Reflections on Leadership: 21st U.S. Secretary of Health and Human Services | Kathleen Sebelius

By | September 4, 2019

and good afternoon. I’m Katherine Heflin, a
second year master’s student at the Harvard School of Public
Health in the Health Policy and Management department
and a Carson Family Fellow. It is an immense privilege to
introduce the 21st Secretary of the US Department of Health
and Human Services Kathleen Sebelius. I had the pleasure
of first meeting then Kansas Governor Sebelius
when she gave my middle school graduation address at the
Topeka Collegiate School, and again during her
final days as Secretary of Health and Human Services
while I was an intern there. Coming as no surprise to us here
at the Harvard School of Public Health, Ms. Sebelius is one
of America’s foremost experts on health policy, health care
reform, human service delivery, and executive leadership. She helped to lead
the president’s charge to pass and implement the
most significant health reform in half a century. In addition to her work on
the Affordable Care Act, she has led numerous
ambitious efforts to provide all Americans
with the opportunity to live happier, healthier,
and more successful lives. Her national and
international leadership has spanned across early
childhood initiatives, women’s health, tobacco
control, HIV/AIDS, and prevention of
chronic disease. As Secretary of Health
and Human Services, she oversaw a trillion
dollar budget, a staff of nearly 90,000, and
dozens of agencies and offices, and she was in charge of the
nation’s public health response to natural disasters and
emerging epidemics including the 2010 Haiti earthquake
and the H1N1 flu outbreak. The reforms Ms. Sebelius
introduced to our nation’s health delivery system are
improving the quality of care patients receive while
driving down costs. Her work to eliminate
health disparities has touched millions
of Americans lives. Before I turn the session
over to Dr. Tim Johnson who will be moderating today, please
welcome Ms. Kathleen Sebelius to the Harvard School
of Public Health and the Voices of
Leadership series. TIM JOHNSON: Madam
Secretary, allow me to begin by personally
saying how much I’ve admired your work
from a distance as the elected
Insurance Commissioner in Kansas, two term
governor, Secretary of HHS. You have said very
publicly and openly that the period of the roll-out
of the Affordable Care Act was the most difficult period
in your professional life. So now looking back a year
later at that whole episode, indicate the two or
three mistakes that were made that in retrospect
were clearly mistakes, but also tell us the positive things that
happened to allow the roll-out to be successful two
months later on December 1. KATHLEEN SEBELIUS: Well, first
of all, it’s great to be here. Great to be at Harvard. Great to be with future health
leaders of this country. We need you. Hurry up. Study hard. Learn all you can,
and get ready. And I have to give
a special shout out to Howard Koh, who has taken a
really important position here at Harvard in health leadership
as a school organizer, but Howard was my Assistant
Secretary of Health. We worked very closely
on a lot of the issues that Katherine
just talked about. So I want to thank him, not
only for being here today, but for that incredible service. The roll-out was awful. Clearly we could have
used more testing. That would have helped. We could have used more time to
actually get all the technology pieces, and it would
have been helpful to have more accurate information. We were told as
recently as a week out by all of the contractors
responsible and by the CMS folks that we are ready to go. That it wouldn’t be perfect,
but that it was ready. And clearly that was a
long way from reality. TIM JOHNSON: And the reason
the testing wasn’t done was you felt an
obligation to meet that October 1 deadline
no matter what almost? KATHLEEN SEBELIUS: The law
said that I as secretary was to design an open
enrollment period. We knew that benefits by law
were to start on January 1, and so we needed to have
people be able to enroll or get a look at the products
before January 1, and so we picked a date
about two years out and drove toward that date. And I don’t know
frankly, Tim, if we had said you know December 1
if that would have just slipped also, but whatever it
was, it was pretty awful in terms of just a
non-functioning system. Having promised the ease
of buying an airline ticket from Travelocity, it was
like buying an airline ticket through a fax machine. Nobody could get in. You saw spinning wheels. At the end of the day, as you
say, we did a couple of things. First of all, we had to own
it, apologize for it, fix it, and then hopefully move on. So the analysis was
done very carefully with lots of new
eyes and ears, lots of kicking the tires saying
we think in eight weeks we can have this functioning. And that was a very scary bet
to make because there weren’t going to be two
bites at this apple. If it had crashed
again, it would have been probably game over. But there was enough confidence
in this new group of tech folks, and some of
the existing folks that they really could
meet those deadlines. So it was a 24/7,
full time operation. And then, the goal really
was to get enough people to enroll by the end
of open enrollment that you actually
had a balance risk pool and a market that worked. And that became rather
than having six months to do that, we have
four months to do that. But at the end of the day
that piece of the puzzle with lots of help and
support with the president using his bully pulpit for
outreach, lots of everybody from NBA players to rock stars
to faith leaders and health leaders, mayors, others really
did this amazing outreach. So rather than having the
target of seven million we had almost 8 million
people sign up by April 15th. TIM JOHNSON: And during
that period from October 1 to December 1, the
second bite of the apple as you say, were you able
