By Dan Diamond

The world may not be ready for a Romney presidency.

Or more specifically: world leaders may not have done enough homework.

An interesting Washington Post story this week suggested that because the foreign polls have been so bullish on President Obama — 82% of Germans in one survey expected Obama to be re-elected — lawmakers around the world may be scrambling to adjust to a new team of U.S. diplomats and set of policies.

Is the health sector better prepared?

Given the close race — as of press time on Wednesday, most polls had the presidential race neck and neck — there’s been growing scrutiny of Republican health proposals. For example, the Kaiser Family Foundation and the Urban Institute on Tuesday released another report on the GOP House Budget Committee’s Medicaid plan.

But there’s been much less examination of the people who would steer Romney’s Department of Health and Human Services and the policies they’d carry out.

Possible, if Unlikely Contenders

A handful of names — all veterans of the George W. Bush administration — have been repeatedly floated as potential HHS secretaries under Romney. National Journal suggested that former HHS Secretary Michael Leavitt could return to the role. Meanwhile, ex-FDA and CMS head Mark McClellan is “the first name that comes to mind for many Republican health policy folks,” Politico’s Jennifer Haberkorn wrote earlier this year.

Yet the two men would seem to be unlikely picks. Leavitt has already been tapped to lead Romney’s transition, marking him as a potential chief of staff; moreover, no HHS secretary has ever returned to the role under a second president. Meanwhile, McClellan has publicly praised the Affordable Care Act, giving him questionable bona fides among conservatives.

As a result, the actual HHS short list appears to be, well, especially short. The thin bench reflects that relatively few Republicans in health policy “have remained active without becoming too embedded in lobbying or industry to be confirmed by Capitol Hill,” according to Ben Domenech, a research fellow at the conservative Heartland Institute and former HHS appointee.

Who’s on the Short List

Here are three of the men perceived to be top contenders to run HHS, and some details about whether their current statements or existing qualifications offer any clue to their priorities as HHS secretary.

Bobby Jindal

A handful of Washington insiders, like ex-CMS head Tom Scully, have suggested that Jindal would be the top candidate to run HHS. And as current governor of Louisiana, and former HHS assistant secretary, Jindal’s “certainly the most qualified person on any list,” Domenech tells California Healthline.

As Domenech notes, Jindal also “was a state secretary of health when most people were getting their diplomas” — Jindal ran Louisiana’s HHS department when he was just 24 years old — and his executive experience would serve him well in a role that oversees an $800 billion budget and 75,000 staffers. Tellingly, the past three heads of HHS have all been former governors.

However, Jindal “strikes me as a very unlikely choice for a number of reasons,” Domenech tells California Healthline. He’s accepted a two-year commitment with the Republican Governors Association, has three years left in his term as Louisiana governor, and appears not particularly eager to return to Washington, D.C.

Tevi Troy

Troy’s also been much-discussed as a future HHS secretary. That’s partly because of his current role — a health policy adviser to the Romney-Ryan campaign — as well as his two years serving as HHS deputy secretary under George W. Bush and five years in the White House before that.

A scholar with the Hudson Institute, Troy has long been focused on public health issues; he’s written that the obesity epidemic is “America’s costliest disease.” He’s also come out in favor of several ideas contained in the ACA, like comparative effectiveness research and accountable care organizations, although he criticized the early ACO regulations as being too unwieldy.

Meanwhile, Troy recently told Health Affairs that he’s concerned about restrictions on the pharmaceutical industry, warning that overly exacting safety standards can protect the public but go too far in hampering market innovation.

Scott Gottlieb

Gottlieb is another Romney health adviser and also much-touted to run HHS. He’s had an unusual, intriguing path — from Wall Street to medical school and advising CMS, then back to touting biotech stocks before returning to Washington in a senior FDA position.

