President Biden ran on the idea of offering Americans a “public option” for health insurance — a government managed healthcare plan that would operate in parallel to private insurance. But what if we extended “public options” beyond health insurance to, say, pharmaceuticals or increased public investment in clinics and hospitals? Dana Brown is the Director of Health and Economy at the Democracy Collaborative and has been writing about just that. She joins Abdul to talk about it.

Transcript

Dr. Abdul El-Sayed: The pressure on hospitals around the country begins to ease as the Omicron surge lets up. The Biden administration pledges 400 million N95 masks for Americans as covidtests.gov opens, allowing Americans to sign up for up to four at-home rapid antigen tests per household. A new review of studies demonstrates the massive impact COVID-19 has had on the mental health of our children. This is America dissected. I’m your host, Dr. Abdul El-Sayed. Can you name the three to four nearest hospitals to your house? If you’re able to do that, how many of those hospital names have changed over the last few years, and how many changed their names after they were bought up by an even bigger health care system? Chances are in your community and in mine, at least one of those hospitals went from being a nonprofit hospital owned by some religious denomination with the word like Catholic or Lutheran or Methodist or Jewish in the name, to being owned by a private for-profit corporation with headquarters far away from where you live. Today, the nonprofit local hospital is becoming a thing of the past. By 2018, nearly two in three hospitals nationwide belong to a hospital chain. Hospitals are buying each other up at a record pace. And if you live in a rural community, you’re even more likely to have watched your local hospital close as a result. In fact, in 2020, a year defined by global pandemic, 47 hospitals were shuttered. Why, you ask? Well, because in rural communities where there isn’t the high density of people and those people tend to be poor, these chains decided it’s better to just shutter the place than run it at a loss. That, of course, leaves hundreds of thousands of people forced to drive hours to get to the nearest hospital. But that doesn’t matter in our for-profit health care system. That’s not the point. The point is profit. But shouldn’t it matter? Isn’t access to a hospital, in case you get in an accident or have a heart attack, something every American should just have? Well, yeah. Hospital consolidation and shuttering is what economists call a market failure, those things that people should have, but the free market fails to provide. So what’s the answer to these market failures? How do we ensure that people everywhere have access to a quality hospital in their community? The answer to a market failure is that government should step in to provide the goods and services that the market fails to, what economists call, quote unquote “public goods.” Now, for decades, this country has failed to treat health care as a public good. But let’s get this straight, health care is a public good even if we don’t treat it that way. And if you listen to this podcast, you know that I believe solving the failures of our for-profit health care system begins with Medicare for All, a government-sponsored health insurance plan for everyone. But some have proposed a halfway point. During the 2020 election, now-President Joe Biden campaigned on and promised to deliver a public goods option:

[clip of Joe Biden] What I’m going to do is pass Obamacare with a public option, become Biden care.

Dr. Abdul El-Sayed: That public option refers to a publicly-owned and operated insurance plan that exists in parallel to the private plans. Well, if you haven’t noticed, one year and five days into the Biden administration, we’re no closer to having a public option for health insurance than we were before he placed his hand on that Bible. But that’s not actually what I want to talk about today. What if we extended the concept of a public option beyond health insurance? What if we extend it to hospitals? The government already funds a set of publicly-funded clinics called Federally Qualified Health Centers, which often plug the health care hole that so many in lower-income communities face. For many people, these FQHC’s are a lifeline. But what about public hospitals? As public nonprofit hospitals are bought and many shuttered by massive for-profit health systems, what if the government stepped in to provide a public hospital option? What if they recognized the public good of hospital care? Well, this isn’t actually a wild or un-American idea. You know, those hospitals I had you thinking about earlier on? Many of them, way back in the day, they used to be public. Take the Detroit Medical Center in the heart of the city of Detroit, it’s now owned by a private hospital corporation. But before that, it was a nonprofit hospital, and way, way before that, it was publicly-owned and operated by the city of Detroit. This idea isn’t crazy. It’s a return to our roots. And then there’s pharmaceuticals. Americans spend thousands of dollars a year more than they should because our medications are manufactured by large corporations who have a clear profit motive to make money off of us. What if the government, which already funds R&D in the form of the National Institutes of Health, delivered a pharma public option? What if they license prescription drugs, or beyond that, manufactured them? What would that look like? Our next guest, well she’s been thinking about and advocating for a much broader approach to public options and health care. More with Dana Brown after this break.