to do some actual testing then for sure? Or were you rolling out
on faith on December 1? KATHLEEN SEBELIUS: Well, it was
a little bit on faith again, because although
we were letting– there were enough
people actually– that sort of beta testing,
if your students are familiar with the tech world, a
lot of the commercial products are rolled out
through beta testing. So they pick a certain
group of people and kind of run them through. Well, when you have a law
that is in place for everybody at the same time, the notion
that I as Health and Human Services Secretary could say,
OK people in Massachusetts can enroll, but nobody else. We’re going to beta
test Massachusetts. The outcry would
have been enormous. That was not a
politically viable option. What happened, though,
during those eight weeks is people were still using
the site, a limited number, and so we were able to
beta test with people using and identified every point along
the way where the problems were and what was going on. TIM JOHNSON: So now
it’s a year later, and we are in the middle
of the Ebola saga. I refuse to use the
word crisis in the US. It certainly is a
crisis in Africa. Since you’re no longer
the manager on the field, you’re sitting in the
luxury box now looking down, what do you think
about what’s happening with the way the Ebola crisis
has been handled by the White House, by Tony Fauci’s
office, and the CDC? There seems to be some
lack of coordination there. KATHLEEN SEBELIUS: Well,
I think that it’s always difficult to predict what’s
coming over the transom next. And I would imagine if you had
asked public health officials, political officials six
months ago list the top 10 things to worry
about, no one would have put Ebola on
the list of issues. I’m a huge fan of
Tom Frieden, head of the Centers for Disease
Control and Prevention. I think he is one of the
best public health experts, not only in this country,
but in the world. Does that mean
everything was perfect? I think he tried to give
a sense of confidence and in hindsight it looked
overly smug, saying, we will stop Ebola in its
tracks in the United States when there was a
breach at a hospital. Was every hospital prepared
to deal with Ebola? Clearly not. I can tell you my
own state of Kansas, I can’t imagine if
somebody had come in the door, which hospital
would have been ready to quiz a patient adequately
enough to even identify where he or she had traveled. Most people don’t even
take social history. So there have been some steps. I can tell you
today hospitals are better prepared than
they were weak ago. I think every hospital
in the country now has identified where
their protective gear is, has a protocol of how
to put it on and off. That probably didn’t
happen before. And, you know, is there a need
to coordinate among agencies? It’s something this president
has believed in very strongly and goes across the board. But I think the difference
may be in having a person, somebody is waking
up now every morning, and that’s all their
thinking about. They’re not Tony Fauci
thinking of a range of vaccines and possibilities. They’re not Tom Frieden thinking
about all the CDC issues, but they’re only
thinking of what are the pieces of
the puzzle for us. TIM JOHNSON: Are you concerned
that the news czar is not a medical person? KATHLEEN SEBELIUS: We
have the expertise, I think, in the right
places as the medical. This is really more
a logistical manager. You know what does Department
of Homeland Security, what role do they
play because they are in charge of airport
screenings and warnings? What role does the
Defense Department, who now is going to put
additional folks on the ground? What is CDC’S role? Both in Africa– So thinking
about the logistics of how to coordinate, how
to communicate, who makes the
decision when, I think doesn’t need to be
a medical provider. TIM JOHNSON: You talked
about Tom Frieden maybe being overly confident in
some of his public statements. I have been forever intrigued,
as someone in the media, by the certainty with
which politicians and public officials are
often forced to speak, maybe against their better
private judgment. Talk about that tension,
when you in a public role are trying to
reassure the public and therefore wanting to use
very strong confident language, but knowing inside that
there are real questions? How do you walk that tightrope? KATHLEEN SEBELIUS: Well, I’ll
put it back into my own world because certainly I was
hauled before Congress 15 times in the lead
up to October 1, 2013, and asked with very
specific information, are you ready to go? Will you be ready to go? Is this site ready? And at each point
I said, absolutely. I was not lying to anyone. I wasn’t trying
to mislead anyone. I was basing it on
the best information I had, and also a sense
of confidence that we would be ready. So when the flaws happened,
and the botched roll-out became very public, then I was
hauled back up saying, well you lied to us, and you
didn’t tell us the truth. So I think it’s a
bit of a catch-22. I think Dr. Frieden did what
he should have done, probably, and was urged to do,
which is confidence that the American health
system had the equipment, had the isolation,
had the training, had the ability to actually
deal with Ebola in a very different way than
Africa, which is really what he was commenting on. What was going on with the
number of deaths in Africa had a lot to do with the
infrastructure in Africa, which was not at all well equipped
to deal with isolating people, training people, getting
protective equipment. So he was giving a great deal
certainty and confidence. And in hindsight, then, it
looks like well, you were wrong. There was a problem. So, I think you want the
American people to have confidence that things
are going to be OK. If he had said from the outset,
well, we’re really not sure. We think we know
about Ebola but maybe people will die here
in this country. Or we hope that
