12 minute read
COLLEAGUE INTERVIEW
Colleague Interview: A Conversation with Jan Malcolm, Commissioner Minnesota Department of Health
Commissioner Malcolm was appointed in January 2018 as Commissioner for the Minnesota Department of Health and is responsible for directing the work of the Minnesota Department of Health. The department has approximately 1,400 employees in the Twin Cities area and seven offices in Greater Minnesota. Prior to being appointed commissioner, Jan Malcolm was an adjunct faculty member at the University of Minnesota School of Public Health, where she co-directed a national research and leadership development program funded by the Robert Wood Johnson Foundation. Earlier she also helped develop initiatives to strengthen the nation’s public health system as a senior program officer at the Robert Wood Johnson Foundation. Commissioner Malcolm previously served as CEO of the Courage Center and as President of the Courage Kenny Foundation following the merger of Courage Center and the Sister Kenny Rehabilitation Institute. She has also worked as Vice President of Public Affairs and Philanthropy at Allina Health. From 1999 to 2003, Ms. Malcolm served as Commissioner of the Minnesota Department of Health. Throughout her career, she has been active in state and national health care, public health associations, and government commissions on healthcare access and quality. Jan Malcolm is a graduate of Dartmouth College and holds an Honorary Doctor of Laws from U of M School of Public Health.
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You’ve been Minnesota’s Health Commissioner under three governors—Ventura, Dayton, and Walz. From those experiences, what have you learned about how governmental public health can best meet the needs of the state?
It has been an enormous privilege to serve Minnesota with each of these governors. Governmental public health has a unique role to protect and improve the health of ALL Minnesotans without regard to whether or by whom they are insured, and who (if anyone) is their regular source of health care. I don’t think that uniqueness is well enough understood by most folks—in either the public or private sectors. The span of our work is enormous, from environmental health to infectious disease prevention and control, maternal and child health, chronic disease prevention and management, tracking healthcare spending and outcomes, formulating policy recommendations, and enforcing the laws and regulations which deal with these things. Public health focuses on prevention, which is very different from what gets the attention and the funding in our system. Governmental public health has been underappreciated and underfunded for decades, and it shows. The US has less appreciation for prevention and the role of public health than most, maybe any other developed country. That is a significant reason for the huge and growing gap between expenditures on health care and population health outcomes in the US compared to other countries. It’s certainly true that the US, and Minnesota, have some of the best capability in the world—great providers and great innovation. Individual patients (some, not all) get fantastic outcomes. It just doesn’t hold for the population as a whole. And that costs us dearly.
How did equity considerations influence your decisions during the COVID-19 pandemic?
We knew from the outset that populations who have historically faced health inequities — populations of color and American
Indians, people with disabilities, and those living in high social and economic vulnerability—would be harder hit by this pandemic as well. A whole confluence of factors put them at greater risk for infection to begin with and for worse outcomes. Their occupations, their housing, transportation challenges, their lack of insurance and paid leave, systemic biases even for those with benefits—all made exposures to SARS CoV2 more likely and their access to testing, care, and immunizations less likely. Despite that knowledge, our early efforts clearly fell short against so many barriers. We knew we had to get deeper into communities and let community leaders show the way. Dr. Nathan Chomilo, Medicaid Medical Director at DHS, joined MDH as a special equity advisor for the pandemic response, and made a huge difference. (I’m grateful to Commissioner Harpstead for sharing him with us!) Dr. Chomilo pushed us hard on the data we were collecting to see where our efforts were falling short. We made good improvements on that front as time went along. We made good progress by funding a large group of COVID Community Coordinators— community-based organizations deeply embedded in communities, along with funding an important group of diverse media organizations to help us communicate more effectively in each community of focus. Employees from all over MDH also came together in a Culture, Faith and Disabilities Branch of our Incident Command System for the response, and it was transformational for our agency. The disparities in COVID outcomes still exist, and we will keep focused on that as the response continues. MDH has also committed to embed the learnings from COVID into our agency and all of our work going forward. To lead that effort Dr. Brooke Cunningham has joined us as the Assistant Commissioner for a new Health Equity Bureau at MDH, which will broaden and deepen our work in this area. Dr. Cunningham is challenging and inspiring us simultaneously and it is wonderful. Dr. Chomilo continues to serve as a senior advisor for equity beyond COVID. I’m excited about their leadership, to put it mildly.