[ad break]

Dr. Abdul El-Sayed: All right. Ready to go?

Dana Brown: Yep.

Dr. Abdul El-Sayed: Fantastic, can you introduce yourself for the tape?

Dana Brown: Sure. My name is Dana Brown. I am director of health and economy at the Democracy Collaborative, a think-and-do tank for the democratic economy.

Dr. Abdul El-Sayed, narrating: Dana Brown is the Director of Health and Economy at the Democracy Collaborative, a research and development lab dedicated to empowering a more democratized economy. She’s been thinking about alternatives to corporate domination in our health care system for quite a while.

Dr. Abdul El-Sayed: Really appreciate you joining on a set of really interesting issues, because we spend a lot of time on this podcast thinking about what’s wrong with health care and obviously, we’ve talked about a couple of solutions about what could be right with health care, but I was really excited to talk to you because you’ve got a bit of a different spin on what can be right with health care that sort of borrows from a concept that a lot of people have heard of, and takes it to a different place. Now, I just want to step back, and I want to ask you, how did you get interested in the role that the government could have in directly providing people health care? It seems like a, from a bygone era approach to thinking about what government does, but but how did you get interested in it for the present and the future?

Dr. Abdul El-Sayed: Sure. Well, I think first and foremost, just being a patient and a taxpayer, I’ve long had that experience that something was terribly wrong on a macro level with the way that we do all things health care in the United States. That is, you know, it’s extractive, expensive, inefficient, and inequitable. And I’ve also had the opportunity to live and work in several other countries in Latin America, in the Middle East, and though most countries experienced some issues in satisfying the growing needs of their population in terms of health care, I’ve just never experienced anything that compares with the level of extraction and waste in particular, but also inequity, of the US health care sector. And that got me thinking about what drives all of that. I’m also back in school now doing graduate work in public health and basically everything in the academic literature really resonates with that experience of mine, and suggests that we don’t have to organize health care in this way. It doesn’t have to be so expensive and inequitable. And frankly, health and health care can really be conceived of as public goods. And from that standpoint, right, thinking of them as something that should be made available to all because they have positive externalities for society, well, that in of itself makes an argument for a big role for the public sector in assuring that those public goods exist and are indeed available to them all. So that’s sort of the starting point for me.

Dr. Abdul El-Sayed: There’s a couple of really interesting and important points there. You know, we cannot tease apart the fact that so few Americans have experience abroad with the Stockholm Syndrome that the health care industry perpetuates on us. And you know, a lot of folks sort of just think this is how health care ought to be, but if you spent some time in other societies—you know, frankly, the places that you mentioned are not all universally high-income countries, many of them middle-income and even lower-income countries that still manage to appreciate the fact that providing people health care isn’t only the right humane thing to do, but it’s also just generally good for societies. And if there are things that we ought to be invested in as a country, it ought to be those things that are good for individuals and good for society at large. Now you think a lot about how we would apply the public option outside of the insurance system to things like pharmaceuticals and even direct health care—now, most people have probably come in contact with the idea of a public option in the context of health insurance. Of course, that’s what President Biden ran on as an alternative to Medicare For All, that there should be a government health insurance plan that operates alongside private plans. That’s the quote unquote “public option” but you’re extending this idea beyond health insurance. Can you talk a little bit about your vision for how we would be thinking about a public option beyond health insurance into the direct provision of health care, or even prescription drugs?

