Public health has never been more political than it is today — and unfortunately, that’s often made it partisan, too. Which is what makes the 1500% increase in local public health funding by the state of Indiana — a state with Republicans controlling both houses of the Indiana State Assembly and the governorship — so important. Abdul reflects on the danger of allowing public health to become a partisan issue. Then he sits down with Dr. Judy Monroe, president and CEO of the CDC Foundation, and Dr. Lindsay Weaver, health commissioner for the state of Indiana to learn how the state of Indiana made it happen.

TRANSCRIPT

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Dr. Abdul El-Sayed, narrating: COVID cases, positivity and hospitalizations begin to plateau as the federal government has fully muffed the new vaccine rollout. Costco does a giant cannonball into American health care, offering direct primary and mental health care for members. The Federal Trade Commission is suing a private equity backed anesthesia group for alleged antitrust violations. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] You know that apocryphal story at the birth of public health. If you listen to this podcast, you’ve heard me tell it several times, but I want to tell it to you just one more. It’s that one about the doctor who in the middle of a serious cholera outbreak in London in the mid 1800s figured out that rather than a miasma causing the disease, it was probably something people were drinking from a specific water pump. That guy, Doctor John Snow, King of the North. He wasn’t content just knowing that a water pump was probably killing many people in his community. He did something about it and that thing he did was get political. He petitioned the Board of Guardians to have the pump panel removed. And removed, situation averted and boom! Public health is born. It’s that last part I want to talk about today. Snow understood that the only way to make his knowledge do what it was actually intended to do, you know, save lives, was to expose it to the realm of politics, to make sure that people with the power to act were persuaded to do so. See from the jump, public health has always been political, and as much as we love to idealize the past as free of the same sorts of petty, cynical and self-serving motives that animates so much of our politics. People were the same back then too. But what wasn’t the same is how people communicated. I probably don’t have to say this, but in 1854, the vast majority of people couldn’t communicate to thousands of people at a time, and those who could couldn’t do so virtually cost free. It required a printing press, which very few people had. And even if you had a printing press and money was no object, you still couldn’t communicate instantaneously with people who were far away, let alone across the world. And the high cost of communicating meant that you really had to be motivated to communicate, and that when you did, you chose your words carefully. That’s decidedly not how things are today. And if politics is about the conversation we share to define who we are and who we want to be. That’s ironically gotten a lot harder to do. It’s on vogue to say that the pandemic was politicized. Of course it was and that’s because social media is a politicization machine. Rather than allow us to hash out the nuances, the takes and counter-takes are so voluminous that no matter how thoughtful or nuanced, they just get tallied up on either side of an information tug of war that’s constantly playing out online and in that environment, rather than a once in a century event bringing us together against an extremely transmissible, very deadly virus. It just served to tear us further apart. It’s like some uncanny fourth law of political physics. Every issue shall be politicized in direct proportion to the proportion of people it affects. We live so completely in the ecosystem created by social media that it’s hard sometimes to appreciate that this environment isn’t natural. It doesn’t have to be this way. And for most of history, well, it wasn’t. In the midst of an all out effort against the pandemic, most of the public health community simply wasn’t ready for what hit us. The way that public health was politicized, how every recommendation to protect yourself and the community from COVID was rendered by the politicization machine into nothing more than a partisan political symbol. How public health officials were pilloried and vilified and attacked. And now that the machine has largely moved on, we’re left to pick up the pieces. And here’s the thing about it. Once something is politicized, it’s hard to undo. Vaccination rates, not for COVID, but for the simple things like measles and polio that we’ve been vaccinated against for decades, they’re down. And a recent Pew Research poll found that the number of Republicans who believe that parents should have to vaccinate their kids for, say, measles, mumps and rubella has dropped by half since 2019. And that doesn’t bode well for the people who have no choice in the matter, those kids. See, public health will always be political, but it doesn’t have to be partisan. And rescuing it from the Partisanship is one of the most important priorities we have right now. Which is why recent news out of Indiana is such a cause for hope. Rather than defund public health, as some red communities, including Ottawa County in my home state of Michigan is trying to do. The state of Indiana has made a massive history making investment in public health. And what makes that so notable is that Indiana has a GOP led legislature and a Republican governor. But those leaders did something important. They quietly, efficiently and honestly led their communities to protect life in their state. I wanted to understand how it happened. So I reached out to Dr. Judy Monroe, president and CEO of the CDC Foundation, and Dr. Lindsay Weaver, health commissioner for the state of Indiana, two leaders who were instrumental in making this happen to understand how they did it and what we can learn about depoliticizing public health. Here’s my conversation with Drs. Judy Monroe and Lindsay Weaver. 