it’s going to be OK, but it depends on
where you live, or it depends on which
hospital you go to. I think the panic that
would have emitted from that kind of
uncertainty would have been palpable and
probably very dangerous. So you’re in a catch-22. TIM JOHNSON: I’ve often
wondered why in that situation public officials can’t say
something like, we can never be 100% sure about
everything, but– this is one KATHLEEN SEBELIUS: And
probably that nuance would probably be very good. And then they’d, I
can guarantee you since I’ve been in
these situations, what aren’t you sure about? What exactly will go wrong? Well what part of it, if
you’re not 100% are you 90%? Are you 83%? Are there going to be 17%
of the people who die? I mean, it’s just so–
unfortunately we live in an era where every word that
comes out of your mouth is then taken as, you
must validate that. What does that mean? What do you have in mind? Well, if you’re not 100% sure
then, are you sure at all? Well, why aren’t you sure? So, it’s hard to have
a nuanced conversation. TIM JOHNSON: How has
your understanding of this very difficult arena
changed during your years as Insurance Commissioner
then governor of a state and then in the very
visible national position, did you have an evolving
understanding of how your role as a
communicator had to change? KATHLEEN SEBELIUS: Well, yes. And I would say it happened
at three different stages. I grew up in a political family. My father ran for office when
I was five for the first time. I thought that’s what
families did in the fall. They went door to door
and put up yard signs. No one told me it was
a voluntary activity. He, I would say, was
less than discreet about his public
comments, and got tagged for it a number of times. Headlines, they became
ads in campaigns, so I learned as a child, he
was very funny, and often very brutally honest, but it
was the kind of thing that you probably
shouldn’t say out loud. But he did. And so I watched
that experience, and learned from that. That that probably, while
you might share some things with friends, you
don’t necessarily want it on the front page
of the New York Times. I learned along the way
from media consultants about ways to phrase things in a
less– not changing my opinion, not changing my
beliefs, but at least putting it in
language that people could grasp and understand. And in even doing
symbolic things. I was the governor of Kansas. Kansas is a big cowboy
state, a big gun state. I do not believe in
conceal and carry laws. We did not have one in
the state of Kansas. I vetoed that law
three or four times as it passed the legislature. But they had me do things like
I vetoed the law in camouflage one year as I was
going out to lead the effort for the governor’s
one shot turkey shoot. Because I could shoot a
shotgun, and I actually could kill a turkey
and that became a way to say I like hunting. I believe in guns
in the proper way, but I don’t think
conceal and carry. So in the office of
Secretary, I had a boss again, and it had been a long
time since I’d had a boss. And that was, I say that
because that was a real learning experience. Because there were
times where I wanted to say things a certain way
or do things a certain way, and I was reminded that
there was actually somebody I work for who is
down the street who may have a different view. It was like, oh yeah
there’s that guy. So it was learning a different
kind of communication and often a scripted communication
where again, I didn’t ever say things that or given a
script that I didn’t believe or things that were
against my philosophy or I would have left the job. But saying only some things
and not saying other things were part of a
regime that I learned about communicating because
there was a whole cabinet doing the same thing. They wanted people
on the same message, so there were evolutions of
communication along the way. TIM JOHNSON: Let’s
jump to a cosmic view of a phrase you just
used a while ago, the American health care system. I cringe when I
hear politicians say we have the best health
care system in the world. As you said in your earlier
talk to the students, we certainly have the best care
available to some people some of the time, but
we do not even have a system, a true national
system of any kind. People fall through the
cracks all the time. And one of the things that
worries me about the continuing saga of the Affordable Care
Act is that it basically still depends on
the preservation of the private health insurance
industry, which to me still is a problematic construct
in terms of a system. Talk about that. KATHLEEN SEBELIUS:
Well I don’t disagree. And again it’s a kind of
uniquely American structure where I think the president made
a calculated political judgment that 180 plus million people had
private health insurance based on typically an
employer relationship or insurance they could buy. And that to go to a single payer
plan or a government run system was too far a leap. And if you look at
the furor caused by just trying to
fill the gap, I think he was right
about that calculus. That would have probably
been impossible. Having said that, we still
are paying a huge price for that additional
layer of cost and that additional
layer of control that most people in the
world both don’t pay, and I think we get more
erratic coverage because of it. Some of those issues have been
smoothed out by the Patient Protection, so no longer
having insurance companies– and this comes from my bias as
a former insurance regulator. The way you made money
in health insurance is sell to people who
promise never to get sick, and if they get
sick throw them out. It’s pretty simple, and
it was very successful. Cherry picking the
market worked well. Designing plans that drove
people out or priced people out or locked people
out was pretty good. So getting rid of
that is a step. I do think that if you can
close the coverage gap, and the biggest drop in
the uninsured population occurred last year,
