Insights

We have been hearing a lot from Elon Musk and Vivek Ramaswamy lately, the chosen co-leads of the President-Elect Trump’s Department of Governmental Efficiency (DOGE). We have even watched Musk take down a government funding extension bill almost single-handedly. But what is DOGE, and what will it do?

What is DOGE?

The idea of a federal agency dedicated solely to improving governmental efficiency may sound like a bureaucratic paradox. (The department of redundancy department, anyone?) However, in some circles, there are growing concerns about inefficiencies, waste, and redundancy in government operations. The new Department of Governmental Efficiency (DOGE) is purported to make government processes more effective, transparent, and cost-efficient.

DOGE is an envisioned federal agency that would act as a central body to evaluate, enhance, and coordinate the performance of various government functions. Its mission would be to identify areas where improvements can be made in operational efficiency, streamline bureaucratic processes, reduce wasteful spending, and ensure that government agencies are delivering services effectively. The goal is for DOGE to serve as a hub for coordinating efforts to eliminate inefficiencies rather than creating new programs or regulations.

In essence, DOGE would be a “management consultancy” for the U.S. government, aimed at rethinking how federal agencies operate on a day-to-day basis. The department would rely on a mix of data analytics, performance audits, process optimization, and employee feedback to identify opportunities for improvement across a wide range of government functions, from military procurement to social services delivery.

Why Does DOGE Seem to be Needed?

Proponents of DOGE base their arguments on the idea that the U.S. federal government, with its vast size and complex operations, is often plagued by inefficiencies. Several issues have sparked calls for systemic changes in the way the government operates: ·

• Wasteful Spending: According to various reports from the Government Accountability Office (GAO), the federal government loses billions of dollars annually through inefficiencies, such as outdated systems, redundant services, and unnecessary administrative overhead. In a time of growing national debt, addressing waste is seen by many as critical.
•  Bureaucratic Red Tape: Federal and State government agencies often face criticism for their cumbersome processes, slow decision-making, and excessive regulation. Citizens and businesses alike find themselves bogged down by layers of approval, paperwork, and delays.
• Fragmented Services: The federal government operates hundreds of departments and agencies, each with its own mandates, processes, and systems. This fragmentation can lead to duplication of efforts, inefficiency, and a lack of coordination across agencies, reducing the quality and speed of public service delivery.
• Public Perception: A recent Pew Research Center poll found that trust in the federal government is at an all-time low, mainly because of frustration with bureaucratic inefficiency and perceived waste. Citizens increasingly want a government that delivers results quickly and effectively.

Given these concerns, DOGE would address the need for a department that acts as a “watchdog” over government operations, identifying areas for reform, and implementing changes that would improve performance, reduce redundancy, and ultimately save taxpayer dollars.

Opportunities for DOGE in Health Care

If DOGE were to focus on health care, there are several areas where DOGE could look at to improve efficiency and deliver better results for patients, providers, and taxpayers alike:

• Reducing Waste in Medicare and Medicaid: Medicare and Medicaid are two of the largest federal health care programs, and although they are popular, they are often criticized for inefficiencies such as fraud, abuse, and excessive administrative costs. DOGE could conduct audits to identify waste areas and recommend changes to improve cost-effectiveness while maintaining or improving the quality of care.
• Simplifying Health Care Administration: One of the biggest inefficiencies in federal health care is the complexity of the systems. Billing, reimbursement, and reporting requirements differ across programs, creating confusion for providers and delays in care. DOGE could advocate for simplified billing systems, electronic health records (EHR) interoperability, and a streamlined process for claims and reimbursements.
• Improving Inter-Agency Coordination: Federal health care programs operate across multiple agencies, including the Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), and the Department of Veterans Affairs (VA). DOGE could help facilitate better communication and coordination between these agencies, ensuring that health care services are provided efficiently and that patients are not caught in bureaucratic red tape.
• Leveraging Technology: Technology has the potential to significantly improve health care delivery, yet many federal health care programs still rely on outdated systems. DOGE could push for the adoption of advanced technologies such as AI for predictive analytics or telemedicine for broader access to care, improving both efficiency and patient outcomes.
• Enhancing Transparency: DOGE could play a key role in improving transparency in federal health care programs. By publicly reporting on cost savings, wait times, and the effectiveness of different programs, DOGE could build public trust in government health care services and create an environment where agencies are held accountable for their performance.