How has the stress of COVID-19 affected you and the staff of MDH and local public health?
It’s hard to find the words, really. It has been devastating. The unrelenting pressure of the last 2 and ½ years— shared with healthcare providers as well, has been incredibly hard. And all of the polarization around COVID goes to the core of what we’re about, at both the state and local levels. We train to stop or contain these things, and this has been something on a level we’ve never seen before, both in the size of this globally, and in the dysfunction of it domestically. We literally could not succeed. Public health and healthcare workers have shared the personal and professional traumas that come with that stress, and that moral distress, exacerbated by the politicization of the pandemic that somehow turned us into being the bad guys instead of the good guys. I don’t think we fully appreciate yet the consequences of the shift away from understanding or believing in science, and the absolute disdain that many have for expertise of all kinds, much less in government. Combined with the threats many of us— both state and local—have faced just for trying to do our jobs, we’ve seen a lot of departures from public health positions all over the country and here in Minnesota, and tremendous burnout among those who remain. Recent surveys have shown that almost half of all public health workers nationwide report significant mental distress, and 40% of those still here are thinking of leaving their jobs. I know that the statistics among healthcare providers are similarly disturbing.
What have you learned over the past two-plus years leading in the time of a worldwide pandemic?
This will be studied and debated and written about for years to come. Since the first weeks and months of the pandemic there has been huge tension between the need to act quickly and the knowledge that our information was very imperfect and fast changing. That leads to a lot of Monday morning quarterbacking. It’s certainly true that we would have made different decisions or had different public guidance and messaging at some points had we known then what we know now. In addition, how to effectively communicate given the dynamics mentioned above, along with the meteoric rise in both mis- and dis-information, remains a really big challenge.
From a “health system” perspective, the pandemic has really reinforced that our non-system is terribly fragmented and misaligned in terms of roles and incentives. The acute care system has done an amazing job of serving under terrible conditions, and of learning and improving quickly when it comes to treatment. But it hasn’t been and isn’t clear what the roles should be between acute care and public health, and between governmental and private payers, when it comes to things like how to assure the right levels of testing, vaccination, and now the test-to-treat model for quickly getting people diagnosed and treated with oral antivirals or monoclonals when indicated. Roles are not explicitly enough defined and incentives are not aligned well enough for us to successfully manage challenges such as what we have faced, and certainly will again. In terms of the continuum of healthcare services, when capacity is stressed, hospitals can’t discharge patients for ongoing rehab and recovery if long-term care facilities can’t admit them due to staffing shortages. Long-term care has been dealing with a growing staffing crisis for years, and it has been made significantly worse by the pandemic. Conflicting reimbursement incentives here too keep the different parts of the continuum in their silos. I would also say that it just isn’t possible to mount an effective response in Minnesota without a stronger national strategy and capacity, and without more global coordination. This must be an urgent priority going forward.
What do you see as the biggest and most pressing challenges facing our healthcare and public health systems in the next 10 years?
Dealing with the issues named in the last question! We have some systemic challenges that existed before the pandemic that have been accelerated and exacerbated by it. Workforce shortages all over the health continuum and all parts of the economy will not be quickly solved. We’ll need new care models, smarter use of technology, and ways of collaborating beyond anything we’ve done before. Incentives and reimbursement systems have got to align, not just in demonstration projects and through “charitable” work, but in the mainstream of health policy. Including but beyond the health sectors, we need to take seriously the challenge of rebuilding trust with the public, and genuinely tackling the systemic challenges behind health and other inequities. And we will need leaders in health care, public health, business, and policymaking that see the possibilities for a better system and are not stopped by the obstacles. I hope that those of us who have been around for awhile can help to support the rising generation of new leaders that we need in order to make it happen. What are the most effective mechanisms and strategies you’ve learned to foster collegiality and collaboration when working with different systems, like government agencies, health systems, and insurance?
