Red State Public Health with Drs. Judy Monroe and Lindsay Weaver

Now book it over to Crooked.

Com Slash Store to shop America Dissected is brought to you by the Debeaumont Foundation. If you're in public health, understanding policy is part of the job. Sharpen your skills and expand your knowledge with strategic skills for public health practice policy engagement, a new book from the Debeaumont Foundation and Apha Press.

Policy engagement demystifies the policymaking process and gives readers the tools and confidence they need to pursue bold change. To learn more and get your copy, visit debeaumont..org.

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.

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, Dr. 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 handle removed, handle 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 idolize the past as free of the same sorts of petty, cynical and self-serving motives that animate 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 countertakes 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 vaccinating 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 and 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 C.D.C Foundation, and Dr. Lindsey 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 Lindsey Weaver. All right, can you?

And so there is some good news actually mixed into this. In some states, it's hard to get the data.

And Dr. Weaver?

We see the cliff coming, the stop 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? We're going to keep on doing the work we have to fund. And so I think that was really the turning point.

When we think about public health.

But how, as you think about coming out of 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?

So that's an area that is super important, but we're already seeing some bust, I mean, the clawbacks from the debt ceiling. There are programs that were 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.

Money and that's being clawed back, and so that's been on the backdrop of the states having received this additional funding. And one of the things I think is a good point is that from the American Rescue Plan, there was $3 billion that was committed, and it's five-year funding. So that part's good. So again, we have this mixed picture coming out of the pandemic regarding.

It became really clear, as we were reviewing 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 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 community was ready for.

We saw some that had really great infant mortality programs, and some that had none at all right tobacco prevention 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 again? That the locals could actually control what that looks like? Because we found that to be so successful.

Yeah, I really appreciate that. And look.

Even without the city of Detroit, which is in our county, our county Health Department accounts for one in 10 residents of our state. And then 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, when you make decisions about how you fund. And so you guys are thinking about this in, I think, a really thoughtful way. The other thing about it is that. One of the things I appreciate about this approach is that 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. And it strikes me that as we've had this sort of turn away from public health. In the way that modern conservatism makes itself up, you're really appealing to a very traditional conservative viewpoint. On saying, listen. We can provide local communities with the capacity to make their best decision for their folk and to make sure that governance happens at the local level. I wanted to just use that as a way to sort of pivot, to ask a little bit about the broader ecosystem of funding in traditionally Republican and Democratic controlled states. So, Dr. Munro, what is the lay of the land in terms of the states that have invested more versus states that have invested less?

Is there a particular political hue that follows, or has it been more?

And so that, to me, is super exciting. I think you absolutely have hit the nail on the head. It's a bit of the magic sauce, 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 health departments and to the local communities, which 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 really does speak to traditional Republican thinking. But it's a win for everybody. This is a time for a win-win because you can lift public health and get everybody on board, which I personally am.

How do you talk about it? What are the central themes that you focus on when you talk about this kind of public health investment? And this is open to either of you. I would love to get both your.

So one of the things I'll jump in is Indiana is largely a rural state, there are a lot smaller counties. And one of the areas that we did focus on in the commission was emergency services, which was a big need. And so that was part of this moving forward and bringing the commission's recommendations to where we are now and actually implementing. So that was one of the secrets.

I think Indiana the starting point for all of this was to say, and I know. Dr. Chris Box, who was the commissioner at the time, was very articulate, saying that. The aim here is to make sure that these core public health services are available to everyone in the state. And I, you know, going back to the rural community, I was a rural practitioner, I practiced in rural Tennessee when I first got out of my residency. And so when you want to talk about equity, I mean, there are communities across this country that are Caucasian, rural America that have a lot of disparities.

So we need to be thinking about everybody and making sure that they all have the services from public health that they deserve. And Indiana did that, so we're going around the state, right?

And I think people our employers really recognize 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 invest and engage in those businesses. People are looking to move to a healthy place. So when we kind of put the side aside, you know, for our 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.

And honestly, you can just kind of click right down the road. And that spoke to them, 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, invite your community-based organizations, invite your clinical specialists, et cetera. Businesses and they're coming, they're coming, and they're having these community conversations and we bring the data to them. We say, this is your county, this is how your county ranks in Indiana.

Here are your health metrics. And you can see their eyes kind of being open, right? That they didn't realize that maybe they were as worse off as they did. And I'll tell you, one of the conversations we had, the police chief was there. And we're talking about their obesity rate.