Dana Brown: Absolutely. And thanks for that question. Of course, I agree that we all deserve the same access to health care via universal coverage, but I think there’s some fundamental structural issues with our health care sector that won’t be solved unless we really do start looking at the provision of health care goods and services. So just to zoom in on one piece for the moment, which is pharmaceuticals, I think we can see that the current model is pretty out of line with that idea, the goal of providing health care as a form of public good or service, right? And just to summarize what’s wrong for a second, pharmaceutical spending is the fastest growing portion of our health care dollars here in the United States. The sector is dominated by huge, powerful, very extractive corporations that are very successful financially. But what they’ve brought us as a society in recent decades really, is a decline in clinically meaningful innovation over several decades, catastrophically high prices, recurring shortages in essential medicines, increasing post-market safety issues, and really a textbook example of regulatory capture. The point for me is that these are the natural outcomes of an industry oriented around the singular goal of maximizing profit. And in fact, there’s some interesting academic research that points to the fact that the pharmaceutical industry in the United States, they’ve been a test case for neoliberal economics, that the Chicago school reached out to pharmaceutical companies to sort of think about how to apply their theory in practice. And it looks like it’s going quite well. But I posit that because these are sort of the natural outcomes of this specific design, that yo get different outcomes, we need a different design. And that’s where public ownership of pharmaceutical companies comes into play, because I really think that public ownership could be a vehicle for the designs that we need to produce superior outcomes for population health, but also for our economy and democracy, which are also kind of upstream determinants of health. So what would that look like? There are a bunch of different ways in which we could organize a full public option for pharmaceuticals in the United States, and there are examples from throughout history and around the world that we can look to. But a basic model might look like this: first, we close the loop on drug development at existing public institutions and empower places like the National Institutes of Health to engage in full-cycle drug development. That is, to take drugs all the way from theory through all phases of clinical trial, and then to manage any intellectual property taken out on those medications in the public interest. And that’s really important. But I think we should also have a public option for drug manufacturing, both to assure a robust supply chain and accessible prices on all medications, but also because this is good for the economy, right? These are the manufacturing jobs of the future. And again, that’s an upstream investment in public health. Manufacturing can be done at the state level or the federal level, or even by creating new municipal or regional enterprises. And then finally, right, to kind of finish the supply chain, we’d have public distribution of medicines. And this could leverage existing public infrastructure like the US Postal Service, the Veterans Health Administration, Federally Qualified Community Health Centers—all of these institutions already have experience distributing medications to all corners of the country and doing it at a very reasonable cost. So I think there’s some really powerful public-public partnerships that we could look to in the future to both kind of—it’s an industrial strategy for the nation that really invests in the economy and invests in health at the same time.

Dr. Abdul El-Sayed: You know, there’s is a point that you made there where we’re still living in the “doing well by doing good” era, and the problem with the concept of doing well by doing good, although you know it is a very attractive idea, is at some point you have to decide if doing well is more important or doing good is more important. And so many of our systems have been optimized to make sure that a large corporation does well, and the doing good sort of comes secondary. And I think the point that you made, pharmaceutical corporations are the perfect example of that. Yes, pharmaceutical corporations manufacture medications that people need to be, to survive. And at the same time, the incentive that they have to do well financially leaves them raising the prices of these products that people fundamentally need to levels where they cannot actually get them. And the problem here is that a lot of, it in the political economy, in the mind of Americans, they say, Well, these companies make stuff that I need, ergo they are doing good. And the problem is by setting the prices so high to do well, in fact, it leaves people without the good that these people are supposed to do. And so the question here is how do we interrupt the sector of pharmaceuticals with well-timed, well-thought through government intervention, and this idea of the government not just seeding the research and development of pharmaceuticals as they do now through the NIH and other agencies—we could actually think about government having a role in the manufacture and the ownership of these. Can you explain a little bit more about, you know, where potentially this has been done, whether in history or maybe in the future? And I know there’s a great example that may be coming up here out of California. Can you talk a little bit more than that?

Dana Brown: Sure, and I think, you know, it’s really important to think about not only what is being done—done well, done poorly—by Big Pharma right now, but also what isn’t being done at all. And I think it’s come up on this show before, right, there’s, because of the profit motive, right, that distorts innovation incentives. And there’s a whole slew of drugs, whole, therapeutic classes where there really is no innovation, particularly in critical areas like infectious diseases. So I think one of the really important roles potentially of public pharmaceuticals—and I like to say public rather than government in the sense that it’s our, right, and we’re talking about producing public goods, what we need to be doing is requiring the state really fulfill that role and be of the people and for the people. So briefly, in terms of examples, there are many, you know, as I was saying, I think a public option for pharmaceuticals can assure that medications most essential to public health are prioritized for development. And that, for instance, is one of the mandates of public pharmaceutical labs in both Cuba and Brazil, where they are directed to develop medications that are, quote, “overlooked by the market” like neglected tropical diseases. Cuba has an entirely public pharmaceutical sector, from R&D through distribution, and provides, I think, at least 60% of the medications for, that to satisfy all of the needs of the island from that public sector or pharmaceutical industry. But they also export and they innovate, they’ve made COVID-19 vaccines that look like they may be really helpful in terms of distributing to lower-income countries that may have trouble meeting the price demands of the Moderna or the Pfizer vaccine or their cold chain requirements. But there are also lots of other places. Sweden, Sweden’s public sector pharmaceuticals specialize in compounding pharmacies, so very specialized therapies that are again not available at decent prices in the market. They also public distribution and retail pharmacies. So there are plethora of examples from around the world. And even in our own history in the United States, there are several states which use to develop and distribute manufacture of their own vaccines, including Michigan.

