Based on Wikipedia: United States Department of Health and Human Services

Here's a number that should stop you in your tracks: 1.293 trillion dollars. That's the annual budget of a single federal department—the United States Department of Health and Human Services, commonly known as HHS. To put that in perspective, it's larger than the entire economy of Mexico. It's roughly what Americans spend each year on cars, gasoline, and car repairs combined. And yet most people couldn't tell you what HHS actually does.

The short answer? Almost everything related to your health.

That pill you took this morning was approved by an HHS agency. The vaccine your child received was developed with HHS funding. When your grandmother gets her Medicare check, that's HHS. When a hurricane devastates a community and emergency medical teams mobilize, that's HHS coordinating the response. The nutrition labels on your food, the clinical trials for new cancer treatments, the grants that fund university research into Alzheimer's disease—all HHS.

The Bureaucratic Colossus

HHS employs around 80,000 people across the country. But that number is misleading, because it doesn't capture the millions of doctors, nurses, researchers, social workers, and administrators whose work is funded, regulated, or coordinated by the department. The reach extends further still. Every hospital in America operates under HHS regulations. Every pharmaceutical company answers to HHS inspectors. Every state health department receives HHS grants.

The department's official motto is "Improving the health, safety, and well-being of America." It's the kind of anodyne government-speak that tells you nothing. What it actually means in practice is that HHS occupies the strange position of being simultaneously everywhere and invisible—a vast machinery of American life that most citizens only notice when something goes wrong.

A Brief History of Caring for Americans

The story of HHS begins not with health, but with security—specifically, social security.

In 1939, as Franklin Roosevelt's New Deal programs proliferated across the federal government, someone realized that health, education, and social welfare programs were scattered across dozens of different agencies with no coordination. The result was the Federal Security Agency, a sort of administrative holding company designed to bring these disparate efforts under one roof.

The first Federal Security Administrator was Paul V. McNutt, and his new agency was a grab bag of government functions. It included the Public Health Service, the Office of Education, the Social Security Board, and—in one of those peculiar historical footnotes—the Civilian Conservation Corps, which put young men to work planting trees and building trails in national parks. What planting trees had to do with social security is a question lost to the bureaucratic logic of the 1930s.

For fourteen years, the Federal Security Agency operated in relative obscurity. Then, in 1953, President Dwight Eisenhower elevated it to full cabinet status, creating the Department of Health, Education, and Welfare—or HEW, as Washington insiders called it.

The first secretary was a remarkable woman named Oveta Culp Hobby. A Texan who had commanded the Women's Army Corps during World War II and published the Houston Post, Hobby brought military efficiency to what had been a bureaucratic backwater. HEW became the first new cabinet department since the Department of Labor was established in 1913—a gap of forty years.

The Great Divorce

For a quarter century, HEW combined three of the most consequential areas of American domestic policy: health, education, and welfare. It was an unwieldy combination. The people who understand infectious disease control don't necessarily know anything about curriculum standards. The experts in Medicare reimbursement rates have little to say about school lunch programs.

In 1979, President Jimmy Carter split the department in two. Education got its own cabinet-level department. Everything else—health, welfare, social services—stayed behind in what was now called the Department of Health and Human Services.

The divorce wasn't complete. In 1995, another child left home when the Social Security Administration was spun off as an independent agency. This was no minor adjustment. Social Security is the largest social program in American history, sending checks to roughly 70 million people each month. Its departure from HHS left the department more focused on health proper, though it retained significant welfare and social service functions.

The Alphabet Soup

Understanding HHS requires learning to navigate an alphabet soup of agencies, each with its own history, culture, and mission. Here are the ones that matter most:

The National Institutes of Health (NIH) is the largest source of medical research funding in the world. Based in Bethesda, Maryland, the NIH consists of 27 separate institutes and centers, each focused on a particular area of medicine. There's the National Cancer Institute, the National Heart, Lung, and Blood Institute, the National Institute of Mental Health, and two dozen more. The NIH doesn't just fund research—it conducts research, operating the world's largest hospital devoted entirely to clinical investigation.

The Centers for Disease Control and Prevention (CDC) is headquartered in Atlanta, Georgia, and serves as the nation's disease detective. When a mysterious illness breaks out—whether it's Ebola in West Africa or a cluster of vaping-related lung injuries in Wisconsin—the CDC sends investigators. The agency also maintains the nation's vaccine recommendations, tracks influenza each winter, and monitors everything from car crash deaths to foodborne illness outbreaks.

The Food and Drug Administration (FDA) ensures that the food you eat is safe and that the medicines you take actually work. Every prescription drug sold in America must pass FDA scrutiny. So must medical devices, from MRI machines to artificial hearts to pregnancy tests. The FDA also regulates cosmetics, tobacco products, and veterinary medicine. If you've ever wondered why American food labels look the way they do, the FDA is the reason.

