 Hey everybody, good afternoon. I'm Dr. Abdul El Sayed and this semester I have the privilege of serving as a Towsley Foundation policymaker in residence at the Gerald R. Ford School of Public Policy. Welcome to this policy talk at the Ford School event with Andy Slavin. Surely we'll be discussing the state of health care in the United States as well as the pandemic of COVID-19 in that context and I'll say more about Andy and our topic in a moment. This event is part of the Towsley Foundation lecture series and I want to thank the Towsley Foundation for their support. Before we get started, a quick note about format. We'll have some time toward the end for questions from the audience. We've received some questions in advance from the registrants and you can also submit questions on the live chat function on YouTube or tweet your questions to hashtag policy talks. Now onto our discussion. Andy Slavin is our guest for the day. He was President Biden's White House senior advisor for the COVID response. He's led many of the nation's most important health care initiatives serving as President Obama's head of Medicare and Medicaid services and overseeing the turnaround implementation and defense of the Affordable Care Act. Andy Slavin is the outsider's insider serving in leading private and nonprofit roles in addition to his government services. He is founder and board chair emeritus of United States of Care, a national nonprofit health advocacy organization as well as a founding partner of Town Hall Ventures, a healthcare firm that invests in underrepresented communities. He co-chaired a national initiative on the future of health care at the bipartisan policy center. He chronicles what goes on inside the government and across the nation at Town Halls in USA Today on his award-winning podcast in the bubble and on Twitter. He's the author of Preventable, a best-selling account of the U.S.'s Coronavirus response released in 2021. He's a graduate of the University of Pennsylvania and Harvard Business School and he and his wife have two grown sons. Andy, welcome to the policy talk. I look forward to continuing conversation. Actually, we had on my podcast and I've had a lot to learn and I know that all of us have a lot to learn from both your service and your experiences. So thank you so much for joining us. Thanks for having me and thanks for the nice introduction. Of course. Well, look, I want to just jump right in. We're in this unique moment just to set the stage from where we are and we can work backward. What is your perception right now about the state of the pandemic? Mind you, you're talking to an audience, mainly in Michigan, where we learned as of two days ago that we are the unfortunate pandemic capital of the country yet again. But what is your perception of the state of the pandemic? What are the key hinge points that we should be thinking about? Probably neck and neck with Minnesota. Look, I think, you know, I know this pandemic feels a bit like Groundhog's Day to everybody and I think one way to look at it is, gee, when will we ever move on? I think there's another way to look at it, which is with each cycle we get what principally changes is we have a better and better set of tools to manage the pandemic, keep ourselves safe and return to more and more of our pre-pandemic existence. So for a lot of people, that means vaccines. It means booster shots. It means, but it also means things like indoor air quality and portable filtration systems. It means things like monoclonal antibodies. Soon it will mean the antivirals that are coming on the market. It also means rapid antigen tests. And so, you know, I think if there are passions in our lives, whether it's, you know, going to a Detroit Lions game, although I find that very hard to believe. One can't really be passionate about that to be fair. But maybe a Michigan game or seeing your family over Thanksgiving or the winter holidays or whatever it is. Those things are increasingly possible if we make use of these tools that are available to us. So I would encourage us to think seriously about the fact that, yes, we have people still at risk. Yes, there are risks in our community. Yes, when those risks get too high, they make our hospitals and our healthcare system work harder than they can. But I would also urge people to think about the fact that we do have these tools. And with these tools, we are able to stay safe in many and most settings. And even if we're not staying 100% safe, we are making things much, much less risky. And none of these tools is perfect, including the vaccine. But all of them together are a pretty great combination and represented in advance of where we were a year ago, or even the last time that Michigan was was facing high case counts. So would you agree that, you know, the statement that a case in 2021, is it quite the same as a case in 2020, that the increasing number of cases doesn't necessarily represent that we are back to where we were or back to square one, but rather maybe is a average function that is driven by the exceedingly high risk among people who have yet to take up vaccines? I think that's right. Look, I think I think the difference today is we have you have an option. Now, it is true that that there's a good portion of the public that is choosing not to take advantage of that option. But by and large, by and large, they're endangering themselves more than they're endangering you if you are taking even simple and basic precautions. Somebody did some math for me, which I found interesting, which is, what's the likelihood that if you if you're vaccinated, if you have a guest over for Thanksgiving, and they're unvaccinated, what's the danger to you? Because I think a lot of us are used to thinking about that as something that we really have to avoid at all costs. Now, it's interesting, the math that someone did for me showed that if you drive 50 miles or more over the holidays, which a lot of people do to visit family, the rate of highway fatalities is about 1 per 100,000. So you've got to you get on the road, you got a 1 per 100,000 chance of being fatality. Now, for most people, that doesn't stop us from hitting the road. We kind of understand that risk. If you are going to a holiday gathering and your chances of getting of coming into contact with someone who is going to infect you and you dying is about 1 in 100,000 if you're unvaccinated. If you're vaccinated, it's about a sixth of 1 in 100,000. So we're talking about, if you're vaccinated, extremely low risks, risks that are, you take greater risks all the time. And so if, for example, you