Creating population health policy for the states is like the proverbial 3-legged stool: it involves the state health agency, the legislature, and the governor's office. But if the inputs from the 3 legs are not in balance, it can get pretty wobbly for whoever sits there.
Interagency and cross-sector collaboration, which can provide a firmer base, was once commonplace. In the current political environment, it requires more intentional effort. And with federal funding for state population health efforts diminished, state health officials (SHOs) will increasingly need to rely on such collaboration to bring in stakeholders and partners in new and creative ways. Leadership education that lays the groundwork for those collaborations is a promising practice, as the Aspen Institute Justice & Society Program, with support from the Robert Wood Johnson Foundation (RWJF), demonstrated over the period 2013-2017, when it conducted a pilot project in its first cohort called the Excellence in State Public Health Law (ESPHL) program and in its second, TeamWork: Leadership for Healthy States.
In a 2016 valedictory, Paul Jarris, longtime executive director of the Association of State and Territorial Health Officials (ASTHO), wrote about the type of leadership public health officials require to be effective: “Cross-sectoral leadership is essential to transforming the health of the public. Health officials must not only take the time to understand the values of their partners, but also learn to speak their language.”1(p106)* Halverson et al.2 argued that success for SHOs could be measured in terms of internal team building and organizational accomplishments, including the creation or enhancement of formal relationships with the governor, cabinet members, other government agencies, and oversight bodies. Critical success factors for SHOs include “experience in government, experience working with the political apparatus, experience operating in the ‘public eye,' and experience in public health/population health.”2(p193)
Civil dialogue, appreciative understanding of values across the political spectrum, creation of a common vocabulary, and silo busting: these are some of the goals of the curricular materials successfully used by the Aspen Institute in its seminar and leadership programs for the past 40 years. These value-oriented conversations have successfully broken down barriers and tapped into shared understandings and concerns.
With assistance from 2 public health policy experts and support from RWJF, we designed a curriculum for public health professionals and other state government officials that would facilitate team-based leadership development across branches of state government. Our working hypothesis was that a common curriculum, off-site team and cohort-wide meetings, regular follow-up, and technical assistance expertise and funding would facilitate the development of shared understanding, shared vocabulary, and shared mission focus.
A total of 13 states participated in the two 1-year cohorts. Each team, selected through a competitive process, was composed exclusively of state government officials, and while the SHO or his or her high-level designee was team lead, teams were required to also include the governor's office staff member with responsibility for public health and 2 legislators—ideally of different parties and from different legislative chambers.
The 2013-2014 teams hailed from Arkansas, Connecticut, Hawaii, Louisiana, Minnesota, Rhode Island, Virginia, and Washington State. The 2015-2016 teams were from Missouri, New Mexico, Oklahoma, South Carolina, and Vermont. Each state team selected a project to advance health in its state (we did not identify a specific content area for either cohort). In cohort 2, we introduced an additional requirement: teams were asked to include a high-level official of a second state agency and to focus their projects on a Health in All Policies (HiAP) approach. We utilized a “thin” definition of HiAP, requiring only that each team include at least 2 state agencies and that it focus “on a flexible, collaborative approach ... that systematically takes into account the health implications of policy decisions in areas not traditionally focused on health.”
Defining success was one of the first challenges. Was the ultimate goal for each team to develop an impressive case study, or was the goal about the quality and durability of the relationships among team members? During a 1-year time frame, how much was too much to ask of the teams? We opted to focus on building trusting and respectful relationships, structuring those relationships so that they would outlast the cohort, and helping team members develop a problem-solving, mission-oriented approach to state policy across branches of government, defining health broadly. Success would be measured by the degree to which the state teams (1) broke down silos within state government, (2) built relationships within their teams and across the cohort, (3) developed and refined effective messaging, and (4) innovated in identifying stakeholders and allies.
