This series is part of a spotlight on members of NASHP’s Academy, showcasing the expertise and leadership they bring to advancing state health policy. Each feature offers a closer look at their work and the meaningful contributions they make to NASHP’s mission.
When Nate Checketts, interim director of Utah Medicaid, and Norm Thurston, Utah State Representative and Executive Director of the National Association of Health Data Organizations (NAHDO), sit down to talk policy, there’s an easy familiarity — the kind that comes from 20 years of professional overlap. In this Q&A, they reflect on what first drew them to health policy, how their teams turned complex policy ideas into real-world impact, and lessons they’ve learned.
Can you both talk about an experience that first pulled you into health policy and how that led to your current roles?
Nate: I was working in the Governor’s Budget Office and was assigned to the Department of Health and had the chance to see the different programs it operated. One was the relatively new Children’s Health Insurance Program (CHIP), and I was excited about how the state was educating families about the opportunity to enroll and receive services. Eventually, I was able to come to the Department of Health, work in the CHIP program, and eventually become its director.
Norm: I spent most of my graduate years looking at health care workforce, specifically physicians. Working in academia, I thought it’s always fun to be involved in research, but what I really want to be doing is policy. It’s much more fun to be in the room where it happens. Later, I did more work on insurance, which led me to the governor’s office, and then NAHDO, which came as a natural consequence of being interested in how science and data translate into real-world policy.
You’ve both worked at the intersection of policy design and implementation for many years. How has collaboration between the legislative and executive branches shaped Utah’s approach to health reform?
Nate: After the Affordable Care Act passed, Utah was not an expansion state for many years. Then we had a proposition that moved the state to expansion and added a tax to fund it. The legislature looked at what was required by the proposition and decided to come in during the next legislative session and add additional requirements. I was Medicaid director at that time, and there was intense discussion with legislative champions related to implementation. They wanted to have the state look at a per capita cap first, before it went into a traditional full expansion, and whether or not we’d be allowed to have a work requirement. It was a very interesting interaction to have the citizens of the state and supporters of the initiative come together and have the proposition pass. Then to provide legislators with information as they had debates. Then to move forward once the bill passed, and work with the Centers for Medicare and Medicaid Services on our waiver applications, was very interesting.
Norm: I spend a lot of time on state employee health benefits, another area where we pay for health care for a lot of Utahns. Having that great working relationship with our Public Employees Health Plan, you can see they really understand the importance of providing something of real value. In recent years, I’ve had more opportunity to work with the legislative and executive branches to figure out what we are doing to attract and retain good employees and make sure our employees and their dependents have high-value and quality health care, and balance all of those in a budget. Utah is really leading the nation in innovative designs for our employee benefit plans.
Utah has a reputation for creative, data-driven policymaking. Is there an example where that innovation has really paid off for residents?
Norm: Hearing from the type 1 diabetes community about the impact of high insulin prices and what that does to their health. When you can’t afford insulin, you tend to not take as much as you should. Or young adults just don’t take it at all and end up going into diabetic ketoacidosis. I appreciate being able to work with our community that is heavily impacted and then design a public policy approach, to make insulin consistently affordable throughout the year.
Nate: Utah’s behavioral health care continuum is something we’ve collectively, both the executive branch and the legislative branch, worked on developing. We have an app our students can use to access mental health resources. Also, our legislators and those in Congress were some of the first pushing the 988 number as a way to provide access to support lines and making that universal across the country.
We’ve followed that up with crisis support services, with mobile crisis outreach teams, and created the Behavioral Health Commission, which allows experts to weigh in about what is the state’s plan, what’s working, what’s not working, and where should we go next.
NASHP’s conference and Academy programs are built around peer learning. Has a conversation or idea from another state influenced the way Utah approached a challenge?
Norm: I would point to the observation of why certain brand-name drugs in other countries cost less there than they cost here. That idea did not originate in Utah, I believe it started somewhere in New England, maybe Vermont. People were looking at that and trying to figure out how you navigate the federal regulations, international relations, etc., and make all this work so you can import that drug at a lower cost. The key is, even though the idea comes from somewhere else, you have to make it your own. We had to customize that program to our geography, to our demographics, and the needs of our citizens.
Nate: Working with NASHP means you have the chance to share and learn at the same time. I’ve inevitably found that even in an area where someone may say, Utah’s far ahead in this area, or New York’s far ahead in this area, even in those circumstances, you’re still learning from other states where they’re strong and you’re not. I think about the State Reentry Learning and Action Network, and the work related to justice-involved individuals, and opportunities states have to share their progress and learn from each other. The network has given our staff a sounding board to say, here’s what we’re working on, here’s what we’re thinking about.
How do you approach the balance between long-term system reform and the immediate needs of communities and families?
Norm: In an ideal world, we wouldn’t need a Medicaid program. That’s the challenge from a policy perspective — how do you take care of immediate needs but always keep a focus on helping people improve their situation permanently, so this is truly a temporary need. It’s part of a much more comprehensive policy system that involves higher education, public education, workforce development, economic development, and so on, so we are providing tools and opportunities for people to advance, grow, and progress.
Nate: I’m in an interim role as the state’s Medicaid director. One of the things we’re doing as we’re transitioning from the previous leadership team is to look at what we’re working on, and prioritizing that work, through the lens of what is providing the biggest impact to the most number of individuals. Then sometimes making hard decisions of saying, this is an area that is very interesting, but we just can’t go there right now. We really need to focus on some of the basics of how our programs run.
For those just beginning their careers in state government or health policy, what piece of advice or perspective would you want them to carry forward?
Nate: I started out as a legislative auditor. It wasn’t necessarily where I thought I would start, but what I loved about it, and what people could try to replicate in other ways, was it allowed me to see how multiple agencies worked. I would encourage individuals new to the field to look for those broad exposure opportunities, that can help narrow down your area of interest, but also to be able to carry those lessons with you as you move into your next role.
Norm: I frequently get asked to speak to school kids as young as 6th or 7th grade, and a lot of them will say, “What did you do to prepare yourself for what you’re doing now?” I always tell them, I did not know, when I was your age, that what I am doing now even existed. The way you prepare for the unknown is to keep the doors open and pursue your interests. Policy is such a broad, undefined thing that you just have to follow up on opportunities where they meet you.