New England HHS director takes to the road for health care reform

WASHINGTON–Christie Hager had a perch in the ultimate ivory tower last spring, teaching public health at Harvard University after a grueling, exciting stint at the center of Massachusetts’s health care reform debate.

But one month after President Barack Obama signed the sweeping federal health reform bill, modeled in part after the Massachusetts law, Hager was back in the political mix, this time on the front lines–in New England, at least–of implementing the nearly 2,000-page Affordable Care Act.

In 2009, when Sen. Edward Kennedy, D-Mass., first nominated Hager to be New England’s regional chief for the Department of Health and Human Services, the fate of federal health reform was unclear. By the time she was confirmed for the post, her patron had died, but Kennedy’s life-long dream–federal health reform–had been signed into law.

And over the past 12 months, Hager, a Massachusetts native and UConn law school graduate, has spent her days driving from one part of New England to another, trying to help officials in the six different states navigate the complexities of the new law.

As she hit her one-year mark on the job this month, Hager had already logged more than 15,000 miles in her government-issued Chevy Impala. She’s been to Connecticut alone about two dozen times, she said.

Whether in Hartford or Montpelier, Hager has fielded questions from governors, state legislators, activists, and single mothers. She’s participated in intense policy discussions, detailed technical briefings, and free-flowing public forums.

Across New England, Hager faces a political patchwork when it comes to the controversial health overhaul. Maine’s new Tea Party-backed governor, Paul LePage, has joined a multi-state lawsuit seeking to overturn health reform as unconstitutional. Vermont’s new chief executive, Peter Shumlin, is pushing the envelope in the opposite direction, towards a single-payer health care system.

Her home-state of Massachusetts, a pioneer in this arena, is now tapping into the health reform law for additional resources, financial and otherwise, to bolster its existing health care system.

In between are states like Rhode Island and Connecticut, which have been receptive to the new law, if not at the cutting-edge of health reform. To make things even more complicated, four of the six states in her purview elected new governors in November–just as the previous administrations were starting to dig into the details of federal reform.

“There was probably a spike in the miles I drove right after the inauguration season was over,” Hager said.

Connecticut, however, has been one of the more seamless transitions. “Connecticut’s been one of those states that’s been very active and engaged in health reform from day one of implementation,” she said.

Allies describe Hager, 46, as hyper-efficient and super smart, but not a tightly-wound, type-A personality. “Laid back” is the description Rep. Joe Courtney, D-2nd District, offered of Hager, who he got to know when he was chairman of the public health committee in the Connecticut state legislature.

“When Sen. Kennedy nominated her to be the regional representative, I was doing back flips I was so excited,” said Courtney, who has also known Hager’s husband, Royal Stark, a Connecticut legal services lawyer, for years. “It’s a very unique time. You’re not about administrating existing programs. This is a real reform era that the department [HHS] is spearheading, and she’s just perfect for the job because she handled a lot of these issues in Massachusetts. It’s a very rare resume to have.”

One of her colleagues, David Abdoo, who handles intergovernmental affairs and media for the New England region, said he expected Hager to arrive from Harvard with professorial airs. He saw all the letters after her name–the J.D. for her law degree, the MPH for her master’s in public health–and figured he was in for a wonky new boss.

“She wasn’t what I was expecting,” he said. “She is a wonk in the way she thinks,” but not in the way she acts. “She is kinetic. She’s always going.”

She is also diplomatic–especially when asked about the political differences she confronts from one state to the next, as she tries to help New England officials put the pieces of health reform in place. Whether it’s accusations of over-reach in Maine or a sense that Obama didn’t go far enough in Vermont, Hager said it’s all in a day’s work.

“That’s an indication of how wonderfully dynamic and engaged this region is,” she said. That makes it “a really exciting environment” to work in.

Hager knows plenty about exciting environments. She was at the center of the action in the Massachusetts state House, when legislators were drafting that state’s health reform law. Hager served as chief health counsel to then-Speaker Salvatore F. “Sal” DiMasi.