The Centers for Medicare and Medicaid Services (CMS) runs the two largest health insurance programs in the country. Medicare covers Americans over 65 and those with certain disabilities. Medicaid covers low-income Americans and is jointly administered with the states. Together, these programs insure more than 140 million people—nearly half the American population.

The budget numbers tell the story of priorities. CMS alone accounts for more than a trillion dollars of HHS spending, dwarfing everything else. The NIH receives around 40 billion dollars annually. The CDC gets roughly 8 billion. The FDA operates on about 6 billion.

The Uniformed Officers You've Never Heard Of

Here's something that surprises most people: HHS has its own uniformed service, complete with ranks, medals, and dress uniforms.

The United States Public Health Service Commissioned Corps is one of eight uniformed services of the federal government, alongside the five armed forces, the Coast Guard, and the National Oceanic and Atmospheric Administration Commissioned Officer Corps. About 6,000 officers serve in the Public Health Service, and they can be deployed anywhere in the country—or the world—in response to public health emergencies.

The leader of this uniformed corps holds a title familiar to most Americans: the Surgeon General. Despite the military-sounding name, the Surgeon General doesn't perform surgery and isn't a general. The position dates back to 1871 and carries significant symbolic authority. When the Surgeon General issues a report—as Luther Terry did in 1964 when he declared that smoking causes cancer—the nation pays attention.

The Surgeon General's official reports have shaped American health behavior for generations. The 1964 smoking report led to warning labels on cigarette packages. A 1986 report on AIDS helped destigmatize the disease. A 2001 report on youth violence reframed how schools approach bullying and aggression.

The Hidden Social Safety Net

When most people think of HHS, they think of health. But the department's "Human Services" half is equally consequential, if less visible.

The Administration for Children and Families runs Head Start, the preschool program that has served more than 37 million low-income children since 1965. It also oversees foster care, adoption services, child support enforcement, and refugee resettlement. When unaccompanied children arrive at the American border, they eventually end up in the care of an HHS sub-agency called the Office of Refugee Resettlement—a responsibility that has generated enormous controversy in recent years.

The Administration for Community Living focuses on older Americans and people with disabilities. It coordinates meals on wheels programs, supports family caregivers, and funds centers for independent living that help disabled Americans participate fully in their communities.

These programs don't command the budgets of Medicare or Medicaid, but they touch millions of lives. A grandmother receiving home-delivered meals. A foster child finding a permanent family. A refugee learning English and starting a new life. These are HHS stories too.

The Troubling History with Vulnerable Children

Not all HHS history reflects well on the agency.

In 2016, a published US Senate report revealed that several dozen unaccompanied children from Central America, some as young as 14 years old, were released from HHS custody to traffickers where they were sexually assaulted, starved, or forced to work for little or no pay. The HHS sub-agency Office of Refugee Resettlement had released approximately 90,000 unaccompanied children during 2013 through 2015 but did not track their whereabouts or properly screen families accepting these children.

To prevent similar episodes, the Homeland Security and Health and Human Services Departments signed a memorandum of understanding in 2016, agreeing to establish joint procedures within one year for dealing with unaccompanied migrant children. As of 2018, they had failed to do so.

This failure illustrates a recurring challenge for HHS: the department's vast scope makes effective oversight difficult. When an agency manages everything from cancer research to foster care, from drug approvals to refugee resettlement, accountability can become diffuse. No single official can possibly maintain detailed knowledge of every program.

Defending Against the Invisible Enemy

Since the anthrax attacks of 2001, biodefense has become an increasingly important HHS mission. The department runs Project BioShield, established in 2003, which funds the development and stockpiling of vaccines and treatments for biological threats. If a terrorist released smallpox in an American city, the emergency response would be coordinated by HHS.

In 2018, HHS released a National Biodefense Strategy built around five central recommendations: centralize biodefense efforts, bring together policymakers and scientists, address human and animal health together, prepare for both foreign and domestic threats, and proactively combat the misuse of biotechnology.

This last point has become increasingly urgent. Advances in genetic engineering—particularly the gene-editing tool known as CRISPR, which stands for Clustered Regularly Interspaced Short Palindromic Repeats—have made it easier than ever to modify pathogens. What was once the province of well-funded state bioweapons programs could now theoretically be attempted by smaller groups. HHS works with the Department of Defense, the Department of Homeland Security, and the State Department to monitor and respond to these evolving threats.

The Privacy Police

If you've ever signed a form at a doctor's office acknowledging your rights under HIPAA, you've encountered another HHS responsibility.

The Health Insurance Portability and Accountability Act, passed in 1996, established federal standards for protecting medical information. HHS enforces these rules through its Office for Civil Rights, which can investigate complaints and impose fines on healthcare providers who mishandle patient data.