Dr. Abdul El-Sayed: Well, I’m glad to hear that we were ahead of the curve, although it seems like we’ve fallen behind, But you raise a lot of really important points. One of them is on the research and development and production of medications that not just are uncommon, but also that are not lucrative to manufacture of prescription drugs for. So, you know, we’ve talked a bit on this podcast about the fact that we are losing the arms race with microbial diseases around antibiotic resistance. And in part, if you think about the incentive to manufacture an antibiotic, you’re literally talking about a medication that you are trying to keep people from having unless they absolutely need it, right? Antibiotic stewardship is literally about making sure you’re not overusing a medication. So if you’re a pharmaceutical corporation that gets paid a certain amount of dollars per use, you really don’t want to put all of your eggs in an antibiotic basket. The problem is, then we don’t actually end up having high-quality antibiotics and once microbiomes are able to to pierce our defenses, at some point we have nothing left. And that is a serious challenge that we are facing literally right now. And I really appreciated the consumer-facing point that you made about the potential to actually get these to people directly. You know, folks may know I ran for governor of Michigan, and one of the ideas that I had when I ran was that as a neighboring state to Canada, where because of their regulations, their prescription drugs are substantially less expensive than ours, I literally wanted to drive a truck to Canada to purchase medications on behalf of the taxpayers of the state of Michigan. And at that point, it would have forced the, what would have been the Trump administration, to make us stop, right, and call attention to the fact that we still have an industry that’s run amuck. I want to ask, you know, let’s dive into this and talk a little bit about what kind of medications we could start with. Let’s say the federal government or an enterprising state government decided that they wanted to answer the call to a public option for pharmaceuticals, what kinds of medications would you recommend starting with off the bat?

Dana Brown: I want to start with the caveat that my firm belief is that there should be a public option for all the central medications because as the term shows, they’re essential, right, to the functioning of our health care system and also essential to our lives. And as we’ve seen, the current model doesn’t consistently deliver on essential medications to those who need them. And again, if we’re not addressing sort of a systemic deficiencies of the current pharmaceutical sector with a systemic solution, I think we’re going to get caught playing Whack-A-Mole forever. That is, one day we’re mobilized around access to HIV medications, and then insulin, and now it’s COVID vaccines and treatments—but do we even know what the big missing piece is going to be next year or the year after that, right? So I think we need a systemic solution. However, I get that we’re probably not going to have it all at once. So if we build the infrastructure to eventually provide essential medications across to all the therapeutic classes, we can get really big returns and change the balance of power between Big Pharma and the rest of us. But yeah, I think there are entry points that are sort of low-hanging fruit. As you say, antibiotics is a place where even the industry has said This is a classic example of market failure, right, there’s no incentive for us to develop antibiotics, they’re intended to be curative. We don’t want to sell something that you take once, we want to sell statins, we want to sell blood pressure medication that you need to take forever, because those are constant returns. So I think there are several places. Vaccines as well are not generally a very good market good—anything that is sort of preventative, and again, all the neglected tropical diseases, diseases in general that affect our more poor and marginalized populations, right? We know that there is historical lack of investment in cystic fibrosis research, for example. So I think it would be very easy to come up with a set of criteria for places that merit most urgent public intervention into the market. And then you can build from there.

Dr. Abdul El-Sayed: I want to dig into the example that’s upon us now in California, and in the most recent budget, the state of California has a plan to start the public provision of insulin. Can you speak to that, and about, and the kind of precedent that that sets for the opportunity that we have moving forward on a public option for pharmaceuticals?

