Cheek to Cheek: The Dance of Leadership

State Health Policy Leadership Population Health COVID-19

“Heaven… I’m in heaven,
And my heart beats so that I can hardly speak.
And I seem to find the happiness I seek,
When we’re out together dancing cheek to cheek.”

— Irving Berlin

OK, so we weren’t exactly Fred Astaire or Ginger Rogers, but when two cohorts of Milbank Memorial Fund state health policy leaders gathered in person in a post-Delta, pre-Omicron window, it felt mighty good to work on health policy leadership development in person. And much of leadership, it turns out, is like a dance.

At a time of decreasing life expectancy and increasing political conflict, the Fund is dedicated to fostering public sector leaders with the skills and commitment to improve the health and health equity of populations. Culture may eat strategy for lunch, as the adage reminds us, but leaders can help determine culture. Creating a culture where all participants feel valued and united by the same population health goals is particularly important when the pandemic continues to call the public policy tune, making it challenging for leaders to do anything more than react.

A chance to expand skills and networks

The Milbank Memorial Fund’s two leadership development programs are the centerpieces of the Fund’s work in state health policy. Now in its fifth year, the Emerging Leaders Program (ELP) brought together 10 legislators, 11 executive branch officials, and two representatives of county government — its largest group ever— who had been nominated by their colleagues for having significant state leadership potential. Through September 2022, under the guidance of Milbank Memorial Fund Program Officer Kate McEvoy and Rich Callahan of TAP International, the participants are following a curriculum that seeks to develop practical, hands-on leadership skills to help them address the challenges and opportunities in today’s complex health policy environment.

Newer to the Fund is its Milbank Fellows Program (MFP), focused on state officials who are in new positions of agency or committee authority. Built on the Fund’s longstanding belief in the value of bipartisan, inter-branch experiences, the MFP started its inaugural run in September with 11 legislators and 10 executive branch leaders. McEvoy and her partners from the Colorado Health Institute and the Public Sector Leadership Group have developed a program to encourage Fellows to expand their leadership capacities to articulate and drive forward a population health vision and agenda. Another goal is to create meaningful connections to evidence-based resources and a new network of colleagues.

The December meetings for both groups were held in warm climates with patio seating, facemasks, and piles of home testing kits. The leadership insights that emerged in a setting dominated by the ongoing public health emergency but in the company of peers from around the country were compelling. As recommended in the celebrated leadership text by Ronald Heifetz and Marty Linsky, the attendees could get out on the balcony and observe the action on the ballroom floor. So, what did they see?

Leadership is relational and reactive

Even state health leaders with authoritative-sounding titles often find themselves not in charge but responding to external events and people whom they didn’t choose and don’t direct. The action moves quickly, and they move with it, sometimes just trying to make sure they don’t bump into colleagues. The emerging and established leaders at our meetings did not pick this pandemic as a dance partner, but it picked them. And as Kate McEvoy has detailed in a recent essay, Medicaid directors, for example, have not shirked from the challenge of the last two years. Everyone has faced new needs to meet and new ways of working. Leaders have had to listen for changing rhythms and establish new directions – giving energy to and drawing energy from those around them.

Leadership takes new skills, constantly

“Sure, he was great, but don’t forget that Ginger Rogers did everything he did…backwards and in high heels.” — Bob Thaves, “Frank and Ernest”

Today’s state leaders may feel a bit like Ms. Rogers as they fulfill their responsibilities with the pandemic as a partner. How do they interpret local epidemiology, and national guidelines in real time to set education and workplace policy? How do they navigate confusing state and federal authorities in a public health emergency? How do they work with private contractors, federal officials, and the National Guard to locate and distribute personal protective equipment, COVID tests, vaccinations? These are the types of inquiries that are on the table for Milbank’s leadership cohorts. While getting to answers may be complex, the value of knowing that these challenges are ubiquitous and that peers are at the ready to engage can be of great benefit.

Leaders are also facing the fact that Black and Native American people are dying from COVID at twice the rate of white people, and also have experienced many other longstanding health disparities, which have cast a bright light on health inequities in the United States. What actions should a state legislator, public health employee, or Medicaid administrator take to address these disparities? How should they use their authority and lived experience to gather data and evidence, frame the problem in way others recognize, and identify and engage populations that have experienced health inequities?

Good public sector leadership involves constantly identifying and developing new skills to respond to the challenges presented. Programs like ELP and MFP provide resources and relationships to help meet both these challenges. And, like dancing, there are steps to be learned but also space for improvisation.

Leadership is exhausting

State officials may not be first responders or frontline workers, but it was clear that these leaders are tired. It takes energy to respond to the inquiries and needs of constituents in a crisis and establish new rules of engagement with colleagues in both branches. Plowing through bureaucratic and personal resistance to change to allow agency staff to be safe and effective from home was not easy. Procurement rules were established for control, not agility, and can inhibit timely, effective actions.

Emails pile up. Weekends become times for catching up, not disengaging. Reacting, not planning, becomes the norm. This work accumulates in an environment of distrust and politicization that is discouraging if not just plain miserable.

In these taxing conditions leaders need to know their own strengths and weaknesses and where possible build teams to complement them. They need to pace themselves — sitting out a dance occasionally. They need to build trust among their colleagues with consistent behavior and regular communication. With their teams, state leaders need to provide clear and consistent direction, affirm people’s contributions, and protect staff from as much incoming turmoil as possible.

Leadership remains purposeful

To a person, the folks at both meetings reported that they found the events rejuvenating. Being in direct — not virtual — contact with peers from around the country underscored that there are easier ways to make a living than public service in a time of pandemic, but not too many jobs that are as emotionally rewarding. The folks in those rooms will always know that they answered the call and did their best at a time when their communities needed them. The song notwithstanding, state leadership is not always heavenly. And for that we owe them gratitude.