Andy Slavitt: Preventable - COVID-19, healthcare, and the future

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Dr. Abdul El-Sayed: Hi everybody. Good afternoon. I'm Dr. Abdul El-Sayed, and this semester, I have the privilege of serving as a Towsley Foundation policy maker in residents of the Gerald R. Ford School of Public Policy. Welcome to this Policy Talk at the Ford School event with Andy Slavitt. Shortly, we'll be discussing the state of healthcare 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 wanna 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 #PolicyTalks.

DE: Now onto our discussion. Andy Slavitt 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 turn around implementation in defense of the Affordable Care Act. Andy Slavitt is the outsider's insider, serving and leading private and non-profit roles, in addition to his government services. He is founder and board chair Emeritus of United States of Care, a national non-profit health advocacy organization, as well as a founding partner of Town Hall Ventures, a healthcare firm that invests in under-represented communities.

DE: He co-chaired a national initiative on the future of healthcare 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 US' 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 a 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.

Andy Slavitt: Thanks for having me and thanks for the nice introduction.

DE: Of course. Well, look, I wanna 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? 

AS: You're probably neck and neck with Minnesota. Look, I think... 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?" But, 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 the 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 anti-virals that are coming in the market. It also means rapid antigen tests. And so I think if there are passions in our lives, whether it's going to a Detroit Lions game, although I find that very hard to believe...

DE: [chuckle] One can't really be passionate about that to be fair.

AS: Yeah, yeah. But maybe a Michigan game.

DE: [laughter] There you go.

AS: 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 health care 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 represent an advance of where we were a year ago, or even the last time that Michigan was facing high case counts.

DE: So would you agree that... 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 an average function that is driven by the exceedingly high risk among people who have yet to take up vaccines.

AS: I think that's right. Look, I think the difference today is, you have an option. Now, it is true that there's a good portion of the public that is choosing not to take advantage of that option. But by and large, they are 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'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 cost. 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 one per 100,000. So you get on the road, you got a one per 100,000 chance of being a fatality. Now for most people, that doesn't stop us from hitting the road. We kinda understand that risk. If you are going to a holiday gathering and your chances of getting... Of coming in contact with someone who is going to infect you and you dying, is about one in 100,000, if you're unvaccinated. If you're vaccinated, it's about a sixth of that, it's about sixth of one 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.

AS: 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 re-unite 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 we feel, and I feel, a sense of gratitude to be able to have some of these people back in our lives again.

DE: 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, in a way, there, as the risk that you're taking with COVID at the actual gathering. And it's a really helpful way of thinking about it, 'cause 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 wanna 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? 

AS: 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 of about, Abdul. And that meant very unequal access to care. We have a country that has people with more pre-existing conditions, but we also have a system that is different if you work by the hour, are a person of color, have lower income, you have come from generations of poverty, than if you get paid a salary, and can work from home. And so those two experiences were quite different.

AS: And 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." And my response is, "Yes, you do. You know plenty of people who have died of COVID. They're the people that grow your food. They're the people that drive your food to the distribution center. They're the people that work in the meatpacking plants. They're 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.

AS: Another factor, we've spent the last few decades really diminishing the role of experts, expertise and institutions, at least, in some form. 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 those are underlying 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 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 protect... Unlike 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.

DE: I really appreciated your framing of the answer around a couple of really key specific poles. One is profound inequity in our society by race, and socio economic position, and 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 health care 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...

DE: 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 have? 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? 

AS: 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 our 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 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 pointed out, it wasn't something that just started happening with the pandemic, but 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 WiFi so they could do some work when they couldn't go to school.

AS: 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 have 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 went something like this, "The greatest threat to our country is if we get such a big deficit that it'll bankrupt us," that is our biggest threat. And so we spent decades neglecting to invest in public health and mental health resources, in safety nets, in child care, in early childhood education, and guess what? Not only people have been suffering along the way, but it turns out that that lack of investment was a bigger threat to us.

AS: Lack of investment in public health, lack of an 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? And I'll tell you that, 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 gonna 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.

AS: 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 Public Policy understand that very well.

DE: I wanna 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 health care, I think, [0:18:14.1] ____ reports that 67% of bankruptcies in this country are attributable to health care. Part of that is folks who aren't even insured in the first place, given the fact that insurance 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 bad old 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 that make a lot of money off of the system as it stands. And so...

DE: 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 credit 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? 

AS: 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 can change 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 polls... 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 cost by 100% every three or four years? 

AS: In the rest of our economy, we're used to things going down in price, if it's there on the market longer not going up, but with drug costs which affects everybody, that's not the case. So, 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 gotta make the basic things that people can't afford affordable and put a priority on that if we're going to make progress. I think 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.

