Contagious Conversations / Episode 5: The State of Health
Fighting for healthier communities at the state level
Dr. Rebekah Gee shares her journey to becoming the secretary of the Louisiana Department of Health and how she is working to fight major health challenges, such as Hepatitis C in Louisiana, and discusses the complexities of bringing together partners to work on a myriad of issues from pregnancy to poverty.
Below: Governor John Bel Edwards (left) and Dr. Rebekah Gee meet with one of the Louisianans newly able to gain access to health care through the Medicaid Expansion, at a 2016 event at the CareSouth Center in Baton Rouge (part of a statewide expansion education tour).
Transcript
Claire Stinson: Hello and welcome to Contagious Conversations. I'm your host, Claire Stinson. Every episode, we'll hear from inspiring leaders and innovators who make the world healthier and safer for us all. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help the Centers for Disease Control and Prevention save and improve more lives.
Joining me today is Dr. Rebekah Gee, secretary of the Louisiana Department of Health. Dr. Gee is an OB-GYN and brings a caregiver's perspective to the people she serves. She is also a trained policy expert who has served in numerous state and national policy roles, and in 2017, she was elected to the National Academy of Medicine. Prior to her role as secretary, Dr. Gee served as the director for the Birth Outcomes Initative, where she led the charge to decrease infant mortality and prematurity statewide. In this episode, Dr. Gee shares her inspiring path to becoming the secretary of the Louisiana Department of Health, and how she is working to fight the unique health challenges such as Hepatitis C in Louisiana. Welcome, Dr. Gee.
Dr. Rebekah Gee: Thanks for having me on your conversation.
Claire Stinson: We're really excited to talk to you today. So, Dr. Gee, let's start by talking a bit about your background. You started your career as an OB-GYN. What inspired you to become a physician?
Dr. Rebekah Gee: So, when I was in the seventh grade, I learned that my mother had breast cancer, and when I was in the tenth grade, I learned that her cancer had returned. I watched the cancer spread to her lungs and her brain, and watched her go through that illness and eventually pass away, and saw how quintessential her caregivers were to our family's experience and to her experience. But also saw some of the gaps that needed to be filled in terms of the patient and family experience, and bringing the family into the healthcare decision making, and so that inspired me to become a physician.
I wanted to take care of women. I didn't know I would be an OB-GYN. I thought I was going to go into cancer care, but OB-GYN is a field that is extraordinary because you're able to hold the hand of a baby and see their eyes open in the first moments of their life, but also care for women as they're dying from GYN cancers and care for women throughout their lifetime. And so, it's a wonderful, wonderful field. But I certainly came upon it by accident, but it is an incredible part of who I am. It informs being a physician, and having been a caregiver, it informs every aspect of the policymaking that I do.
Claire Stinson: That's really inspiring. Do you feel like you really bring that caregiver's perspective to everything you do?
Dr. Rebekah Gee: Absolutely. I see myself as an advocate for the patient. Everything we do at the health department touches the lives of the 4.6 million people in this state, and whether it's clean water or ensuring that we are prepared for a hurricane when it's coming our way or dealing with the aftermath of flooding in our capital city in 2016 or making sure that people have covered services. I understand what it's like for patients. I've also been a patient. I was in a terrible accident that killed my first husband, and it required that I spend several months in a wheelchair. And so I've been a patient. I've been a caregiver for someone who was a patient. I am a physician and so that perspective informs the decisions I make, and I always try to think of the patient first, and then all of the other considerations second.
Claire Stinson: That's really amazing that you have experienced both sides and both perspectives. That's probably really important for a physician to have.
Dr. Rebekah Gee: Yeah, absolutely. So many of the conversations... I have a mantra that is informed by Don Berwick which is, "Nothing about me without me," and so that perspective informs how we make policy, and whether it's creating an office of Community Partnership and Health Equity here at the Office of the Secretary, or it's doing statewide tours before we make big decisions and get input from our communities, from our physicians, from our patients. It is a different approach from what I've seen previously in Louisiana, and it has definitely improved our relationships with communities and our outcome with patients.