Dr. Abdul El-Sayed: All right. Can you introduce yourself for the tape? 

Dr. Judy Monroe: I’m Judy Monroe, the president and CEO of the CDC Foundation. 

Dr. Lindsay Weaver: And I’m Lindsay Weaver, the state health commissioner for Indiana. 

Dr. Abdul El-Sayed: So stepping back, I just want to um set the set the lights, so to speak, on stage here for what I think is just really an incredible uh moment in public health in this country, post-pandemic. Um. Dr. Monroe, what is the state of local and state public health investment post-pandemic? Like if you had to give us um maybe a grade or um a good, bad and ugly on this, what would you say it was? 

Dr. Judy Monroe: You know, I think post-pandemic were it would be maybe average. And the reason I say that, first of all, public health funding is pretty complex to track. But if you look at some of the most recent reports, like from Trust for America’s Health, um at least 13 states have cut funding. So that’s not good. But at least 34 have either maintained or increased funding. And so there is some good news actually mixed into this. Um and some states it’s hard to get the data. 

Dr. Abdul El-Sayed: Mmm. And and, Dr. Weaver, um give us a sense of where Indiana was when it comes to the the pandemic and the experience of the pandemic and then attitudes post-pandemic about what mattered and what doesn’t. 

Dr. Lindsay Weaver: So I would say before the pandemic and then through the pandemic, one of the things that the Governors Public Health Commission, uh which is a group of people our governor put together, to really look at public health in Indiana, recognized that we had been funding our local health departments at the same rate for over 20 years. So no increase over time. So it was very stagnant. And then we saw during the pandemic, when we did have this influx of funding, just how we could very quickly implement programs, make a difference, be nimble with that funding to make you know a greater good, a greater just uh um a greater improvement to public health in Indiana. So we the governor’s public health commission recognized that this is something we need to continue. Right. We see the cliff coming, the stop of the of the federal funding coming in. And we’ve made such good momentum in moving all of this forward and that funding is a part of it. Right. If we’re going to keep on doing the work we have to fund. And so I think that that was really the turning point. 

Dr. Abdul El-Sayed: Hmm. You know, when we think about public health funding writ large, one of the hardest challenges that we have is that it’s feast or famine. It’s boom or bust. It’s all of a sudden you’ve got a whole lot of money you got to spend on one thing and you don’t really have the infrastructure to spend it, let alone um the need for all of that one thing. And then all of a sudden all the rest of the funding goes away. And what will happen is in the legislative uh or even executive cycle, folks will point back like well you all got all that funding. And and it it is it’s crazy making uh to to be honest. But how as you think about coming out of this this COVID moment, how has thinking shifted around trying to address these boom or bust or feast or famine cycles in public health funding generally? 

Dr. Judy Monroe: Yeah, well, just to build on what you said, it’s a horrible way to fund public health. With the boom and bust, because you can’t you can’t manage all this influx of funding like, like you were saying. So I think coming out of of the pandemic, again, it’s a mixed bag that we’re beginning to see. Uh. But I’m super encouraged by Indiana and Kentucky actually are two states that have in the pandemic have taken note of public health transformation. And uh as Dr. Weaver said, you know making sure that um here’s not the cliff and having that sustainable funding. So that’s that’s an area that is super important. But, you know, we’re already seeing some bust. I mean, the the clawbacks from the debt ceiling, there are there are programs that we’re expecting funding from federal government that now are losing that. And some of that’s going to impact our sexually transmitted infection control, particularly things like syphilis and congenital syphilis. There were states that were expecting immunization modernization uh money, and that’s being clawed back. And so that’s that’s been on the backdrop of the states having received this additional funding. And I one of the things I think is a good point is that the um from the American Rescue plan, there was um you know $3 billion dollars that was uh committed and its five year funding. So that part’s good. So again, we have this mixed picture coming out of the pandemic regarding overcoming the the boom and the bust. 

Dr. Abdul El-Sayed: One of the things I love about this plan that you all have ushered forth in Indiana is that you’re trying to actually get past boom or bust. You’re trying to think a little bit about what is the the broader baseline investment that needs to happen toward a healthier Indiana, thinking locally about the opportunities to to invest through local health departments, can you talk about how you settled on that vision for a future of public health Dr. Weaver?