The program consisted of 3 primary organizational components:
- Retreats: Orientation, midterm, and end-term retreats were held at sites that brought the full cohort together, away from the teams' state capitals, and were organized to include team breakouts to discuss projects and foster horizontal integration, sessions based on branch of government and/or job description (one for legislators, another for SHOs, and so on) to examine common challenges and opportunities within each sector, and plenary sessions to encourage relationships across the cohort.†
- Required in-state meetings: Multiple team meetings reinforced horizontal integration and, together with regular check-in calls, allowed Aspen Institute staff to monitor progress.
- Case studies: Each team's production of a case study, which was presented at the final retreat, was less an end goal than a device to foster team identity, shared values, collaboration, and a common vocabulary, while enabling teams to experience success and reflect on progress and insights within the limitations of a 1-year cohort.‡
The curriculum for both cohorts featured works of political philosophy and other values-based readings, as well as materials on skills and methods: negotiation, team building, public messaging, collective impact, and systems leadership theory (and, for legislators and other “electeds,” some core materials on public health concepts). Teams were also given access to technical assistance funding of $10 000 to $20 000, as well as connections to a variety of public health law research, policy analysis, and other resources. A blue-ribbon Advisory Committee included among its members the longtime executive director of the American Public Health Association, leaders from ASTHO and the National Conference of State Legislatures, former governors, and experts on both public health and state and local governments.§
Highlights From Sample Team Projects
Promoting joint use agreements and access to sports
Project turning point: After engagement with local stakeholders, project transitioned from a broad campaign centered on prominent athletes to a more targeted, community-specific approach.
Reducing adult binge drinking
Project turning point: ESPHL-funded statewide polling enabled the team to weigh the political feasibility of various initiatives, resulting in a pivot toward enhancing and expanding the use of ignition interlock.
New Mexico (TeamWork)
Developing a resource toolkit to address food deserts in tribal communities
Project turning point: Regular collaboration and consultation with the state's tribes, pueblos, and nations facilitated new partnerships and ensured that as the project evolved it took into account indigenous food systems, food sovereignty concerns, and the need for sustainable interventions.
Conducting a health impact assessment (HIA) of K-3 summer learning programs and effects on downstream health and academic risk factors
Project turning point: Identification of barriers to data sharing led to an agreement between the Departments of Education and Health, while HIA training for staff and other partners have begun to influence policy decisions at the local level.
Analysis and Results
Monitoring by Aspen Institute staff, the ESPHL/TeamWork expert consultants, and Advisory Committee members occurred at each retreat throughout both cohorts. Monthly check-in calls enabled regular collection of feedback from participants on their projects and the program curriculum, capped by the teams' final case studies. These data sources were supplemented by core competency self-evaluations (requiring both quantitative and qualitative responses) that participants were asked to complete at each retreat. During the second half of both cohorts, an outside consultant conducted anonymous interviews with at least 2 participants from each team. Finally, 2 years after the conclusion of the ESPHL cohort, a team lead from each team was reinterviewed to assess the strength and sustainability of the relationships and alliances formed through the program.
Together, these various methods of analysis revealed a remarkably similar trajectory during both cohorts: team members steadily improved the effectiveness of their interactions, strengthening communication and negotiation skills and forging durable working relationships.
To a somewhat surprising degree, at the outset of their participation, neither state officials nor state legislators in either cohort had a very good understanding of each other's opportunities and constraints. To the health officials, legislators were poorly informed on policy drivers and had short time horizons driven by political considerations (in the words of one health official, legislators were often simply “people who say no”). Legislators viewed the agency officials as petitioners, who met with them only when they needed to ask for something. Several legislators had little knowledge of what the agencies did and often saw policy proposals only at a late stage. They believed that health officials had little understanding of the competing priorities that constrain elected officials' bandwidth and of the rigors of balanced budget requirements. Finally, while the governor's office set priorities and tone for the agencies, it often became involved in policy only on topline items.
