Introducing: Assembly Required with Stacey Abrams

Transcript

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Speaker 19 Hey guys, it's Tommy. We're taking a break for the holiday season, but we've got something special for you today.

Speaker 19 Instead of our usual episode, we're dropping a new one from Assembly Required, hosted by the one and only Stacey Abrams.

Speaker 19 In this episode, she talks with Celine Gowder, an infectious disease specialist and epidemiologist, about the threats to public health with the incoming Trump administration.

Speaker 19 They dig into what's at stake with appointees like RFK Jr., how to bring science back into policymaking, and the path forward to driving real change.

Speaker 19 If 2024 is leaving you with a lot of questions about the future, or if you've also found found yourself shouting at the TV more than usual, stay tuned for this great episode because if anyone knows something about not giving up, it's Stacey Abrams.

Speaker 19 Don't forget to subscribe to Assembly Required, wherever you get your podcasts and on YouTube.

Speaker 17 Welcome to Assembly Required with Stacey Abrams from Crooked Media. I'm your host, Stacey Abrams.

Speaker 17 Since the election, we've been unpacking how the incoming administration and Project 2025 will actually work. What's possible, and how can we respond?

Speaker 17 As a reminder, Project 2025 is the 900-page-long policy blueprint published by the conservative think tank, the Heritage Foundation.

Speaker 17 With a complicit Congress and a compromised Supreme Court, their to-do list could undermine everything we rely on for a just society.

Speaker 17 From civil rights protections and environmental defenses to public education, free speech, and today's topic, healthcare.

Speaker 17 When we think about human rights, when we think about the core of what makes us who we are, there is nothing more relevant and more fundamental than healthcare.

Speaker 17 The ability to participate in society begins with good health. I grew up in a family without health insurance.

Speaker 17 I grew up knowing that if I got hurt, if it wasn't major, it was going to be treated as minor, not because my parents didn't care, but because they simply didn't have the resources to get access to health care.

Speaker 17 And in fact, since I grew up and got access to health care, since my parents finally have health insurance, I can see a night and day difference in the way our lives are lived.

Speaker 17 And I also feel an incredible degree of privilege. because I know what it means to not have health care and to have it now.

Speaker 17 I am also deeply annoyed and sometimes outraged because the fight over healthcare is a fight that the people stopping it don't have to have. Every elected official in Washington, D.C.

Speaker 17 has healthcare, and it's the height of hypocrisy to deny it to others. And in the wake of COVID-19, now more than ever, we should understand how vital and essential healthcare as a human right is.

Speaker 17 So, while fighting to protect and improve healthcare in this country is not new, here are some of the ways that healthcare may be impacted by the next administration.

Speaker 17 One, there is an intent to dismantle or gut the Department of Health and Human Services, which is one of our nation's core agencies. And let's be clear, HHS, as it's called, has a very broad mandate.

Speaker 17 It's in charge of Medicare, Medicaid, the healthcare marketplace, the children's health insurance program, the Food and Drug Administration, the National Institutes of Health, the Centers for Disease Control and Prevention.

Speaker 17 They also cover the human services side. So, TANF, the temporary assistance for needy families, Head Start, child care, and child support.
And that's not an exhaustive list. HHS is under attack.

Speaker 17 Number two, they want to split the CDC into two agencies, one for data collection and one for public policy recommendations.

Speaker 17 And this effectively takes away the already limited authority of the CDC to provide public health guidance.

Speaker 17 It slows emergency response, and it could hurt state and local governments that rely on the CDC for public health guidance. For example, in the case of another pandemic.

Speaker 17 Number three, they want to tinker with the Food and Drug Administration's drug approval process. For example, take away the approval from Mifiprestone.

Speaker 17 And number four, at the state level, the goal is to turn Medicaid, the vital national healthcare program that covers the poor, the elderly, the disabled, and some children, to turn that program into block grants, which means that states would have further permission to deny access to health care to the most vulnerable in our society, because states would have less money and limited federal accountability.

