“She’s more of an operator and also politically sophisticated,” Andy Slavitt, who worked closely with Cohen in the Obama administration, told POLITICO. “She’s going to come in with a little bit less of a pure academic perspective.”

The CDC became a lightning rod during the pandemic, as many Republican leaders rejected its guidance around social distancing, masks and vaccinations, and accused it of bowing to the fears of teachers unions in setting school reopening guidance. Democrats are far more supportive, but have found fault, too, with the agency’s shifting recommendations and inability to quickly process data.

Walensky, an infectious-disease specialist who joined the CDC in January 2021, departs June 30. She cited the end of the Covid public health emergency last month when she announced her decision to leave.

As North Carolina’s top public health official, Cohen spoke for the administration of Democratic Gov. Roy Cooper in the face of a GOP-controlled state House and Senate. Before that, she held high-level roles in the Centers for Medicare & Medicaid Services during former President Barack Obama’s administration.

In their letter, Cohen’s GOP detractors, including two North Carolinians, Sen. Ted Budd and Rep. Dan Bishop, and five other senators, Ted Cruz of Texas, Mike Lee of Utah, Eric Schmitt of Missouri, J.D. Vance of Ohio and Mike Braun of Indiana, told Biden they weren’t ready to let Covid go, or give Cohen a pass.

“Dr. Cohen is unfit for the position,” they wrote. “Throughout her career, Dr. Cohen has politicized science, disregarded civil liberties, and spread misinformation about the efficacy and necessity of COVID vaccinations and the necessity of masks,” they wrote.

Her congressional critics have no hope of blocking her appointment; Cohen doesn’t need Senate confirmation.

But the Republicans’ opposition, especially if it’s more widely shared in their caucus, could make it harder for Cohen to complete Walensky’s agency reorganization, which aims to communicate faster during disease outbreaks, be more transparent with the public and prepare for the next pandemic.

Walensky’s plans rely on Congress; she has asked lawmakers to help the CDC respond better to the next pandemic by requiring states to share more data with the agency.

The question of trust dogged Walensky and made it difficult to get congressional buy-in for her plan. Lawmakers focused little attention on it during her last congressional appearance earlier this month.

Cohen did not respond to an interview request. But in a recent commencement speech at Guilford College, she described her own tenure in North Carolina as productive.

“It was those states and communities that were able to build and maintain trust that saw the best long-term results, and I can say with certainty trust was built here in North Carolina,” she said.

And some prominent critics of the CDC’s Covid response, such as Stanford University Health Policy Professor Jay Bhattacharya, have credited her with pushing to reopen schools earlier than others.

But the Republican lawmakers’ position indicates there’s no going back to the agency’s pre-Covid relationship with Congress. With the pandemic years now under the House GOP’s oversight microscope, the CDC director cannot stay out of the political fray. “We all want to see that job removed from politics,” Slavitt said. “But for it to be removed from politics, you actually have to understand politics.”

“A boatload of common sense”

Cohen, 44, followed her mom, an emergency room nurse practitioner, into medicine, but often had one foot in Washington, even interning for Sen. Ted Kennedy (D-Mass.) before going to medical school.

She got a degree in public health at Harvard and another in medicine from Yale, then trained in internal medicine at Massachusetts General Hospital, where her interest in policy was evident.

Along with now-Surgeon General Vivek Murthy, an internist at nearby Brigham and Women’s Hospital at the time, Cohen worked on Doctors for Obama, a physician group that campaigned for the future president, and later rebranded as Doctors for America to work on health care reform.

“From when she was a medical student to her time as secretary of health in North Carolina, Dr. Cohen has always been guided by an enduring desire to help improve the lives of people and communities,” Murthy told POLITICO in a statement.

Cohen would go on to work at the Department of Veterans Affairs and at CMS, where she was instrumental in implementing the Affordable Care Act, according to those who worked with her.

During the “eight weeks from hell” in 2013 when the health care website HealthCare.gov failed to launch, Cohen was part of the SWAT team that made sure it got up and running, said Kathleen Sebelius, who was Health and Human Services secretary when Cohen was at CMS and calls her “a terrific talent.”

Cooper named Cohen to head the North Carolina Department of Health and Human Services after his 2016 election win, which also returned a Republican Legislature.

In an interview, Cooper described Cohen as clear-eyed and transparent about that challenge, “with a boatload of common sense,” and credited her with laying groundwork that resulted in bipartisan legislation expanding Medicaid.