Since leaving government service, Gottlieb has been critical of FDA’s policies under the Obama administration, suggesting that the White House’s decisions have led to a shortage of generic drugs and also weakened the agency’s regulatory authority. At the same time, Gottlieb also has argued that the FDA’s gained too much control over stem cell research thanks to a recent court ruling, Alec Gaffney writes in Regulatory Focus.

Moreso than Troy, Gottlieb’s been deeply critical of the ACA. In a piece published last month, he contended that the law has “fatal flaws,” pointing to several key provisions — like the ACA’s planned high-risk pools and the long-term care program — that have either been disappointing or been abandoned since the law was passed.

Looking Forward

Keep in mind — being discussed as a potential cabinet secretary during campaign season guarantees nothing more than being discussed during campaign season. Current HHS Secretary Kathleen Sebelius was little-rumored for the role until the eve of her nomination; Obama had wanted his longtime mentor Tom Daschle to lead health reform efforts, before a snafu over Daschle’s taxes prompted him to withdraw his HHS candidacy.

That speaks to another wrinkle for a would-be HHS secretary: Even if Romney wins election, whoever is chosen to implement his health policies will be highly scrutinized and likely face an intense confirmation battle on Capitol Hill. Those partisan battles began in earnest in 2010 after the passage of the ACA and when Republicans successfully pushed back against Don Berwick, Obama’s choice to head CMS.

“I’m generally pro-confirmation for qualified and ethical people, even if I disagree with them ideologically,” Troy wrote at National Review about a year ago. If Troy’s eventually chosen to be HHS secretary, it’ll be interesting to see if Senate Democrats agree.

Here’s what else is happening around the nation.

Rolling Out Reform

• A delay in implementation of the Affordable Care Act is creating uncertainty among states and health insurers tasked with creating health insurance exchanges. It is widely assumed that the Obama administration is delaying action on major regulations until after the presidential election. However, it is unclear how quickly the regulations could be issued after the election (Reichard, CQ HealthBeat, 10/16).

On the Hill

• Last week, Sen. Orrin Hatch (R-Utah) sent a letter to HHS Secretary Kathleen Sebelius requesting detailed information about every contractor and subcontractor that will help build the federally run health insurance exchange created under the ACA. Hatch noted some of the companies that won contracts to help build the exchanges have been acquired, adding that he wants information about steps HHS has taken to ensure that the companies’ new owners do not have conflicts of interest. He also asked for data about the companies’ bids and selection (Baker, “Healthwatch,” The Hill, 10/19).

Studying Its Effects

• A new CMS program will tie millions of Medicare dollars to patient experiences, but hospitals and providers say that the agency’s patient surveys may not be the best way to access care quality and provider interactions. Under the ACA’s Value-Based Purchasing program, which launched this month, 1% of Medicare payments to hospitals will be tied to care quality. Specifically, performance on quality metrics will account for 70% of the VBP score and 27-question patient experience surveys will account for the remaining 30% (Adamy, Wall Street Journal, 10/14).

Inside the Industry

• So far this year, merger and acquisition deals among U.S. health insurers in the managed care sector have reached a combined value of $13.4 billion, the highest recorded total since 2007, according to a report by SNL Financial. The report attributes the high number of consolidations to insurers looking to expand their Medicaid enrollment following the U.S. Supreme Court‘s decision to uphold the ACA (Dunning, Crain’s Business Insurance/Modern Healthcare, 10/12).
• Although a provision in the ACA intended to expand health coverage to children with pre-existing conditions resulted in many insurers stopping the sale of child-only policies, 22 states and the District of Columbia are having some success encouraging insurers to sell such plans, according to a new Commonwealth Fund report. When the ACA provision took effect, many insurers said they were concerned their costs would substantially increase if they had to cover all children regardless of their health status (Andrews, Kaiser Health News/Washington Post, 10/22).

Dan Diamond (@ddiamond) is Managing Editor of the Daily Briefing, a CaliforniaHealthline columnist, and a Forbes contributor. This post originally appeared at CaliforniaHealthline.org.