25% lower now than it was at the beginning
of open enrollment, and that’s good news. If we can get a payment
system under everybody, then I think you have a
way to really grind down those overhead costs. Medicare runs at an
overhead cost of 2% to 3%. Private health insurers are
anywhere from 12% to 30%, so there’s a lot of give
in that puzzle still. And even with the
80-20 rule that says they could charge
up to 20% overhead cost, I think that’s way too high. TIM JOHNSON: Medicare,
as you said earlier also, sets the stage and the tone
and the specifics, very often, for the private
insurance industry. You painted a very optimistic
picture in your comments downstairs about
the changes that are being wrought
by Medicare that will spread throughout
the entire system. You really think
that’s going to happen? KATHLEEN SEBELIUS:
Well, I sure hope so, because if it
doesn’t, we won’t have Medicare in five or 10 years. I mean it just will not be
financially sustainable. The program will be blown up. So you have, I
think, two choices. One is a program that
has been, or a proposal that’s been put forward that
says you basically guarantee a contribution, an
amount of money. You let Americans basically
shop for their benefits with that amount of money. You risk, adjust a little
bit, you give a little bit more money to people who
are low income or people who are chronically ill, but you
have a guaranteed contribution system. Medicare right now is a
guaranteed benefit system. You have certain benefits when
you get Medicare eligible, but that relies on, the
guaranteed benefit system relies on then changing
the costs trajectory. It is right now four and a half
years after the Affordable Care Act was passed and
signed into law. We are at the lowest growth ever
in the history of the Medicare program. Ever. We’ve never seen costs
rising at such a low level, and they’re really
trending with GDP. And if that can happen,
Medicare can survive. And, I think, it is a
far different program as a guaranteed benefit
system, which is, I think, very helpful. because you can’t risk
adjust everything. You don’t know when
you’re going to get sick. You can’t promise you won’t
have a stroke tomorrow, and as you say I’m
an optimist, though. I’m a pro-choice Catholic. I’m a Democrat
from Kansas, and I root for the Kansas City Royals. 29 years, who knew? We’re back! TIM JOHNSON: As we all, I
think, are doing, by the way. KATHLEEN SEBELIUS: You bet. So optimism is part of my DNA. TIM JOHNSON: I have to tell
you one little story that illustrates the problem
in so many ways. When Bill Frist was still
Senate Majority Leader, and I was still
working at ABC News, I was invited to an evening
dinner in his private dining room with two other
guests, Hillary Clinton and Newt Gingrich. And they were there to
assure me that within six months via Medicare there would
be a national standard for IT allowing total
interchangeability of medical data. This was 12 years ago. It still hasn’t happened. Isn’t that an
example of how hard it is to control the private
enterprise system in health care even with a monolithic
powerhouse like Medicare? KATHLEEN SEBELIUS: I remember
that era when actually there was a lot of activity with
Newt and Hillary around IT. I would say we’re a whole
lot closer than we were. And in fact, there’s
lots of demand now by providers
for interoperability that wasn’t there before. To me interoperability
is a team sport. It’s fine to have Tom
Brady or Eli Manning, but if you don’t have
a receiver down field, it really doesn’t matter
who your quarterback is because you’re still not able
to throw a pass that anybody can catch and anybody can score. That’s sort of where we are
right now where there are lots of systems beginning
to exchange. But I got to tell you, the cry
for providers– first of all, there’s been a great adoption
of electronic records over the last four years. Standards have
been set nationally that never existed before. And providers are
right now saying we have to get to
this next step. They didn’t even know this
terminology four years ago. That was not a conversation
in health care. So I think we are
at the tipping point where it can’t come
from the outside imposed on the medical
system, but I think now the providers are
saying this is something that we have to have
in order to practice good medicine into the future. And I think it will happen. TIM JOHNSON: My
25 minutes are up. It’s now your time,
and I’m encouraging you to ask any and all
kinds of questions. You may want to
ask more questions about Madam Secretary’s
personal experience and growth in leadership. But feel free to ask
whatever’s on your mind. If it’s inappropriate,
I’ll tell you so. Yes? And we ask you to give
your name and your status. LOU KELLEN: My
name’s Lou Kellen. I’m a master’s in Public Health,
Global health student here. What would you like
to be remembered for? TIM JOHNSON: What
a great question. KATHLEEN SEBELIUS: Well, I’d
say the legacy of the Affordable Care Act is a wonderful
legacy to have, but I guess in a
more global sense, just having made a
difference, having made a positive difference
in people’s lives and working hard to do that. So maybe not one particular
thing, but just that’s what I’ve been trying
to do most of my life. TIM JOHNSON: And I’ll
just add the observation that while the Affordable Care
Act was a terrible experience for you at the time
of the role-out I do believe it will turn
out to be a positive legacy. That’s my personal opinion. Another question? Let’s go here. SAI PATEL: My name’s Sai Patel,
and I’m a fourth year med student at Mayo Clinic, and I’m
doing an MPH in global health here as well. My question is in
2017 a lot of states can have innovative programs
under the Affordable Care Act, what are your thoughts
on Vermont’s sort of single payer-esque move? KATHLEEN SEBELIUS: I think that
Governor Shumlin in Vermont is very determined
that that will be one of the models