Dr. Lindsay Weaver: I think another kind of a silver lining or something that we learned from the pandemic is that where we were the most successful was when we worked with the people within the community, right? The local health departments, the community based organizations, the hospitals. They knew where there were the risk was, where their opportunities were, what was successful. They knew you know who to communicate with. They knew who the partners were in the community. And so those were some of our most successful outcomes. It became really clear as we were viewing public health and where we could go with all of this, that there had to be local control, we had to get the funding to the local level and let them and invest in a way for what their needs are. And we really did see that the needs were different. I mean, some similar across counties, right. But in a different way. And then also what that um community was ready for. They we saw some that had really great infant mortality programs and some that had none at all right, tobacco [?] programs and some that had none at all. So how do we really all work together to move the entire state forward in a way um, again, that the that the locals could actually control what that looks like, because we found that to be so successful. 

Dr. Abdul El-Sayed: Yeah, I really appreciate that and look, as a director of a local health department, um I wish more decisions were made that way um because the needs that you have in a in a very diverse state like in Indiana, like in Michigan, are going to look very different. And, you know, one of the frustrations that we just sort of ran into um here in in in Michigan was about uh how decisions were made around dividing um a pot of federal money. The city of Detroit uh got a big chunk of it, and then the state got a big chunk of it. And then the state went and divided it evenly across 44 health departments, despite the fact that, you know, our county, uh even without the city of Detroit, which is in our county, our county health department accounts for one in ten residents of our state. So um and then, you know, you kind of wonder how inequities form. Well, they form when you make decisions about discounting the bodies of folks who live in traditional urban places, um when you make decisions about how you fund. And um and so you guys are, you know, are thinking about uh about this in a in a in a I think a really thoughtful way. You know, the other thing about it is, is that one of the things I, I I appreciate about this approach is that um wherever you stand on the political spectrum and I don’t want the conversation to get political, but local control has always been a precept of traditional conservative thought. The idea that folks who are closest to the ground make great decisions about how to spend money. Um. And it strikes me that, you know, as we’ve had this sort of turn away from public health in in in in the way that modern conservativism makes itself up, you’re really appealing to a very traditional conservative viewpoint on saying, listen, we can we can provide local, uh local communities with the capacity to make their best decision for their folk um and to make sure that governance happens at the local level. Um. I wanted to, you know, just use that as as a way to sort of pivot um to ask a little bit about, you know, the broader ecosystem of funding in traditionally Republican and Democratic controlled states. So, Dr. Monroe, um what is the lay of the land in terms of the states that have invested more versus states that have invested less? Is there are, you know, a particular um political hue uh that that that that that that follows? Uh, or has it been more of a hodgepodge? 

Dr. Judy Monroe: Yeah. I mean, it actually is a bit of a hodgepodge. I mean, there is a mix. And so when we look at across the nation un the states that have invested uh more in public health, um you know we think typically we think they’re going to be the blue states. But but there are red states that are investing um and there are red states in the [?] that are looking to invest more. Um. And so that to me is super exciting. Um. I think I think you absolutely have hit the nail on the head. Uh. It’s it’s a bit of the magic sauce so you know, this was the secret sauce, if you will, in Indiana to say it’s going to be local control. My co-chair, Senator Luke Kenley, kept telling us, you got to get this to the local uh health departments and to the local communities, which um in Indiana is unleashing partnerships like I don’t know if they’ve ever seen before. Interest in public health at that local level where you really are bringing people together. And so your point that’s that really does speak to, you know, traditional Republican thinking, um but it’s a win for everybody. This is a time for a win win because you can lift public health um and um and get everybody on board, uh which I personally am really excited about. 

Dr. Abdul El-Sayed: It strikes me that so much of the way we think about action has increasingly been sieved through a very particularly online kind of cultural debate where different words are used or to to signal different values. And oftentimes when you think about substantiating public health in a traditionally uh liberal or progressive ecosystem, you’re going to be talking about things like equity and you’re going to be talking about things like government and investment. Um. The question of sort of collective action for the public good seems to be baked into the the central ethos here that the government can do good things and this is one of them. I want to understand a little bit more about how you’ve presented or the idea of public health has been echoed, presented, framed um for a more conservative type of policymaker. How do you talk about it? What are the central themes uh that you focus on when you talk about this kind of public health investment? And this is this is open to either of you, would love to get both your perspectives. 

Dr. Judy Monroe: So one of the things I’ll jump in is Indiana is largely a rural state. There are a lot of smaller counties, and one of the areas that um we did focus on in the commission was um emergency services, which was a big need. And so that was part of this moving forward and and uh you know bringing bringing the commission’s recommendations uh to to where we are now and actually implementing. So that was one one of the secrets. Um. I think Indiana, the starting point for all of this was to say um and I know Dr. Kris Box, who was the commissioner at the time, was very articulate, saying that the the aim here is to make sure that these core public health services are available to everyone in the state. Um. And I, you know, going back to the rural community, I, I was a rural practitioner. I practiced in rural Tennessee when I first got out of my residency. Um. And so when you want to talk about equity, I mean, there are there are communities across this country uh that um are that are Caucasian, rural America that have a lot of disparities. Um. So we need to be thinking about everybody and and making sure that they all have the services from public health that that they deserve. And Indiana did that. 