Claire Stinson: So let's talk a little bit about your work in Louisiana. First, can you tell us what led you to your current position at the Louisiana Department of Health?
Dr. Rebekah Gee: So, I met my husband 10 years ago totally by accident at Jazz Fest. It just ended, but I recommend to everyone listening that you come to Louisiana, experience our music and our culture. I fell in love with my husband and with Louisiana, and had always wanted to be involved in public health policy and in clinical practice. And so that passion led me to work in the Medicaid program, and we elected a governor who was a Democrat, and he asked me to serve in part because I had been the Medicaid medical director and had run the Birth Outcomes Initiative, which was an effort to reduce prematurity. I have always been interested in advocating for and working on behalf of vulnerable populations, and certainly in Louisiana Medicaid is where that's at, but our office also, as I mentioned earlier, oversees emergency preparedness, disability services and a variety of areas of public health that are important for vulnerable populations.
Claire Stinson: So, as health secretary, I'm sure you are confronted with a myriad of health issues that citizens and politicians want you to address. How do you prioritize these? And how does data factor into those decisions?
Dr. Rebekah Gee: So first you prioritize the safety of the public. So the governor and I in the first two years of our time experienced over 80% of our parishes or counties under federal declaration because of severe climate events that happened in our state. And so, certainly as priorities go, if there's a crisis like a hurricane or a flood where thousands of people are impacted, the Zika virus threat, anything that is a major public health challenge is the priority. And then of course running a good Medicaid program is always at the top of the list. It's our largest budget item, working cross-sector with other secretaries and other agencies. Our Hepatitis C elimination project has been very, very exciting and a top priority, because Hepatitis C kills more Americans than any other infectious disease, and so you look at the number of people, and you use data to determine how many people are impacted by a certain disease or condition.
There's always the politics that factors in, so the advocacy groups and political considerations also determine how things are prioritized, but I also recognize that there are groups that do not get the advocacy at our capitol, like individuals who are aging in our communities and are isolated. Or public health conditions for people like those with Hepatitis C, where there may not be the advocacy strength but the need is there. I try to fill in those gaps and advocate for those populations, and speak for those whose voices often aren't heard at the capitol.
Claire Stinson: So you mentioned Hepatitis C. Why did you decide to tackle that issue in Louisiana? And what kind of progress are you making?
Dr. Rebekah Gee: Hepatitis C kills more Americans than all other infectious diseases combined, and so as a public health challenge, really nothing is as significant as Hepatitis C in our time. Also, Hepatitis C has a cure. Unlike the common cold or HIV, we actually have a cure for Hepatitis C. And it was unacceptable to me that there would be people who would suffer and some of whom would die in our country, today, because of the cost of this medication being prohibitive for what I think should happen, which is universal cure. And so, we have set out for the past three years to solve the price equation. It was an equation that could not be solved with our current drug pricing structure, and so we're proud to say that Louisiana has innovated and is the first state in our nation to create a subscription model for access to Hepatitis C.
We're really, really excited about this. It was a rate limiting step to be able to afford the drug. At the previous price, the cost of curing all of the people in Medicaid and corrections, which are about 35,000 people in our state, would have been more than our combined budget for all administrative functions of government, corrections and K-12 combined. So just it was an impossible thing, and so now that we are at a point where we can afford the drug, we're able to then innovate on delivery systems and think about how we access patients differently, how we get to people where they are rather than make them come to us, and think about transforming infectious disease care for our state.
We're going to be having the national experts on hepatology come to our state next week and talk about new ways of testing in an environment that's not resource constrained like we have now because of cost, but is resource unlimited. So we're really excited to be leading these conversations, not just about drug pricing, which we're proud to have done. We were able to bring together through the NGA eleven different governors from a variety of states, of both Republican and Democrat, and talk about solutions to this, and we're also leading national conversations about how we solve problems of infectious disease. And so, it's a wonderful area of focus, and one that we've already made significant progress on.
