely. That would leave low-income families having to pay out of pocket to vaccinate their children.

Kennedy will also be ultimately responsible for two giant public insurance programs: Medicare, which covers seniors, and Medicaid, which is overseen by the states and covers low-income people.

In both programs, the amount of money disbursed by the federal government is in part determined by how good of a job the states and private insurers do in vaccinating children and older adults enrolled in these programs. Kennedy could pressure the CMS administrator to eliminate that vaccination requirement, one reason Trump’s choice at CMS will be one to watch.

It’s not clear what the timeline would be to accomplish any of these tasks; there’s no precedent for a president and HHS secretary who are so openly hostile to US public health infrastructure assuming control of it. Even if it takes a while, there’s widespread concern that giving such a platform to someone who denies vaccine science could further degrade public trust not only in the vaccines, but in the many other health recommendations and interventions that together comprise American public health and health care. Already, more isolated outbreaks of measles and other diseases that had previously been stamped out by vaccines are occurring at the same time vaccination rates are slipping.

Paul Offit, a pediatric infectious disease doctor who directs the Vaccine Education Center at the Children’s Hospital of Pennsylvania in Philadelphia, said Kennedy has had such a big platform for so long that it’s unlikely he’ll be able to scare people about vaccines more than he already has. It’s in delivering the vaccines through programs like Vaccines for Children where he could perhaps do the damage: “If he were able to disrupt that, that would be a problem.”

The US began fluoridating drinking water in 1945. An estimated 209 million Americans now drink tap water that contains added fluoride. The intervention is considered a historic public health win: It dramatically reduces tooth decay in children and also reduces tooth loss in adults.

Kennedy, however, has said he would immediately advise the removal of fluoride from local water supplies. Why? Because he is exaggerating the actual risk.

Most of the fluoride and US tap water is added by water utility companies, but some tap water contains naturally occurring fluoride it absorbs from the local water table. The resulting high-fluoride tap water, which about 2 million Americans drink, contains about twice the amount of fluoride the US government recommends. According to a recent report from the US National Toxicology Program, drinking high-fluoride water might be linked to slightly lower IQ scores — by 2 to 5 points in some children — though IQ scores are an uncertain measure of intelligence.

However, there is no indication that tap water containing normal fluoride levels poses this risk — and its benefits to children’s and adult’s dental health are immense.

The decision to fluoridate water is one that happens at the state and local level, which is why Kennedy could only advise fluoride’s removal. However, his leadership at HHS could give an opening to anti-fluoride action at the state level, where Republican leaders are increasingly hostile to what had been settled public health practices.

Kennedy has called for a campaign against chronic disease that he’s branded as “Make America Healthy Again.” It is an ambiguous and wide-ranging platform, but the consistent theme is undoing what Kennedy sees as Big Pharma and Big Agriculture’s undue influence on what Americans eat and how they manage their health over time.

Some of the ideas share the same pseudoscience as Kennedy’s views on vaccines. Kennedy recently posted on social media that the FDA had “waged a war on public health” by “aggressive suppression” of Americans’ access to raw milk, among other things. States aren’t required to pasteurize milk, but the FDA requires milk sold across state lines to be pasteurized. Despite raw milk’s risk of causing life-threatening diarrheal diseases (and now, bird flu), states can already carve out exceptions that allow their residents to drink it.

Some of Kennedy’s ideas about food are more rooted in reality. For example, his take on nutrition’s role in chronic disease: He has correctly noted that the US has developed a terrible record on preventing diabetes, heart disease, and unhealthy weight, and places the blame where nutritional experts do — on permissive government policies and dietary guidelines that promote eating lots of ultra-processed foods and low levels of physical activity in schools.

As part of his fight against ultra-processed foods, Kennedy recently said he wants to do away with entire departments at the FDA, including the Center for Food Safety and Applied Nutrition. According to recent reporting in Science, he could indeed pressure whoever is appointed to lead the agency to eliminate that center, which makes Trump’s choice for FDA commissioner a critical one in setting his administration’s public health agenda.

However, if Kennedy wants to restrict the use of already-approved food additives, he needs more resources — not fewer: The process involves rigorous reviews of data, issuing public warnings, and actively monitoring the food supply. If Kennedy succeeded in closing the food safety office, that would reduce the number of people who could be dedicated to the job, making it harder rather than easier to rein in the use of these products.

Other actions could be taken by the Trump administration to reduce the amount of ultra-processed food in the American food supply, but many of them would be taken outside of HHS. The US Department of Agriculture (USDA) sets the guidelines that govern school lunch programs, which means much of what children eat is determined by that agency; Trump has not yet nominated a USDA commissioner. The USDA is also primarily responsible for overseeing factory farming, another industry Kennedy has heavily criticized throughout his public career and pledged to target if he were to take a role in the federal government. He would likely need to work with the USDA to follow through.

Kennedy is correct that food safety regulation in the US is currently a mess, says David Acheson, an infectious diseases doctor who has led food safety efforts at both the USDA and the FDA. Meat, poultry, and egg plants are inspected daily under the auspices of the USDA, while every other kind of food production facility — including the farms whose produce is responsible for most of the food-borne illness in the US and the nation’s countless other industrial food manufacturers — are inspected by FDA inspectors at most once a year.

It would make far more sense to unify these functions under one agency and harmonize the frequency of food production facility inspections so none are falling through the cracks. That is the kind of organizational shake-up that could actually make a difference.

Acheson would also like to see Kennedy take on the FDA’s process for regulating supplements, which are currently subject to lax oversight despite obvious health risks.

At a town hall earlier this year, before dropping out of the race for president, Kennedy said that if elected, he’d tell the NIH to pause drug development and infectious diseases research for eight years and instead focus on chronic diseases. He also pledged during his own campaign for president that he would block “gain of function” research — in which scientists purposefully make viruses more dangerous in hopes of learning how to better combat them — that has come under more scrutiny since the pandemic.

Apart from the fact that the NIH already spends about $20 billion annually on chronic disease, this would be disastrous: The basic research the agency funds and conducts in its own institutes lays the groundwork for therapies pharmaceutical companies develop to treat most medical conditions.

Kennedy has called for firing 600 of the agency’s nearly 19,000 employees and replacing them with new ones, who presumably would be more keen to carry out his priorities. Conservatives have also floated restructuring the NIH, and Trump proposed cutting its $48 billion budget during his first term.