Speaker 17 Okay, so I've just done a very long list of what's at stake. And it's not just about what's in the proposed policy papers from Project 2025.

Speaker 17 It's about who Trump wants to put in charge of that vast agency.

Speaker 20 In the words of 77 Nobel laureates in medicine, chemistry, physics, and economics, RFK Jr.

Speaker 20 at the helm of the Department of Health and Human Services would put the public's health in jeopardy and undermine America's global leadership in the health sciences.

Speaker 20 This in a letter addressed to members of the United States Senate, listing off the health secretary nominees' most sensationalist conspiracy theories on public health.

Speaker 17 The incoming president's decision to nominate Robert F. Kennedy Jr.
to be the Secretary of Health and Human Services is indeed a source of much anxiety in the medical and scientific communities.

Speaker 17 So much so that Nobel laureates, a group that usually tries to stay out of politics, felt compelled to speak up. But there are other nominees.
As I mentioned, HHS is huge.

Speaker 17 So, among the list of people whose names are being put forward include Mehmed Oz to lead the Centers for Medicare and Medicaid Services and Marty Makari as the head of the FDA, both of whom have been controversial, to say the least, in their respective medical practices.

Speaker 17 I've just given you a lot of information, and right now, like almost every day, listening to what's to come can feel like daily doom scrolling. And unlike 2016, when people talked about resistance,

Speaker 17 This time, people have responded by saying they need to protect themselves first. I totally get that.
The rule is put your own mask on first.

Speaker 17 But we're not on this trip alone. So eventually, we'll need to help our fellow travelers.
I'm here to help us prepare for when and how we engage and insist.

Speaker 17 That begins by understanding what's really at risk versus what's just hateful, wishful thinking. What impact can these proposals have? and what's not being said.
And as always, how do we fight back?

Speaker 17 So let's get straight into it with our interview today.

Speaker 17 Dr. Celine Gounder is an infectious disease specialist, epidemiologist, and a science communicator.
She is the editor-at-large for public health at KFF Health News.

Speaker 17 She produces podcasts and other content to help us understand what's going on in public health.

Speaker 17 And she was a regular guest on news shows during COVID-19, bringing us grounded, reasonable, and actionable information when misinformation and disinformation met a wave of panic and worry.

Speaker 17 Does that sound familiar to anyone? So here to keep us all informed and sane is Dr. Gounder.
Thank you so much for being here.

Speaker 16 It's great to be here. Thanks, Stacey.
Dr.

Speaker 17 Gownder, I have a public health crisis question for you.

Speaker 17 Are American politicians and policymakers allergic to science?

Speaker 16 I think this is something that is very much on the mind of those of us working in science, in medicine, in public health, and related fields right now.

Speaker 16 What we saw during the pandemic was really an attack on science and public health.

Speaker 16 Because many of the conclusions of the science were politically inconvenient, did not reflect well on certain politicians and leaders, I do think there is room for discussion if we start from a place of shared understanding, facts, science, and then to to weigh what are some of the trade-offs.

Speaker 16 How do you weigh different values, whether it's value of human life, value of an elderly person's life, value of a young student's schooling, et cetera?

Speaker 16 But I think we have gotten to the point in some of these conversations where instead of having a conversation about values, we are attacking the science or some of those some of us are attacking the science

Speaker 16 because they don't want to have that honest conversation about what they actually value. It's more convenient.
It's easier to say the science is wrong.

Speaker 17 That language is perfect. That it's when science is politically inconvenient.
And it's actually a perfect encapsulation of one of the reasons I started with that question.

Speaker 17 There was the letter from the over six dozen Nobel laureates about RFK Jr.'s appointment to lead the Department of Health and Human Services.

Speaker 17 And then there's just the incoming Trump administration's overall approach to public health, which seems to be laser focused on finding those who reject science as a foundation for policymaking and giving them the highest appointments possible.