Claire Stinson: Wow, that sounds like you are making a lot of progress in Louisiana. So I understand that Hepatitis C is a disease that not many people understand or think about, would you agree with that sentiment?
Dr. Rebekah Gee: So this is a disease that's very very infectious. As opposed to HIV, your chances of getting Hep C are much higher if you get stuck with a needle or share a needle, and so the opioid epidemic is causing an uptick in number of infectious Hepatitis C cases, but also we saw in the Baby Boomer generation many many people exposed to Hepatitis C through blood transfusions that at that time were not screened for Hepatitis C. So, it's something that takes time to cause harm though, because over time it causes scarring of the liver or can cause liver cancer, but those are not problems that people realize in the first year of infection. It's something that people generally get over a decade or decades of infection, and so that's the challenge. I think also there's some stigma about Hep C and so people don't talk about their illness with Hepatitis C, and so it's something that we're going to need to do a lot of education about, something that we're really excited about actually putting in the rear view mirror, again, because this is an infection that can be cured.
Claire Stinson: Absolutely, and it sounds like in a lot of ways Hepatitis C can be a silent disease and a silent killer. So, it's really important that you all are tackling that in Louisiana.
Dr. Rebekah Gee: That's right. Many people don't know that they have Hepatitis C, and so many of our efforts will be focused on educating people, getting them tested. We're encouraging universal testing in our hospitals throughout the state, particularly in regions that are high-risk like New Orleans and our capital city, Baton Rouge. Some people don't have severe symptoms, and some people do. The bottom line is there are people today who have chronic and long-term damage to their livers that could be cured and we just simply were not able to provide the cure to them early enough to prevent that damage. And so that's the goal of the Hepatitis C initiative is to prevent anyone from getting sick from this virus going forward.
Claire Stinson: Well, congratulations on the progress you have made so far.
Dr. Rebekah Gee: Yeah, also I think it's important to note that this was a major breakthrough in medicine. The vaccines that have saved so many lives were a breakthrough, but the Hepatitis C direct-acting antivirals were very, very instrumental and exciting, and so I think it's important to... part of the dance that we've done is to recognize that, and to celebrate the pharmaceutical industry for helping to produce a cure and for helping to bring that to market and broad-scale access throughout the world. But also working with this pharmaceutical partners to come up with a new pricing mechanism that allows more people access. But at the same time, we needed to provide access to people right now. So it's been a delicate dance.
Claire Stinson: We'll be right back with Dr. Rebekah Gee.
Since this is a show about contagious conversations, we want to hear from you. Each episode will ask you a question, and this episode's question is: what is the best career advice you ever received? Just email info@cdcfoundation.org to answer. That's info@cdcfoundation.org, and if you share your thoughts with us, you'll have the chance to win some CDC Foundation merchandise.
And now, back to our conversation with Dr. Gee.
I was interested to see that you were involved in an initiative related to infant mortality and prematurity prior to your role as Secretary, can you tell us a little bit about that?
Dr. Rebekah Gee: Yeah, so the Birth Outcomes Initiative was one of the first broad-scale quality improvement efforts at the state level, at least for Louisiana. We were the first state to engage the Institute for Healthcare Improvement in all of our major delivery hospitals to both create a culture of quality improvement or help to foster that, but also to create a really safe team culture where nurses' voices were heard, and the entire healthcare team was involved in complex patients. We also implemented a novel way to pay for deliveries that allowed us to know whether you were delivering a baby before 39 weeks for a medical reason or not, and be able to pay differently. And so, it was a very successful initiative that had impact on infant outcomes, and we mentioned the 25% decrease in infant mortality, and the significant drop in deliveries before 39 weeks as well as the decrease in NICU admissions.