tested, but actually there are now six states that are
doing all payer experiments. Arkansas is one of them. Maine is another looking
at ways that you really can have a different kind
of health care delivery. If everybody was at
the table– if you put in private
employers and the state and the federal
government and shared data and shared information. So states have always been
laboratories of innovation. They’ve always been well ahead
of the federal government. What’s exciting is, I think
some of the national programs are finally catching up. So I’m really eager to
figure out what folks learn. That whole dual
eligible population, which is the most costly
population at least in public health
programs, we finally have authority for
states to actually try to manage that population
in a very transparent way. That wasn’t available
when I was a governor. I would have loved to
have been able to do that. So there’s a lot going
on the state space, and this single payer in
Vermont is just one of them. But exciting innovation. Exciting ways to look at
their high cost, high risk patients, ways that they can
deliver care differently, ways that they can open up the
scope of practice that I think will really inform better
health care in the future. TIM JOHNSON: In the back, and
then we’ll come back down here. -Hi, my name is Dominic Caruso. I’m a student in the
one year MPH program. Just wondering, when
regarding Medicaid expansion, when you received
Arkansas’s application to use Medicaid funds
for premium support for buying insurance
on the private market, how did you approach
their application, and how difficult was it
to make that decision? TIM JOHNSON: And just
give a little context for our viewing audience also. KATHLEEN SEBELIUS: Well, when
the Supreme Court decision came down, well they upheld the
vast majority of the law. They struck down the
provision that said, basically that HHS could use
levers and withhold Medicaid funds from states to chose not
to– how about that technique? Remember? H1N1? Learn how to sneeze– States
who did not expand Medicaid, so they made it a
voluntary provision. But they went further than that. And that’s really what
Arkansas is about. They basically,
the court decision says there’s the traditional
Medicaid program, which was written into law in 1965,
and then the new Medicaid. And they made the newly
insured population a kind of different entity. And Arkansas, Mike Beebe, who
is the governor of Arkansas wanted very much
to expand Medicaid. And we’d had numbers of meetings
and numbers of conversations before he came in with
the exact proposal. And he basically said, I need
something that we can say is not traditional Medicaid. And we said, well that’s fine
because actually the court gives you that permission. We outlined for
him very clearly. Mike is the former
Attorney General. He understands
the law very well. He’s very savvy. He had a Republican
legislature and not just a Republican legislature,
he had a provision in Arkansas that said 3/4 of
the legislature has to vote for Medicaid expansion. So he was facing this
really high hurdle. But we worked on it,
and what we realized is that if he could
figure out this strategy, it also could open
the door for others who wanted to do the
health expansion, but didn’t necessarily want
to say they were collaborating with the president or
expanding Medicaid. So there was a lot
of back and forth. And when he finally
submitted the application, we knew it was an
application we could accept. And the language was available. A couple of lines in the sand. Lots of states wanted
to expand only to 100% percent of poverty,
and put everybody else into the exchange. That became a
barrier to expansion. Said you have to go to 133%. That’s the way the
law was written. That’s what was designed. So lots of conversations
around that. And how much could
you impose on people below the poverty level
in terms of charging them any co-pays or penalizing
lack of support. Again, that was a principle
that Medicaid had, always had a limitation
on under poverty. Above in the 100%
to 133%, there was a lot of flexibility
for governors, and that’s really what
we kind of designed. I think you’re going to
see, hopefully very soon, Utah about to come in
the door under that same. Pennsylvania has a variation
of it, but what we knew is that if we could design
a plan for Arkansas, it would really be a model. It was principles
of that plan that could be used by
lots of other states, and that’s what’s happened. TIM JOHNSON: Good. Question here. We have a microphone
right behind you. ROSA: Hi, my name’s Rosa. I’m in the MPH policy
program here at the school. So, something that our
dean often refers to is a public health momentum
that we’re currently living in with the ACA, with
Medicaid expansion, trans fat ban, et cetera. I was wondering based
on your experiences as a public health leader,
what kind of advice could you give to us as future
public health leaders to keep up this momentum in
the face of adversity. KATHLEEN SEBELIUS:
That’s a great question. I mean, first of
all, I’m encouraged that there’s so many
bright talented folks who want to go into public health. That a great place to
start this conversation. And I do think there is
an awareness of, by lots of ordinary people, that staying
healthy in the first place is good for them
and their families. It’s longer, happier
lives, better futures, so I think that you see
a very different attitude than certainly when I was
growing up about smoking, about seat belt
use, about– you’re beginning to get
people to pay attention to nutrition and diets. Salt is still a big issue. But I mean, I think
that’s coming. So there are conversations going
on now that certainly weren’t going on 10 or 15 years ago. I was struck as we went
through the health reform– the American Medical
Association, by the way, always opposed health
reform up until 2010. That’s the first time the AMA
ever, nurses always supported it, but the AMA always