HIPAA gets misunderstood constantly. It doesn't prevent doctors from discussing your case with each other. It doesn't prohibit hospitals from calling your emergency contacts. What it does do is establish that your medical information belongs to you, that healthcare providers must take reasonable steps to protect it, and that you have the right to access your own records.

The Office for Civil Rights handles more than just HIPAA complaints. It also ensures that hospitals receiving federal funding don't discriminate based on race, national origin, disability, or age. In a healthcare system where racial disparities persist stubbornly, this enforcement role carries real weight.

Prevention, Wellness, and the Basics of Health

HHS maintains extensive programs aimed at keeping Americans healthy before they get sick—what public health professionals call prevention and wellness.

Vaccines and immunizations represent perhaps the most successful prevention effort in medical history. HHS agencies develop vaccine recommendations, monitor safety, and coordinate distribution. The annual flu shot, the childhood vaccination schedule, the COVID-19 vaccines that arrived with unprecedented speed—all involve HHS coordination.

Nutrition and fitness programs address the lifestyle factors that underlie so much chronic disease. Mental health and substance abuse programs tackle the rising toll of addiction and psychological suffering. Environmental health researchers study how physical surroundings—air quality, water purity, chemical exposures—affect human wellbeing over both short and long terms.

These prevention efforts don't generate the headlines that emergency responses do. Nobody writes news stories about the disease outbreak that didn't happen because enough people got vaccinated, or the heart attacks that didn't occur because public health campaigns encouraged better diets. But prevention remains the most cost-effective form of healthcare, and HHS invests billions in it annually.

The Current Upheaval

As of early 2025, HHS faces its most dramatic reorganization in decades. The announced changes would reduce the number of top-level divisions from 28 to 15, merge five existing agencies into a new "Administration for a Healthy America," and eliminate approximately 20,000 positions—roughly a quarter of the workforce.

The FDA and CDC would each see their staff reduced by 20 percent. The CDC would be reoriented to focus primarily on infectious diseases, moving away from its broader public health mission that includes chronic disease prevention, injury prevention, and health promotion. The Administration for Community Living, which serves older Americans and people with disabilities, would be broken up.

Perhaps most controversially, reports emerged in February 2025 that HHS planned to "eliminate public participation in many of the agency's policy decisions"—reducing the public comment periods and advisory committee meetings that have historically given citizens a voice in health policy.

These changes have generated intense debate. Supporters argue that HHS has become bloated and unfocused, that consolidation will improve efficiency, and that the department needs to return to its core health mission. Critics warn that the cuts will devastate public health capacity, that institutional knowledge will be lost, and that vulnerable populations will suffer.

Following the Money

The fiscal year 2020 budget authorized $1.293 trillion for HHS—making it one of the largest departments in the federal government by spending, exceeded only by the Social Security Administration (which, remember, used to be part of HHS).

But that topline number obscures as much as it reveals. The vast majority of HHS spending flows through mandatory programs—primarily Medicare and Medicaid—over which the department exercises limited control. These programs operate on autopilot, paying benefits according to formulas set by law. The money goes out regardless of what HHS officials decide.

Discretionary spending—the portion of the budget that Congress and the executive branch actually control—tells a different story. The fiscal year 2020 budget included cuts of $1.276 billion to the CDC and $4.533 billion to the NIH. These cuts, along with other changes, comprised a total decrease of over $24 billion in revised discretionary budget authority across HHS.

In practical terms, this meant fewer grants for medical researchers, smaller budgets for disease surveillance, reduced capacity to respond to emerging health threats. When COVID-19 arrived mere months later, some critics would argue that these cuts had left the department unprepared.

The Department Nobody Knows

There's a fundamental tension at the heart of HHS. On one hand, it's a vast bureaucracy spending more than a trillion dollars annually, touching virtually every aspect of American health and welfare. On the other hand, it operates in relative obscurity, known mainly to healthcare professionals, policy wonks, and the occasional journalist covering a public health crisis.

This invisibility is partly by design. Much of what HHS does works best when you don't notice it. Food safety inspections prevent outbreaks that never happen. Drug approval processes catch dangerous medications before they reach patients. Disease surveillance identifies threats before they become epidemics.

But invisibility has costs. When Americans don't understand what HHS does, they can't meaningfully participate in debates about its future. They can't evaluate whether proposed cuts will improve efficiency or devastate essential services. They can't hold leaders accountable for failures or credit them for successes.

The next time you take a medication, eat a meal, or visit a doctor, consider for a moment the invisible architecture that made that experience possible. Consider the researchers who developed the drug, the inspectors who verified the food's safety, the regulations that protect your medical information. Consider the public health officers who stand ready to respond if something goes wrong.

All of that is HHS. All of that is the trillion-dollar department you've probably never thought much about. And all of it matters more than most Americans realize.