I think one of the sad things was that while we were doing this work, however, we did not realize that we had a crisis of maternal mortality or mothers who were dying, because of their pregnancy, and so that's our focus now, and something that we need to address nationally. In fact, there are severe disparities and outcomes and that race matters, and in Louisiana, when we did our material mortality reviews of Caucasian women, when we looked at their deaths, 9% of their deaths could be preventable. But with women of color, African-American women, 59% of their deaths were preventable.
So if that doesn't convince you that we need to have a conversation about implicit bias and race and how that relates to maternity care, I don't know what would. And so, we're really interested in not just improving outcomes for babies, but also for mommies and that's our current focus. But we certainly, the U.S. has a long way to go compared to the developed world outcomes for both babies and mommies, and in particular our outcomes for African-American women are unacceptably bad, and for African-American babies as well, and so we need to understand and address these issues. And certainly Louisiana is committed to that.
Claire Stinson: All really important points, and the CDC Foundation is also involved in a project related to maternal mortality, so it's an issue that is very important to us as well. And I am five months pregnant right now, so I can say that I am very proud of the work that we're doing, and I appreciate the work that you're doing to protect mothers.
Dr. Rebekah Gee: Thank you, and I do want to underscore how important the Medicaid expansion has been, not just for women of reproductive age, women who are pregnant, but for all of the citizens of this state. That when the governor and I took over, one in four adults in this state did not have insurance. That meant that one in four adults did not get cancer screening, one in four adults did not get mental health screening or treatment. One in four adults did not get treatment for their substance abuse or primary care. They got their care in an emergency room. The expansion has transformed our state. We now have an uninsurance rate of 8%. Women are getting care not just during pregnancy and then being kicked off like they were before, they're getting care before, during and after their pregnancies.
We've treated... I told you my mom died of breast cancer, nearly 700 women have been diagnosed with breast cancer as a result of the expansion, including a patient I saw in my office a few weeks ago. And so, we're able to improve the quality of care people are getting and that will certainly pay dividends in terms of our birth outcomes and our maternal outcomes, but also has already paid dividends in terms of lives saved from preventable, late-diagnosis of cancer, and from untreated mental illness. So, this is something we're really, really proud of. Nearly 500,000 Louisianians have benefited from the Medicaid expansion that Governor Edwards made very central to his campaign, and he's very proud of.
Claire Stinson: So it really does sound like your perspective as a physician and a caregiver really does play into everything you do.
Dr. Rebekah Gee: That's right. I think that it's great to have a physician or a nurse or a caregiver in a job like this, because it layers on a perspective that somebody that just has a finance background, let's say, wouldn't have, or somebody who hasn't been a patient wouldn't have. It takes being in a hospital gown and have the humility that occurs when that happens to really understand frankly how important nurses are. And when you're in pain and you need a nurse, no one's more important than your nurse. And we doctors are taught that we're the center of the world, and that's just not true. But I think having those diverse perspectives certainly does help inform what I do.
Claire Stinson: Absolutely. So, what would you say is the most complicated part of your job as Secretary of the Department of Health?
Dr. Rebekah Gee: So, politics is the most complicated part of the job. The American political system is robust and vibrant, but it's... there are many, many, controversies. There are a lot of trigger areas. We had a today a debate about vaccines at our legislature... the fact that we're even debating vaccines―the single arguably most important invention that has saved lives in terms of a healthcare intervention in the world's history―and then we're sitting here debating it, is very frustrating. It's frustrating that people have low attention spans on this Twitterverse and constant news cycle has led people to kind of create instant facts and not to do the reflective thinking that's required to understand complex issues. And so, trying to navigate that is very difficult, but also trying to reach people.