During the initial ESPHL and TeamWork retreats, participants got to know each other and began to refine projects that were, in general, too ambitious. By the second retreat, the team members liked and respected each other but viewed the Aspen Institute as something of a taskmaster they wanted to please. We let the teams struggle a bit on goals and scoping, not out of duplicity but on the theory that the struggle itself would foster bonding and build social capital. Success, in other words, would come not with the destination but with the journey.
Between the second and final retreats, the teams became more focused, disciplined, and cohesive, with members relying on each other and working together more effectively. By the final retreat, all had something to report on their projects and, more importantly, their relationships.
In addition to significantly improved understanding of the scientific basis for each team's project, participants reported some of their greatest gains in the areas of communication skills (and in particular engagement with media outlets), community and stakeholder engagement, and appreciation of all team members' roles in assisting the population health mission. Moreover, TeamWork participants reported the greatest professional development in their abilities to effectively address population health issues, to develop and strengthen valuable working relationships, and to collaborate across state agencies and branches of government.
Health department and legislative participants explained that their views of each other improved significantly, with more trust and respect on both sides. Participants reported that team building succeeded both within the health agency and across sectors. Teams developed a greater appreciation of the importance of stakeholder involvement and, in particular, early stakeholder engagement in the policy development process. Team members also learned about messaging and the need to craft different messages for different audiences within government, the media, and the general public. In the words of one: “[As] important as evidence and best practices are, if you discount culture and norms, the merits don't matter. [We] must think about how people's lives work, or else the evidence will not be persuasive.”¶
Participants in both cohorts reported improved leadership skills and, most importantly, a reset of relationships. Participants referenced substantial improvements in group cohesion, organizational-level communication, and mission orientation.∥ A member of the first cohort called the approach “a force multiplier.”# According to a member of the second:
I learned the importance of spending time with legislators, and having face-to-face time to talk about things that are important.... Before this, legislators were just people I had to talk to or justify in front of so they made a particular decision. I didn't see them as people who care passionately, and people I should therefore sit and work with so we can find a common path on something of importance.**
The nurturing of trust and shared values was critical—as one participant said, it all comes down to “relationships, relationships, relationships.” We observed several instances of this growth during both cohorts. Legislative team members not only became activated around their project content areas but also started functioning in more of a problem-solving way around other population health issues, where they saw potential wins on policy. Partisan allegiances began to recede as controlling factors. Population health officials learned more about the opportunities and constraints for legislators caught up in budgetary and session cycles and gained new insights into and respect for their dedication and commitment. The result was creation of a new norm for policy work and a recognition that change is incremental, building on messages and relationships that do not neatly track to a single legislative cycle.
Of course, neither cohort was without challenges. In each cycle, a team leader was lost to a tragic accident in his or her home state. Legislators were pulled away from cohort retreats due to the press of business during legislative sessions. And a single year sometimes seemed like a dauntingly short amount of time for a team to make a significant dent in its selected project.
Would these trust relationships built over the course of a year endure? According to a summary of follow-up interviews conducted 2 years after the conclusion of the ESPHL cohort:
Relationships between legislative and state health department team members blossomed into full working relationships on an ongoing basis. These relationships proved essential in changing policy related to the focal topics of the teams during the fellowship, but more importantly supported policy changes on other public health concerns. The relationships enabled several of the state health officers to complete policy changes efficiently, and in some cases, in the face of opposition.††
Likewise, at the conclusion of the TeamWork cohort, three-fourths of participants from the governor's office, legislature, and non–health agencies agreed that their experiences would improve their future interactions with health officials, and two-thirds of those from the Department of Health anticipated better engagement with members of the legislature.‡‡
Team South Carolina's HiAP Approach to an Underserved Population
South Carolina releases about 900 inmates from state prisons annually. Too few who are Medicaid-eligible reenroll upon release, creating gaps in the vital health services and medication that bolster their chances for successful reintegration into the community. South Carolina's TeamWork project, a collaboration between the State Department of Health and Human Services and the State Department of Corrections, created a mechanism to reenroll prisoners in Medicaid effective upon release, improving health and other outcome measures (including an expected drop in recidivism) while achieving efficiencies and cost savings by eliminating duplicative coverage (the state recovered more than $1.4 million in improper premium payments to managed care companies). Team South Carolina's innovative approach also yielded an important discovery about the potential for interagency HiAP collaborations: working across state agencies that do not regularly have overlapping jurisdiction can reduce the risk of battles over funding and program control.
