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Can Mandy Cohen, director of the CDC, achieve consensus in Washington?

The new director of the Centers for Disease Control and Prevention, Mandy Cohen, has a secret weapon: she knows how to communicate with Republicans.

Cohen’s record as North Carolina’s Health and Human Services Secretary from January 2017 to December 2021 was remarkably bipartisan in a state with a reasonable amount of partisan rancor.

She persuaded prominent conservative legislators to support Medicaid expansion, although her successor would ultimately finalize the agreement. She gained the support of the Trump administration for an innovative and progressive $650 million Medicaid waiver to address social determinants of health, such as homelessness, food insecurity, and a lack of transportation.

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

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The question now is whether she can establish bridges with Washington’s Republicans. After all, it is much easier to cultivate relationships in a small-ish state capital than in Washington, and there is a large contingent of Republicans in Congress who have made their disdain and mistrust of public health experts abundantly apparent.

However, some officials who have previously collaborated with Cohen are optimistic that she will succeed.

“Mandy comprehends the task before her. And I believe she will approach this issue by reaching out to critical members of the opposing party to determine where they believe the CDC can and should improve. And if she finds agreement with that, she will work night and day to achieve those changes,” said former North Carolina Senator Richard Burr, a consistent Republican voice for public health preparedness until his retirement in January.

The Republican co-chair of the Senate Health Committee from North Carolina, Jim Burgin, was not a COVID denier; he attended far too many funerals to dismiss it. As a conservative politician and businessman, he disagreed with Cohen regarding the length of school and restaurant closures and the scope of pandemic measures.

However, he stated that he came to trust her. He valued the fact that she spoke to him rather than past him and that she listened. He stated that he never questioned her motives or her efforts to adhere to the scientific method. He stated, “I believe she always tried to do the right thing, and if she erred, it was on the side of safety.”

This is not how Republicans in Washington typically discuss public health leaders.

Others who know Cohen note that her ability to achieve consensus in North Carolina was all the more remarkable given that she had not spent years accumulating political capital in the state’s health care trenches.

“I believe her first visit was for the job interview,” said Democratic Governor Roy Cooper, who appointed her. Actually, Cohen had vacationed in Asheville before. Cooper stated that many Republican legislators came to trust her word.

Even though she is brilliant, she is approachable, the governor said. “She possesses an abundance of common sense. And she is a charming individual.”

During the pandemic, her likeability was evident as she attempted to be as forthright and honest about the unknowns as she was about the knowns. One health policy expert in the state, whose family is quite conservative, reported that his mother frequently called him after Cohen’s television appearances to remind him “to do what that nice Mandy Cohen says.”

Cohen, who is petite and appears to be younger than her 44 years, wears a gold necklace with the Hebrew term for “life,” a gift from her mother when she began medical school. Cooper learned about her because she held multiple positions in the Obama administration, was reared on Long Island, attended Yale and Harvard, and was educated at both institutions. In addition to working for the Obama administration, she assisted in the implementation of Obamacare.

In summary, her biography did not position her for success in North Carolina, a politically divided state whose legislature has shifted to the right. However, even her ideological opponents acknowledge that she is a good listener and a bridge-builder who can bolster trust, a crucial task at the pandemic-ravaged Centers for Disease Control and Prevention.

At her final appearance before a North Carolina legislative oversight committee commanded by the Republican Party, she received a standing ovation.

Cohen did not conduct interviews during her first week of employment. However, in interviews and panel discussions over the years, she has emphasized the importance of bridging partisan divides one by one, preferably before a crisis.

“Even when we didn’t have all the answers [during the height of the COVID pandemic]—which we didn’t—wwe were able to rely on the fact that we were open and communicative… People knew at least that we were working hard, and I believe that made a difference,” she told a forum sponsored by the journal Health Affairs as she stepped down from her North Carolina health post and joined Aledade, a company that helps physicians collaborate to develop new cost-effective, well-coordinated care delivery models.

Not everybody is bewitched. When Cohen’s name surfaced as President Biden’s likely choice for the CDC post, 28 conservative Republican senators and members of Congress sent him a letter stating 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 masks,” they wrote. “She also has a history of engaging in partisan leftwing politics,” they added, citing her support for the Affordable Care Act and a prohibition on semi-automatic rifles, as well as her characterization of climate change as a public health emergency.

However, 28 Republicans is not many. Sen. Ted Budd and Rep. Dan Bishop, who are both quite conservative, were two of the signatories from North Carolina. However, the state’s other Republican senator, Thom Tillis, and the other six Republican members of Congress from North Carolina did not sign. (There are seven Democrats as well.)

Cohen is not required to win over every legislator. As she lobbies for the CDC budget, which is unlikely to increase in the current political climate, and asks Congress for adjustments to make the massive public health agency more agile, she needs only a handful of Republicans to cross the aisle. And this is where her bridge-building abilities could be useful.

“She will never acquire everyone’s support. Burr, a former senator who is now a health lobbyist, stated, “However, I believe she has a strong chance of gaining the support she needs to ensure that the CDC is provided with the necessary resources.”

Cohen accomplished much during his five years in North Carolina. It was advantageous that she was able to find common ground early on on relatively bipartisan issues such as narcotics and mental health.

Under Cooper’s predecessor, who was a Republican, the state decided to implement Medicaid managed care, or Medicaid “transformation,” as the GOP termed it. Cohen did not enter and attempt to rectify that. Instead, she pledged to make it work and increase the predictability of Medicaid expenditures. In exchange, she urged Republicans to take a broader view of Medicaid and consider how expanding Medicaid under the Affordable Care Act could be a wise investment for the state and its health providers.

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 how to navigate political minefields while serving as CMS administrator and FDA commissioner under President George W. Bush, praised Cohen’s emphasis on measurement and accountability.

It took Cohen a few years to garner support for Medicaid expansion; the Biden administration’s financial inducements assisted. Under her watch, expansion was not consummated; it became entangled in various other budgetary and policy conflicts. Cooper and Cohen’s successor, Kody Kinsley, were able to finalize it this year due to the enduring framework Cohen created. Since the early years of Obamacare, only North Carolina and Virginia expanded Medicaid via bipartisan ballots in their state legislatures in 2018. Other conservative states were compelled by ballot initiatives to expand. Approximately ten individuals are still resisting.

North Carolina missed its July 1 deadline to begin expansion because the state budget, a prerequisite, has not been finalized. Both parties assert that the negotiation is still on track— late but not derailed.

The “Healthy Opportunities” waiver required additional effort. Cohen would emphasize to Republicans that addressing social determinants of health yielded a positive return on investment and was the moral thing to do. And she received widespread support, in part due to the conversion of state Senate leader Sen. Phil Berger. At the time, he stated, “Our working relationship with Secretary Cohen has been excellent.”

Cohen also obtained the state via COVID. In the 2021 budget, the legislature placed restrictions on a governor’s ability to proclaim a state of emergency beyond 60 days without lawmakers’ approval. However, it did not become efficacious until this year, after the worst of the pandemic had passed. And Republicans did not strip the Department of Health of all its authority or restrict health officials’ access to masks and vaccines in the event of another COVID outbreak or other emergency. In light of what has transpired in more than half of the states, health officials deem this a success.

The governor is aware that the CDC will be harsh. Cohen “will face congressional investigations and political attacks from the outside,” he acknowledged. She previously worked in Washington to help construct Obamacare when Republicans were attempting to dismantle the program. She was a national Democratic voice on COVID when the pandemic broke during the Trump administration.

Cooper stated, “She has taken her slings and arrows.” She is an ideal option.

An earlier version of this article incorrectly described Senator Phil Berger’s position.

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