asked your aunt or uncle who weren't vaccinated to take a rapid antigen test, or take some other kinds of precautions, we're talking about being able to really reunite with family members and begin to put some of the things that are important in our lives back. And I think that's a real change. And hopefully, you know, we feel and I feel a sense of gratitude to be able to have some of these people, you know, back in our lives again. Yeah, I appreciate that context. It's a really helpful way to put it. So in order to have the same risk at Thanksgiving, if you're vaccinated, vis-a-vis interactions with an unvaccinated person, you would basically have to drive for 300 miles. And that would be the same risk and the way you're there as the risk that you're taking of COVID at the actual gathering. And that's a really helpful way of thinking about it. Because you're right. I mean, we do a lot of things to protect ourselves from the risk of automobiles, but we tolerate that risk. I want to step back and think a little bit about the genesis of the pandemic, something you've written a lot about in your book, Preventable. It is, of course, a complex thing, a pandemic. It's not just a virus, but it's the context within which a virus makes its landfall into humanity. How did America's circumstances prior to the pandemic shape the outcome of the pandemic that we ultimately experienced? That's a really well phrased question. I think there were a few things about the country that in retrospect really were pretty determinative of the outcome here. One, for example, is we simply had no prior experience with pandemics. Countries that did, Hong Kong, places in East Asia, had a very different reaction and much, much lower death count. Number two, we had a healthcare system and an employment system here where only certain people had access to healthcare, something you talk quite a bit about Abdul. That meant very unequal access to care. We have a country that has people with more preexisting conditions, but we also have a system that is different. If you work by the hour or a person of color have lower income, come from generations of poverty, then if you get paid a salary and can work from home, those two experiences were quite different. It didn't lend itself to the level of empathy for people who felt relatively safe during the pandemic for many communities that have been relatively unsafe and still are. Even yesterday someone said to me on Twitter, you don't get it. Most of us don't know people that have died of COVID. My response is yes, you do. You know, plenty of people have died of COVID. There's the people that grow your food. There's the people that drive your food to the distribution center. There's the people that work in the meatpacking plants. There's the people that work in the grocery store. You may not know their name, but they're a big part of your life and you wouldn't be eating without them. So we don't see this anymore. It becomes much less visible and that's one of the other things. Another factor, you know, we've spent the last few decades really diminishing the role of experts, expertise in institutions. I should at least in some form, you know, we know there's a good quarter of the public now that doesn't believe in experts and expertise in science and have had a hard time crossing the chasm of being able to really relate to and get on board to the kind of solutions and the kind of tools that have been available in this pandemic. So, you know, those are underlined societal issues. Our healthcare system, kind of our view of science and expertise, the very unequal nature of the country, our lack of experience with pandemics. And, you know, therefore, because of all that, we rely on our technical expertise and our wealth to try to stop the pandemic before it happens. So it's all kinds of criticism of the CDC and of things we did wrong and so forth because we in this country don't expect to be protected. We expect, I should say, to be protected, unlike the most of the rest of the world, which feels like part of what they have to do is come together as a society and prevent these bad things from happening. Here, once you penetrate the walls, once the virus started spreading, and we have a very rapidly spreading respiratory virus, and it comes to counting on one another to keep each other safe, that's where we perform very poorly. I really appreciated your framing of the answer around a couple of really key specific polls. One is profound inequity in our society by race and in socioeconomic position, also by geography. And that inequity really does explain so much of the differential in lost lives and livelihoods. But another piece of the framing that you offered was around collectivism. And you pointed to the role of the healthcare system. And in some respects, when you look at our society and our healthcare system, something that you've done a lot of work on and I've done a lot of thinking about, our healthcare system really is the sort of tip of the iceberg when it comes to our failure to invest collectively in people. We have a deeply fractured system, but also a deeply unequal system. Even if you are covered on Medicaid, reimbursements for your care are substantially lower than they would be if you had private health insurance. And I wonder, two questions here. What was the role of the structure of our healthcare system specifically in explaining the kind of outcome we had? But then, secondarily, where do you think we should go from here? What should the debate look like following a pandemic of this magnitude? And have we learned any lessons that may reshape our healthcare system or do you feel like we are just entrenched in what we have? Well, in the community where I live, I can get my way to a hospital if I need to. I can get my way to one of a number of urgent care centers. There's plenty of specialists here where I live in California. And I have means to get there. I have means to pay for that care. I have insurance that covers most of it. And likewise, the kids around here, most of them have internet in their homes. So if they're missing school, they can still study. They have access to enough food in their refrigerator. And so, you know, we have this, many of us have this kind of safety net in life that we're so fortunate to have. And if you look at the scope of history, the scope of human history, most people on this planet don't have that level of safety net. And indeed, in this country today, a large number of people live without that level of support and safety net with them. And that happened before the pandemic. As