They Called It “Secret,” We Call It “Confidential”

Milbank State Leadership Network

“Secret Health-Law Huddle.” The headline made me shudder. It appeared in a national newspaper, describing a meeting hosted by the Milbank Memorial Fund.

“Secret” implied scandal where there was none. That the meeting happened was no secret. The proceedings were, however, confidential. Yes, we had a meeting. No, we weren’t going to talk about what was said. There is a world of nuance between the two, which is important to acknowledge when understanding the work of the Fund.

Some of the work we do involves convening meetings for state health policymakers on topics of importance to them. This is in keeping with the Fund’s mission to improve population health by connecting leaders and decision makers with the best evidence and experience.

We bring together legislators and executive branch officials in a nonpartisan setting to listen and learn from one another. Participants understand that these meetings adhere to what we call “Milbank Rules”—or, in other words, that “what’s said here, stays here.” More formally, this means nothing said is for attribution and participants can’t speak of what took place at the meeting unless permission is granted or the information was known outside the meeting.

A Safe, Neutral Space

These meetings have enabled us to build trust among participants. If there is reason to believe their words will be repeated out of context or and in other settings, participants will be more guarded and less frank. Learning is diminished. The mutual commitment to follow the rules builds the trust necessary for openness and learning.

These meetings have enabled us to build trust among participants.

And it works. Face to face, free of cameras and fear of misunderstandings and retribution, officials from across the aisle and across the continent learn from one another about building coalitions and common cause, about how to acquire evidence and educate others. They can be free to admit failures or ignorance or to express their curiosity, essentials to learning that are not always encouraged in the public sphere. These convenings, which are known to be safe and neutral environments in which state leaders can speak openly to one another, have been described as unique in health policy. They are also effective.

While we have convened meetings like this for decades—most notably with the Reforming States Group, a standing bipartisan group of state legislative and executive branch leaders—the pace is picking up. In recent months, we have worked closely with CMS’s Center for Medicare & Medicaid Innovation (the Innovation Center) to convene meetings with participants of the Comprehensive Primary Care (CPC) Initiative to share the outcomes of their work. We also convened a set of Regional Health Improvement Collaboratives and their corresponding state partners to discuss more effective collaborations on claims databases.

The Headline that Got Away

The “secret huddle” headline referred to a meeting for states that wanted to explore their options prior to the Supreme Court ruling on the permissibility of subsidies in the federal health insurance exchange. States were facing the collapse of individual insurance markets, the prospect of having millions of people uninsured, and conflicting calls to “do something” or let the Affordable Care Act fail. What were their options? What were the financial, operational, and political risks and benefits associated with each?

If ever there was a need to learn in a high risk, toxic environment, this was it. Representatives from some states did not even want their attendance to be noted, for fear of being seen as cooperating with Obamacare. Much as journalists asked us to confirm what they had heard about the meeting, we did not—nor did the participants—because of the commitments we had made.

What about public trust? Aren’t openness and transparency necessary for public officials to maintain the trust of those they serve? As a former official, I’d say “yes.” To protect the public against the influence of particular interests, public officials are guided by state rules for disclosure and public meeting record-keeping to build trust. As an independent foundation, our interest is to see population health improve. But the Fund has no business interest in the decisions made by participants at our meetings.

So “secret huddle” made for a good headline, but was not the whole story. Trust may be intangible, but it is also invaluable in this process. It is built by keeping one’s commitments, including those of confidentiality and discretion. If the policy leaders who come to our meetings cannot trust one another, they cannot learn and become better public servants. And if our constituents cannot trust that the Fund is true to its mission, then our values and our word will lose the effectiveness to which we aspire.