In N.C., Mandy Cohen built bridges to GOP. Can she find consensus as new CDC director?

Mandy Cohen, who this week became the new director of the Centers for Disease Control and Prevention, has a secret weapon: She knows how to talk to Republicans.

As North Carolina’s Secretary of Health and Human Services from January 2017 to December 2021, Cohen had a remarkably bipartisan record in a state with a fair share of partisan rancor.

She convinced leading conservative lawmakers to back Medicaid expansion — although the deal would be finalized later by her successor. She won the Trump administration’s support for an innovative — and progressive — $650-million-dollar Medicaid waiver to address social drivers of health like homelessness, food insecurity, and lack of transportation.

And Cohen led North Carolina through much of the coronavirus pandemic, not without controversy but without the toxic backlash that has prompted other Republican-led state legislatures to eviscerate the power of their public health agencies and officials.

The question now is whether she can build bridges to Republicans in Washington. It’s a lot easier to cultivate relationships in a small-ish state capital, after all, than it is in Washington — and there’s a large contingent of Republicans in Congress who have made clear their disdain for, and distrust of, public health experts.

But some officials who have worked with Cohen previously are hopeful she can break through.

“Mandy understands the task in front of her. And I think she will approach this one, reaching out to key folks on the other side of the aisle to find out where they think CDC can perform better and should perform better. And if she finds agreement with that, she will work night and day to make those changes,” said former Sen. Richard Burr of North Carolina, a consistent Republican voice for public health preparedness, who worked closely with her until he retired in January.

N.C. State Sen. Jim Burgin, a Republican who is co-chair of the Senate Health Committee, wasn’t a Covid-denier; he went to way too many funerals to shrug it off. But as a conservative lawmaker and businessman, he disagreed with Cohen — about the duration of school closures, restaurant shutdowns, and the breadth of pandemic measures.

But he said he came to trust her. He appreciated that she was talking to him, not past him, and that she listened. He said he never questioned her motives, or that she was doing her best to follow the science. “I think she always tried to do the right thing, and if she erred, she erred on safety,” he said.

That’s not how Republicans in Washington generally talk about leaders in public health.

Others who know Cohen point out that her ability to gain consensus in North Carolina was all the more remarkable because it wasn’t as though she had been working in the health care trenches there for years, building political capital.

“I think the job interview was the first time she’d been here,” said Democratic Gov. Roy Cooper, who appointed her. (Actually, Cohen had visited Asheville once on a vacation.) Cooper said a lot of Republican lawmakers came to believe her word was good.

“She is relatable, even though she is brilliant,” the governor said. “She has a boatload of common sense. And she’s a likeable person.”

That likeability was apparent during the pandemic, as she sought to be as honest and clear about the unknowns as the knowns. One health policy expert in the state, who comes from a quite conservative family, said his mother kept calling him after Cohen’s TV appearances and reminding him “to do what that nice Mandy Cohen says.”

Cohen, who is petite and looks younger than her 44 years, wears a gold necklace spelling out the word for “life,” in Hebrew, a gift from her mother when she started med school. She was raised in Long Island, trained at Yale and Harvard, and held several posts in the Obama administration, which is how Cooper heard about her. Not only did she work for the Obama administration, she helped implement Obamacare.

In short, her bio didn’t make her a shoo-in for success in North Carolina, a politically divided state where the legislature has shifted right. But even her ideological opponents acknowledge she’s a good listener and a bridge builder who can shore up trust — an important challenge at the pandemic-battered CDC.

At her final appearance before a GOP-led legislative oversight panel in North Carolina, she got a standing ovation.

Cohen was not doing interviews during her first week in the job. But in interviews over the years, and in several panel discussions, she’s spoken about closing partisan gaps one at a time, and about building trust day by day — preferably before a crisis.

“Even when we didn’t have all the answers [at the height of the Covid pandemic] — which we didn’t — we were able to lean on the fact that we were being transparent and communicating.… Folks knew at least that we were working hard and I think that mattered,” she told a forum sponsored by the journal Health Affairs as she stepped down from her N.C. health post and joined Aledade, a company that helps physicians work together to create new ways of providing cost-effective, well-coordinated care.

