The Centers for Disease Control and Prevention is staring down several legislative battles just as President Joe Biden’s pick to replace outgoing CDC Director Rochelle Walensky is expected to take the reins.

Mandy Cohen, the former secretary of the North Carolina Department of Health and Human Services and Biden’s expected pick to head the public health agency, would take the helm at a critical time. The agency will spend this summer lobbying Congress to increase its funding and authorities via two must-pass bills: the reauthorization of a pandemic preparedness law which expires on Sept. 30, and fiscal 2024 appropriations legislation.

[Biden to pick Mandy Cohen to lead the CDC]

But she’ll make her pitch even as Congress and the White House’s debt agreement limits spending and rescinds unspent pandemic relief money from a 2021 COVID-19 relief law.

She’ll also face additional political pressure in the wake of criticism of the agency’s handling of the COVID-19 pandemic.

Cohen has not formally been tapped to head the agency, and the White House would not comment on reports that she has been picked to replace Walensky, but a source familiar with the White House’s decisions confirmed to CQ Roll Call late Thursday that Biden plans to name her for the position.

Over the last few years, the public health agency has shifted from a rarely discussed agency to a kitchen table topic and political lightning rod. Republicans are especially wary of boosting the agency’s budget.

The White House has asked Congress to increase the agency’s discretionary budget, combined with the Prevention and Public Health Fund and Public Health Service Evaluation Fund, to nearly $11.6 billion — nearly $2.4 billion above 2023 enacted levels — something that many say is unlikely thanks to caps set by the debt ceiling bill.

‘A cultural overhaul’

Walensky’s tenure overlapped both the COVID-19 pandemic and a widespread mpox outbreak — an era when many Americans lost trust in the agency.

Cohen’s appointment will not require a Senate vote, but given the environment, analysts said she will undoubtedly face congressional scrutiny.

“The CDC needs a cultural overhaul,” Senate Health, Education, Labor and Pensions Committee ranking member Bill Cassidy, R-La., said when asked about what he’d like to see in a new CDC director. “So you need somebody who is able to overcome the inertia of bureaucracy to complete such an effort.”

Republicans have launched several investigations into the CDC’s handling of COVID-19 and repeatedly called Walensky to testify before Congress. On June 13, she is set to make one of her final appearances on Capitol Hill before the Select Subcommittee on the Coronavirus Pandemic.

Paul Offit, the director of the Vaccine Education Center at Children’s Hospital of Philadelphia and a former CDC vaccine advisory board member, said the current nature of the CDC would make it difficult for anyone to succeed in front of Congress.

“It’s not so much the person as the setup,” he said. “It has to be set up in a way where somebody can succeed, where they have the resources and the independence to succeed.”

CDC priorities

Walensky said late last year that she wanted to overhaul the nation’s public health infrastructure by expanding the CDC’s ability to collect and share data and beef up the United States’ shrinking public health workforce. To do so, she launched an effort to reorganize the CDC and increase communication and transparency with the public.

But those efforts require more money from Congress, and the spending caps set by the debt deal will mean the CDC will more than likely see flat funding for fiscal 2024.

The bipartisan debt deal would impose two years of caps on discretionary funding. Many of the nondefense budget cuts would come from clawing back yet-to-be-spent pandemic relief — $1.7 billion of that coming from the CDC’s coffers.

Georges Benjamin, executive director of the American Public Health Association, predicted the deal will mean flat funding or a roughly 1 percent cut across the board in fiscal 2024 for the CDC. And the CDC still has several critical programs to pay for that are separate from its new ambitions — programs related to the opioid epidemic, maternal health crises, gun control, vaping and vaccine development, among others.

“With those priorities on their plate, we want to make sure that all those policies continue to move forward during the transition,” Benjamin said. “When Dr. Walensky leaves, the leaders [at the CDC] need to just keep the trains on the track.”

The reauthorization of the 2006 pandemic preparedness law expires in September and is the only major must-pass health bill Congress is considering this year.

Walensky was lobbying Congress to use the vehicle to expand data authorities as requirements for labs and hospitals wind down after the public health emergency. Republicans were already hesitant to give the agency more authority, but now with budget cuts, it’s looking less likely.

“We do know that there’s very little wiggle room here,” said Jen Kates, senior vice president at KFF, formerly known as the Kaiser Family Foundation.

The CDC’s goals of rebuilding the nation’s public health infrastructure and public health workforce, which is roughly 80,000 workers in deficit, is highly dependent on congressional money. Kates said that now, “there’s just not going to be room to make those kinds of improvements.”

The debt deal’s pandemic rescissions left untouched other agency initiatives, such as investments in next-generation vaccines, test procurement capacity and long COVID research. The debt deal left $10 billion for these priorities.

A familiar face

Cohen will join the Biden administration with just a year and a half left before Biden’s term ends, but many say that her preexisting relationships will help her hit the ground running.

She held senior positions at the Centers for Medicare and Medicaid Services during the Obama administration, including chief operating officer and chief of staff, and served as acting director of the agency’s Center for Consumer Information and Insurance Oversight. She worked closely with current White House Chief of Staff Jeff Zients during her time in the Obama administration.

After her time at CMS, Cohen led North Carolina’s Department of Health and Human Services from January 2017 to January 2022, where she led the state through the COVID-19 pandemic and implemented the state’s Opioid Action Plan.

J. Stephen Morrison, senior vice president at the Center for Strategic and International Studies, who co-wrote a report on how to improve the CDC, described Cohen as the right pick for this congressional climate.

Heading into election season, many say this is not the time for the White House to shake things up with a public health appointee, he argued, but Cohen brings experience in health agency management to the role.

Plus, she was not a nationally known public figure during the pandemic — something that could play to her advantage.

“They wanted somebody that was not a pure political operator but wanted someone who had some political operation and acumen,” Morrison said.

While the CDC director does not currently require Senate confirmation, the recent omnibus spending law included a requirement that the Senate confirm the CDC director beginning in January 2025.

Were Cohen to stay on as CDC director in the next presidential administration, she would face the confirmation gauntlet.