you point out, Abdul, it wasn't something that just started happening with the pandemic. But kids, you know, we learned a lot during the pandemic about how many kids needed to go to school just to get, just to eat. How many kids sat inside parking lots outside of liquor stores just to get access to some Wi-Fi so they could do some work when they couldn't go to school. Indeed, in the healthcare system, how many people just don't routinely even have a place to get their blood pressure checked to deal with an addiction problem, to deal with a mental health problem. And we've systematically under-invested in the resources that exist throughout the country. There was this narrative that we were asked to believe since early 1980s and since the days of Ronald Reagan, which was something like this, the greatest threat to our country is if we get such a big deficit that it will bankrupt us. That is our biggest threat. And so we spent decades neglecting to invest in public health, in mental health resources, in safety nets, in childcare, in early childhood education. And guess what? Not only have people been suffering along the way, but it turns out that that lack of investment was a bigger threat to us. Lack of investment in public health, lack of investment in things that we can't see but which societies do invest in, particularly wealthy societies. And we didn't. So the question you're asking, I think, is the appropriate one, which is will we have learned our lesson here and what can we do? I'll tell you that if I think that if people ask me the number one most important thing to do out of the pandemic, I'd say making that child's tax credit that just was in one of the earlier Recovery Acts, making that permanent. Because oddly enough, if we don't fix that problem, then I have very little hope that we're going to fix bigger problems out in the future. That one was thrust right in front of us, right in front of our face. And if we can't make a decision that we know will take half the kids in this country and move them out of poverty into a situation of at least some breathing room, then we don't have the guts to make any decision that doesn't just benefit us and ourselves. And we can return to this narrative that says that we have to fear is too high taxes or some deficit or debt or something like that. And indeed, good management suggests that all of those things are important considerations. But we have in the last 40 plus years really robbed ourselves of the ability to have any level of comfort or cushion in the case where things like this happen and people face this every day. People who don't live in my community but live in a community that's seven, eight miles away from here can't find the very things that I'm talking about very easily. And they live 10 years shorter of a lifespan and that happens all throughout the country and all of you who are part of the School of Health Policy understand that very well. I want to zoom in on the healthcare system because I do think that when you look at the crux of the system of inequity that you're talking about, the choice not to guarantee every person in our society basic healthcare, I think sits at the core of that. 67% of bankruptcies in this country are attributable to healthcare. Part of that is folks who are even insured in the first place, given the fact that insured's product today is not the same thing as it used to be, more deductibles, more out-of-pocket in the form of co-pays and co-insurances, higher out-of-pocket limits. And in some respects, you go before the pandemic, in the battle of days, before the pandemic, healthcare was the number one issue. And it's interesting, because in so many ways that conversation tends to be dominated by talking points from corporations make a lot of money off of the system as it stands. And so part of public provision isn't just the public policy choices being made in a vacuum, it's public policy choices being made against the lobbying of corporations who may benefit or lose on the back of public policy choices. And I wonder what your thoughts are on whether or not there is a space for real healthcare reform. I agree with you that the childhood tax credits is an obvious thing we have to do. I would agree that paid family leave, universal pre-K, all of these things on which we're behind are obvious. But I do think that healthcare is such a profoundly important one to the everyday voter, and it's such a profoundly important one to thinking about the future. What do you think about the potential or the movement for real reform when it comes to healthcare? Where do we go from the position that we're at right now to potentially where we need to be, where we truly do have a healthcare guarantee, and ideally a healthcare guarantee that provides everybody equitable access to healthcare, not just access to some healthcare? Well, I'll take this in a couple of bites, because right in front of us right now, in addition to the childhood tax credit, we have the first ever opportunity to pass legislation which contains the negotiation of drug prices, not just for Medicare and Medicaid, but for everybody. That is the most popular provision in healthcare that I've ever seen. It pulls like 90% of the public believes that the government should be able to negotiate drug prices. Libertarians believe we should be able to negotiate drug prices, so only if you work in a drug company do you think that you should be the only people on the planet that don't have to have a drug price that's reasonable. Now, we could have arguments and debates and very valid ones about rewarding innovation, rewarding the kind of innovation that created the vaccines. I think we're all for that, but do we really need to reward that insulin that's 1% different than the insulin everybody else changes and be able to increase in costs by 100% every three or four years? In the rest of our economy, we're used to things going down in price as they're on the market longer, not going up, but with drug costs, which affects everybody, that's not the case. I think it's important, you're asking a question about something more universal and something that guarantees everybody coverage, but it's important not to lose sight of the fact that we've got to make the basic things that people can't afford affordable and put a priority on that if we're going to make progress. Beyond that, I think the question is, what is the political will to continue to move in that direction? You and I, I think, and probably many people listening would have basically very high levels of agreement on what should be done. There may be 