Speaker 17 These Nobel laureates, though, these chemists and medical professionals and economists are very deliberate about pointing out that RFK Jr.

Speaker 17 has no credentials or relevant experience, quote unquote, in science, public health, or medicine or administration.

Speaker 17 And as you pointed out, this is a question of value. So how important is it to not only have

Speaker 17 driven decision making and science driven decision making, how important is it to have science and scientific knowledge and experience to be the Secretary of Health and Human Services?

Speaker 16 I do think could you be a Secretary of Health and Human Services without being a scientist?

Speaker 16 I mean, we have one right now, Javier Bassera, you know, but he has other skills he brings to the table, being able to manage a large administration, understanding sort of institutional norms and practices.

Speaker 16 So he does bring a certain skill set.

Speaker 16 And this is where your career civil servants are really important, which is to say the scientists, the technical experts who work under numerous different administrations, who are not political appointees, who are not partisan, you can rely on those people to help inform your decision making.

Speaker 16 take the science, the expertise that they are using to advise you, and then make decisions that may be partisan decisions, but at least informed by that science.

Speaker 16 Now, what we're seeing are conversations coming from the incoming president and his team about eliminating some of those civil service protections to make it easier to fire, hire whomever they want in those scientific, technical expert roles.

Speaker 16 And the problem is if those roles are filled by people who do not have the qualifications, the scientific, medical, public health expertise, then the person at the top is not going to be appropriately counseled.

Speaker 16 So you don't necessarily yourself, as the leader of HHS, need to have that expertise, but you do need to have people who have that expertise to advise you.

Speaker 16 And if we don't have either, then we're in real trouble.

Speaker 17 Well, that brings us to the other nominees. So while a lot of tension has focused on RFK Jr.
heading HHS,

Speaker 17 the two of the top jobs are also under consideration. And one of the pending nominees is Maymet Oz.
The other is Matt McCarry, both of whom are physicians, but who each have had controversial

Speaker 17 behaviors. And there have been questions about their fealty to scientific principles and their work or the implications of their policy proposals.

Speaker 17 So, what do their nominations tell you about the incoming administration's thinking about this? So, to your point about combining

Speaker 17 the need for science and for policymaking, What happens when you have a scientist who doesn't seem to

Speaker 17 believe or at least live those beliefs?

Speaker 16 You can have differences of opinion as to whether you should mandate masking or vaccination or whether schools should be closed in the context of a pandemic, but you should start at least with a common understanding of what the science is.

Speaker 16 What we saw, Jay Bhattacharya, who's nominated to head the NIH,

Speaker 16 and some of his colleagues, Marty Macri, who's now nominated to run the FDA, they came up with estimates of what they thought the infection and death rates for COVID.

Speaker 16 Their estimates were really flawed and very small compared to, very low compared to what actually played out.

Speaker 16 And so we do need to start with people who understand how to make these estimates, who understand how to advise us and say, you know, these are the trade-offs.

Speaker 16 You with your values, your politics, your partisanship may make different choices, but at least start with that basic level of understanding.

Speaker 16 And I think that's also, you know, what's scary because we may have another pandemic on our hands before too long. Unfortunately, we in this country have not been managing the H5N1 bird flu situation

Speaker 16 as well as we could, and that is putting us at risk for a pandemic sooner than later. So these questions are really quite pressing and imminent.

Speaker 17 And you just pointed out that we are already on shaky ground and this administration is not only rejecting expertise or bringing in people who have demonstrated a flawed use of their expertise, but there's also, as you said at the top of the conversation, this intent to replace civil servants who have that expertise with hires who are based on loyalty and not capacity.

Speaker 17 You mentioned H5N1 as one of the possible outcomes.

Speaker 17 Can you talk a little bit more about the implications of this lack of capacity when it comes to public health, not just in terms of pandemics, but just the larger public health universe?