Pitfalls and Challenges

While DOGE could have a significant impact on improving health care efficiency, there are several challenges that must be considered:

• Resistance from Health Care Stakeholders: Health care providers, insurance companies, and even governmental health agencies might resist changes proposed by DOGE, especially if these changes threaten their existing practices or financial interests. Resistance from powerful health care lobbyists could slow down or block meaningful reforms.
• Political Gridlock: Health care is a highly politicized issue, and efforts to reform federal programs often face strong opposition. Even if DOGE identifies areas for improvement, political polarization could prevent any support. Also, and more importantly, Congress may be hesitant to delegate its authority to a new department, especially when it comes to decisions that affect millions of constituents.
• Lack of Direct Legislative Power: Without the authority to pass laws or implement changes directly, DOGE’s ability to enforce reforms would be limited. (See larger discussion below.)
• Complexity of Federal Health Care Programs: U.S. health care is a labyrinth of federal regulations, state-based programs, private insurance systems, and various health care providers. This complexity presents a significant challenge for DOGE to navigate and reform, as any proposed changes would need to account for local differences and legal constraints.
• Initial Implementation Costs: While DOGE’s long-term goal is to reduce costs, the initial effort to set up the department, assess health care programs, and implement reforms could be expensive. The government would need to balance short-term investments with long-term savings to justify the creation of DOGE.

How Will DOGE Get Anything Done Without Congressional Authority?

One of the most significant hurdles DOGE would face is its lack of direct legislative authority. Congress holds the power to dictate federal policy, and any attempt by DOGE to overhaul operations could be met with resistance from lawmakers. However, there are ways in which DOGE could make an impact even without direct Congressional approval:

1.  Executive Orders: The President could establish DOGE through an executive order, mandating the department to improve government efficiency. While this may not grant the department the power to enforce its findings directly, it could set a tone for change and demonstrate the administration’s commitment to reform.
2. Collaboration with Congress: DOGE could work closely with lawmakers to craft policies that incentivize government agencies to implement efficiency recommendations. By showing clear benefits in terms of cost savings and service delivery, DOGE could build political support for broader reform efforts.
3. Public Advocacy: By focusing on transparency and publishing the results of its efforts, DOGE could garner public support for reforms. Public pressure could, in turn, push Congress to adopt some of its recommendations.

 

In addition to alternative approaches, Musk and Ramaswamy have brought in a “closer” to ensure tasks are completed effectively. The addition of Brad Smith to the DOGE team is expected to enhance the team’s focus on efficiency. His unique combination of private and government experience positions him to identify opportunities for improvement effectively. Mr. Smith, is an entrepreneur, Rhodes Scholar, and former head of the Center for Medicare & Medicaid Innovation (CMMI) in the last Trump Administration (Side Note: His latest company, CareBridge, just announced its sale to Elevance Health in a deal worth $2.7 billion.) He will likely be able to push through health care reforms with less resistance than those considered “D.C. outsiders.”

Conclusion

The Department of Governmental Efficiency (DOGE) could offer an innovative solution to address the inefficiencies plaguing the federal government for decades. While it faces significant challenges, including resistance from entrenched interests and a potential lack of authority, its potential to improve government performance, save taxpayer money, and restore public trust is considerable. It’s all up to politics now—whether DOGE can become a transformative force in modernizing the U.S. federal government, or is this all just political theater?

In the final days of his presidency, President Joe Biden is expected to propose a bold move to limit nicotine levels in traditional cigarettes. The anticipated regulation aims to reduce addiction and smoking-related health issues, honoring a long-standing pledge to tackle tobacco use and public health risks. 

 

The proposal, which could be announced within days, focuses solely on traditional cigarettes, excluding e-cigarettes and nicotine replacement products such as patches and lozenges. If finalized, it would mark a significant effort to reduce nicotine levels to make cigarettes minimally or non-addictive. Public health advocates have said this action would be a historic step toward reducing addiction, particularly among young people who are most vulnerable to starting smoking. 

 

“Making cigarettes less addictive would save millions of lives,” said Erika Sward, Assistant Vice President of National Advocacy for the American Lung Association. Studies have shown that dramatically reducing nicotine content could prevent millions of future smokers. For example, a 2018 Food and Drug Administration (FDA) study estimated that such a regulation could result in 16 million fewer smokers by 2060, with even greater impacts over the coming decades. 