10 different ways on how to get there and on different provisions of different ways and so on and so forth, and it gets complex. But the bigger question is, how do we build the political will in this country? Right now, the people that are in favor of even the Affordable Care Act, which I think we'd all say is a partial step, are in deep danger of being voted out of office in favor of people who wanted to repeal it. So the political sentiment in this country around healthcare, and I, by the way, I know you wanted to hear the question healthcare, but the same is true about climate. The people who want to reward people who create renewable energy are very serious danger being voted out by people who want to keep expanding fossil fuels. So I don't think that we're on a realistic cusp of moving in the dramatic direction of getting healthcare available to everybody in this country in an equitable fashion. Until such time as we decide that those things are important, they're important enough to vote for, and they're an important part of what we need to have. And, you know, I think it's incumbent upon people running for office and people voting to keep articulating those issues and do so in a way that continues to build momentum. All of these policies around low taxes and everything else, the reason that they've been able to stick is because they've been run at the grassroots. They ran at the grassroots and state legislatures, they ran at the grassroots with the Freedom Caucus and the Tea Party, and that it is far more effective to run a grassroots campaign than it is to run some lobbying campaign. So you can overturn the will of the lobbyists if you have effective grassroots support for basic and fundamental things. But I'd put healthcare high on the list, I'd put climate high on that list, I'd put gun safety laws high on that list. All of these are things that the vast majority of the public supports but have not been able to convert into political victory to the degree that we should. Yeah, I agree with all of those and I, you know, I have some experience with elections and, you know, albeit having ran once and lost once, maybe my thoughts here aren't as relevant. But I do think that in order for us to be able to build the kind of grassroots momentum that we need, we have to be dead set on doing it. And the frustration sometimes is that the party that's opposing those folks who want to run against science and the consequences of science tends to be unclear about what we actually want. And that can be, you know, a bit frustrating. And what does win elections is clear messages. And one of the frustrating pieces I think of this moment is that the message coming on on the side of providing more people healthcare, addressing climate change, taking on the power of the gun lobby and saving lives tends to be less concerted, less clear and less honest about the direction forward and galvanizing message. And I think that that can be some of the big frustration. Toward the end though, right, the shocking thing I think to any of us watching the pandemic who believe in science and believe in the process of science is that the most galvanized group to come out of the pandemic politically tend to be folks who want to take science out of public policy. You know, I think here in Michigan they're trying to pass a citizens committee to reform the public health code that was written in 1978 that gives health directors basic powers over public health. And you can see these kinds of drives across the country. The worry I have is that a lot of this has not just in the short term limited our capacity to take on the pandemic by limiting people's belief in the safe and effective vaccines, which we know work, but also have the potential to undercut public health, which is a paradox considering how poorly we had invested in public health in the first place. How do we take on the anti science, you know, anti frankly anti structured knowledge approach that we're seeing sort of crop up in the grassroots among or within our politics? Well, look, there are a number of people who have what I would consider to be a freedom fetish. They really want to have it both ways. They want to live in a country of one where their commitment to one another only goes so far as their own personal self interest and wishes. So in a world like that, anything a government does that in any way restricts what they believe to be their unadulterated freedom is something that they that they object to. So, you know, taken to the logical conclusion, that's that's a society where everybody's allowed to drive drunk because we live in a country of one and we can all police ourselves and the state shouldn't be moving to prohibit those sorts of activities and those sorts of behaviors. We can have a debate over where the reasonable limits are. And we should be respectful of people's views. And we should be able to have this conversation in a civil fashion and both sides disrespect each other and insult each other too much in my opinion for that to happen. So, like being able to do have these very real important debates in a civil way with people we disagree with has to be has to be able to happen. That's not necessarily an anti this is not necessarily anti science but it's related. It's people who really are just view anything that the government does as by definition wrong. Now, I would say that the other side of the equation is that there are it has now become the now the most as reliable sources you can find is whatever you see next on Facebook that happens to roll up into your Twitter feed or into your Facebook feed because the algorithm suggests that you're going to be susceptible to a message. So, what you say at a school of public health if you spend years studying something you have authority versus what someone who has mastered the algorithms of Facebook says you're at a distinct disadvantage. It takes away any form of objective truth for used to believe in and look science is not about finding a middle ground between two facts. As someone said to me the other day, if I say the world is flat and you say the world is round we don't compromise and say the world is oval. But yet there are also times when scientists are uncertain and when scientists are uncertain I think my warning to scientists is not to over express confidence in the opinions you're giving but in fact to say we have plenty of places where we have unsettled science and we have to learn and have mature conversations with people and tell people the truth and respect the differences where people come from. Is it unreasonable for