Dr. Lindsay Weaver: So we’re going around the state right now and um and have been and talking to counties about you know what are their needs, how are they going to invest this funding locally. And I’ll tell you, some of the people who are most excited about it is our business community. So we’re proud of our economy here in Indiana. And there is a business case for this. And I think people or employers really recognized during the pandemic it is important to have a healthy workforce. Right. And also, as we’re recruiting more businesses to come to Indiana and the employees that are needed to to invest and engage in those businesses, people are looking to move to a healthy place. So when we kind of put the [?] aside you know for legislators, for our local elected officials and say, look, here in Indiana, where we have invested in the past in our economy and our education, we do really well in national rankings. Where we haven’t invested which would be on the public health side. We’re one of the worst, right, 46th in the nation for obesity, 45th for smoking. Um. And honestly, you can just kind of click right down the row. And that that spoke to them they they said they acknowledge that, you’re right. Where we’ve invested in the past, we’ve been very successful and then we’ve taken that conversation to the local level. So as we go around to the counties, we say invite your local elected officials and invite your community based organizations, invite your clinical specialists, etc., businesses. And they’re coming. They’re coming and they’re having these community conversations and we bring the data to them. We said, this is your county, this is how your county ranks in Indiana. Here are your health metrics. And you can see their their eyes kind of being open, right? That they they they didn’t realize that maybe they were as worse off as as they did. And I’ll tell you, one of the conversations we had, the police chief was there and we said, were talking about their obesity rate. And he’s I know exactly where that’s at in our community. You know, they only have access to a convenience store. And and you can see, like the wheels turning and the community kind of wrapping their arms around it to say, okay, there is a problem and here let’s start thinking about ways that we can address it as a community. 

Dr. Abdul El-Sayed: I really appreciate that point. And I’m hearing um there is an opportunity to sort of frame around first response and first responders uh and support for them. I’m hearing uh there’s an opportunity to to make a business case and to work with the business community around. Um. You know, the fact that the public is both your uh both your labor force and your consumers and um the healthier that you are, the better you are, the healthier they are, the better off you are. Um. And the the recognition that um that if you appeal to, you know, particular localities uh and their interests, that there’s an opportunity to sort of cut beyond some of the the noise um that we’ve heard, that that tends to frame a lot of the misinformation that came out of the pandemic. I want to ask you, right, because one of the challenges, I would imagine tends to be around the consideration of of equity. And, you know, I ran for office uh in Michigan, and one of the most um profound recognitions that I had was that when you talk to low income, marginalized folks, whether you’re talking about rural white folk or urban Black folk, they tend to talk about the same challenges. They talk about lack of access to health care. They talk about the fact that their kids school looks exactly the same way it did when they went there. They talk about worrying about the poisoning of their water, whether it’s lead in a place like Flint or PFAS uh in a place like Oscoda. They talk about um a worry about the environment, but it shows up differently, right? Most folks, you know aren’t going to come talk to you about climate change unless they’ve um they’ve been reading specifically about it. But they will talk to you about the way that climate change affects them. The the growing season is a lot shorter or longer. I worry about the smoke coming out of the smokestack that comes up over my kids school um and those issues tend to be the same. The problem, though, is because our country is so segregated that it’s really easy for folks to tell others or tell them that the reason why is those other people over there, whether you’re pointing from a city into the rural community or you’re pointing from a rural community into the city, um and that tends to uh be a reason why we don’t invest in global public goods like public health, because basically we say, well, I’d love to give something like this to my community, but I don’t know that those people over there deserve more of it. Right? And let’s be fair, right? Given the history of structural racism in our country, it tends to be a lot more the rural communities pointing to the city. Right. And I’ll tell you, in Michigan, I don’t know much about Indiana, but I’ll tell you in Michigan, it tends to be pointing into Wayne County and Detroit and saying, well, those folks, they get all the handouts and they take our money and I don’t even know what they do when they can’t govern themselves, etc., etc.. I want to understand a little bit about how you all were able to get past that divisive politics, um to get to something where you can say, listen, as a state, we’re going to invest in every one of our communities, whether we’re talking about Indianapolis or we’re talking about the most rural of rural communities uh in in a different part of the state. I’d love to hear just how you bridged that and whether or not there was a least common denominator in that conversation that helped you to move forward um and convince people out of that kind of, you know, zero sum kind of politics. 