This proposal represents a continuation of Biden’s earlier efforts to combat tobacco addiction, including a push to ban menthol cigarettes. While that pledge remains unfulfilled, the nicotine cap reflects the administration’s commitment to addressing smoking as the leading cause of preventable death in the U.S., killing more than 480,000 Americans annually. 

However, the proposal faces significant hurdles. Critics argue that reducing nicotine levels could lead to unintended consequences, such as smokers compensating by consuming more cigarettes or turning to a black market for higher-nicotine products. Additionally, the time-intensive process of finalizing such a regulation means its implementation could take years and will depend on the incoming administration’s priorities. Judging how the second Trump Administration may act when it comes to tobacco regulation is no easy task. On the one hand, during the first Trump Administration, the FDA restricted the sale of certain flavored e-cigarettes over concerns that they were being marketed in a way that appealed to minors.  He also signed legislation that increased the federal minimum age to purchase tobacco to 21 years of age. On the other hand, during the presidential campaign, Trump said he would “Save vaping again.”  

Public health advocates remain optimistic about the potential impact. Yolonda C. Richardson, president of the Campaign for Tobacco-Free Kids, called the proposal “game-changing,” emphasizing its potential to fight chronic diseases like cancer and cardiovascular disease. 

As President Biden’s term ends, this initiative underscores his administration’s desire to leaving a lasting public health legacy. The proposed nicotine limits could shape the future of tobacco regulation in the United States. However, as President Biden prepares to leave office and President-elect Trump prepares to assume it, the future is as cloudy as a smoky room.  

With Republicans maintaining control of the House of Representatives and regaining control of the White House and Senate, the landscape of U.S. health policy has changed significantly. The incoming leadership on key congressional committees will be pivotal in determining the future direction of health care legislation and reforms over the next two years. Here’s an overview of the new leaders in these committees and what we can expect in the 119th Congress. 

House Committee on Energy and Commerce 

Chairman: Rep. Brett Guthrie (R-KY) 

Rep. Brett Guthrie (R-KY), now at the helm of the House Energy and Commerce Committee, replaces retiring Rep. Cathy McMorris Rodgers (R-WA).  Rep. Guthrie previously served as the chair of the committee’s Health Subcommittee. During his subcommittee chairmanship, Guthrie supported legislation to reauthorize Alzheimer’s research funding, address the opioid epidemic, and increase transparency in the health care industry.   

So, what does a Guthrie-led Energy and Commerce focus mean for health care?  We could see the committee take up bills that failed to pass the House in the 118th Congress. For example, the committee could renew efforts to pass the Building America’s Health Care Workforce Act, which Rep. Guthrie introduced in the last Congress. This bill would have extended certain COVID-era flexibilities, which waived certain training and competency requirements for nurse aids to help skilled nursing facilities and nursing facilities maintain an adequate workforce. This bill passed out of the Energy and Commerce Committee but failed to become law before the last Congress adjourned. This could be especially relevant if the incoming Trump administration repeals President Biden’s nursing home staffing mandate and Rep. Guthrie wants to show the Energy and Commerce Republicans have policy ideas to tackle the nursing home staffing issue. Rep. Guthrie’s new position as chair of the Energy and Commerce Committee also positions him to influence the debate over the Inflation Reduction Act (IRA’s) drug pricing provisions, which are likely to face scrutiny from the incoming Trump administration and Republican majorities in Congress.  

Ranking Member: Rep. Frank Pallone (D-NJ) 

As the returning Ranking Member, Rep. Pallone will lead Energy and Commerce Democrats in opposing any Republican efforts to repeal or roll back the ACA or the IRA. Additionally, Rep. Pallone will certainly oppose any attempts to change Medicaid to a block grant funding model, which Democrats have argued will gut the program and harm beneficiaries. He will also likely focus on bipartisan opportunities, such as Medicare payment reforms and the potential for revisiting the CURES Act to expand medical research. 

Rep. Pallone could also advocate for legislation to advance key Democratic health care priorities and showcase what Democrats would do with a House majority. For example, on December 19, 2024, Rep. Pallone introduced the Lowering Drug Costs for American Families Act.  

House Energy and Commerce Health Subcommittee 

Chairman   Buddy Carter (R-GA) 

Rep. Carter, who is a pharmacist by profession, is the newly selected Chairman of the House Energy and Commerce Health Subcommittee. Carter is expected to advocate strongly for issues related to prescription drug prices and pharmacy regulations. He also may find ways to push reform in Medicaid and Medicare by tackling fraud and waste in these programs. Carter is also a critic of the ACA and may try to reduce government spending on health care. 