Speaker 16 Well, one of the things that I think was made very clear during the COVID pandemic is we've very much underinvested in public health. Some of the areas of real need are our data systems.

Speaker 16 When we were dealing with public health departments faxing their data into the CDC, to Debbie Burks' team at the White House,

Speaker 16 you know, that is not something where you can get real-time data, quality data.

Speaker 16 Part of the challenge here is, and this is something a lot of people don't understand still, is that public health powers reside at the state level.

Speaker 16 There's only so much the government, federal government can do.

Speaker 16 Yes, the federal government provides funding, technical expertise, advice, guidelines, but they're not the ones actually that institute mandates, requirements, or do the boots on the ground work.

Speaker 16 And so this creates issues in terms of how well health departments are funded at the state level.

Speaker 16 Do they have the capacity and funding from their state legislatures to do what's needed, including the data modernization issues? And then do they report that to the CDC?

Speaker 16 So they can choose not to report. They can choose to report only certain things.

Speaker 16 The CDC has some levers it can use tying some of that reporting to funding, but in general, they're not usually too aggressive with that because of the potential harms of withholding funding.

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Speaker 17 Can you talk a little bit more about state and local public health preparedness? Because that's one of the issues we try to focus on here on Assembly Required.

Speaker 17 We have a lot of attention that necessarily needs to be turned towards the federal government, but often the real levers of power, and particularly the accessible levers of power for our listeners, happens at the state and local level.

Speaker 17 So, can you talk a little bit more about how state and local public health works and how public health preparedness works at that level?

Speaker 16 Yeah, so the Constitution does not provide public health powers to the federal government. Again, the federal government has the right to tax and spend,

Speaker 16 to regulate interstate commerce. But that's really the limits on federal powers and all of the other federal powers really derive from those too.

Speaker 16 So if you're somebody who's concerned about public health, yes, you should pay attention to national politics, but it really is at the state level and to some degree the local level that you can have the most impact.

Speaker 16 So that's where I would say pay attention to what's happening in the state legislature, what your local health department is doing.

Speaker 16 At the state level, we've seen increasingly public health powers eroded.

Speaker 16 We've seen some of the recommendations around vaccination being eroded, where you have increasing non-medical exemptions around vaccination. So, what vaccines kids need to get to go to school.

Speaker 16 Another area that you should be paying attention to is public health versus the economy, public health versus industry. It will always be a theme.

Speaker 16 And so it's sort of balancing those different trade-offs, values.

Speaker 16 But you do see this play out very concretely as it is right now with H5N1.

Speaker 16 There's a reason certain states have reported a lot more cases of humans infected. It is very much related to how much testing is happening, also how much testing of the herds, of the milk.

Speaker 16 This is all related to how aggressive the states have chosen to be. So you have states like Michigan, Colorado, California.

Speaker 16 Yeah, they're reporting a lot of cases, but it's because they're testing so much. And so we don't have a clear view into what's happening in other states.
And why does it play out differently?

Speaker 16 Well, this is a question of values to some degree.

Speaker 16 And wanting to maybe protect industry from what some of the economic impacts might be of realizing they have a bigger problem on their hands than they want to know. And this is also about

Speaker 16 the impact of influence of industry in certain states on what happens, right?

Speaker 16 So if you have a very powerful dairy industry lobby in that state, that's going to be very different from a state where your political interests might be a lot more diverse and varied.

Speaker 17 Can you think of an example or a time when

Speaker 17 citizens or local citizens sort of raised the alarm and had an effect at the local or state level because sometimes it can feel like industry is too big and the problem is too big we can't do anything about it you've spent a lot of time advising local and national policymakers when have you seen citizens actually take what you use and have an effect We did see a very real impact of citizens in communities on COVID mitigation measures.

Speaker 16 And this played out differently in different communities. There were communities where people wanted to reopen businesses, they wanted their kids back in school as quickly as possible.

Speaker 16 There are places where parents had good reason to be very concerned.