AS: There may be 10 different ways of how to get there and on different provisions and 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 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 want the question on healthcare, but the same is too about climate, the people who want to reward people who create renewable energy are in very serious danger of being voted out by people who want to keep expanding fossil fuels.

AS: 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 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 to save legislatures, they ran at the grassroots with the Freedom Caucus and the Tea Party, and that... It is far more effective to run grassroots campaign than it is to run some lobbying campaign.

AS: 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 in the list, I'd put climate high in the list, I'd put safety laws high in that list, all these are things that the vast majority of the public supports, but we've not been able to convert into political victory to the degree that we should.

DE: Yeah, I agree with all of those, and I have some experience with elections and 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 wanna run against science and the consequences of science tends to be unclear about what we actually want. And that can be 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 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 a galvanizing message, and I think that can be some of the big frustration. [0:25:18.3] ____ Towards the end, though, 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.

DE: 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, anti... Frankly, anti-structured knowledge approach that we're seeing crop up in the grassroots among or within our politics? 

AS: 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 wanna live in the country of one, where their commitment to one another only goes so far as their own personal self-interests and wishes. So in a world like that, anything the government does that in any way restricts what they believe to be their unadulterated freedom is something that they object to. So take into the logical conclusion, that's a society where everybody is 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 being able to do... Have these very real important debates in a civil way with people we disagree with has to be able to happen.

AS: 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... Now the most 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 gonna be susceptible to a message. So what you say at the School of Public Health, if you spend years studying something and you have authority, versus what someone who has mastered of the algorithms of Facebook says, you're in 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."

AS: 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 starts with acknowledging that that's a very reasonable feeling, but at the same time, we have to be able to explain to people how under their unadulterated sense of their own freedom infringes on everybody's health and safety. And that should be a reasonable dialogue as well.

DE: 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, 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 whatever you need to know about COVID-19, you could have found in a book. And if the scientists 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? 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 you took home from what was effective and maybe what was not? 

AS: Look, always tell the truth, and always as if... 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 asks you a complex question? If she said, "Hey, do these vaccines work?" Now...

DE: My sister would be explaining it to me probably, but... [chuckle]

AS: Right. So put the shoes on your sister explaining it to you. 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 wane. The vaccines aren't perfect. The vaccines are just one tool, let's keep using other tools." That is nuance. It's not as soundbitey or quick or easy, but it's the truth and 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 scientist to do is to say, "I'm wrong."

AS: 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 I had in January. Now that I know different, of course, I feel differently." Well, that sounds like a lot of Ivory Tower of Babel to some people. Instead of saying, "Hey, you know what? I was wrong in January, because I didn't know that X, Y, Z." 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 it and trying to position with the public. The public is too smart. The press is too smart. You'll never gonna gain trust by trying to oversimplify things. So get the message well, talk as if you're talking to a family member 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 tend to run into things like, What should I do if? 

AS: 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 in somewhat an unfair game because we're playing against misinformation and misinformation specialist 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 wanna place their trust, which is the people they know locally, doctors, etcetera.

DE: I wanna ask you, as someone who has worked 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 do we get wrong about the incentives that policy maker space in public health and healthcare 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 public positions, making hard decisions every day? And what have you found particularly helpful, both to someone who's worked in government, but then also someone who's advised on the outside, as you called yourself an outsider's insider? What is that crosstalk that's the most beneficial? And to young people who are interested in getting involved in government, what are the skill sets that they should be building right now? 

AS: It's really important that no matter what you're doing whether in a 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. It's very easy in Washington. The people who have most access to you are the people that have big lobbying organizations. 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 it from the pharmaceutical lobby and the healthcare lobby, I wanna know what consumer groups have you talked to, what hospitals have you talked to, what doctors have you talked to? No one has monopoly on the truth, everybody sees things differently from their different angle. Their job is to assimilate it all into the values they're supposed to represent the public, but really to understand what's going on, and a lot gets missed between well-intended policies and things that really work for people. But we don't take the time to stop and ask the question, "What is it that really works for you?"

AS: So 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. And the number one issue in people's minds from a healthcare standpoint, you can all 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 other people, that is people's number one fear and issue and concern, is how to take care of someone in their family as they age or get sick, or need care or are disabled, and it's largely never talked about in the policy arena. So I only point this out to say that like everything, seek to understand before you seek to be understood. Seek to 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, this problem of caregivers, there's gonna be a lot of people out there saying, "They still don't get it. They still don't get me. They're not speaking to me."