And he's, I know, exactly where that's at. In our community, they only have access to a convenience store. And you can see the wheels turning and the community kind of wrapping their arms around it. To say, Okay, there is a problem. And let's start thinking about ways that we can.

And the recognition that, if you appeal to particular localities and their interests, that there's an opportunity to cut beyond some of the noise that we've heard, that tends to frame a lot of the misinformation that came out of the pandemic. I want to ask you, because one of the challenges, I would imagine tends to be around the consideration of equity. And I ran for office in Michigan and one of the most 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 healthcare, they talk about the fact that their kid's 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 in a place like Oscoda, they talk about a worry about the environment, but it shows up differently. Most folks aren't going to come and talk to you about climate change unless they've been reading specifically about it.

But they will talk to you about the way that climate change affects them. The growing season is a lot shorter or longer. I worry about the smoke coming out of the smokestack that comes up over my kid's school, 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.

And that tends to 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. And let's be fair, given the history of structural racism in our country, it tends to be a lot more the rural communities pointing into the city. And I'd 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 in Detroit. And saying, Well, those folks, they get all the handouts and they take all our money, and I don't even know what they do. And they can't govern themselves. Et cetera, et cetera. I want to understand a little bit about how you all were able to get past that divisive politics 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 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 to move forward and convince people out of that kind of zero-sum kind of politics.

I think this was key, this was the most transparent method. I mean, everything was recorded, every last word. But one of the things that 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 and I was so impressed with the leadership of Indiana. Really deeply listening to every community, anybody that wished to come speak about whatever it was that they were troubled by. And so just that action alone went a really long way in getting to where, what you're talking about and where we were able to go. And then the other, I mean, the leadership, there was a lot of humility in the leadership, Dr.

Chris Box Just my hat's off to her and to Dr. Weaver. They approached this with such humility in their listening, but then sincerely expressing that they wanted this to be for everyone. That again, those core public health functions that are going to lift everyone, lift the state at large. 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. You know, we're all human beings and we all want our children to get a healthy start. So that was helpful. So I think it was multifactorial, but would love to hear Dr.

Weaver.

And we kept it personal, right that if we give you funding and we say, you know, with this funding, if you won, 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 into the funding. But if they do agree to opt into the funding, they agree to do these core public health services, but they get to address that core 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 and young children.

And these are the things that they want to address, right? So 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.

ORG You know what book I'm reading right now? How elites ate the social justice movement, that's right, and you know where I bought it?

Bookshop?

Org. Whether you're searching for a political expose, an examination of class and society, or a fantasy novel that sweeps you away, Bookshop.org has just the book you're looking for when you purchase from Bookshop.org. You're supporting local independent bookstores, so they'll be around for all of us to enjoy in the future. Book recommendations on Bookshop..org come from real people who love books, not algorithms. And the best part, when you purchase from Bookshop..org, you're supporting local independent bookstores. So they'll be around for all of us to enjoy in the future.

Bookshop?

ORG has raised over $27 million for local bookstores, and they're unapologetically anti-Amazon. They believe local bookstores are essential community hubs that foster culture, curiosity and a love of reading, and they're committed to helping them survive and thrive. Bookshop..org is a certified B Corp. and named Best for the World by B Labs. Visit Bookshop..org. Slash Crooked and use code AD to get 10 off your next order. That's code AD at checkout for 10 off your next order.

America dissected is brought to you by article. Don't you just love it? When the things you buy come as they say they were, they come fast and they last for a long time. Yeah, I do, that's why I love article.

Article believes in delightful design for every home, and thanks to their online only model, they have some delightful prices too. Their curated assortment of mid-century, modern, coastal, industrial, Scandian Boho designs make furniture shopping simple. Article's team of designers are all about finding the perfect balance between style, quality and price. They're dedicated to thoughtful craftsmanship that stands the time and looks good doing it.

Article offers fast, affordable shipping across the U.

S and Canada. Plus, they won't leave you waiting around, you pick the delivery time, they'll send you updates every step of the way. Article's knowledgeable customer care team is there when you need them to make sure your experience is smooth and stress-free.

Article's offering our listeners $50 off your first purchase of $100 or more. To claim, visit Article..com Slash ad, and the discount will be automatically applied at checkout. That's a-r-t-i-c-l-e.com Slash ad for $50 off your purchase of $100 or more. Marguerite Casey Foundation is proud to announce the 2023 Freedom Scholar Award recipients.