opposed health reform. It was going to be
socialized medicine. It was going to, the
world was going to end. But my favorite ad,
my very favorite ad, which I went back
and saw was around Medicare– they
opposed Medicare also, by the way– was an ad that the
AMA put out that had a doctor. It was a print ad. I think it was in Life
magazine, which doesn’t even exist anymore. A doctor sitting
on his patient’s bedside giving advice about
the health care system going to hell in a hand basket
smoking a cigarette. Really, this was the print ad. So we’re in a different era. I think people kind
of get the fact that that doesn’t
make a lot of sense. And I would say
that relating again, public health makes that
terminology kind of makes people’s eyes glaze over. They don’t know what
you’re talking about. They don’t really care
what you’re talking about. But relating it to them. I mean, how these five
steps for our pregnant women make a difference in
your baby at the time that he or she is born and make
a difference for like– people kind of get that. Your child eating more
fruits and vegetables when he or she goes
to school as opposed to ketchup as a vegetable
makes a difference. Having gym class three
times a week actually makes them able to sit
down and learn math. And so, kind of connecting
it to people’s lives and why it makes a
difference to them, I think, is a way to sort
of push through. So you’re not in
a lecture circuit. It’s really more how this
effects me and my family and why I should
care about it and why it should be a priority. And I think that conversation
is beginning to take hold and can be really important. You all have a great opportunity
to push that forward. TIM JOHNSON: I notice you left
out Mayor Bloomberg’s passion for soda size in
you litany there. KATHLEEN SEBELIUS: The big gulp
you know it’s an important– TIM JOHNSON: Down here. KATHERINE HEFLIN: Hi, I’m
Katherine Heflin, again, masters student here in
Health Policy and Management, and I actually wanted to
speak to you about Kansas. I was very appreciative of your
leadership there as governor. You were recognized by Forbes
for your leadership there. You were a Time’s top
governors of all time. And I was wondering if you
could speak a little bit to that and, give us some leadership
advice from your time as governor back to when
you were your own boss, and if there are things you were
specially proud of while you were governor of Kansas. KATHLEEN SEBELIUS:
Well, getting elected was a big deal and reelected,
but I’d say being the governor, I think is the best
political job in America. If any of you are thinking
about politics, that’s the job you want because
you don’t have all of the international– Really
you’re a CEO of a state, and you can really
kind of move the needle and watch things
happen and states, unlike Washington–
with Washington punting is a sort
of way of life. For the five years, and Howard
knows this as well as anyone, we didn’t have a budget at HHS. Did not have a budget. Now this is the largest domestic
agency in the United States government, 90,000
people, eleven agencies, Congress just didn’t want to
pass a budget so they didn’t. And so you didn’t
literally know– and the government was
shut down three times during that period of time. Sometimes for short
periods of time. Sometimes for a long
period, but think of what that does
to people who are supposed to come
to work every day. They really don’t
know if they’re going to get a paycheck. They don’t know if you’re going
to be able to hire new people or lay them off. You have these crazy rules. So states actually run. They have to get things done. They move things ahead. And as governor,
Katherine knows this, but I inherited a long
time school finance battle that had been
unresolved and was working its way
through the courts. I mean unresolved
for eight years. And we finally, I always
had a Republican legislature the whole time I
was there, so this wasn’t with Democrats
working with me. But we resolved that
and got the court to declare the new
law constitutional. It took three or
four tries, but that was a huge deal going forward. We had a lot of success and
in terms of job creation and created an entity that
my successor has sort of dismantled, but a
bioscience authority that basically
looked at the assets we had and had a way to
divert new taxes from jobs created in the bioscience
sector into investment. So we ended up with startup
companies and various kinds of investments in Kansas. So there was a lot going on
that was actually very positive, I think, for the state. Two weeks from
now, I’m hoping it can return a little to sanity
because Kansas has been now experimenting with a, not my
words but other people’s words, the most radical tax
plan in the country where the current governor
has slashed income tax levels for all corporations
for high end individuals. The state’s going to
have about a $200 million shortfall this year, but about
a trillion dollar shortfall going forward. Schools have had
the biggest cuts they’ve ever experienced
in the state. Three financial downgrades have
occurred in the last two years in Kansas by the
financial markets. So it’s been a very
big swing, and I think the voters
are going to have to decide what’s the model
that they want going forward because it’s a real difference. TIM JOHNSON: And what are
the polls showing currently? KATHLEEN SEBELIUS: Currently,
the Democratic candidate continues to be three to five
points ahead, so we’ll see. TIM JOHNSON: Now we’ll all
look with great interest at the results. Other questions? Yes in the back. DOUG JACOBS: Hi my
name is Doug Jacbos. I’m in between my third and
fourth year of medical school and also here for
the MPH and actually interned at HHS as well. And so my question is now
that you’ve been governor and now that you’ve been
the Secretary of HHS, what’s in your
future, and how do you feel like you can continue
to impact the world? KATHLEEN SEBELIUS:
