Leading for Health 

Milbank State Leadership Network
Focus Area:
State Health Policy Leadership
Population Health State Policy Capacity Health Equity

It may have been lost among the many other year-end news stories, but the Centers for Disease Control and Prevention (CDC) released its most recent U.S. life expectancy data in late November. Drably titled “Provisional Life Expectancy Estimates for 2022,” the release maps how far the country is from assuring a long life for all its residents. In recent Milbank meetings, state health policy leaders described how they are navigating the challenges of leading responses to this damning data in a complex and demanding environment. 

Flat and Disparate Life Expectancy Rates 

The CDC’s report describes a country’s health that has rebounded only moderately from the depths of the COVID pandemic. In 2022, life expectancy at birth was not at pre-COVID levels, continuing the worrisome flattening trend of the last 10 years (Figure 1). 

Figure 1. Life expectancy at birth, by sex: United States, 2000-2022

Notes: Estimates are based on provisional data for 2022.  
Data: National Center for Health Statistics. National Vital Statistics System, mortality data file. 
Source: Arias E, Kochanek KD, Xu J et al. Vital Statistics Rapid Release Report. No. 31. Centers for Disease Control and Prevention. November 2023.

The overall trend masks persistent differences not only by gender but also by race and ethnicity, with an Asian newborn expected to outlive her American Indian and Alaskan Native neighbor in the next bassinet by a full 17 years. Similarly, the rebound in life expectancy post-pandemic has not been equally shared (Figure 2). 

Figure 2. Life Expectancy at birth, by Hispanic origin and race: United States, 2021-2022

Notes: Estimates are based on provisional data for 2022. Life table by Hispanic origin and race are based on death rates that have been adjusted for Hispanic-origin and race misclassification on death certificates. 
Data: National Center for Health Statistics. National Vital Statistics System, mortality data file. 
Source: Arias E, Kochanek KD, Xu J et al. Vital Statistics Rapid Release Report. No. 31. Centers for Disease Control and Prevention. November 2023.  

Analyses in the report illuminate how systemic social conditions manifest themselves in medical conditions — and death. For American Indian and Alaskan Native groups, increases in deaths due to “unintentional injuries” (including motor vehicle accidents, poisoning, and murder) constituted almost one-third of the drag on life expectancy increases between 2021 and 2022. For Black populations, perinatal conditions constituted almost three-fifths of the drag — consistent with other data pointing to the abysmal maternal and child health outcomes for Black families. 

Little of this is new. The poor and relatively worsening U.S. performance on life expectancy indicators, and persistent differences in health based on one’s race and ethnicity, have been well documented. The pandemic, however, has revealed how a fragile system responds poorly to an enormous shock.  

The Role of State Policy Leaders 

If you are, by choice or assignment, in a position of influence over policies that affect health, and the data show that people’s health is suffering, what can you do? 

Milbank had the chance to pose this and similar questions in five separate gatherings of emerging public sector leaders and senior officials in our leadership development programs and during issue-specific convenings over the last month. We discussed effective strategies for using one’s authority and influence to address pressing issues that threaten the health of the people these folks serve. The discussions can be grouped in three broad strategies. 

Know the evidence — and its limits. One aspect of leadership is developing and using one’s authority. Some of that authority comes from role and title, but equally important is doing your homework. Marshaling the facts on an issue like changes in life expectancy will not assure a solution, but in our meetings, officials spoke to the value of using data to identify a problem as well as strategies to address it. This takes fluency and focus. Legislators, for example, are presented with a bevy of problems from constituents they are supposed to solve — and often lobbied with solutions that are easy, incomplete, and wrong. Effective legislative leaders dig into their own analysis, rather than taking an interested party’s word for it. With focus, they build a reputation among their peers for their expertise.  

No data, however, are perfect. Population health leaders must have a deep suspicion of simple problems and simple solutions. They understand that systemic social factors like race, gender, and income interact and affect the health of populations in ways that are not always well understood. They ask questions. Curiosity and humility are important partners in any effort to develop effective public policy. 

Know what matters to you and why. Many demands are placed on government leaders. Whether in the legislative or executive branch, officials face thorny and complex problems. Resources are limited. Constituents — frequently agitated by social media — are often narrowly focused, skeptical, and rarely sympathetic. In the wake of the pandemic, these dynamics have been amplified.   

As a result, effective public leaders must understand and be able to articulate their own motivations for taking on a population health issue like maternal and child health inequities, behavioral health delivery, or Medicaid eligibility determination. Some leaders describe being fueled by their own experience with injustice and inequity, and a desire for their constituents to benefit from programs that benefited them. Others are motivated by a sense of obligation to serve others, and the sense of purpose they receive in doing so. And others, who my psychologist colleagues would describe as being endowed with “an enhanced superego,” speak to a sense of responsibility to fix the problems they see. 

Regardless of the motivation, leaders must maintain what a Catholic nun once referred to me as “the theology of the long haul” — a willingness to do what one can now to bring about change in the long term, grounded in persistence and a firm understanding of one’s personal values. This quality is perceived by others as “authenticity,” a priceless asset when establishing the trust necessary for collaboration and progress. The leaders in our meetings also expressed appreciation for the necessity of collegiality and of “filling one’s cup” regularly to help maintain their commitment.

Know what matters to others and why. Yet, being informed, motivated, and grounded does not necessarily lead to being effective. The skills of emotional intelligence, communication, and collaboration — always necessary in developing effective policy strategies — are particularly precious when advancing population health issues. Leaders find themselves challenged just to communicate the realities of poor overall health and differences in outcomes. In our discussions, they referred to the “weaponizing” of certain words in the current public discourse, such as the terms “diversity,” “equity,” and “inclusion.”  For some, these are foundational principles for a better world — constitutive to “life, liberty, and the pursuit of happiness.” For others these terms are associated with government over-reach, accusation, cultural guilt, moral superiority, and lowered performance standards. Some have used their political power to banish the promotion of the concepts, if not the usage of words themselves, from public institutions.  

With meanings blurred, leaders struggle to find new ways to establish and convey “self-evident truths.” Just lamenting the problem, however, is insufficient leadership. In our meetings, participants shared strategies for building common cause, such as cultivating relationships with people with different backgrounds, listening intently, utilizing one’s ability to convene, capitalizing on the power of personal testimony, and finding a shared vocabulary. “It does not always work for me to use ‘equity’ when I talk about my department’s work,” said one attendee. “But I can get a lot of head nodding when I ask if every kid in my state ought to reach their first birthday healthy and with a fair shot at success.”   

The flattening of life expectancy in the United States and the differences between groups are a condemnation of our society. The calculus of risks and benefits for responses will vary for each leader and context, but policy changes to give everybody an equal chance at a long and healthy life —whether it be covering more people with health insurance in North Carolina, improving vaccination rates for Black people in Mississippi, or paying primary care clinicians more to do more team-based care — are possible. And leaders who know the data and understand what drives themselves and others will help make it happen.