State Health Leadership: Hot Seats, High Stakes

Reforming States Group The Health of Aging Populations

Sue Birch has a problem.

As the director of the Washington Health Care Authority, she has to find a new Medicaid director. The current director, MaryAnne Lindeblad, is retiring in July. You might say that Birch has had it easy up until now. Lindeblad is a grizzled veteran who guided the state Medicaid agency for nine years and earned the deep respect of colleagues in the Apple State and nationally.

But now Birch has to find someone with the wisdom and skills to lead an organization that finances the medical care and critical community services for 1.9 million people — 25% of the state’s population — with a budget of over $12 billion annually. The person in this position will also need the political acumen to relate to legislators, as well as a host of stakeholders such as families, health providers, and insurers, whose lives or livelihoods may depend on agency decisions.

Jobs That Make a Difference

The future director must also be willing to be paid substantially less than they could be earning in the private sector. In 2018, the median salary for Medicaid directors was between $130,000 and $170,000, or about one-tenth of what health care leaders with comparable responsibility in the private sector earn. Those are the same people with whom Birch’s Medicaid director will be contracting for services; the same people she has to recruit from to get the “private sector know-how” she is encouraged to seek.

Birch is not alone. Her colleagues in at least 10 other states have been also looking for Medicaid directors in the last few months. With a median tenure of 21 months (Lindeblad was an outlier), the Medicaid director’s seat is always hot and frequently open.

Lots of other state health care leader seats are also open. The COVID-19 pandemic has thrust state health officers to the forefront in the last 18 months. Trained as epidemiologists or clinicians, state health officers have become the lightning rods for public concerns about an array of issues — from mask mandates to business shutdowns to hospital capacity and nursing home infection protocol. State health officers have had to not only create guidelines based on ambiguous evidence but do so in the face of withering public attention and intense passions.

State health and human services secretaries and commissioners running the super agencies that include Medicaid and state health departments lead sprawling bureaucracies that touch as many as half of all lives in a jurisdiction. Their colleagues in state legislatures weigh numerous proposed health care industry laws every year, affecting one-fifth of the state’s economy. They also set many social policies, such as those related to tobacco, labor, immigration, civil rights, and the environment, which have health implications.

These leaders’ decisions make a difference. Life expectancy in states varied by seven years in 2018. Overall US life expectancy would two to three years longer if a core set of policies found in some states were adopted by all.

More recently, the United States has seen a seven-fold variation in COVID-19 mortality rates by state. Many factors contribute to the variation, including rurality, civic culture, and demographics. But policy decisions — like mask mandates and restaurant dining limitations — have been shown to make a difference too. These policy differences likely account for some of the high death rates seen in states like Arizona, Michigan, and South Dakota, and the lower death rates in their demographically similar neighbors. What’s more, death rates from COVID-19 are up to two-and-half-times as high based on one’s race and ethnicity, with great variation in this disparity by state (Figure 1).

Figure 1. Risk for COVID-19 Infection, Hospitalization, and Death by Race/Ethnicity

Rate ratios compared to White, Non-Hispanic personsAmerican Indian or Alaska Native, Non-Hispanic personsAsian, Non-Hispanic personsBlack or African American, Non-Hispanic personsHispanic or Latino persons
Cases1.6x0.7x1.1x2.0x
Hospitalization3.3x1.0x2.9x2.8x
Death2.4x1.0x1.9x2.3x

Note: Race and ethnicity are risk markers for other underlying conditions that affect health, including socioeconomic status, access to health care, and exposure to the virus related to occupation, e.g. frontline, essential, and critical infrastructure workers.
Source: National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases, Last updated May 26, 2021. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html

Milbank Memorial Fund Leadership Programs Offer Support

So state health policy makes a difference for population health, and leadership makes a difference in state health policy. For this reason, the Milbank Memorial Fund has recommitted itself to the strategic priority of identifying, informing, and inspiring state health policy leaders.

In addition to offering the new Milbank State Leadership Network (a successor the Fund’s Reforming States Group) briefings on timely topics, newsletters, and state-to-state technical assistance, the Fund has expanded its commitment to state health policy leadership development through two programs.

