David Sundwall Discusses Strategies for Incorporating Public Health in States’ Healthcare Planning Activities

May 03, 2017|10:34 a.m.| Anna Bartels

Healthcare is evolving at a rapid pace and bringing together new partners who are working together to achieve improved population health and lower healthcare costs. In response, ASTHO and its partners developed the Integration Forum, which serves as a platform for primary care, public health, and others, to share ideas, learn about successes and challenges, and develop closer connections. The Integration Forum membership is comprised of partners from various sectors of the health industry, including, but not limited to, representatives from state and local public health agencies, medical societies, health insurance plans, federal agencies, academia, and more.

This year, the Integration Forum is launching a new issue brief series to inform the work of state health officials as they navigate through a shifting health landscape and pursue public health and primary care integration. The current national healthcare debate signals new opportunities for state health officials to become involved in discussions at the highest level of government and develop cost-effective, evidence-based, public health solutions that advance population health and economic growth. The first issue brief addresses how public health leaders can get a seat at the table and become better involved in state healthcare planning activities.

With this in mind, ASTHO sat down with David Sundwall, MD, one of the leading members of the Integration Forum and former executive director of the Utah Department of Health, to learn about his experience as a state health official and the strategies that he used to ensure that public health was integrated into his state’s healthcare planning.

Can you describe how you engaged with your governor’s office when you served as a state health official?

When I was a state health official, I was a cabinet member, which made it easier to engage with the governor because we met regularly, at least every month but sometimes more frequently. Even if you don’t have a regular cabinet meeting, it’s a good idea to schedule face time with the governor. The bureaucracy of state organizations might make that challenging, but it is critical to have a working relationship with the top executive in the state if you are going to be successful. This recommendation came to me from James O. Mason, MD, a wise and informed public health leader who was previously the assistant secretary for health at HHS, as well as director of CDC, and a former head of the Utah Department of Health. There needs to be person-to-person contact to avoid filters or potential misunderstanding.

Can you tell us about a leadership challenge you encountered as a state health official and what you learned from that experience?

In one of my first years as Utah’s state health official, I proposed a preferred drug list (PDL) for Medicaid. A PDL indicates the drugs that will be covered without question. Providers must then request or make the case for drugs that might be more expensive or not included in the PDL. Utah was one of only about a dozen states that did not have a PDL at the time, and this is an essential component to managing drug costs in the Medicaid program. However, once I proposed it, boy, did I get beat up in the state legislature. I was astonished at the push back. I quickly realized the power of the pharmaceutical industry, which I learned to both fear and respect. I also learned that I should have done more groundwork before going to the Hill with such an important change in Medicaid policy. I should have consulted in advance with key legislators, which would have saved me some time and embarrassment, because they would have better understood why we were seeking this change. You don’t just present an idea in a hearing; you do the groundwork in advance and build relationships. Later on, I tried to cultivate friendships and name recognition, and that served me better.

How do you recommend state health officials plan ahead as the health and healthcare landscapes shift?

This question makes me think back to the H1N1 epidemic, which was a major challenge to the whole public health enterprise at the state, community, and national levels. At the time, I was interviewed on the news so frequently that I’d become a recognizable face in the community. At one press conference, I said, “It’s important to be alert but not alarmed.” And I think that applies to the change in policies that we’re dealing with today. As state health officials, we need to be hyper-vigilant and aware of potential shifts, but, in my view, it’s not productive to be alarmed and spend our time fretting. We need to be alert and then plan in advance for how states may adapt their budgets and deal with other changes.

I do think it is a particularly difficult task to anticipate change because the landscape seems to be shifting all the time in Washington. There is a common sense of anxiety, which is understandable because we don’t know what is coming. But we do know some of the proposals for health reform coming from Republicans in Congress and the Administration, each of which have common elements and some of which are not necessarily terrible for public health, aside from the potential for deep budget cuts. It’s just that these proposals, in my opinion, don’t constitute a replacement for ACA. At the end of the day, we need to be aware of what’s being talked about and identify if there are areas of concern for public health. Then we need to be thoughtful and come to the table prepared with alternative plans and ideas.

Which types of partnerships can state health officials develop to safeguard and optimize the health of all during times of change?

First, when you’re the state health officer, you are an employee and representative of the governor and you must defend the governor’s budget. You don’t propose what you would like or want instead. You must understand your responsibility to defend and seek support for your chief executive’s budget, whatever that might be, but you also need to collaborate closely with advocacy groups. They can say things that you cannot. If you have a good working relationship with advocacy organizations—be it patient or provider organizations, hospitals, or nonprofit organizations—they can carry the water for you. I’ll add a note of caution that health officials should not work around the governor to actively seek things beyond the proposed budget; however, these partnerships with advocacy groups are essential in helping to build bridges with the legislature and getting an appropriate budget to meet your public health responsibilities.

Do you see the role or capabilities of state health officers as being unique among other health and healthcare stakeholders?

Yes, they are unique among other stakeholders. A state health officer is the highest-level, official spokesperson for health in a state and should be the most recognized voice for public health. Also, public health leaders are what I call the “white hats.” They’re the good guys, meaning that public health doesn’t have a vested interest in anything other than sustaining the public health infrastructure and serving the whole population. This brings credibility and is a great opportunity to collaborate and work across the entire political spectrum, while keeping in mind the need to respect other points of view.