The Fund supports several networks of state health policymakers to help identify, inspire, and inform policy leaders.
The Fund identifies and shares policy ideas and analysis on topics important to state health policymakers, particularly on issues related to state leadership, primary care, aging, and total costs of care.
Keep up with news and updates from the Milbank Memorial Fund. And read the latest blogs from our thought leaders, including Fund President Christopher F. Koller.
The Fund publishes The Milbank Quarterly, as well as reports, issues briefs, and case studies on topics important to health policy leaders.
The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
January 20, 2016
Christopher F. Koller, President
Back to President’s Blog: The View from Here
The hip-hop Broadway musical about Alexander Hamilton’s life may be the hottest ticket in town, but Hamilton’s well-known advocacy for a strong national government is not getting much love on the campaign trail or in political discourse. The views of his perennial foe, James Madison, are faring much better. Dwelling on the tyranny and incompetence of the federal government is all the rage—whether the topic is the Affordable Care Act or firearm violence.
This centuries-old debate was on my mind last month when our Reforming States Group (RSG) Steering Committee met for two days in Washington, DC. In addition to reviewing recent work and setting the direction for upcoming RSG projects, the bipartisan group of state legislators and executive branch officials met and had informal discussions with two different sets of senior federal administration officials from across the spectrum of health and human services.
It was a setup for a showdown. If there is one thing Republicans and Democrats from the states can agree on, it is the agony of dealing with federal officials. When you are in state government, the concern is not that the federal government can steal your liberty, but that it can suffocate it with rules and paperwork, and delayed and ambiguous interpretations.
And so our guests—who implement critical federal policy in Medicaid, housing, aging, and food stamps, among other topics—walked into the lion’s den, facing off with 25 scarred veterans (or victims) of repeated negotiations with the federal government.
And you know what? There was no loss of life, limb, or liberty. As the two groups interacted, a deeper perspective emerged about the necessary, even productive, tensions between them and the interconnectedness of their work.
While much attention is paid to the passing of federal legislation, most of the exchange between federal and state officials takes place in the implementation and administration of these laws. In negotiating terms for Medicaid payments, applying for and administering federal grants, coordinating regulatory enforcement, and countless other daily activities, state and federal agencies interact in constructive or destructive ways that help or hinder the people they serve. These interactions create the stereotypes that often characterize state-federal relations: cautious, rules-obsessed federal bureaucrats and sloppy state officials, who are looking for money and authority with as few conditions as possible.
The discussions touched on these stereotypes, but also focused on shared policy goals that both groups are attempting to address—improving the health of specific populations. The conversations highlighted the skills required of both federal and state officials in working with one another to meet those goals. I came away with a few impressions:
Leadership matters. The leaders we elect in national and state elections appoint agency officials who reflect their values. These officials set the vision and values for their agencies. They create environments that make it easier or harder for career civil servants to do their work. While some of these civil servants are counting the days to their retirement, the majority are committed to public service and looking for leadership that will enable them to fulfill their responsibilities and do meaningful work.
National laws set standards that must be interpreted. The tension between local variability and national consistency is woven into our constitution—whether we were debating slavery 160 years ago or access to health insurance now. Federal and state officials constantly try to interpret how much latitude a federal regulation gives a state, for example when negotiating terms for Medicaid expansion or applying fair housing standards.
The results of such interpretation and negotiation may rarely rise to tyranny, but can create real conflict. I hear it in the exasperation of federal officials who, for instance, see impoverished people with varying levels of access to services (“Where you live makes a difference,” one attendee proclaimed) and in state officials who wrestle with inconsistent and arbitrary application of federal laws to local settings.
Partnerships are real if not easy. You cannot attend a public event with state and federal officials without hearing reference to a “partnership.” Watch carefully for lip-tightening and averted eyes. Sorting out responsibilities and authority is hard work. It requires a strong sense of goals, strategic thinking, and the ability to build productive relationships. Each party has to understand the motivations and limitations of the other. Trust has to be built and reinforced. Communications have to be direct—requests are easier to understand when they are clear. In response, it is often better to hear “no” or “yes, if,” rather than “perhaps” or “it depends.”
Often the responsibility for building and maintaining these partnerships rests not with appointed leaders who will soon depart, but with the career staff who serve under them.
In the work of improving population health, the good news is that state and federal governments need one another. This has never been more true than in implementing the Affordable Care Act. The federal government may have the purse, but the states have the legislators and regulators who expand or constrain Medicaid, protect patients, and oversee commercial insurance, public health, and health care providers.
Hamilton and Madison did not resolve their differences on the appropriate limits of federal reach. They moved from partnership to conflict as they worked to establish the country. Our nation’s governing structures were stronger as a result of this tension. State and federal officials similarly are always negotiating their respective roles and responsibilities as they help citizens—and their communities—live long and full lives.
Jan 24, 2020
Jan 21, 2020
Jan 13, 2020
Get the Latest from the Milbank Memorial Fund
An endowed operating foundation that engages in nonpartisan analysis, collaboration, and communication, with an emphasis on state health policy.