This fall, the Emerging Leaders Program will enroll its fifth cohort. The Emerging Leaders Program is a 10-month project for 15 early-to-mid career executive and legislative officials in state and large-county government who have been identified by senior colleagues as having the potential to be leaders in their health policy environments. With a curriculum focused on skills development and lessons from senior officials, including an optional mentor program, the Emerging Leaders Program can help states and counties retain and develop future agency and legislative leaders. Alumni from the Emerging Leaders Program have gone on to assume greater responsibilities in state government. In program evaluations, they credit the program with broadening their perspectives about their work and their careers.

New this fall is the Milbank Fellows Program. This program is targeting up to 15 participants, either state health and human services officials or legislators new to senior positions — agency directors and committee chairs — to help them think strategically about how to have a lasting impact on the health and well-being of the people they serve. The Milbank Fellow Program will take these leaders through a year’s worth of in-person and virtual programming to give them the tools and the inspiration to make a difference in their jurisdictions.

Gretchen Hammer is a consultant and former Colorado Medicaid director who is working with Colorado Health Institute to design and execute the Milbank Fellows Program year. “Improving population health requires partnership and collaboration between the legislative branch and the executive branch,” Hammer says. “The Milbank Fellows Program will be a unique opportunity for senior health and human services leaders to learn together and learn from one another about how to effectively make progress and implement big ideas.”

The pandemic has reinforced our dependence on public health efforts and the health policymaking process. It has also forced Sue Birch and her government colleagues across the country to react almost daily to changing demands. Priorities have shifted based on incomplete information. Interagency and federal relations have been tested. The importance of effective communication has been repeatedly reemphasized.

Yet public gratitude for such public sector leadership is muted. The criticisms are always louder than the thank-yous — and you don’t become a media darling or a one-percenter in this line of work.

But these leaders are making an enormous difference in their communities by improving and even, over time, extending the lives of entire populations. It is hard but rewarding work.

To nominate state officials for our Emerging Leaders and Milbank Fellows programs over the next three weeks, please see https://www.milbank.org/leadership-programs/.

Response from Sue Birch:

Washington Health Care Authority Begins Search for New Medicaid Director

In the blog post above, my friend and colleague Chris Koller reminds us of something important: leadership matters.

State leadership in health care and public health policy has always been important — never more so than now as we navigate out of a pandemic and work toward social justice and health equity.

Washington has been extremely fortunate to have decades of leadership by State Medicaid Director MaryAnne Lindeblad, who retires this summer after 40 years of dedicated public service. She built a team and a Medicaid program that will endure.

Her leadership — aligned with a governor focused on first-in-nation health care delivery system, seasoned legislators who value the importance of healthy populations, and many public and private partners — led to successes like the ones we have seen over the past decade in Washington:

  • Medicaid expansion and a health benefit exchange that has led to historically high health care coverage
  • Cascade Care, the first public option in the nation
  • Medicaid transformation, including investing in health-related social needs such as supported housing and employment
  • Integrating physical and behavioral health statewide to treat the whole person
  • Moving to value-based purchasing in our contracts to build awareness of the balance between cost and quality

A nurse and big-picture policy thinker, MaryAnne is truly one of a kind, and our state is better for her leadership. While her retirement is a huge loss, we don’t have a problem. From where I sit, I see a state full of great minds, leaders, and thinkers, many of whom had the privilege of knowing and working directly with MaryAnne. Under her leadership, she has equipped our state to carry on the work.

Real leadership creates lasting change.

We want to find the right future leader who will focus on the next generation of transformative work, where we are focused on value-based purchasing; building person- and community-centered systems; and ensuring equitable access to care.

And now under a new federal administration, we are refueling and reprovisioning for the next bold push forward deeper into social determinants of health, health equity, primary care payment redesign, rural health systems, and health information technology.

We are beginning our search for our next strong and courageous Medicaid director to serve with the one of the most supportive governors, some of the strongest aligned partners, and one of the highest-performing health systems in the country.

(By the way, Chris describes MaryAnne as a grizzled veteran. Anyone who knows MaryAnne would hardly describe her style as grizzled — it’s her chic shoes and focus on customers first that guided so many of her successes.)