Dana Brown: Sure. And I really like that question about that, the precedent that it sets, right? Because I think for me, this is really about shifting the balance of power, right? At the moment, we’re beholden to Big Pharma because they’re the only game in town and the only folks who make medicine for us. And so, you know, I do just want to put emphasis on that point that I think, you know, in a macro level, how do we negotiate better drug prices? With leverage. Right? If Big Pharma doesn’t want to sell a sense of insulin at affordable prices, well we make it ourselves. And frankly, that’s what Brazil and Thailand did to regarding anti-retrovirals, right? They used their manufacturing capacity to say, You give us a better price or we’ll just compulsory license it and make it and you don’t have a market here. So I think that is really important point. And then to answer the specific question about California, as you said this past Monday, Governor Newsom unveiled his blueprint for the state budget for this year, and that included reference to an initiative to have the state manufacture or contract the manufacturing of insulin to ensure affordability. This isn’t a totally new idea. It’s actually part of a process in California, where they passed legislation in 2020 that made the state a retailer for generic medicines. It created something, a public generic label called Cal Rx. And the idea of that was that that label would always contract the manufacturer of generic essential medicines and then sell them to Californians, and that this would reduce overall prescription spending for the state and its residents. So it looks like the idea is simply to start with insulin and to start by contracting with an existing FDA-approved manufacturer to provide lowest-cost insulin. But the same legislation for 2020 also does require the state to commission a report on the feasibility and advantages of direct public manufacturing of essential medications. So it looks like this contracting is a first step. And it makes sense, again, that we start with insulin. If you think about it, the insulin story is really instructive right now. Insulin was developed in a public lab in Canada 100 years ago. The inventors didn’t want to patent it. When they eventually did, they sold the patent for a dollar, assuming that that would allow it to be distributed to the largest number of patients at the lowest cost. And part of the reason that they ended up deciding that they needed a private sector partner to distribute insulin was because they didn’t have the public sector capacity to scale up manufacturing very fast, right? They wanted to be able to serve as many patients as possible. And so the fact that public sector in the United States is now looking into manufacturing is key, right? It’s a counterfactual. We can’t prove it, but if Canada had had public manufacturing capacity for medicines when insulin was invented, would these inventors have needed to go to the private sector. I think it’s a provocative question that we should be asking ourselves and, you know, really begs us to think about these structural, systemic alternatives to the profit-driven system that isn’t delivering for our needs right now.

Dr. Abdul El-Sayed: Yeah. And you can imagine the idea of a public option pushing well beyond pharmaceuticals and in some respects it’s just scratching the surface. And, you know, oftentimes when we talk about a lot of these ideas, they have a lot of precedent in history. One of them is the public hospital. You think about the late 1800s, early 1900s, there was an explosion in the building of hospitals, which sort of followed on the idea of science-based medicine. When medicine actually started to work, at some point, people demanded a lot more of it, which then spurred on the building of major hospitals, and many of them were public. And what we see today is a major incursion of private capital into the health care system, the buying up of previously public and now-nonprofit hospitals, and turning them into these massive private hospital chains, with a lot of implications for, as you talked about, corporate power and the imbalances that that imposes on patients and even providers. What would it look like for us to be rethinking the government imperative to actually provide direct health care? Can you point to a couple of examples of where we still have public hospitals working, and if they are, what are they doing right and what can we do to empower them?