Hager said while others call themselves “architects” of that law, she saw herself as the “general contractor.” When her boss or other legislators told her they’d agreed on a certain provision, she’d draft the language, put it in the bill, and figure out what other parts had to be tweaked or nixed as a result.

Courtney said that since Hager had a major role in the Massachusetts debate and has heard all the arguments, pro and con, it would probably be “tempting for her to cut people off at the path.” But that’s not her style.

“She’s not trying to come in to different states to lay down the law. She’s really respectful of the roles that the legislatures and the governors have, and all the different groups that are anxious” about the myriad provisions in the law, Courtney said.

Hager said the Massachusetts effort, while much smaller in scale, was in some ways harder because all the issues were new and the resources were limited. Massachusetts didn’t have the federal government as a partner, offering funding and advice, as Connecticut and other states currently do.

Under federal reform, she noted, “There’s grant funding, there’s technical assistance and a closer relationship between the department and our partners in the states.”

She said that because HHS Secretary Kathleen Sebelius is a former governor of Kansas, the focus on each state’s role in implementation is intense.  “I have very clear directions from her to make sure I’m out there and make sure I’m identifying where there are issues and concerns and needs” in the states, Hager said.

Thus the 15,000 miles clocked so far. She said she generally starts her day at about 5 a.m., long before setting foot in the office. Indeed, it’s not unusual for co-workers to get emails from her at 4 in the morning. That can be a good time, she said, to plow through the cascade of emails from the field or Washington headquarters–squeezing in a little work before her 3-year-old daughter is even awake.

But, she added, “most of my days and most of my time is either driving to other parts of New England or being on the phone with folks in New England.”

So she was in Vermont recently for a health care event with seniors. Then there was a trip to a Rhode Island bowling alley, whose owner had just learned he’d be getting a $10,000 tax credit this year thanks to health reform, for paying 100 percent of his employees’ health care costs. And last week, she was in Hartford, meeting with Connecticut, New York and Maryland officials about the health care exchanges that are to be set up by 2014.

“None of this is a matter of distributing language of a statue or a regulation and saying ‘Here, this is what you do. Here’s the plan book’,” Hager noted. “It’s more a matter of some dialogue and back-and-forth,” which is why she has to spend so much time on the road.

Hager said she can’t complain about all the time on the road, and even enjoys being out and about. Plus, she said, her husband’s driving routine is just as bad. They met in law school at UConn, and Stark is now an attorney with Connecticut Legal Services. So when he starts out from their downtown Boston home each morning, his commute is about 90 minutes one way, depending on whether he’s going to Hartford for a court hearing or the Legal Services’ Willimantic office, where he’s based.

Hager went to UConn because of one man: the late Joseph M. “Jay” Healey, a professor of community medicine and health care, who she said was a “great mentor” to her. He died unexpectedly of cancer at the end of her first year. But she stayed under the tutelage of another professor, Barbara Blechner, also a protégé of Healey’s.

Hager said she always knew she wanted to be a lawyer, but only after graduating from Smith College did she gravitate toward health policy. After Smith, she delayed her graduate studies for a job as a research assistant at the New England Journal of Medicine, working for the editor in charge of health policy articles.

In that job, she was “fascinated” by the intersection of health and law. She went on to get a master’s in public health from Boston University before seeking her law degree at UConn.

After the Massachusetts law passed, Hager went into academia, serving as a lecturer on health policy and conducting research on state regulation of health care. But when the HHS job opened up, she could not resist.

“I have spent my career in health policy and state regulation,” she said. “I thought the Regional Director of HHS? And the role they will play?” She was sold.

Of course, even as she tries to help states apply for grants and set up their exchanges, the health care law remains a moving target-the focus of legal challenges from states and political attacks in Washington. But Hager seems happy to tune that all out and focus on the here and now.

“There are so many moving parts and pieces of the Affordable Care Act because that’s part of this historic infrastructure of increasing access,” she said. And if that means hopping in her Impala again, she’s ready, even if her goal of health reform implementation isn’t always fully embraced when she arrives.

A “major theme” of the law is “flexibility for the states,” Hager noted. “And the six [in New England] have been wonderful examples of what that flexibility means and how that flexibility plays out.”