New Ranking Member: Rep. Diana DeGette (D-CO) 

Rep. DeGette is expected to continue her advocacy for protecting the ACA and the IRA. She has been an active proponent of women’s health and reproductive services and was a key player in the development of the CURES Act. DeGette may also find common ground with Republicans on issues like Medicare Advantage and Pharmacy Benefit Manager (PBM) reform. 

House Committee on Ways and Means 

Chairman: Rep. Jason Smith (R-MO) 

Returning as Chairman of the Ways and Means Committee, Rep. Jason Smith will influence key health policies, especially those impacting Medicare. As a champion of improving access to care in rural communities, he will likely push for reforms to Medicare payments, particularly to hospitals, with an eye toward addressing access to care in rural and underserved areas. Additionally, with the Committee’s jurisdiction over tax policy, Smith could be instrumental in efforts to address health care costs through tax reforms and expanding Health Savings Accounts (HSAs). Smith may also play a central role if Republicans seek to revisit the ACA or IRA. 

Ranking Member: Rep. Richard Neal (D-MA) 

Rep. Neal returns as Ranking Member and will likely continue his efforts to protect the ACA and IRA. Known for his bipartisan approach, Neal could potentially work with Republicans on Medicare payment reforms and other areas where there is potential for collaboration. 

House Ways and Means Health Subcommittee 

Chairman: Rep. Vern Buchanan (R-FL) 

Rep. Vern Buchanan, returning as Chair of the Ways and Means Health Subcommittee, will play a key role in debates related to Medicare payment reforms, particularly those related to Medicare Advantage. Buchanan has long advocated for transparency and market-driven health care solutions, which will likely continue as focal points of his leadership. 

Ranking Member: Rep. Lloyd Doggett (D-TX) 

Rep. Lloyd Doggett, as the Health Subcommittee Ranking Member, will focus on protecting the ACA and IRA while continuing his strong advocacy for controlling drug prices and ensuring robust consumer protections. 

Senate Committee on Finance 

Chair: Sen. Mike Crapo (R-ID) 

With Republicans taking control of the Senate, Sen. Mike Crapo becomes the influential Senate Finance Committee Chair. Crapo is expected to be a driving force behind changes to the ACA, IRA, and Medicaid. He has expressed support for increasing Medicaid flexibility for states, which could lead to proposals like block grants or per capita caps. Additionally, Crapo has shown interest in lowering prescription drug costs through increased competition and transparency. 

Ranking Member: Sen. Ron Wyden (D-OR) 

Sen. Ron Wyden, now the Ranking Member of the Finance Committee, can be expected to continue to protect the ACA and IRA. Wyden, a known advocate for bipartisan Medicare payment reforms and PBM reform, will likely seek opportunities to collaborate with Republicans where possible. 

Senate Committee on Health, Education, Labor & Pensions (HELP) 

Chair: Sen. Bill Cassidy (R-LA) 

Sen. Bill Cassidy takes the reins as Chair of the Senate HELP Committee. Known for his background as a physician, Cassidy is expected to focus on tackling health workforce shortages and reforming programs at the FDA. As a member of both Finance and HELP, he will also play a significant role in discussions on Medicare and Medicaid. As a past leader on legislation to address surprise medical bills, expect Cassidy to play a leading role should concerns arise surrounding this issue or around health plans’ provider networks. 

Ranking Member: Sen. Bernie Sanders (I-VT) 

Sen. Bernie Sanders, as Ranking Member, will focus on protecting the ACA and IRA. However, there may be opportunities for bipartisanship on issues like health workforce initiatives and community health center funding, areas where Sanders and Republicans like Cassidy could find common ground. In related news, Sanders joins the Senate Finance Committee, where he will also have the ability to directly impact Medicare and Medicaid payment policy. 

What’s Next for Health Policy? 

With new leadership in both the House and Senate, various health care proposals will be debated and shaped in the coming years. From potential changes to the ACA and Medicaid to efforts to tackle rising drug costs, the leadership of these committees will be instrumental in shaping the next chapter of U.S. health policy. 

While partisan divides remain, there are significant areas for bipartisanship—particularly on issues like Medicare reform, PBM regulation, and workforce shortages. The coming months will likely see a flurry of activity as these new leaders make their mark on the future of health care in the United States.