But Price can exercise some of the broad powers of the secretary’s office right away to make the ongoing effort to implement Obamacare more difficult, even if some of those provisions survive what is expected to be a rapid move in Congress to repeal it. For one, the text of the ACA was noted—and derided—for its thousands of references to the secretary of HHS in sections known as the “secretary shall” clauses, which placed quite a bit of the burden on the department itself to determine the final shape of several reforms.

Among the reforms left in the purview of the department are the actual creation and maintenance of the HealthCare.Gov website, the establishment of federally run exchanges in recalitrant or struggling states, and the administration of the Center for Consumer Information & Insurance Oversight, which is designed to implement the private-insurance reforms of the ACA. After a year that has seen large increases in premiums, the exit of major insurers from the exchanges, and a reluctance among young people to sign up for insurance, the Obama administration has leaned on this statutory authority to make fixes, including plans to recruit additional insurers and bolster outreach to young people. With exchanges in such a precarious position, Price’s department could choose not to pursue these additional reforms or simply cease improving and effectively administering exchange functions.

One part of Obamacare that Price and Verma would have authority over on day one is the added branch of CMS designed to test and implement changes in the actual delivery of and payment for healthcare in the country. The Center for Medicare and Medicaid Innovation was established in the Affordable Care Act, and has been authorized to act as a grantor and innovation lab for different state plans to address some of the largest cost drivers in health.

Price has been an outspoken critic of the innovation center, especially as it has experimented with shifting Medicare payments from fee-for-service to a value-based model that would not pay physicians on traditional volume metrics, but on a set of metrics emphasizing quality and efficiency. Price has expressed concern that these changes limit the discretion of physicians, and intrude into the doctor-patient relationship. One of the main populations of patients affected by these CMMI demonstration grants are “dual-eligibles,” or patients eligible for both Medicaid and Medicare—generally those at the intersection of old age, low-incomes, and often disabilities. The new HHS and CMS could roll back any potential patient gains or data gleaned from these projects.

A lesser-known provision of the Affordable Care Act is its Section 1557, the nondiscrimination portion required by the Civil Rights Act, which applies to HHS’s authority even beyond the individual reforms of Obamacare. Price’s department has the authority to interpret that provision in its regulations. This year, under Secretary Sylvia Burwell, HHS used that rule to grant protections to transgender individuals and ensure that they could not be denied coverage or treatment on the basis of gender identity. Given Price’s objection to the Obama administration’s recent guidelines on bathrooms for transgender people, it seems likely his HHS might renege on the promise to transgender people.