Speaker 16 For example, here in New York City, you had a lot of parents and families of color, lower-income neighborhoods, multi-generational households, where they were concerned not just for their kids, but for other family members in the household, what it would mean if their kids were back in school before a lot of people had been vaccinated,

Speaker 16 what that would would mean for elderly relatives living at home.

Speaker 16 And so what we saw, this sort of patchwork reopening,

Speaker 16 reflected a lot of those local values.

Speaker 16 And,

Speaker 16 you know, some of that was the parents, some of that was teachers who are concerned for themselves. And

Speaker 16 whether you agree or disagree with those particular decisions different communities took, you know, regardless of that, aside from that, that was the local community that was the local communities that were dictating those decisions.

Speaker 17 Well, let's stay there for a second because, you know, I talked about the allergy to science among policymakers, but there's a second strain that seems to have affected segments of the general public.

Speaker 17 And, you know, Project 2025 and its acolytes, they tend to harp on the uncertainty of COVID. and the changes we adapted to.

Speaker 17 And as you describe, the uneven and sort of patchwork response, which seemed to prove that nothing was true, therefore nothing would ever be true.

Speaker 17 You know, there is the, you know, first we all wipe down every surface, and then we realize wiping down every surface isn't necessary.

Speaker 17 And opponents of science hold this up as, you know, proof that the public should turn against the scientist.

Speaker 17 How do you respond to people who might be convinced that no one is right without invalidating how difficult that time was?

Speaker 16 I think there's a real understanding of what science is and the scientific processes.

Speaker 16 I think there are people who think scientists are a bunch of liberals who already have an opinion and they just use science to back up that opinion. That is not science.

Speaker 16 Science is you start with saying, I don't know. Here are some hypotheses.
I'm going to try to disprove that hypothesis.

Speaker 16 And then based on what I learned from that, I'm going to create another experiment and repeat and repeat and repeat.

Speaker 16 And that means you are going to build your understanding knowledge over time in an incremental way. That's just how science works.

Speaker 16 You're not going to be able to jump from this is what I think and here's the thing that proves it. It just doesn't work that way.
I think most people find that approach to be very counterintuitive.

Speaker 16 It's not the way we normally think.

Speaker 16 Normally we think in what I would call a more lawyerly way, which is to say we already start with this is the conclusion that we want to back up and then we try to find things to support that.

Speaker 16 And that really does also lead to things like cherry-picking and confirmation bias and looking for things that will back up what you already believe.

Speaker 17 So basically, I'm going to translate this into television. We need to be more like Dr.
House than we are like law and order.

Speaker 16 I think, yeah, I think that's a great way to put it. Yeah.

Speaker 17 So as a practical matter, as a practical translation, if I'm having a conversation over the holidays with someone who tells me, well, we didn't get it right in COVID, and that's why I'm not paying attention to H5N1.

Speaker 17 That's why, you know, we don't, it doesn't matter who's in charge.

Speaker 17 What's the pithy response that we want listeners to be able to give, or at least how do they start a conversation in a way that reminds us all of our high school bio classes?

Speaker 16 Well, I think also to be aware of what your pre-existing biases and opinions might be. So to ask them, well, you know, what matters to you? Let's say another pandemic breaks out tomorrow.

Speaker 16 What would be your number one, two, and three concerns and why?

Speaker 16 What was your experience of the COVID pandemic? And I think starting with that kind of understanding and being aware of why you might already have certain opinions,

Speaker 16 and then also just explaining, you know, what is the scientific process,

Speaker 16 I think are two different ways to go about this.

Speaker 17 So part of the genius of Project 2025 and the effectiveness of the Trump administration approach is that by targeting everything,

Speaker 17 our attention has nowhere to focus and it's nearly impossible to concentrate. And that is especially true in this assault on health because HHS is such a mammoth agency with so many responsibilities.