Not everyone is charmed. When Cohen’s name emerged as President Biden’s likely choice for the CDC post, 28 conservative Republican senators and members of Congress wrote him that she was “unfit for the position.”

“Throughout her career, Dr. Cohen has politicized science, disregarded civil liberties, and spread misinformation about the efficacy and necessity of COVID vaccinations and the necessity of masks,” they wrote. “She also has a history of engaging in partisan leftwing politics,” they added, noting her support for the Affordable Care Act and for a ban on semi-automatic rifles, as well as her depiction of climate change as a public health crisis.

But 28 Republicans isn’t a lot. And although two of the signatories were from North Carolina — Sen. Ted Budd and Rep. Dan Bishop, both quite conservative — the state’s other Republican senator, Thom Tillis, didn’t sign on, nor did the other six Republican members of Congress from the state. (There are also seven Democrats.)

Cohen doesn’t need to win over every single lawmaker. As she lobbies for the CDC budget, which is not likely to rise in the current political climate, or asks Congress for changes that will help her make the giant public health agency more agile, she just needs a handful of Republicans to cross the aisle. And that’s where her bridge-building skills could come into play.

“She will never gain the support of everybody. But I think she stands a great likelihood of gaining the type of support she needs to make sure that CDC is provided the tools that she needs,” said Burr, the former senator who is now a health lobbyist.

Cohen got a lot done in five years in North Carolina. It helped that she was able to find some common ground early on in relatively bipartisan areas, like opioids and mental health.

Under Cooper’s GOP predecessor, the state decided to introduce Medicaid managed care — Medicaid “transformation,” as Republicans called it. Cohen didn’t waltz in and try to undo that. Instead, she pledged to make it work and to make Medicaid spending more predictable. In return, she asked Republicans to think about Medicaid more broadly and about how expanding Medicaid under the Affordable Care Act could actually be a smart investment for the state and its health providers.

Cohen also won points with her emphasis on measurement and accountability, said Mark McClellan, who worked closely with Cohen on technical aspects of implementation as director of the Duke Margolis Center for Health Policy and who learned a thing or two himself about navigating political minefields when he served as both CMS administrator and FDA commissioner under President George W. Bush.

It took Cohen a few years to build support for Medicaid expansion; financial sweeteners that the Biden administration threw in helped. Expansion didn’t get finalized on her watch; it got caught up in assorted other budgetary and policy battles. But the framework Cohen constructed endured, enabling Cooper and Cohen’s successor, Kody Kinsley, to finalize it this year. Since the early years of Obamacare, only in North Carolina and Virginia in 2018 did a hold-out state expand Medicaid through bipartisan votes in the state legislature. Other conservative states were forced to expand via ballot initiatives. About 10 are still resisting.

North Carolina just missed its July 1 deadline to start expansion because the state budget hasn’t been finalized, a pre-condition. Both sides say it’s still on track — late, but not derailed.

The “Healthy Opportunities” waiver also took work. Cohen would stress to Republicans that addressing social determinants of health was good ROI — and was the right thing to do. And she got broad support — partly because people like Sen. Phil Berger, state Senate leader, came around. “We’ve had a great working relationship with Sec. Cohen,” he said at the time.

Cohen also got the state through Covid. The legislature in the 2021 budget did include some limits on a governor’s ability to declare a state of emergency past 60 days without lawmakers’ agreement. But it wasn’t effective until this year — after the brunt of the pandemic was over. And Republicans didn’t gut all the powers of the health department, or tie health officials’ hands on things like masks and vaccines if there’s another surge of Covid or a different emergency. Given what’s happened in more than half the states, health officials say, that’s a win.

Gov. Cooper knows the CDC will be tough. Cohen is “going to have to deal with congressional inquiries and outside political attacks,” he acknowledged. But she’s been there before — she was working in Washington helping build up Obamacare when Republicans were trying to bring it down. And she was a national Democratic voice on Covid when the pandemic broke out under Trump.

“She’s taken her slings and arrows,” Cooper said. “She’s a perfect choice.”

Correction: An earlier version of this story incorrectly described Sen. Phil Berger’s title.