Dr. Judy Monroe: So first of all, the commission was very thoughtful in terms of the membership of the commission. Uh. And so the Indiana Minority Health uh Association was, you know, represented the hospital association, the rural health association. Um and and we had counties, we had elected officials. So I was really impressed with the representation statewide that really represented, at the end of the day, all communities one way or another. So that that was a starting point. Second part was the transparency. I think this was key. This was the most transparent [laugh] method. I mean, everything was recorded, every last word. But one of the things that uh was done were the listening sessions going into the communities and really listening. I participated in a few of those. I live in Atlanta, so I couldn’t go to all of them. Um. And I was so impressed with the leadership of Indiana, really deeply listening to every community, anybody that wished to come speak about you know whatever it was that they were troubled by. And so that just that action alone went a really long way in in getting to where what you’re talking about and where we were able to go. And then the other I mean, and the leadership, um there was a lot of humility in the leadership. Um. Dr. Kris Box I just uh my hat’s off to her uh and to Dr. Weaver. They approached this with such humility um in in there listening, but then sincerely expressing that they wanted this to be for everyone. That again, that those core public health functions that are going to lift everyone, lift the state at large, uh one of the areas that we focused on were children and adolescents. So that’s common. You get a lot of common ground when you talk about children. Uh. You know, we’re all human beings and we all want our children to get a get a healthy start. So that was helpful. So I think it was multifactorial, but uh I would love to hear what Dr. Weaver how she would answer that question as well. 

Dr. Lindsay Weaver: Yeah. I think something um great that the Governors [?] Health Commission did um and then we continue to do is the engagement of the of the of our local elected officials. I mean, they live in those communities. They understand their communities, um and this is personal and it should be personal. Um. And we kept it personal. Right. That if we give you funding and we say, you know, with this funding, if you if you, one, they get the option whether or not to accept the funding. So not every county did right. We way exceeded our expectations and we’ve had 86 of our 92 counties did opt in to the funding. But if they agreed to do the, if they do agree to opt into the funding, they agree to do these core public health services, but they get to address it for public health service as what they need for their community. So an example I like to use is trauma and injury prevention, right? We have a key performance indicator, identify a leading cause of trauma and injury prevention in your community. So you know the elected official local health departments, we have a high number of farming accidents. We had four teenage suicides last year. We had a high number of drownings in young children. And and these are the things that they want to address, right? So if they have the funding, they have the ability, they’re going to do something and it’s personal. And I think that kind of cut through, I mean, to use your words, it cut through all the noise. They can see how this funding they could take back home and make a difference. [music break]

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Dr. Abdul El-Sayed: Can you can you walk us through just what the details of both the commission structure and the outcomes were? Um. How did you structure the the conversation? Under what what what premise and then what what came out of it? And how does that operate moving forward? 

Dr. Judy Monroe: Yeah, I’ll start. I’ll start with the commission. So this started actually with an executive order from the governor. So Governor Eric Holcomb had an executive order that that came out outlining the the development of the of the Commission and outlined the different positions as I described. So the [?] statewide representation. And we were making sure that we had both elected officials, health officials and and members that could really represent the community at large. Um. Then the structure was we were also charged with like six areas that we had to focus on, and that you know that included things like like governance uh and funding of public health, of the um preparedness, and taking a look back at how Indiana had had managed during COVID, uh children adolescence I mentioned. Data was a really big area that that we dove into. So anyway, there were these there were these charges that we had um in the executive order, uh health equity was called out as well. Um. It was stated that we needed to address that and and then we met once a month and all those, like I said, were recorded. My co-chair and I would um we’d alternate who chaired the meeting typically. And that process really mattered. I I advise all states to do this process. As co-chair, I saw hearts and minds changing over the course of the year that we met. We met in person. It was a regular cadence. The the university, the Fairbanks School of Public Health, along with uh experts from the state Health department presented data. They also presented national data. So the commission got to see what was happening in Indiana compared to what was happening nationally. Um. And that process of relationship building among commission members, uh coupled then with these listening sessions that were taking place uh throughout this process as well, gave input. There was public comment that was available so at the beginning of each commission meeting, uh we would have a readout of all the comments and questions that had come in from the public uh and those were you know acknowledged and and referenced and debated and those types of things. So I personally I just thought it was an outstanding process. But again, I honestly saw hearts and minds changing even among the commission members as they learned more about the state of public health in Indiana. 