Generally, I think we can all be proud that collaboration among the key players is better in Minnesota than in most places. At least that’s my conclusion from talking to colleagues around the country. But I also think the mechanisms to foster collaboration beyond individual relationships are really lacking, and we should work on that. Individual relationships, and trust, are necessary, but not sufficient. Those take time to develop, and even the strongest relationships and the trust gets very stressed in a crisis. The last 2 and ½ years have reinforced my belief that it’s the people in the health system writ large in Minnesota that make a critical difference, and how important it is to not give up on that. We are not done with this pandemic, and we have work to do to think deeply about what lessons we should learn from this experience in order to build a stronger system going forward. Not just for future emergencies—and unfortunately, we should expect that there will be more of those given all of our global challenges—but also for our day-to-day service to Minnesotans. We have to keep at it.
How can/should organized medicine assist you and your agency?
As mentioned in the earlier questions, medicine and public health have to come closer together. We need to see how essentially interdependent our missions and outcomes are, and we need to figure out how to best leverage both our different roles and our overlapping ones. That will take deeper engagement from both of our sectors. When it comes to helping the legislature understand the importance of public health, they need to hear from you. They hear the rationale differently from you. From us, it too often sounds to them like we are just trying to build the bureaucracy.
Any specific requests or tasks come to mind for TCMS as we dive into our mission to engage physicians in community-driven public health initiatives?
I really appreciate your embrace of public health and the broader social determinants context of what actually promotes health and what threatens it. The data have gotten more and more robust that we can’t improve population health without attention to social determinants, but our public policy-making generally has not reflected that. Your voices can make a tremendous difference at the legislature and among private sector business and healthcare leaders.
During your Robert Wood Johnson Foundation tenure, did any Twin Cities teams get trained in the Interdisciplinary Research Leaders Program?
In the very first cohort we had a great Twin Cities team: Rebecca Polston, founder and director of Roots Birthing Center, and Dr’s Katy Khozimannil and Rachel Hardeman at the U of M. They studied the impact of culturally-focused midwifery services on birth outcomes, where Minnesota has had some of the worst inequities in the nation. All three are rising stars, and I hope the IRL program gave them some extra encouragement and connections.
What is the best way for an interested party or system to collaborate or start a conversation with MDH?
Drop me an email. jan.malcolm@state.mn.us I get a LOT of emails and am sometimes slow to answer, but I will!
What is your most proud accomplishment?
Can I take the liberty of naming a few? From my private sector career, I would say two things: helping to craft a very forward-looking and comprehensive health reform bill in 1992 that contained MinnesotaCare, progressive insurance market reforms, and some really good ideas for cost control that were passed and too soon repealed; and serving as CEO of the Courage Center and working with Dr. Penny Wheeler to create Courage Kenny Rehabilitation Institute from the merger of Sister Kenny and Courage Center. It’s now one of the most comprehensive and innovative centers in the nation serving people with disabilities. From my public sector career, it would be the comprehensive tobacco prevention and control program we put in place with tobacco settlement dollars under Governor Ventura (the ongoing State Health Improvement Program, SHIP, still carries some of the same ideas); improvements in the regulation of assisted living centers under Governor Dayton and passage of assisted living licensure under Governor Walz. And I think history will show that we in Minnesota with Governor Walz’s leadership did a pretty credible job of managing the COVID-19 pandemic when we look at the whole picture of health, economics, and social factors. And in health, I think we will be shown to have been leaders by looking at things like excess mortality over time. That will capture both the direct and less direct impacts of the virus. I am enormously proud of and grateful to my colleagues in public health and in health care for their incredible dedication and skill.
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