Dana Brown: I love this question, and I guess I’d like to start with a question that I generally like to ask people: so the U.S. health care sector currently consumes something like 20% of GDP. And my question is, if you asked almost any doctor, nurse, public health expert, patient, or public policy specialist to take 20% of US GDP and design a system to maximize the health and well-being of Americans, would anyone design anything that remotely resembles the health care sector that we have now? And my bet is that they wouldn’t, right? So that’s my starting place, is what do we actually need to make and keep Americans healthy, and how can the sector provide that, right? What does it need to look like? So again, I like to conceive of it as what if health care was a public service? What would it look like? And I think first and foremost, we actually need and we deserve a system of health care, not a fragmented set of bits and pieces that are very unequally distributed across the nation, and also totally disconnected from one another. Right? I move from one state to another, my doctors don’t know anything about my medical history. I have specialists and a primary care physician, they work at different places—they don’t talk to one another. No one is coordinating my care. I am not part of a system, right? I think that to me says that we need a plan. And that doesn’t mean there’s no role for the private sector necessarily, but I guess, if we think about the provision of care and the right type of mix of services that we need to sustain our population, that to me again necessitates a plan, it necessitates intervention, it necessitates geographic equity that we’re not getting out of market-based health care, and even non-profits that tend to sort of work like businesses anyway. So, you know, I think about what if we win Medicare for all but the provision of care is still largely left in private hands? Will those private sector providers, particularly in geographies where they have near monopolies, will they accept Medicare prices? What about places where needs are just not being met, that there aren’t primary care physicians or hospitals? How do we address that without the public sector stepping up? So I like to look at what is already working in the public sector, what can we learn from and build from? And I think there’s really a lot to learn from institutions like the Veterans Health Administration—which is a federal, so a national-level, integrated, fully public system of provision of care—and also Federally Qualified Health Care Centers. And both of these institutions provide low-cost, high-quality, evidence-based care that is largely appropriate for the patient populations that they serve, right? They could use further investments. There are still improvements to be made, but I think there’s real opportunity there to think about how to build up these institutions that are working and that are delivering in a way that also, that ultimately makes something like Medicare For All more achievable and financially sustainable over time. So I think it’s really about starting by conceiving of what do we need, what assets do we have, and how do we build up from there? And again, I think we sort of push back on the private sector and abstraction in health care by doing, right, by providing from the public in the investments that we already have, right? Leveraging Medicare and Medicaid, all these public dollars and your and my tax dollars that go into this, and just funneling more of those back into the public sector where there’s not a profit motive that gets in the way, where there’s more transparency measures, where there are more opportunities for more of us to interact and—for instance at Federally Qualified Health Centers, be a part of the board, right? These are institutions that are run 51% by community members that they serve. So I think we really have to kind of reclaim the public sector for the public and make it work for our needs.

Dr. Abdul El-Sayed: On that thought, I really appreciate you coming to join us to help us think about all of the different ways we can apply public provisions of health care and health goods. And that was Dana Brown. She’s the Director of Health and Economy at the Democracy Collaborative. Thank you so much for joining us.

Dana Brown: Thank you. It’s been a real pleasure.

Dr. Abdul El-Sayed: As usual, here’s what I’m watching right now: for the first time since Omicron took hold, last week, the number of people admitted with COVID has declined. Trust me, that is welcome respite for millions of health care workers around the country and a huge relief to everyone who’s watched Omicron spread throughout their communities, making us, our friends and our family members sick, shutting down schools and flights and trash collection, and turning up the COVID anxiety to a ten. For their part, the Biden administration began to distribute 400 million N95 masks from the Strategic National Stockpile across pharmacies and community health centers this week. Last week, they soft launched covidtests.gov, where folks can sign up to receive up to four at-home rapid antigen tests per household. This is what President Biden had to say about the initiative last week at his press conference:

[clip of President Joe Biden] Should we have done more testing earlier? Ye. But we’re doing more now. We’ve gone from zero at-home tests a year ago to 375 million tests on the market in just this month.

Dr. Abdul El-Sayed: Though the masks and tests are just a touch late to make their biggest impact on the Omicron search, it’s certainly better late than never. I hope this means that the administration will keep their pedal to the metal on tests and masks even after the surge is over, because better too much than too little. And even as Omicron appears to be cresting, new research is showing the scale of the pandemic’s consequences for young people. A new review of studies published in the journal JAMA Pediatrics demonstrates the massive impact COVID-19 has had on our children’s mental health around the world. The researchers analyzed 36 studies from 11 different countries that looked at the mental and emotional health consequences of school closure during the first wave of the pandemic, looking at factors like distress, screen time, usage, depression and anxiety, and suicidality. Across the studies, the findings showed 25 to 60% of children showed signs of emotional distress. It’s a reminder that this pandemic’s health consequences extend well beyond COVID-19 itself.

Dr. Abdul El-Sayed: That’s it for today. On your way out, I want to ask you to do me a favor: can you please rate and review our show? It really does help get the show to like-minded folks. Also, if you love the show and want to rep us, I hope you’ll drop by the Crooked store for some America Dissected drip. We’ve got our logo mugs and T-shirts, our Science Always Wins t-shirts, sweatshirts, and dad caps, and our Safe and Effective tees.

America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producer is Olivier Martinez. Veronica Simonetti mixes and masters the show. Production support from Tara Terpstra, Lyra Smith, and Ari Schwartz. The theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Sarah Geismer, Sandy Girard, Michael Martinez and me, Dr. Abdul El-Sayed, your host. Thanks for listening.