“She had excellent relationships with both Democratic and Republican leaders in the Legislature. They respected her intellect and also appreciated the way she could get things done,” Cooper said.

Mark McClellan, who led the Food and Drug Administration and later CMS under former President George W. Bush, worked closely with Cohen in North Carolina during the pandemic from his current perch at Duke University.

He described Cohen holding virtual meetings with lawmakers on both sides of the aisle throughout the pandemic, as well as small group discussions, where she thrived.

Cohen has a “proven ability to actually do stuff in government,” said McClellan, now the director of Duke’s Margolis Center for Health Policy. He described Cohen’s effort to bring together people with different viewpoints to solve pandemic problems, including health care workers, community and business leaders.

In some arenas, the fruits of her efforts seemed to pay off. A 2021 POLITICO analysis of how each state fared during the pandemic gave North Carolina above average marks for health and the economy. (The state scored below average for well-being and education.)

Cooper dismissed the GOP lawmakers’ letter to Biden. “I think that’s to be expected from anti-science election deniers,” he said. “Dr. Cohen inspired confidence in the vast majority of North Carolinians, despite those who constantly politicize the pandemic for partisan gain.”

While it might be politically advantageous to deride Cohen now, Cooper noted that Republican state senators commended her work when she stepped down in 2021. State Senate President Pro Tempore Phil Berger, for example, praised her leadership during turbulent times and called her instrumental in the state’s successful Medicaid transformation.

Another Republican, former state Sen. Tommy Tucker, told North Carolina Health News that he’d gotten along better with Cohen than any previous health secretaries. “Secretary Cohen and I had major policy differences. But it was always a civil debate,” Tucker said.

For her part, Cohen says she was always honest with the public.

“I think folks misconstrue trust being the same thing as perfection,” she told POLITICO’s Ben Leonard in September, when asked about her Covid-era messaging.

Cohen has estimated she held roughly 150 Covid press conferences, sometimes up to three a week.

“We tried really hard in North Carolina to just tell folks what we knew in the moment we knew it, and tell folks what we didn’t know and what we were working toward trying to understand and find out,” she told Leonard. “I think that builds credibility and builds trust.”

Still, the GOP reaction on Capitol Hill in advance of her appointment shows Cohen’s return to polarized Washington politics will be more fraught than her time in North Carolina.

While North Carolina Republican Sen. Thom Tillis did not sign the letter opposing Cohen’s appointment, he told POLITICO in a statement that he thinks Cohen has her work cut out for her in restoring faith in the CDC.

“While Dr. Cohen has a wealth of medical experience, there are legitimate questions being raised about her role in recommending school shutdowns and enforcing the state’s emergency declaration for far longer than was necessary,” Tillis said.

Been there before

Cohen’s official work at CDC will revolve around the agency overhaul that Walensky started — either completing it or revising it — while restoring workforce morale and public trust.

But she’ll also be the Biden administration’s advocate on public health policy on Capitol Hill, and will be asked by Republicans to defend CDC Covid guidance she had no role in formulating.

It’s a tough job, but she’s been there before. In 2014, for example, Cohen garnered media attention for cooly fielding questions from Republicans on Obamacare’s maternity coverage requirement during a congressional hearing — while eight months pregnant herself.

“She’s someone who doesn’t run away from tough stuff,” Slavitt said. He described Cohen’s instinct to be the one to deliver bad news, a quality she honed as a doctor, when delivering it sometimes meant telling patients they were going to die.

“She’s someone who brings humanity and compassion when people are inclined to kind of close up and be very robotic and buttoned up,” he said.

Walensky is leaving Cohen with a plan of action for the CDC, which Sebelius sees as a benefit.

She’ll enter the agency with a roadmap for improvements from someone who has done on-the-ground interviews about where the agency is falling short. “She doesn’t have to make this up, and she also doesn’t have to start all over again,” Sebelius said.

Like the CDC, North Carolina’s health department was beaten down and suffering from low morale when Cohen came on, according to Cooper, who said she injected hope and vision into the agency and gave it a plan of action.

She’s also never lost sight of the reason for the work, he said, which is keeping Americans healthy.

“She keeps that as a polar star for her even during times when politics tries to thrust itself into the public health arena,” Cooper said. “She understands that that’s a reality. She’s battle-tested.”

Ben Leonard contributed to this report.