Launched in 2020, the Freedom Scholar Awards grant unrestricted support to leaders in academia whose research provides critical insight from and to social justice leaders. And whose ideas encourage us to imagine how we can radically improve our democracy, economy and society. Get to know this year's Freedom Scholars conducting research in cutting-edge areas of scholarship as varied as feminist prison abolition, global urbanism, alternatives to militarized policing, and so much more. Each one a leader in critical fields of research that are too often underfunded. Meet the Freedom Scholars at caseygrants..org. Slash Freedomscholars. That's c-a-s-e-y-g-r-a-n-t-s..org slash Freedomscholars.

America Dissected is brought to you by Smalls. Our next partner has truly made a positive impact on the lives of two of the most important beings in my life. Look, I love my wife and my kids, but you know, I got to give some love to my cats and their food. Well, it used to stink, I used to dread every time we had to feed them and it was boring.

I could see them losing interest. Cat food has been the same forever. It's time for cat food to move into the 21st century. That's why you've got to try smalls. Are you still feeding your cat kibble?

Now is the time to update your cat food with Smalls. Smalls. Cat Food features protein-packed recipes made with preservatives-free ingredients you'd find in your fridge. And it's delivered right to your door. Smalls was started back in 2017 by a couple of guys home cooking cat food in small batches for their friends. A few short years later, they've served millions of meals to cats around the world. Look, I love smalls because, well, Socks and Yoda, my two kitties, love smalls.

And if they love it, I love it. It also doesn't smell bad. And I feel like I'm feeding my cats real food at this point, you might be wondering, Why can't I just feed my cat kibble? Believe it or not, your cute kitty descended from ferocious desert cats who hunted live prey for food, and your cat isn't any different.

They still need fresh, protein-packed meals. Look after making the switch to Smalls, 78 of cat owners reported their cats had shinier and softer fur, and 90 reported overall health improvements. That's a big deal. The team at Smalls is so confident. Your cat will love their product that you can try it risk-free. That means they'll refund you if your cat won't eat their food.

Give your cat the gift of great cat food this holiday season. Head to Smalls.com slash ad and use promo code AD at checkout for 50 off your first order plus free shipping. That's the best offer you'll find. But you have to use my code AD for 50 off your first order one last time, that's promo code AD for 50 off your first order, plus free shipping.

Can you walk us through just what the details of both the commission structure and the outcomes were? How did you structure the conversation, under what premise, and then what came out of it? And how does that operate moving forward? Yeah, I'll start with the commission. So this.

So anyway, there were these charges that we had in the executive order. Health equity was called out as well. It was stated that we needed to address that. And then we met once a month and all those, like I said, were recorded. My co-chair and I would alternate who chaired the meeting typically, and that process really mattered. 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 university, the Fairbanks School of Public Health, along with 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. And that process of relationship building among commission members, coupled then with these listening sessions that were taking place throughout this process as well, gave input. There was public comment that was available. So at the beginning of each commission meeting, we would have a readout of all the comments and questions that had come in from the public. And those were acknowledged and referenced and debated. And those types of things. 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 learn more about the state of public.

So, working with the outcomes of the recommendations and then again with our local elected officials. You know what would be important for them to be in this legislation, for them to be comfortable with? They kept on, you know, massaging that throughout our last session to come up to where we're at now. So we appropriated funding from our legislators. 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, 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 5,000 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 big it was. So a minimum for the smaller counties. And also additional funding if your life expectancy was less than two years from our average life expectancy in Indiana. And also for communities that had a higher social vulnerability index or 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, opt-in. And so we know we're at 86 of our 92, which is again greater than what we thought.

But, I mean, I think just underscores the tremendous amount of just constant conversations and working with each other across the state, locally. And making sure that they have the support, you know, to actually implement all this funding. So they're submitting their big budgets to us right now. That funding is going to go out the door on January 1, and then, you know this, of course, with funding 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, what are we trying to do here?

How are we going to move the needle on these things? And then the counties are going to have to come up with their local KPIS and we'll work with them to develop those utilizing data. Right to inform those and be side by side to support the counties as they move this process forward. So, 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 have funding to do this and the infrastructure, then I wish we could do this. And this is a time where.

Why is there any rhyme or reason around why you wouldn't just take free money from the state to invest in your people?

I mean, it varies.

And others just want to take a, you know, sit back and see how all this looks, 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 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 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 of. We're all going to do the same core public health services, and 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 watching it, you know, we're collecting the data. Then we'll be able to pivot 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 that are what we're calling. Them are regional administrators, but 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. And that has been a really positive outcome of this whole process as well.