Dr. Lindsay Weaver: So after the governors public health commission, a bunch of recommendations came out of it. Some of it would require legislation. Some of it we’re just doing as an agency, as a Department of Health, to move these recommendations forward. But a big part of it was funding, right? So so working um with the outcomes of the recommendations and then again with our local elected officials, you know what what what is would be important for them to be in this legislation, for them to be comfortable with uh and we kept on you know massaging that throughout our last session um to come up to where we’re at now. So uh we’re appropriated funding from our legislators um that you know 75 million this year, 150 million next year is available to our local health departments and there’s a funding formula with that. It’s per capita, um there’s a minimum for our really small counties because, I mean, talk about inequities, right? I mean, if you only have a county of 5000 people, you don’t generate the tax revenue to be able to really do some good public health work. Right. And so there was a huge difference depending on where you live, how your how big it was. So a minimum for the smaller counties and also additional funding um if your life expectancy was uh uh less than two years from the from our average life expectancy in Indiana and also for um communities that had a higher social vulnerability index, there’s some additional funding there. So kind of incorporated all of that in there. And then they have the ability to opt in or opt out. So all the counties have actually until today [laugh] uh to opt in. And so we know we’re at 86 of our 92, which is again, greater than what we thought. Um. But I mean, I think just underscores the tremendous amount of just constant conversations and working with each other um across across the state locally um and making sure that they have the support you know to actually implement all this funding. So they’re submitting their bid budgets to us right now. That funding is going to go out the door um on January one. And then you know this, of course, with money has to come some accountability. And so we’re going to have we have state level KPIs, which is a first right? To say like, let’s look at all public health and say, where what are we trying to do here? How are we going to move the needle on these things? Um. And then the counties are going to have come up with their with their local KPIs, and we’ll work with them to develop those utilizing data, um right to inform those and and be side by side to support the counties as they as they move this process forward. So um you know that’s where we’re at now. We’re really excited. I mean, again, the conversations with these counties and the excitement around it and the things that they’re thinking about doing, it’s kind of like, you know, they’ve known for a long time, if only we had funding to do this. And the infrastructure that I wish we could do this. And this is a time where they’re getting to do all these I wish I coulds. 

Dr. Abdul El-Sayed: That’s that’s really phenomenal. Um. And I really appreciate the the thought and the the the way that outcome came out of process. I want to ask you, I mean, six of Indiana’s counties opted out. Did they did they give a reason why? Is there any rhyme or reason around why you wouldn’t just take free money from the state to invest in your people? 

Dr. Lindsay Weaver: I mean I, it varies. And yes, we we definitely have continued to have conversations with them. I think, you know, some of it is just um there it’s kind of a watch and watch and wait. They want to see what other people do. Maybe they didn’t feel like they were in a place to um you know receive these fundings and then actually start implementing some programs or some of them are like, like just give us some more time um and others just want to take a you know sit back and see how all this looks. Um. You know, I think about other programs that we’ve implemented from the state level and also that come down from a federal level. They often come with you know lots of I don’t know what a better word, but strings, right? Like you have to do this and there’s all this reporting and it can honestly be very cumbersome. And so I think that’s part of it, too. Some worries about that. But that is really I mean, it’s brilliant. I personally think what what we finally ended up with our legislation that it does allow that flexibility for them really to do what they need to do locally under the confines that we’re all going to do the same for public health services. And we’re going to we’re going to monitor ourselves, right? We’re going to hold ourselves accountable. And so I keep telling, you know, every program isn’t going to be successful but because we’re we’re we’re watching it, you know we’re collecting the data, then we’ll be able to pivot. And then or if it’s really successful, double down, right? And then share that among the counties, which is something we haven’t talked about here. But something else that we did is we do now have people out there um that are what we’re calling them, are regional administrators, but they’re they’re helping bring the counties together. So now all of our counties are talking to each other. So nobody’s reinventing the wheel, right? They’re hearing from other counties what they’ve done in the past, what’s worked, what hasn’t worked, maybe even working together in some instances to do something you know as kind of a unit of a couple of counties, especially in our rural areas, to work on things. Um. And that has been a really positive outcome of this whole process as well. 

Dr. Abdul El-Sayed: Has there been pushback?

Dr. Lindsay Weaver: I think with anything that’s new, yeah, there has been pushback. But you know to Dr. Monroe’s point, just the thoughtfulness um of of of Doctor Box and of Senator [?] and Dr. Monroe um and the governor’s Public Health um Commission to really I mean, and then really those elected officials I mean, the Chamber of Commerce Farm Bureau came and testified for this. I mean, we’ve really brought together the entire community to move this forward. Um. So, like I mean, yes, there’s just always the questions, you know, are you sure? Are you sure? And what about this and what about that? And some of those things we can’t answer. Um. But I think because we have as a collective um worked on this together, people really want to see and be successful, which is also really exciting, right? Because that means that they’re they’re bought in and they’re going to help to make sure it is successful. 

