As the nation\u2019s top health official and leader of one of the federal government\u2019s largest departments, the secretary of Health and Human Services makes life-or-death decisions every day that affect millions of Americans.<\/p>\n

But not all important work is serious.<\/p>\n

One former HHS secretary, Kathleen Sebelius, recalled a highlight of her tenure: recording a public service message with \u201cSesame Street.\u201d \u201cThe Elmo commercial was to teach kids how to sneeze,\u201d she said. \u201cWe were trying to spread good health habits.\u201d<\/p>\n

The script called for Sebelius to ask her co-star to \u201cbend your elbow and sneeze into your arm.\u201d<\/p>\n

\u201cElmo has no elbow,\u201d the beloved red Muppet replied, veering off script. So, Sebelius said, they swapped roles: \u201cElmo taught me how to sneeze.\u201d<\/p>\n

Her story punctuated a rare, intimate conversation Wednesday with three HHS secretaries, past and present \u2014 and across party lines. Secretary Xavier Becerra, the agency\u2019s current leader, joined Sebelius, who worked under then-President Barack Obama from 2009 to 2014, and Alex Azar, who worked under then-President Donald Trump from 2018 to 2021. Their candid discussion took place at Aspen Ideas: Health, part of the Aspen Ideas Festival, about the job each of them held.<\/p>\n

The panel discussion, taped in Aspen, Colorado, before a standing room-only crowd, was hosted as a live episode of KFF Health News\u2019 weekly policy news podcast, \u201cWhat the Health?,\u201d and is now available to stream<\/a>.<\/p>\n

Becerra, Azar, and Sebelius spoke not only about the common bullet point on their resumes, but also about their shared understanding of what it means to lead the agency at a time when health is at the front of American minds \u2014 and in the crosshairs of American politics. Becerra and Azar have led HHS during the covid-19 pandemic, and Sebelius was in charge during the implementation of the Affordable Care Act.<\/p>\n

They offered frank and at times strikingly similar perspectives on leading a department with more than 80,000 employees; a budget of more than $1.5 trillion; and an agenda most often set by outside events or their boss at 1600 Pennsylvania Ave.<\/p>\n

Azar, who described fielding \u201ctwo to five\u201d daily phone calls from Trump, which could come at nearly any hour, said he started his days huddling with senior staff \u201cto discuss what could hit us in the face today.\u201d<\/p>\n

\u201cThe White House is not a patient place,\u201d said Becerra, who described losing 11 twin towers\u2019 worth of Americans to covid-19 every day when he took the reins. \u201cThey want answers quickly.\u201d<\/p>\n

\u201cIt truly is life and death at HHS,\u201d Becerra added. \u201cThe gravity, it hits you. And it\u2019s nonstop.\u201d<\/p>\n

The panel offered some behind-closed-doors takes on today\u2019s top issues, including the bruising fights over skyrocketing drug prices under Trump and ACA contraceptive coverage under Obama.<\/p>\n

Deciding which \u201chills do you die on\u201d was Azar\u2019s top challenge as HHS secretary, he said. \u201cWhen do you fight and when do you not fight with, say, the White House?\u201d He pointed to his push to eliminate drugmaker rebates paid to health plans and pharmacy benefit managers, which drugmakers and others have criticized for driving up drug costs.<\/p>\n

\u201cI left a lot of blood on the field of battle just to try to outlaw pharmaceutical rebates,\u201d he said.<\/p>\n

All three secretaries agreed that one of the least understood but most important aspects of the department\u2019s work happens outside the United States, performing what Sebelius called \u201csoft diplomacy.\u201d While many countries are loath to welcome officials from the State Department or the military, \u201cthey welcome health professionals,\u201d she said. \u201cThey welcome the opportunity to learn.\u201d<\/p>\n

Asked what they felt unprepared for when they got the job, Azar \u2014 who had worked at HHS previously as general counsel then deputy secretary \u2014 replied: \u201cThe Trump administration.\u201d<\/p>\n

Coming from the administration of former President George W. Bush and later a stint as president of the U.S. division of the drugmaker Eli Lilly, Azar said he was \u201cused to certain processes and ways people interact.\u201d Working in the Trump administration, \u201cit was different.\u201d<\/p>\n

The atypical assembly of current and former political appointees also offered a chance for some unusually friendly banter.<\/p>\n