Has there been pushback? I think with anything that's new, yeah, there has been pushback. But, to Dr. Monroe's point, just the thoughtfulness of Dr. Box and of Senator Kenley and Dr. Monroe and the governor's Public Health 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. 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, but I think because we have as a collective worked on this together. People really want to see it be successful, which is also really exciting, right? Because that means that they're bought in and they're going to help to make sure it.

And one of the key points you've made, and I think is really important to make, is to remember that marginalization comes in a lot of different forms. And in some respects, 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 and we tend not to include that in the conversation that we have. At the same time, though, as we talked about earlier 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? That really does address all the forms of marginalization? That does focus on the health and well-being of all of us. What can you share from the process, what you heard on the ground, and what ultimately came of it?

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 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.

If you look at some very wise work that has been done, if we lift everyone, we actually make the world healthier and more productive for all. That's the other piece of all of this. So I think we've got to use language that resonates with folks and folks can really understand how it impacts them. Because it's not a zero-sum. If I give to you, that doesn't. Actually, I'm lifting myself.

I'm lifting my whole community, I'm decreasing crime, I'm decreasing potentially my taxes. Because if folks have more opportunity for employment and education, that lifts the entire society up. I don't know that we do a good enough job explaining that.

One of the things we talked to our legislators about, as we're preparing for this big conversation, was looking at our life expectancy. And that life expectancy in Indiana has actually been going down. Then we shared, life expectancy is going down, and it's mostly in our young working people, 25 to 65 years old.

People, they were surprised at first, and then they acknowledged that, probably to be true because of mental health, substance use, other things going on in society. Then we had a map that showed the difference in life expectancy per county, and that there's a 10-year life expectancy based on where you live in Indiana. I heard one of the legislators say, who found himself on the map and said, Oh, we have one of the better life expectancies. But our neighbor right next door is low. Why?

He said I feel guilty. I think it was just again just putting the information in front of people and then empowering them again to do something about it. Then, I think, too, is that we can't do this in silos. 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.

We're seeing our counties do that the hospitals know about their infant mortality.

The Organization for the Northern Hispanic Health Coalition in Elkhart, which is up there by you guys. They know about what's going on in their community. They are all coming together to say, Okay, where are commonalities here? Where's our highest risk? Then? What are we going to do? We have to do it together because that's the only way this will be successful.

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 across these different organizations in typical silos. Again, the businesses we were talking to, the entertainment community and tourism, everybody was coming together. It's a continuation of that.

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 interest and our interest in one another, can come together and ask, What can we do for everyone here? Then you got it done, you got it done in a context where, if all you watch is the grand narrative that gets played out on. I don't know what the website's called now, the one that used to be called Twitter. Then you come away feeling like it's impossible. When you actually look in the nooks and crannies. Across this country, there are really good people coming together, despite differences, to make good things happen. I just want folks to appreciate that that is both possible and that it is happening.

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. You all came together, you tried and you did. I just really appreciate that leadership, I appreciate the effort. I appreciate the opportunity to learn more about it from you and the work that you're doing on the ground to see it through, and also the time that you took to come share it with us.

Our guests today are Dr. Judith Monroe, she's the president and CEO of the C.D.C Foundation, and Dr. Lindsey Weaver, who is the state Health commissioner for Indiana. I really appreciate you all making the time.

Appreciate it, thanks for having us.

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 have 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 healthcare 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 hot dogs or rotisserie chickens. You can now buy a primary care visit.

At Costco, they're offering direct online primary and mental healthcare 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 healthcare 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 healthcare system. They're literally bypassing the traditional insurance-based system to offer direct to consumer primary or mental healthcare. And when a massive mainstream retailer does that, it's a telling indictment on the nature of the healthcare 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 healthcare. As we discussed in an episode about their growing influence over healthcare 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 healthcare is that, unlike other goods and services, you have to get healthcare 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 healthcare 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 F.T.C. lawsuit, U.S. Anesthesia bought up nearly every last 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 F.T.C. is finally taking a stand. And if you're a regular listener to the show, you'll know that. I've been calling for more FTC involvement in healthcare 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 America, dissected Merch.

America dissected is a product of crooked media. Our producer is Austin Fisher. our associate producers are Tara Terpstra and Emily Frank. Vasilis Fotopoulos mixes and masters the show. Production support from Ari Schwartz.

Our theme song is by Takar Sazawa and Alex Uguiera. our executive producers are Leo Duran, Sarah Geismer, Michael Martinez and me. Dr. Abdul El-Sayed, your host. thanks for listening.

This show is for general information and entertainment purposes only. It's not intended to provide specific healthcare or medical advice and should not be construed as providing healthcare 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 host and his guests, and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human and Veteran Services.