Dr. Abdul El-Sayed: I want to step back. Um. You know, most most of the listeners of the show are not going to be from Indiana. But so much of what you talk about here is about how do we build an equitable, inclusive public health conversation. And most of the time, it’s it’s really about trying to focus on marginalized communities who tend to be forgotten. And one of the key points you’ve made, and I think is really important to make, is to remember that um that marginalization comes in a lot of different forms. And in some respects, uh when we think about, you know, calling back to an episode we did about the injustice of place, a lot of the poorest communities in the country are rural, uh and we we tend not to include that in the conversation that we have. At the same time, though, as we talked about earlier in in this episode. One can’t be zero sum about who you include. And sometimes when we talk about rural communities, there is a need to push out other communities we talk about. And so I guess what should this experience here teach us about how we advocate for a truly inclusive public health um that really does address all the forms of marginalization, that does focus on the health and well-being of all of us. Um. What can you share from from the process? What you heard on the ground and what ultimately came of it? 

Dr. Judy Monroe: You know I’ll jump in. I mean, that’s a it’s a terrific question. And, you know, from my my point of view, I think the conversations really matter. Relationships really matter. I think sometimes we we get into trying to tackle these issues without maybe having all the people around the table to be able to have those conversations that are not charged. I think that was one of the things that the commission was able to do was to be able to dive into difficult topics without it and without it being charged. It was thoughtful. Everyone was respectful and listening to one another and then going out into the communities to try to do that as well. There’s um you know, if you look at some very wise work that has been done. There’s there’s if you lift or if we lift everyone, we actually make the world healthier and more productive for all. That’s the other piece of all of this. And so I think we’ve got to use language that um is is, resonates with folks and folks can really understand how it impacts them, because it’s not a it’s not a zero sum thing. You know, if I if I give to you that doesn’t I actually I’m lifting myself. I’m lifting my whole community. I’m decreasing crime. I’m decreasing, uh you know, potentially my taxes. Because if folks have more opportunity for employment and education, that lifts the entire society um up. So I don’t know that we do a good enough job explaining that or helping people understand. 

Dr. Lindsay Weaver: Um. I agree. I think that’s a really great question. Um. I think back to so one of the things we talked to our legislators about as we’re you know we’re preparing for the this big conversation was looking at our life expectancy. That life expectancy in Indiana has actually been going down. And then we shared, you know, life expectancy is going down. And it’s mostly in our work, young working people, 25 to 65 years old. Um. And people, they were surprised at first. And then they and then they acknowledged that probably to be true. Right, because of you know mental health, substance use, you know other things going on in society. And then we had a map that showed the difference in life expectancy per county and that there’s almost a ten year life expectancy based on where you live in Indiana. And I heard one of the legislators say who you know found himself on the map and said, oh, we have a good one of the better life expectancies, but our neighbor right next door is low. And like, why? He said, I feel guilty. Right? And so I think it was just kind of um again, just you know putting the information in front of people and then empowering them again you know to do something about it. And then I think too, is that we can’t do this in silos like this will not work if it is just the Department of Health or if it’s just the local health department. The part of the legislation is that they are to bring people together and have a community conversation about how they’re going to invest the funding. And we’re seeing our counties do that right. The hospitals know about their infant mortality. Right. And the uh you know the Organization for the Northern Hispanic uh you know Health Coalition in in Elkhart, which is up there you know by you guys, um they know about the what’s going on in their community. And so they are all coming together to say, okay, what are where are commonalities here? Where’s our highest risk? You know and then what are we going to do and we have to do it together because that’s the only way this will be successful. And I think that is partly that’s one of the other things that came out of the pandemic, is that we did start to work you know across these different organizations and typical silos again, the businesses, we are talking to the entertainment you know community and tourism like everybody was coming together. Um. And so it’s it’s a continuation of that. 