You know I don’t know exactly what
is in my future. I’m in the process
of having lots of conversations
about that right now. I am a grandmother. I have a two-year-old,
nearly perfect grandson, so that is definitely
in my future and having a little
bit more flexible time to hang out with
George is something that has been a lot of fun. But I’m looking at doing
some continued global health work, which I found interesting
and compelling and really important. I am doing some speaking. I probably will do a
little bit of teaching. I’m having conversations
with private sector companies that are looking at the
financial side of how you startup companies with
disruptive technology, potentially in this
delivery system area. I’ve been in the public
sector for 30 years. So it’s really
fascinating to talk to people about what actually is
going on in the private sector and how that needle
can be moved maybe. So I don’t know exactly all
the pieces of the puzzle, but so far it’s been really
interesting to explore. And I am doing some
speaking around the country, and that’s kind
of nice because I can pick and choose saying I
will do that and not do that. And trying to catch
up on sleeping and reading and seeing friends. TIM JOHNSON: Yes? ARIEL: Hi, my name is Ariel
I am a Master of Science student in Global
Health and Population. I was wondering what were some
of the skills and knowledge bases that you found
most useful and how did that change throughout
the roles you held? TIM JOHNSON: And
tell us a little about your
educational background in terms of coming
to your first elected position with certain skills. KATHLEEN SEBELIUS: Well, I
majored in political science with a minor in history
in my undergraduate years. And had absolutely
no idea what I wanted to do when I
got out of school. And didn’t have any plan. I was telling
students downstairs that the notion somehow that
you have to have a master plan, and that you’ve failed life
if you don’t know where you’re going to be in five
years and in 10 years. I’m here to tell you
that I hadn’t a clue. My resume make sense looking
from where I am now backwards. It looks like I had
this nice plotted plan. Not true at all. I went to Kansas
because I married a Kansan I’d been
there twice in my life. So this wasn’t a well
thought out strategy either. And actually I worked for
a Lawyers Association. I worked in corrections
first, for a number of years. And then I worked for
a Lawyers Association. And the reason I ran for the
legislature in the first place was because I want to go home. I was working about
60 hours a week. I had a two-year-old
and a five-year-old. And my lifestyle and my
children and my husband was a busy trial attorney,
wasn’t working very well. And the legislative seat
in our district opened up. And in Kansas the
legislature’s a part-time job. So people have said
to me, oh well you ran for the legislature,
be governor. I said, no I really
ran to go home. It was a part-time
job that I could do much more easily
with my kids. I mean, I love the politics. I’d grown up in politics. I was a volunteer. I did a bunch of stuff, but I
didn’t really have this plot. I think risk taking is a
big important part of going forward, and I
don’t mean standing at the top of the
Washington Monument jumping off risk taking,
that’s just stupidity. I mean knowing that you
may not know a hundred percent of what
you’re getting into. That you have some confidence. That first it’s really
interesting to you, and you’re willing to learn it. And secondly, that you can take
a deep breath and go for it. You will never get a job
unless you apply for it. You will never
have an opportunity unless you try to take it. So I do believe in being
willing to take a risk, which means that you
could lose, right? You know you can’t
run for office unless you’re willing to lose. You have to have a
plan to win, but you have to also be willing to
lose because that does happen. So I think being willing
to take risks knowing that life is a continuous
learning experience and that you– I’d say the best
kind of advice is find the best mentors
you possibly can find. Something you like
and want to do. Not for the rest of your
life, even short term. And then figure out who
does it best that you know, and go ask them to help
you learn about it. People are delighted to
tell you what they love and how they do it. So there’s always something
that somebody does better. I think as an
employer, I learned quickly bringing the best
possible people around me. You know, who had all the
skills that I didn’t have, who was really smart at
doing things and being willing to listen to them and
then take advice from them. HHS, one of the best
things about it, and I mean there are hugely
amazing things about that five years, 5 and 1/2
years, but I worked with the smartest,
most dedicated, most incredible people I will
ever work with in my life. People who were well below their
market value, who just came to do the mission
and came because they believed in Health
and Human Services. And they were there every
day doing incredible things. People like Howard Koh,
who just said put me in. I’m ready. I’m here, and came from all over
the country, all over the globe and that was just,
that was amazing. So surrounding yourself with
good people good mentors and then learning
what you don’t know, I think is always a great thing. TIM JOHNSON: Great advice. Some more questions. Yes, we’ll take the young
lady and then behind. KELLY VITSOME: Hi, everyone. My name is Kelly Vitsome. I’m a master student in Social
and Behavioral Sciences here. I wanted to ask about your 2011
decision around minors access to emergency contraception and
what were the factors at play in you’re making that decision? KATHLEEN SEBELIUS: Well,
it’s a great question. This was an FDA
approval process that I had been briefed about
as it went along. It was a– TIM JOHNSON: Maybe just back
up again with a bit of context for others who might be watching
