President Joe Biden has nominated health policy veteran Chiquita Brooks-LaSure to head the federal Centers for Medicare and Medicaid Services (CMS), arguably the second-most powerful health care role in Washington after the Health and Human Services Secretary. 

Health care — in particular expanding the Affordable Care Act (ACA) — was a critical issue in Biden’s presidential campaign. If she is confirmed by the Senate, Brooks-LaSure could play a major role in shaping his agenda, which could have significant impacts on women and LGBTQ+ people.

Brooks-LaSure would be the first Black woman to hold the role, overseeing a $1 trillion agency responsible for large health insurance programs including Medicare, Medicaid, the Children’s Health Insurance Program and the individual insurance marketplaces run through the Affordable Care Act. She would also wield tremendous influence over how states experiment with their Medicaid programs, potentially opening the door to coverage expansions that don’t require approval from Congress.

Under former President Barack Obama, Brooks-LaSure worked within CMS to implement the ACA, which overhauled much of the American health insurance system, expanded access to health care to more than 20 million people and instituted health insurance protections for women and LGBTQ+ people. Prior to joining CMS, she helped develop the law as a staffer for the House Ways and Means Committee.

Brooks-LaSure, an ardent defender of the ACA, has argued in favor of efforts to build on the law, which has still failed to provide coverage for 29 million people. She has also focused on racial inequities in health care, and in particular has advocated for developing policies to tackle the nation’s crisis of pregnancy-related deaths. Government data shows that Black and American Indian/Alaska Native women are two to three times more likely than White, Latina and Asian American women to die within a year of childbirth.

“She really cares about people having coverage and does have a particular interest in maternal and infant health and maternal mortality,” said Joan Alker, executive director of the Georgetown University Center for Children and Families and an expert in Medicaid policy. “On maternal mortality and infant mortality, the U.S. is not where we need to be, and we have huge racial disparities. The Medicaid program has a critical role to play there.”

It’s unclear when the Senate — which has yet to vote on Biden’s other top health pick, Health and Human Services nominee Xavier Becerra — will begin the confirmation process. But experts say speed is critical, especially as lawmakers are moving quickly to act on the president’s health care agenda. 

“They’re going to need to get her in as quickly as possible,” said Cynthia Cox, a vice president at the Kaiser Family Foundation, a health care research and policy organization.  

As part of its new COVID-19 relief package, Congress is moving to bolster access to health care, specifically through a proposal in the House of Representatives to give states more money if they choose to expand eligibility for Medicaid. That optional component of the ACA could particularly benefit transgender people, one in five of whom are  uninsured, and research suggests it could benefit pregnant and postpartum people.  A dozen states have declined the expansion, including Texas and Florida. 

The House version of the relief package would also encourage states to extend Medicaid coverage for people who give birth so that it covers them for up to a year postpartum. That change could be a critical lever in addressing pregnancy-related deaths.

Currently, pregnant people who qualify for Medicaid — which has a more generous income threshold for pregnant people and covers almost half of the nation’s births — keep their coverage for only two months after giving birth. Meanwhile, researchers note deaths are increasingly occurring later in the first year postpartum, and argue that improving access to insurance could be a critical lever in preventing some of those deaths. 

If those changes pass, it would add to the urgency of having CMS leadership confirmed and ready, Cox said.

“CMS is going to need to move more quickly to implement all of this and they’re going to need the leadership in place to do that,” she said.

Under the proposed legislation, states could still opt out of policies such as Medicaid expansion and extending postpartum eligibility. Having a CMS administrator who actively supports those policies could make a difference, policy experts say. 

“The CMS administrator could make public statements to encourage specific states to act on Medicaid expansion, and on expanding maternal health benefits,” Cox said. “That could include going to a state and talking to the press in that state, to try to put pressure on state leadership.”

Brooks-LaSure has also written about other ways to expand health care access — in particular, efforts to implement so-called “public options” that would allow people to buy into a government-run health insurance plan if they chose. 

In 2018, she advised the state of New Mexico about different strategies to let people buy into its Medicaid program, which is another strategy states have considered to expand coverage. And at a 2019 congressional hearing, she spoke about allowing people slightly younger than Medicare eligibility — currently set for 65 — to buy into the program, which is run entirely by the federal government and targeted toward older people.

Biden campaigned on a public option, which could particularly benefit women, since they are more likely to cite cost as a reason they cannot get health insurance. 

Even with Democrats controlling Congress, though, it’s not clear they have the votes to pass such a program, at least on a federal level, Cox said. But as administrator, Brooks-LaSure could encourage states to seek federal approval — though the so-called Medicaid waiver program — to implement their own pilot public insurance options. That would be a reversal from the past four years 

“Instead of promoting state waivers that are seen as antithetical to the ACA she would be promoting state waivers that likely take the ACA a step further,” Cox said.