Q&A with HHS Assistant Secretary for Health Rachel Levine, MD

By Paul Snyder

There are many reasons to look forward to the return of in-person events at Plastic Surgery The Meeting 2021 in Atlanta, but one of the most anticipated guests is Rachel Levine, MD, assistant secretary for Health in the U.S. Department of Health and Human Services.

Dr. Levine made history earlier this year as the first openly transgender federal official to be confirmed by the Senate. She was nominated for this position by President Joe Biden on the strength of her accomplishments as Pennsylvania’s secretary of health, which saw her not only lead the state’s response to the COVID-19 pandemic, but also tackle issues such as the opioid crisis, health equity and healthcare for LGBTQ+ individuals.

Dr. Levine is a Fellow of the American Academy of Pediatrics, the Society for Adolescent Health and Medicine and the Academy for Eating Disorders. She also served as Association of State and Territorial Health Officials president.

In addition to her recent posts in medicine and government, Dr. Levine is the author of numerous publications on the opioid crisis, adolescent medicine, eating disorders and LGBTQ+ medicine. Ahead of her presentation in Atlanta at the annual meeting, she took time to speak to PSN about some of the matters she’s now focused on at the federal level – and how plastic surgeons can affect change at the national level.

PSN: What are your three main goals as HHS assistant secretary for Health?

Dr. Levine: COVID-19 has to remain my most urgent and primary focus. We can see a light at the end of the tunnel with our robust vaccination program, but we’re not done yet and we have to continue to expand our vaccination program. We’re addressing vaccine hesitancy and we need a strong equity component in our vaccination program. As a pediatrician and adolescent medicine specialist myself, it’s important to make sure right now that with the vaccine approved for 12- to 17-year-olds, we get our medical teams vaccinated.

The second is something I’ve worked on for many years at that intersection between physical health issues and mental behavioral health issues. When I was at Penn State, I started and ran their eating-disorder program, and at the state and federal level, I’m concentrating on mental-health issues – particularly substance-use disorder issues, such as opioid addiction and the nation’s overdose crisis. I’m co-chair of the Behavioral Health Coordinating Council, which was just formed by the HHS secretary, and we’re going to be working on a number of mental-health issues that are facing the nation.

The third is environmental health. We’re creating the office of Assistant Secretary for Health of Climate Change and Health Equity, which will involve environmental issues and environmental justice – we need to work to protect disadvantaged communities and vulnerable populations that experience a disproportionate share of climate impacts.

PSN: What lessons learned from Pennsylvania’s response to COVID-19 helped craft the national response?

Dr. Levine: One of the important lessons of the pandemic is that we’re all interconnected, and that brings up the issue of healthcare disparities and equity. COVID-19 exposed the area below the surface and we absolutely have to work on that. The situation highlighted the importance of public health, and at local, state, federal and international levels, public health officials need to collaborate and coordinate. We need the resources, workforce and IT capabilities to protect the health of our nation and the world – and we’re going to need sustainable funding.

We’ve also expanded telemedicine significantly in the United States during the pandemic and will be looking at telemedicine regulations that have been suspended, current telemedicine practices and what we need to continue.

PSN: What immediate steps need to be taken in combating the opioid crisis?

Dr. Levine: We had a program in Pennsylvania I like to call “opioid stewardship,” the parallel being to antibiotic stewardship. Antibiotics are essential medicines and have allowed us to deal with so many infections, but due to overuse, there are severe issues in terms of bacterial and microbial resistance. Opioids are also essential medicines for acute care and patients with severe chronic pain, but clearly, the over-prescription of opioids has been one factor among many in the overdose crisis in this nation over the past decade or more.

We’ve worked in Pennsylvania and we’re going to work nationally with the medical community and other specialties on the judicious and careful prescription of opioids. We’ve already reached out to the AAMC about education on pain and addiction. We want physicians to have continuing medical education about that. We brought prescribing guidelines to the Board of Medicine in Pennsylvania, and every state now has a prescription drug monitoring program. We want to make sure that we strengthen the knowledge in those programs about the over-prescription of pain medications. It’s an important issue for plastic surgeons in terms of post-op pain and chronic pain.

PSN: There have been articles in the past – and this gets into the public misperception of plastic surgery – about overprescribing opioids for cosmetic procedures. Given that our doctors are also reattaching limbs, treating patients with severe burns and performing transplants, pain management plans can differ.

Dr. Levine: That’s what we get into with the stewardship issue – we don’t want patients to suffer major pain or chronic pain. But the default has been, “30 days of Vicodin,” and we can’t continue to do that after surgery. There must be a balance. We don’t want people to suffer, but we must be very cautious about how opiates are prescribed.

PSN: ASPS has been working to combat recent bills in various states that seek to regulate and criminalize transgender surgery for minors, as well as punish doctors who perform the procedures. Are there efforts being made at the national level to protect these doctors and patients, and what are your concerns about what the passage of such legislation in more states might lead to?

Dr. Levine: I thank ASPS for advocating for LGBTQ+ individuals and, in this case, for transgender youth. It’s so challenging and unfortunate that these laws being passed are directed against transgender youth – who are vulnerable to bullying and harassment, and this significantly exacerbates that situation. My view is that this is politics; unfortunately, some people are using transgender youth as a wedge issue. This includes trying to prohibit transgender youths from participating in sports, and the most egregious are the discriminatory bills against gender-affirming care for transgender youth. We need to advocate at all levels. I will be working on two fronts – speaking about it publicly and then advocating with policy. We will be working across HHS and with the Biden administration on bills, rules and regulations to protect LGBTQ+ individuals.

One example of success that HHS has already achieved is that the Office of Civil Rights declared that its interpretation of Section 1557 of the Affordable Care Act is that the term “sex” includes sexual and gender minorities, sexual orientation and gender identity. All aspects of the ACA will be looked at under that light. That will have a significant impact. The amazing thing is that we have a president that supports, advocates for and is the biggest ally I know for the LGBTQ+ community. There have been executive orders about this and in his first address to Congress, he said – and I always keep the quote with me – “To all transgender Americans watching at home, especially the young people: You’re so brave. I want you to know your President has your back.” I want transgender youth and LGBTQ+ youth – and adults – to know that I have their back, and I will continue to lead at the federal level and do everything I possibly can on their behalf.

PSN: What are some of the most important or immediate steps plastic surgeons can take in helping inform national healthcare policy?

Dr. Levine: The plastic surgery community is small but mighty. You have a strong voice and it’s important not to become complacent. Use that voice at every level. We need your voice advocating at the congressional, state and local levels for healthcare equity, and to protect all vulnerable communities. I often quote – and it’s not a joke – Yoda from Star Wars: “Fear is the path to the dark side. Fear leads to anger, anger leads to hate, hate leads to suffering.” People fear what they don’t understand. Educating people about LGBTQ+ individuals goes a long way toward dispelling fear and other negative emotions that can lead to these regressive bills. Acceptance starts at the local level and all of us can work toward that. You can do that by using the right pronouns, using the right names, medical records or working with your staff in offices, medical centers and medical schools.

Don’t underestimate the impact people have on state legislatures by writing letters, testifying and advocating even through the press about the bills that we’ve been talking about. Medical centers and academic institutions have a powerful voice, and elected officials pay attention. If we use our voice, it can be a powerful tool to turn the tide.