and didn’t catch the question. KATHLEEN SEBELIUS:
Well there was a drug that was not approved. Well it had it long
and torturous history in the United States. It had been approved in
Europe for a long time. That was approved during
the Bush administration for over 17-year-olds
over the counter, under 17-year-olds
with prescription only. And it was– the
decision at that time was based on a
lack of evidence is what the scientists
said at the time. That they didn’t have the
evidentiary background to have the clinical trials
available for the younger group to be appropriately using
it over the counter. An application came in
from the company saying, we want to take the age
limit off and put it over the counter for everybody. And submitted with
that application was clinical trials that
only went down to age 16. And then an
interpolation that said but we think it’s
appropriate for anybody. I mean, menstruation
basically starts in some girls as early as 10 and 11. Twelve is about the average age. There was no clinical
data for 12-year-olds, for 13-year-olds
for 14-year-olds. And in over the counter
one of the issues is do you have the
comprehension to adequately read and understand
the instructions. Can you use it appropriately,
which makes a distinction between over the counter
and with a prescription. The FDA who had, I
think, been frustrated at earlier problems
with it and felt that the ruling had been
overly political, came forward. And I talked to Dr. Hamburg,
the head of the FDA at the time, and said I’m really troubled. I need to get more
background and briefing, but I understand that there’s an
issue within your drug approval folks, but we still are
missing this clinical data. Why didn’t the company either
submit the application along with the age group that
they had the data for or do the clinical trials
on a younger group? Well, they could recruit
the younger group. I said well that’s
really, again, a problem because
this is going to be a politically
controversial issue. I know that. But if you don’t have,
then, the scientific backup to say, well, we
know it can be used. It’s been demonstrated. We’ve taken a look at it. We’re in this real catch-22. I also felt it
was very important that the FDA
process be pristine, and that it not be, if a
decision was made to turn down the application that
it be me that make it. Not that I tell Peggy
Hamburg to make it, which is what had happened
in the Bush administration. There had been a directive,
a secretarial directive, that the head of the FDA
intervened in the drug approval process. So I made the decision. I knew it would not
be very popular, and basically we
also communicated to the company that either
submit additional clinical data or amend the application. People said, well why
didn’t you just approve it for over the counter for
the age group that you had? That is not– that
wasn’t an option. Once a company comes in with
an application, it’s yes or no. You don’t have the
authority to amend the application along the way. That would’ve been the
easiest thing to say, OK, 15 and up absolutely, it
should be over the counter. Anybody else, come in
with new clinical data, but that wasn’t an option. So it was not an
uncomplicated decision, and I know it riled
a lot of people in the public health community. They did subsequently,
very quickly, the company came back and
submitted the application, amended the application
for the age group that they had the data for. And it was very quickly
approved and went through, but that was really the issue. TIM JOHNSON: OK, I’m getting
the “hi” sign that we’re coming down to the
last five minutes, and the plan is Madame
Secretary for you to summarise in three
minutes all the leadership skills that you’ve learned
in your entire life, and then we’ll close it off. KATHLEEN SEBELIUS: Well I don’t
think I’ll try to do that. TIM JOHNSON: You do
whatever you want. KATHLEEN SEBELIUS:
But, well, I want to take just a couple of
minutes to tell all of you that I really do think you
are at an historical time and entering the health field
at an amazing opportunity. Where there is, I think
transformation is an overused word, but to use it in
the context of what’s going on in health
care right now is not at all an exaggeration. There is a lot going on. Delivery system reform,
overall health reform, a lot of public
health conversations that just were not even
possible a number of years ago. Global collaboration in a way. And I think the upside of
some of this Ebola outbreak will be an understanding
of how connected we are in a global world. That we really can’t sit
back in the United States or in an industrialized
country, and say it really doesn’t matter what happens over
there because what happens over there is going to
be ours in a moment. And that was a difficult concept
to even to talk about five and six years ago. So you are really at an edge of
a new beginning, a new chapter. It’s a very exciting
place to be. We need competent,
globally minded, health in all policy folks emerging
because really we will not be a prosperous, successful
country unless we are healthier country. And we won’t be a
healthier country unless we help to make
a healthier world. So I just want to
congratulate you for choosing this,
first of all, but also to tell you that we
need great leaders. And you’re going to
be well positioned to do very exciting
things in the future and I’m just
delighted to be here. TIM JOHNSON: I am also
supposed to remind everybody that the next forum is
November 4 with Paul Farmer from Partners in Health. And I want to close
this session by saying that while there have
been some questions and controversy surrounding
some of your policies, I have never heard
anybody question your personal integrity or your
desire to help those in need, and we’re honored to
have you here today. Thank you very much. KATHLEEN SEBELIUS: Thank you. Thanks so much.

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