people not to want the government to step in and tell them what to do? That's a very reasonable feeling. Maybe start with acknowledging that that's a very reasonable feeling but at the same time we have to be able to explain to people how their unadulterated sense of their own freedom infringes on everybody's health and safety and that should be a reasonable dialogue as well. Yeah, I appreciate that point about misinformation and one of the frustrations I think about this moment is that there had not been a baseline level of investment in science communication about the process of science and the problem is the way that we educate science is that we almost educate people to believe that science is a body of knowledge. You learn science in a book and you know whatever you need to know about COVID-19 you could have found in the book and if the sciences change their message that means that they lied to us about what was in the book rather than science being a process and the process itself not having resolved to a firm and consensus outcome and that's particularly true when you're trying to message the outcome of science in the context of unsettled science in the middle of a pandemic of a new virus that's just emerged. How should scientists and frankly the public be thinking about how we message science in an era of dis and misinformation? How do scientists maybe make their work more about messaging the process rather than the top-line messaging and you know in your experience as a senior advisor to the COVID task force largely responsible for much of the public messaging what were some of the tips that that you took home from what was effective and maybe what was not? Look always tell the truth and always pretend like you're talking to your sister. So would you take an extra two minutes to explain the nuance to your sister if she asked you a complex question if she said hey do these vaccines work? Now my sister would be explaining it to me probably but you might say yes they work you should get vaccinated which is what we say in public but you might also say hey the vaccines Wayne the vaccines are perfect the vaccines are just one tool let's keep using other tools those are that is nuance it's not as sound by the quick or easy but it's the truth that it's the advice you'd give your own family member and I think we always regret it if we don't try to do that and I found it was very important to just speak bluntly and say it in as simple words as possible when I was at the Biden White House if there was something that wasn't going well to just say it's not going well and then to talk about what we were doing about it and how long I thought it would take to fix if we didn't know something I think it's important to say I don't know and the other thing that's very hard for scientists to do is to say I'm wrong and I will tell you that there's a lot of power in that because what scientists are used to saying is hey I said what I said back in January because that was the best information they had in January now that I know different of course I feel differently well that sounds like a lot of ivory tower babble to some people instead of saying hey you know what I was wrong in January because I didn't know that XYZ and people I think can rightly accuse science and scientists and public communicators of science of being arrogant of thinking they're infallible and I don't think that that creates much much trust and saying look this isn't settled we don't know but we're trying to protect the greatest number of people so this is what we're saying and this is what we think as opposed to masquerading and trying to position it with the public the public's too smart the press is too smart you're never going to gain trust by trying to simplify things so get the message well talk as if you're talking to a family member in that level of with that level of care that level of simplicity and that level of nuance I get questions all the time as I'm sure you do as I'm sure many of you do on the phone and the questions are tend to run into things like what should I do if and you tend to try to answer people very carefully and I think when we talk publicly it's no different we should just try to answer things very very carefully but also recognize we're playing a we're playing a in somewhat an unfair game because we're playing against misinformation misinformation specialists who will play dirty and so the only way to beat that is by regaining trust and establishing trust at a level of where people really want to place their trust which is the people they know locally doctors etc. I want to you know ask you as someone who has worked in in the federal government now in two very different types of roles one is acting director of CMS and the other on the COVID task force what what do we get wrong about the incentives that policymakers face in public health and health care and really what do we get right and as folks engaged in the policy space what kinds of output and thought leadership is the most valuable for people in in public positions making hard decisions every day and what have you found particularly helpful both as someone who's worked in government but then also someone who's advised on the outside as you call yourself an outsider's insider what what is that cross talk that's the most beneficial and to young people who are interested in in in getting involved in government what are the skill sets that they should be building right now so it's really important that no matter what you're doing whether in government or some other decision maker you have some reliable way of connecting to the real world and the real issues and not just hearing from one party I mean it's it's very easy in Washington the people who have most access to you are the people that have big lobbying organizations um so the question I would always ask my team when they made a recommendation is who did you talk to and who did you listen to and if you've heard from the pharmaceutical lobby in the in the health plan lobby I want to know what consumer groups have you talked to um what hospitals have you talked to what doctors have you talked to um no one has monopoly on the truth everybody sees things differently from their different angle their job is to assimilate it all and into the into the values that you they're supposed to represent the the public but really to understand what's going on and a lot gets missed between um well-intended policies and things that really work for people um and we don't take the time to stop and ask the question you know what is it that really works for you um