AS: I think in all of these roles, being able to actively listen, being able to observe, being able to hear the hard truths is a vital skill. And I think the... For younger people out there who wanna consider careers in government, I think the new model is going to be for people who get to have a life and a set of experiences in the public sector and maybe move in and out a little bit, do some public health work, do some academic work, do some private sector work, do some government work, and get a flavor for what all of that is like, and I think you learn that the people inside the government are just like the people inside any organization. They're very smart. They're very well-meaning. They have a limited set of resources and they need to do the best job they can understanding what the circumstances they're trying to solve are. And there's no other way to understand what their world is like than to live in their world for a couple of years. So I think if people are willing to do a few years in the state, federal or local government role, and then go back and work on change, it will certainly help.

DE: I appreciate that. I wanna move to questions from the audience, so if you have them, please do make sure to post them, you can also just tweet them @policytalks. This is from Twitter, it's our good friend Kristin Urquiza. She lost her dad to COVID on the 30th of June in 2020. Then she put the blame directly on the government, and since then, she spoke at the DNC and founded the group @MarkedByCovid, go ahead and check them out on Twitter. Her question ultimately is, how do we regress the loss of life and the millions of us in deep grief? 

AS: Yeah, well thank you for the question, Kristin. I am at least a little bit familiar with your work and admire, and I think it's exactly that... I think the way this question is phrased indicates one reality, which is there are a lot of unaddressed issues that have come out of the pandemic, and by the way, they don't all look alike, but they're all important. Many of us have lost family members, many of us have lost friends, many of us have lost school years, some people have started businesses. 15 years ago, that was their life dream and they closed it because of COVID. Those are all losses. All of this is suffering, and I think the first step is acknowledging 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 until we can do that, I think it's hard to heal.

AS: It's hard to move on unless we can achieve some level of understanding of what's there, some acknowledgement. I often, 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 use of this emotion that I can try to find?" which is exactly what Kristen is doing here is what action can we take? What greater understanding can I achieve? And what can I share with others or build with others that helps people to move to a place where they feel like their loss wasn't purpose-less, feels like they can honor the people they lost in some way to create some legacy that changes something about the world for other people to make it better so it's not in vain.

AS: And many of us, who've lost parents at various points along the way, have struggled with that very question. I think that helping people understand through those stories is one step. I think deciding what action is important to take to get to some level of... I don't even wanna say closure, but some level of purpose that makes things better 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, but I do think that the opportunity to say... To basically face off to your community and say, "We had this loss, we have to learn from it. We have to make it better," is in part the healing process and seeing things change and seeing things different because you can never recover what's lost, you could only change what happens next and I always tried to say during this pandemic, "Whatever we've screwed up so far, the most important life is the life 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 need to do everything we can to save the next 1500," and it is in that sense that I think we eventually hopefully make ourselves better. I don't think these losses sadly ever completely heal, but I do feel certainly for her and her situation, and I admire what she's doing.

DE: Yeah, me too. What I love about Kristin's project is exactly that, is that she's found in her grief an opportunity to bring other people together to prevent that kind of grief for other people. I wanna move to a couple of other questions that we got. What are the kinds of things that students in particular, but frankly anyone out there who is concerned about our particular circumstance right now, and in particular, the 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 and to support the effort to improve funding and prevent the next one? 

AS: Yeah, I mean, the cost of neglect is high, and I would also say... We are going to see a number of people in public health profession and healthcare in general burning out and leaving the profession in really large numbers. And so we're starting from a position of a real challenge, and we also have, if not half the country, certainly have the politicians in the country that come out of this pandemic convinced that public health is even less worthy than going in, and you said this, Abdul, but there's a silver lining here that's going to emerge. The other day, I asked my niece, who is a rising freshman here in California at Cal Poly what is she majoring in. And she said, "Oh, public health." And somebody... And I said, "Are you alone?" She said, "Oh, no. A lot of my friends are majoring in public health." And I think about this from the standpoint of what people have lived through, what younger people have gone through. And they see public health as nothing but a land of possibilities. And it has all these great things in it, 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.

AS: It's a very intriguing career. And I think we need a... As with everything else, we need younger people who are going to energize around these concepts in addition to fighting for the day-to-day funding, etcetera, 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 who can invest of themselves and invest their time and into this infrastructure, who know what this means. Who understands the great advances we'd make as a country when we look out for one another. And at some level, this goes back a little bit to the question around Kristen, is like, we gotta have some reconciliation here about what's gonna make this world a better place, what's gonna make this country a better place to live in, some real dialogue which is, "Hey, you know what? When 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 gotta deal, or he's gotta deal with his or her own trauma. And they've got to... And one of the best things that we could do is listen to them. Listen to them tell us what it was like. Honor their stories, honor them, honor what they're carrying forward, help them all heal. And part of that, I think, is the path back.

AS: There's always a million reasons to be pessimistic, and there's always a 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.