Team members' experiences—and our own observations—during the ESPHL and TeamWork cohorts offer some takeaways for those considering efficient and effective design of population health policy at the state level:
- For governors: Some governors mandate that contacts between the legislature and the health agency occur only via top-level officials. The TeamWork experience shows that this may be counterproductive. Contact early in a gubernatorial term that enables departments to establish relationships and lines of communication can facilitate co-creation of policy and smooth the way for legislative support.
- For executive agency officials: Many teams benefited from early incorporation of the views of legislative team members (eg, one Vermont legislator possessed a long institutional memory that significantly sharpened the focus of their project). Conversations early in the legislative drafting process can create a more cooperative relationship between the political branches and make legislators better ambassadors to stakeholders in their districts. Regular briefings to interested legislators at the beginning of the legislative session can reduce later misunderstandings, and increased contact between agency officials and legislators can cultivate legislative champions.
- For legislators on key committees: Asking the health department what you need to know, even if it is not in connection with specific legislation, will be beneficial in the long run. Learning can take place over months or years and may lead to better mutual understanding and relationships.
- For budgeteers: Given how much our ESPHL/TeamWork teams were able to accomplish with relatively modest investments of technical assistance funding, states may want to consider innovation funds within health agency budgets. These would enable underwriting the good ideas that staff members generate, offering them a chance to seize opportunities for service improvements and cost savings.
- For designers of curricula for health and other policy officials: One of the hardest things in government is cutting through complexity to solve problems. Data are important. But without a values-driven narrative, data are less persuasive. The ESPHL/TeamWork approach enabled teams to improve the richness of their persuasive powers by assisting with the nuances of messaging and encouraging them to look beyond accustomed stakeholders to a broader set of assets. It nudged participants toward developing a common vocabulary free of partisan and positional cues. Materials on collective impact and systems leadership proved to be a powerful, nonpartisan tool in thinking about problem solving.
The ESPHL/TeamWork approach fostered precisely the cross-sector relationships and success factors for SHOs and other health agency staff described by Jarris and Halverson et al. in 2016. It is worth replicating and scaling. The National Governors Association, ASTHO, and other entities conduct policy academies and boot camps for newly elected or appointed officials; by contrast, the ESPHL/TeamWork program has been one of the few to utilize a team approach focused primarily on skills and values rather than on transmitting content.
The program also shares elements with the Reforming States Group (RSG), supported by the Milbank Memorial Fund. Like RSG, the ESPHL/TeamWork approach cuts across branches of government, focuses on problems rather than partisanship, and seeks to bring the best available quantitative and qualitative evidence to policy leaders and decision makers. RSG stakeholders may wish to examine our findings.
Policy innovation will rely heavily on state drivers for the foreseeable future, and the ESPHL/TeamWork approach offers a unique tool to foster collaboration, achieve efficiencies, and improve outcomes. It may also prove useful for innovation in mixed models such as state-county teams of large municipal governments.
Perhaps the most significant insight gained over the course of the ESPHL/TeamWork experiment was the enduring impact of a collaborative approach based on shared values. Every participant entered state government with the same, admirable goal: to improve the lives of the people who elected them and the taxpayers who pay their salaries. Helping them reclaim that basic motivation makes our experiment a promising approach for other states and localities that are interested in winning the battle for healthier people in their jurisdictions.