the so the the number one policy concern on most people's mind the number one is never talked about in public policy arenas not once do you hear it in any legislation or any bills in the number one issue in people's minds from a healthcare standpoint you can all like do your silent guessing it's support for caregivers support for caregivers support for caregivers of people of their parents who are getting old of family members of their kids of of other of other people that is people's number one fear and issue and concern um is how to take care of um someone in their family as they age or get sick um or need care or are disabled um and it it is largely um never talked about of the policy arena so I I only point this out to say that um like everything um seek to understand before you seek to be understood seek to see understand what's going on before you say I've got the greatest policy idea in the world because if your policy idea doesn't address for example the problem caregivers there's gonna be a lot of people out there saying they still don't get it they still don't get me um they're not speaking to me so um I think in in all of these roles being able to actively listen being able to observe being able to hear the hard truths um is is a is a vital skill and you know I think the for younger people out there who want to consider careers in government um I think the new model is going to be for people who um get to have a life and a set of experiences in the public sector um and and maybe move in and out a little bit you know do do some public health work do some academic work do some private sector work do some government work and get a flavor for um you know what all of that is like and I think you you learn that the people inside the government are just like the people inside uh any organization they're they're very smart they're very well meaning they have a limited set of resources um and you know they need to do the best the job they can understanding what the the circumstances they're trying to solve are and um and there's no other way to understand what their world is like than to live in their world for a couple years so I think if people are willing to do a few years in the state federal or local government role um and then go back and work on change uh you know it will certainly help I appreciate that I uh want to move to questions from the audience so if you have them please do make sure uh to post them you can also just tweet them at policy talks um this is uh from Twitter uh it's our good friend Kristin or Erquisa uh she lost her dad to COVID on the 30th of June in 2020 and she put the blames directly on the government and since then she spoke at the DNC and founded the group at marked by COVID go ahead and check them out on Twitter um her question ultimately is how do we redress the loss of life and the millions of us in deep grief yeah well thank you for the the question Kristin um I am um at least a little bit familiar with your work uh and admire it and I think it's exactly the um um the I think the way this question's phrase um indicates one reality which is there are a lot of um unaddressed um issues that have come out of the pandemic and by the way um they don't all look alike but they're all important um many of us have lost family members many of us have lost friends many of us have lost school years um some people have started businesses uh in 15 years ago there was their life dream and they closed it because of COVID you know those are all losses all of this is suffering and I think the first step is acknowledging that the suffering and the pain that exists and that has existed and that it all doesn't look alike and it's all real and um until we can do that I think it's hard to heal um it's hard to move on unless we can achieve some level of understanding of what's of what's there some acknowledgement you know I often when I when I deal with pain and grief and suffering and loss I try to figure out well eventually I come to the question what's the productive what's the productive use of this emotion that I can try to find um which is I think exactly um what what uh what Kristin is doing here um is what action can I take what greater understanding can I achieve um and you know what what can I share with others or build with others that helps people um to move to a place where they have um uh feel like their loss wasn't purposeless uh feels like um that they can honor the people they lost in some way that creates some legacy that changes something about the world for other people to make it better so it's not in vain um and you know many of us who've lost parents at various points along the way um have struggled with that very question I think uh I think that helping people understand through those stories is one step I think deciding what action is important to take um to get to some level of um of I don't even want to say closure but some level of purpose um that that makes things better is is really the challenge it's really the journey and I don't know that there's any one specific way that works for everybody um but I do think that the opportunity to say to um to to basically face off to your community and say um we had this loss um we have to learn from it we have to make it better is in part the healing process um and seeing things change and seeing things different because you can never um recover what's lost you could only change what happens next and I've always tried to say during this pandemic whatever whatever we've screwed up so far the most important life is the life we have we can save today and save tomorrow and if we screw up today then we gotta wake up tomorrow and save more lives because there's another 1500 people every day that are dying from COVID and if we didn't save the last 1500 we needed to do everything we can to save the next 1500 um and it is um it is in that sense that I think we eventually hopefully make ourselves better um I don't think these losses sadly ever completely um heal but but I do feel certainly for her and her her situation and I admire what she's doing yeah me too I what I love about um person's project is is exactly that is that she's found in her grief and opportunity to bring other people together um to prevent that kind of grief for other people I want to move uh to a couple other questions that we got um what are the kinds of things that uh students in particular but but frankly anyone uh out there who's concerned about our particular circumstance right now and in particular the uh lack of funding and support for local health departments and local health