DE: I really appreciate that. And to all the folks out there thinking about what they wanna study, public health is one of those amazing outcome-oriented disciplines. And similar to public policy there are a tremendous number of skill sets that you can bring in either public policy or public health that all are down to a set of goals to be a more just, equitable, sustainable society and to deal with all of the context that shape health and well-being above the skin. And so 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.

DE: There is a question about which particular healthcare stakeholder, doctors, pharma, patient's insurance companies, etcetera, have the greatest potential to play a role in solving health inequities? Or is the solution, more of a patchwork of improvements on all the stakeholders part? And I'll just say for my part, I believe that people who have been leading this fight have been the nurses and the healthcare support staffers across hospitals and clinics. 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's been on the wrong side of health reform, whether it was Medicare or it was 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 space. And the fact that doctors are getting nickeled and dimed by large corporations to be on the right side of this fight. Andy, I'd love to hear your thoughts on that question.

AS: So for two years, I sat as CMS Administrator, and I would take outside meetings and people would come in and explain to me in great detail how much to blame some other party was from something going wrong in healthcare. So 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 the nurse unions and the insurance companies. And 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 industry get? Zero? 1%? Are you the ones that do everything right? Because you've got a really clean articulation of everybody else's problems, but 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 it's someone else than you are probably the biggest problem, including me. We all have a sense of, "Well, I get it. I get it." But you know, as we learned 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 are structural policies you're upholding.

AS: We're learning this. We're still learning this. Many of us are going on this journey and learning this all the time, and the same thing is true here. There is so much inequity that's built into just the way we do things as a system, and every time we make things better for one party and don't make things equally better or put more effort in making it better for everybody, we're exacerbating the challenges. And so, you really have to... And anyone and every one of those roles that we're talking about here and every other one, if you're a 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 for people, as we talked about earlier, to get even the basics of what they need from the healthcare system. But here's a great news. Why not think innovatively? Why not think about how to do even better for people who have less or are more challenged? Why not go out of our way? We learned this with COVID.

AS: Once we got it and understood how people live, we started bringing vaccines to people's churches, to people's places of work, to their homes, we started getting people free Lyft and Uber rides to get to the vaccine sites. Once we started thinking innovatively, we closed the gap pretty quickly, at the very least, that level of measurement. Expanded Medicaid over the course of the five years after the program passed, dramatically reduced disparities in almost every measure. 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 foreclosure rates at homes, I'm talking about the ability to hold on to a job, I'm talking about the ability to accumulate wealth, I'm talking about cancer disparities and cardiac disparities, all of them improved. Now, if you are a doctor and you don't take Medicaid patients because the government is too much of a pain, reimbursements are too low, etcetera, 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 my gratitude for facing off on these challenges. And so you either have to... You get to decide every day. Put it this way.

AS: 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... And 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 served the same people for years, and 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 everyday, we get to make that choice. It's not always easy, requires courage, but that's how shit changes.

DE: I appreciate that and I wanna finish on a final note, you are the author of a book called Preventable, and our final question from a viewer is, please expand on what we can do next time to prevent this horrific chapter in our history from repeating itself. And final thoughts that you have for us today.

AS: Well, look, we're not always gonna prevent the vaccine from coming... I'm sorry, the virus from coming to our shores. 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, so we need to understand that in those situations, those situations occur. It really is going to be critical, not that we just have a better technical response or a better political leadership, God willing, we'll have better political leadership 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, Abdul, who I don't know, unless you care about mine, then 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 much more commonality, where income levels are closer, where people live more similar lives. You look at, again, this would be East Asia, this would be Africa, Scandinavian countries, others, when there is more of a bond and less wealth disparity, those countries have shown more support for one another in getting through the pandemic.

AS: If you look at countries with great extremes of wealth and poverty, like India, Russia, Brazil, United States, they do less good, and it's people at the bottom end that suffered disproportionately. So 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, honestly, we just gotta be better people. And I don't mean that to make that sound as judgmental as it sounds, but we just have to be willing 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.

DE: Andy, I think that's a great place to wrap it up. I wanna 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 wanna thank all of the good folks at the Ford School, Erin Flores and Daniel Rivkin for their incredible work in putting this together, and I thank all of you for taking the time to engage in this conversation, to offer your questions and to offer an opening ear. And on the final note on my end, I just wanna say that I do believe that we have the opportunity to build 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 in my time at the Ford School and my time running for office and before that, that the most powerful force in American public life is the passion and the commitment of young people.

DE: And I do hope that there's been something in the conversation that we shared today that inspires you and gives you that passion. And I hope that we can continue to walk a path together toward building the kind of America where something like this does not happen. And if it does, where the consequences are not so inequitable 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 in attendance, and I hope that you all have a great rest of your day.