Dr. Abdul El-Sayed: I really um, really appreciate both of your thoughtful engagement with this. And one of the big reasons I wanted to have both of you on is just because I think we live in a moment post-pandemic where, you know, as my my friend and colleague Katelyn Jetelina calls it, we’re in this pandemic revisionism phase where everyone wants to look back at the pandemic and be like, well, that wasn’t so bad, uh except for it really sucked. It really sucked. And uh it sucked in a lot of ways. But one of the ways that I think is somewhat frustrating was how it was used to tear us apart in a moment when all of us faced an existential threat that should have brought us together. And I think if I was surprised by anything in that time was it was that we we really couldn’t come together on a broad societal sense. But what I love about this experience is that you’re showing that in your state, some thoughtful leadership around all of us, recognizing that all of our self-interest rests in our collective interests and our interests in one another. Come together and ask, What can we do for everyone here? And then you got it done. And you got it done in a context where if all you watch is the the the grand narrative that gets played out on uh I don’t know what the website’s called now, um the one that used to be called Twitter, uh then you, you come away feeling like it’s impossible. But when you actually look in the nooks and crannies across this country, there are really good people coming together despite differences to to make good things happen. And I just want folks to appreciate that that is both possible and that it is happening. And one of the ways in which the forces in our society that do want to tear us apart operate is to tell us that it is impossible that you should not try. And you all came together. You tried and you did. And so I just really appreciate that leadership. I appreciate the effort. I appreciate uh the opportunity to to learn more about it from you and and the work that you’re doing on the ground to see it through and and also um the time that you took to come share it with us. So our guests today are Dr. Judith Monroe. She’s the president and CEO of the CDC Foundation, and Dr. Lindsay Weaver, who is the state health commissioner for Indiana. I really appreciate you all making the time. 

Dr. Lindsay Weaver: Appreciate it. 

Dr. Judy Monroe: Thanks for having us. 

Dr. Abdul El-Sayed, narrating: [music break] As usual, here’s what I’m watching right now. First, the good news. While cases, hospitalizations, and deaths to COVID 19 are still climbing, they’re climbing way slower than they had been a few weeks back. That suggests that Covid spread is starting to plateau. Now for the rest of the news. That doesn’t mean that we’re quite out of the woods, that things won’t accelerate again, which is why it’s so critical that we get more folks vaccinated this fall. But here’s the problem. This fall’s rollout has been, for all intents and purposes, shambolic. Nursing homes, you know, the places where the most vulnerable people are concentrated are still waiting for their stock. Folks are being turned away from vaccine appointments for lack of vaccine. And still others are being asked to pay directly, even though their insurance is supposed to cover it. Why? Remember, this fall was the first time that the vaccine was supposed to be quote, “commercialized,” meaning that manufacturers were supposed to sell it directly to the public. But just like commercialization in health care overall, it’s meant that vaccine access has been disjunct, inconsistent and hard to explain which is exactly what you don’t want for a vaccine that only 20% of Americans got last year. In other news, forget hotdogs or rotisserie chickens. You can now buy a primary care visit at Costco. They’re offering direct online primary and mental health care visits for members. Their partner, Sesame, doesn’t accept insurance. Instead, they charge a flat fee of $29 for a primary care visit and $79 for a mental health care visit. All right. Let me put my cards on the table here. I love Costco. From the fact that they provide a living wage and real growth opportunities for their employees to the selection of high quality, affordable products to yes, the tasters, of course the tasters. I’ve been a Costco fanatic since I was a kid. But Costco’s play here says something far bigger about the nature of our health care system. They’re literally bypassing the traditional insurance based system to offer direct to consumer primary or mental health care. And when a massive mainstream retailer does that. It’s a telling indictment on the nature of the health care system that it’s failing so many people, that there’s an obvious market for products that bypass it entirely. Direct primary care is only going to grow. Watch this space. Unfortunately, the other thing that’s growing is the power of private equity firms in health care. As we discussed in an episode about their growing influence over health care a few months back. Private equity firms are capital aggregators that make their money by buying small businesses and then selling them for profit by either breaking them into small parts or, quote, “rolling them up” as a part of a bigger string of similar businesses. What makes them so pernicious in health care is that unlike other goods and services, you have to get health care where you physically are. And when they roll up companies, they reduce or even eliminate local competition, allowing them to use their monopoly power to raise rates and squeeze people, people who are there to get health care they fundamentally need. And that’s exactly what the FTC is alleging, that private equity firm Welsh Carson did by creating a subsidiary company called U.S. Anesthesia Partners, built specifically to monopolize the anesthesia market in Texas, all so that they could jack up prices on consumers. According to the FTC lawsuit. U.S. Anesthesia bought up nearly every lost large practice in the state and then colluded with the remaining practices to price fix. Private equity firms have been doing this for a while. What’s new is that the FTC is finally taking a stand. And if you’re a regular listener of this show, you’ll know that I’ve been calling for more FTC involvement in health care for a while now, and that’s because consolidation is accelerating and reaping worse and worse consequences. And this well, this is a great first step. Kudos to you, FTC. That’s it for today. On your way out, don’t forget to rate and review. It really does go a long way. Also, if you love the show and want to rep us, I hope you’ll drop by the Crooked store for some American Dissected merch. [music break] America Dissected is a product of a Crooked Media. Our producer is Austin Fisher, our associate producers are Tara Terpstra and Emma Illick-Frank. Vasilis Fotopoulos mixes and masters the show. Production support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer, Michael Martinez and me, Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the hosts and guests and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.