professionals what are the kinds of things that they can do to advocate uh and to uh to support the effort uh to improve funding and prevent the next one yeah I mean the uh the cost of um the cost of neglect is high and I would also say you know we are going to see a number of people in public health profession and healthcare general burning out and leaving profession in really large numbers and so you know we are starting from a position of a real challenge and we also have you know if not half the country certainly have the politicians in the country um that come out of this pandemic convince the public health is even less worthy than than going in and you said this of dual um but there's a silver um uh lining here that's going to emerge um the other day um I asked my um niece um who is a rising freshman here in California at Cal Poly um what is she majoring in and she said oh public health and oh somebody and I said are you alone she said oh no a lot of a lot of my friends are majoring in public health and I think about this from her from the standpoint of what people have lived through what what younger people have gone through and they see public health as nothing but a land of possibilities it's how do you and it has all these great things in that how do you solve problems for society how do you work on interesting issues how do you touch healthcare if you like healthcare but hate the sight of blood which is true for a lot of people like um it's a very intriguing career and I think we need a um as with everything else we need younger people um who are going to energize um around these concepts um in addition to fighting for um you know the the day-to-day funding etc uh you know that that we need so look I think there is finally more money out there to be spent I think we need talented and creative people um who can invest of themselves and invest in their time uh and into this infrastructure who know what this means who understands uh the great advances we make it's a country um when we look out for one another and you know at some level this goes back a little bit to the question around Kristen is like we got to have some reconciliation here um about what's going to make this world a better place uh what's going to make this country a better place to live in some real dialogue which says hey you know what one this one this nurse was working 24 hour shifts four days in a row and we were out being careless maybe we should just listen to that nurse now talk because she's got a deal or he's got a deal with his or her own trauma and and and they've got to um and the one of the best things we could do is listen to them listen to them tell us what it was like honor their stories honor them honor what uh they're carrying forward help them all heal and um you know part of that I think is is the path back it's there's there's always a million reasons to be pessimistic and there's always an equal number of reasons you could choose to be optimistic and I'm sure we all bounce back and forth a little bit between them but at the end of the day if we don't choose the optimistic path we don't build for something better then it'll be harder to get there I uh I really appreciate that and you know the all the folks out there thinking about what they want to study public health is um one of those uh amazing outcome oriented uh uh uh disciplines and similar to public policy there are there are a tremendous number of skill sets that you can bring um in either public policy or public health that uh that all redown to a set of goals uh to be a more just equitable sustainable society and to to deal with all of the context that uh shape health and well-being above the skin and so um whether it's public health or public policy I think it's critical for folks to be thinking about this in this way and I appreciate that point Andy um there is a question about you know which particular healthcare stakeholder doctors pharma patients insurance companies etc that have the greatest potential play rule in solving health inequities uh where's the solution more of a patchwork of improvements on all the stakeholders part and I'll just say for my part I believe that um you know people who have been leading this fight have been the nurses and the health um healthcare uh uh support uh staffers across hospitals and clinics um I will say that I think it's time high time for doctors to get in the fight in the right way and for a long time the AMA has been the wrong side of health reform whether it was Medicare or uh or it was um the the ACA up until the very very end and so I do think that doctors have a unique opportunity now recognizing the changing shift in the healthcare um space and the fact that doctors are getting nickled and dimed by large corporations to be on the right side of this fight Andy I'd love to hear your thoughts on uh on on that question so for two years I sat as CMS administrator and I would take outside meetings and um people would come in and explain to me in great detail um how um much to blame some other party was for something going wrong in healthcare so you know the pharma companies would come in and lambast the insurance companies the insurance companies would come in and blast the hospitals and the pharma companies the hospitals would come in and blast um the the nurse unions and uh and the insurance companies uh and and and you know I would always try to go at some point in the meeting I would ask the same question so out of curiosity what percentage of the blame do you get does your your industry get zero one percent are you the ones that do everything right um because you got a really clean articulation of everybody else's problems but no I've heard no articulation that you understand your own contribution to it and so I'd say if you think you're not if you think you're it's if you think it's someone else and you are probably the biggest problem including me you know I think you know we all have a sense of well I get it I get it but you know as we learn with um with structural racism you don't have to be out there as a racist to be contributing to the misery of people who are getting discriminated against because there's structural policies you're upholding you learn we're learning this we're still learning this many of us are going on this journey and learning learning this all the time and the same thing is true here um there is so much uh inequity that's built into just the the way we do things as a system and every time uh we make things better for one party and don't make things um equally better or put more effort in making it better for