I have two master's degrees and a medical degree. My knee jerk is to explain things in complex terms, but then we lose people, so it's how do you communicate things with the public so that they understand why we're doing it, and that's a big challenge too. I think arguably one of the biggest failures of the Affordable Care Act was that the American people didn't understand it. They didn't understand what was going on, why it went on, why healthcare prices were rising and so on, and so I think that's really important. We have focused on communications around the Medicaid expansion, and I do think that we've been successful. We know that about 78% of Louisianians approve of the expansion, and I do think when you drill down and focus on what matters to people in ways that they understand and engage the public in sharing information, you can do a lot better job making good policy and making sure that that policy endures.
Claire Stinson: Yes, understandable. So what is the biggest public health challenge you face in Louisiana?
Dr. Rebekah Gee: So, I'll define public health in its broadest terms. I think poverty is our biggest challenge. The fact that 40%... We're one of three states in the nation where 40% of our folks or more are under 200% of poverty. We have children every day who wake up hungry. We have communities that are hopeless, where jobs have left, just like many parts of this country, and it's that hopelessness and that poverty that leads to poor health, that leads to infectious disease. Our biggest opportunity is to help create a more robust economy. The Medicaid expansion alone created 19,000-plus jobs. Our unemployment is going down. But there is still a long way to go, and it's certainly poverty and lack of education that creates the conditions for poor public health, and is our biggest challenge.
Claire Stinson: That's really interesting and important perspective. So here's a question I'm excited to ask you today. What career advice do you have for the future public health leaders of America?
Dr. Rebekah Gee: As a former public health professor, what I would tell the students or folks interested in public health careers is that you have to marry not just your idealism with good policy, but you have to think about the financial case for good policy. I was just on the phone before this with Andy Slavitt who was in the Obama administration and was a senior leader in that administration. We were talking about this issue around community health workers. Many of us support this notion that you should have a home visit or a community health worker, that women should have a doula as an advocate if they need one. But until we have a model to pay for that, we're not going to have large scale implementation, so I think that what public health needs is a marriage of the good ideas and the population health framework with ideas that are financially viable.
And so, as Secretary of Health, I have the good fortune of overseeing both the Office or Department of Public Health, as well as Medicaid, and so we marry those ideas and the implementation of those together through our programs. But often public health is siloed. Public health is an afterthought, and our individuals that are public health professionals don't have the opportunity to be central in the discussions about how we move forward with a delivery system, but delivery system and public health need to be married for those to be optimized.
Claire Stinson: That's important advice. So, do you have any specific advice for women who want to be public health leaders?
Dr. Rebekah Gee: Well I'm the parent of five children. I have a set of twins and then when I married my husband, he had a set of twins and a little boy, and so we have five children in our home. And when I was asked to do this job I was told by several people that I couldn't do it, because I had two-year-old daughters, and I think my advice for women is do whatever you want, and sometimes the system needs to bend to you. You don't have to bend to the system. You don't have to change. You don't have to give up on being able to be a mother and having a life that you want if you want to be a leader.
You can do both, but that sometimes means that you don't go to every dinner you're invited to, or you don't always have to have every meeting in-person, but you do have to be present and passionate, and you have to lean in. But you can be powerful and you can have a family. I want my girls to know that they don't have to make sacrifices, but we have a long way to go. There was an article last year, there are more men named John as head of Fortune 500 companies than there are women. That should give us all pause, and I think we need to think about how to support women and the work that they do, and allow them to also be parents.
Claire Stinson: All really important advice, thank you. Thank you so much for sharing your story with us today, Dr. Gee, you have had such an interesting career path, and I enjoyed talking with you today.
Dr. Rebekah Gee: Thanks so much. I really appreciated talking with you.
Claire Stinson: Thanks for listening to Contagious Conversations, produced by the CDC Foundation and available wherever you get your podcasts. Be sure to visit cdcfoundation.org/conversations for show notes and bonus content, and if you like what you just heard, please pass it along to your colleagues and friends, rate the show, leave a review, and tell others. It helps us get the world out. Thanks again for tuning in, and join us next time for another episode for Contagious Conversations.