Dr. Mandy Cohen on Fixing the Broken Systems of Public Health

What does it actually take to fix a broken health system — and what happens when the progress you've built starts to unravel? Dr. Mandy Cohen, former CDC Director, former Secretary of the North Carolina Department of Health and Human Services, and longtime leader at the Centers for Medicare and Medicaid Services, joins Dr. Rohan Ramakrishna for a wide-ranging conversation on what it means to lead at the intersection of medicine, policy, and operations.Dr. Cohen traces her journey from accidental operator during the HealthCare.gov crisis to architect of one of the country's most ambitious social determinants of health programs in North Carolina — and ultimately to the helm of the CDC during its most consequential rebuilding effort in decades. She speaks candidly about the promise and limits of value-based care, the systemic importance of primary care–led ACOs, and why she's deeply concerned about the current state of vaccine infrastructure. She also shares her framework for building public trust — transparency, relationships, and results — and why getting the payment models right is the only way AI will actually improve health outcomes rather than just optimize revenue.New episodes are released every other week, wherever you get your podcasts. For more from Roon, visit: ⁠https://www.roon.com/⁠ Sign up for our substack: ⁠https://rohanramakrishna.substack.com/⁠ Find us on Instagram and X: @roondoctors If you have a question, comment, or suggestion for a future guest, please email us: [email protected](00:00) Intro(03:15) Welcome — Dr. Mandy Cohen(03:37) Why she went into public service(06:06) Discovering she was an operator: The HealthCare.gov crisis(08:30) The limits of ambition in government(10:40) Coalition building as a leadership tool(11:51) The origins of value-based care and CMMI(13:45) The case for primary care-led ACOs(16:31) Physician-led vs. hospital-led value programs(17:22) The complexity problem in programs like TEAM(19:10) Blood pressure control as a key intervention(20:25) Day one as NC Secretary of Health and Human Services(22:15) Rebuilding culture before setting priorities(23:30) Working across the aisle in North Carolina(25:11) The Healthy Opportunities Pilot: Social determinants at scale(26:53) Navigation as the highest-impact intervention(28:57) Behavior change and the limits of education programs(30:39) Coalition building for social determinants policy(33:26) Lessons that other states have learned from NC(34:13) Arriving at the CDC post-COVID(36:10) Modernizing siloed data systems(38:00) Rebuilding the CDC's lab infrastructure with private sector(40:01) Where pandemic preparedness stands today(42:55) The return of measles — and what it means(43:58) How Dr. Cohen rebuilt public trust during COVID(46:30) Trust in three parts: Transparency, relationships, results(49:05) Advising health systems on AI(51:00) Payment models and the AI trap(52:54) AI tools she's excited about(55:13) How health systems should evaluate AI vendors(58:31) Does Epic have too much power?(1:00:20) Paying for outcomes, not activity(1:03:22) Doctors building their own tools(1:04:42) Leadership philosophy for change management(1:08:30) Making hard calls that will upset people(1:10:54) Communicating under uncertainty(1:13:58) What the medical community should have done differently(1:17:17) Quick Hits: Mentors, books, and inspiring leaders(1:20:08) Guest recommendation for Good Medicine(1:20:39) Closing