everybody uh we're exacerbating the challenges and so you know you really have to um ever in any one in every one of those roles um that we're talking about here and every other one if you're part of the healthcare system and you're not actively making equity a part of how you're doing your job every single day then you're probably making inequity a part of how you do your job every single day because it is just so much harder uh for people as we talked about earlier to get even the basics of what they need uh from the healthcare system but here's the great news like why not think innovatively why not think about how to do even better for people who have less or are more challenged um why not go out of our way we learned this with covid um once we got it understood how people lived we started bringing vaccines to people's churches to people's places of work to their homes we started giving people free lift and uber rides to getting vaccine sites once we started thinking innovatively we closed the gap um pretty quickly in uh the very least um that that level of measurement um medicare means your medicaid expanded medicaid uh over the course of the five years after the program passed dramatically reduced disparities in almost every measure um so everybody who participated in that should feel pretty darn good about the closure of gaps and i'm talking maternal mortality i'm talking infant mortality i'm talking for closure rates in homes i'm talking about uh ability to hold on to a job i'm talking about ability to accumulate wealth i'm talking about cancer disparities and cardiac disparities all of them improved um now if you are a doctor and you don't take medicaid patients uh because you know governments too much for pain and reimbursements are too low etc that's fine that's your right no one's gonna say it's not your right but you are not part of the solution and you don't deserve you don't deserve my gratitude um for um facing often these challenges um and so you either have to you know you have you get to decide every day put it this way you get to decide every day what you believe in based on what you do every single day you get to make the call not based on what you say but based on your actions based upon how you choose to do your job based on uh when i say this to my kids when you choose to speak up in a room when everyone in the room seems to be heading a direction towards ratifying a decision that's gone and serve the same people for years and um somebody's voice comes in the room and says you know what i think this decision isn't fair or i think there's another way to think about it if someone doesn't do that if someone doesn't have the courage to do that then life continues to go on so every day we get to make that choice not always easy requires courage uh but that's how shit changes i appreciate that and um i want to finish on a final note you the the you are the author of a book called preventable and uh our final question uh from a from a viewer is uh please expand on what we can do next time to prevent this horrific chapter in our history from repeating itself and you know final thoughts that you have for us today well look we're not always going to prevent the vaccine from coming the i'm sorry the virus from coming to our shores we're we're we are going to have overwhelming viruses and by the way not just viruses but other threats bacteria climate change things that antibiotics are resistant towards um so we need to understand that in those situations those situations occur um uh it really is going to be um critical not that we just have a better technical response or a better better political leadership god willing we'll have better political leadership um that is honest with the public and so forth but that we recognize that unless we have a commitment to one another even people we've never met before unless i care about your family abdual who i don't know unless you care about mine then you know we don't actually have as great a chance of getting through this without lower loss of life and if you look at societies that have um much more commonality where income levels are closer where people live more similar lives you look at again this is b east asia this would be um africa skin and avian countries others when there is more of a bond and less wealth disparity those those countries have shown more support for one another in getting through the pandemic if you look at countries with great extremes of wealth and poverty like india russia brazil united states um they do less good and it's people at the bottom end that that suffered disproportionately so you know i i think there's lots we can do better technically to prevent this from happening we can elect better leaders but at the end of the day um honestly we just got to be better people um and and i don't mean that to make that sound as judgmental as it sounds but we we just have to be um willing to take to do even slight make even slight sacrifices for one another and if we know that other people's lives who we've never met are at stake i think we're more likely to do that andy i think that's a great place to uh to wrap it up i want to thank you for your work and your service as well as your book and for taking the time to join us here today i also want to thank uh all of the good folks at the ford school erin flores and daniel riftkind for their um incredible work in putting this together i don't think all of you for taking the time uh to engage in this conversation to offer your questions and uh and to offer an opening here and uh you know on a final note on my end i just want to say that um i do believe that we have the opportunity to to build uh from where we are right now and i do think that in this moment it does feel like there are so many forces pushing back but i've seen you know in my time at the ford school and my time um running for office and before that the most powerful force in american public life uh is the passion and the commitment of young people and um i do hope that uh there's been something in the conversation that we shared today that inspires you and gives you that passion uh and i hope that we can continue to walk a path together toward building the kind of america where something like this um does not happen and if it does uh where the consequences are not so inequitable um and fall hardest on the backs of people for whom our oppression unfortunately has already done so much damage so with that i really really appreciate you joining us andy i really appreciate everyone uh in attendance and i hope that you all have a great rest of your day