Speaker 17 I gave a little bit of a primer at the top of the episode, but I want to spend a few minutes with you really making sure we understand what the Department of Health and Human Services is and why these attacks matter.

Speaker 17 So, number one, can you break down what we need to understand about the agencies within HHS? And what are you most closely paying attention to?

Speaker 16 There are many agencies within HHS, but I'll focus just on three.

Speaker 16 The three big ones are NIH, which does biomedical research, the CDC, which is the nation's public health, well, main public health agency.

Speaker 16 And then you have the FDA, which is in charge of food and drug safety, most food. You have certain things that fall under the USDA.

Speaker 16 So why does the NIH matter? NIH is the world's biomedical institution and funder. And a lot of that research actually happens outside of NIH.

Speaker 16 Some 80 plus percent of the research is actually outside of NIH itself. It's awarded to researchers at academic medical institutions and other institutions to do that research.

Speaker 16 And it's a way of really getting a diversity in the kinds of questions being asked, the places where they're being studied.

Speaker 16 But we have created a system of funding for research where government funds the earlier research, the basic research, and then we leave it to industry to take that research and to turn it into drugs and vaccines and diagnostics and other products.

Speaker 16 And I think what's unfortunately happened is we as taxpayers fund what the NIH is doing, but if you don't have the pharmaceutical companies, device makers, et cetera, who use that science and then translate that into affordable, accessible products for the population, the general public may not benefit from those investments.

Speaker 16 And so I think what part of what we're seeing is a real frustration with

Speaker 16 this money being spent on research and people not necessarily feeling the tangible benefits.

Speaker 16 Now, I would say the COVID vaccines are a great example of a very tangible benefit of 20 plus years of research on mRNA vaccines.

Speaker 16 We had no idea that COVID was going to come along, but we were very lucky to have had that research already already in the can where we could then pivot to using those for COVID and we were able to develop vaccines very quickly for COVID.

Speaker 16 And it's a platform that's really ideal for pandemics because you can so quickly tailor those

Speaker 16 for the next pathogen. So that's you have NIH.
Then you have the CDC. The role of the CDC is partly as a funnel, frankly, of funding to state and local health departments.

Speaker 16 So that's, you know, a lot of the funding does not stay at CDC. It goes down to the ground.

Speaker 16 But then also to collect data from the state and local health departments, to analyze that, to feed that back to the states. We've already talked about some of the data issues there.

Speaker 16 To also

Speaker 16 help develop guidelines, and it's not just for vaccination, but for any number of public health issues, to provide guidance and technical support to the states.

Speaker 16 CDC cannot mandate or enforce any of that. That is, again, at the state and local level.

Speaker 16 And then you have the FDA, and where people will be most familiar is the FDA's role in approving drugs. This is also something that I think people don't understand: is the FDA,

Speaker 16 take generics, for example. RFK Jr.
has expressed frustration that the FDA is somehow blocking people's access to generic medications for additional indications, so

Speaker 16 using existing medications for additional uses, those sorts of things.

Speaker 16 And it's not the FDA, it's essentially a market failure where pharmaceutical companies, again, are the ones that pay for the clinical trials, the studies,

Speaker 16 that

Speaker 16 determine whether something is safe and effective. They then take that data, they send it to the FDA in application, and they say, will you approve this medication for this purpose?

Speaker 16 And so if there's not a profit incentive for these companies to do so, The FDA is never going to be able to approve that medication.

Speaker 16 Now, the FDA is partially funded by fees on these companies when they submit an application. That's a decision we've made.

Speaker 16 So we could decide we're going to use more taxpayer money for vetting these applications. We've decided to partially fund it with these fees.

Speaker 16 And we've decided that

Speaker 16 this kind of approach to funding R ⁇ D for drugs, diagnostics, vaccines, et cetera, we want that in the private sector.

Speaker 16 And that is going to have certain implications for what becomes available to people, how accessibly and how affordably.

Speaker 17 So let's go back to the CDC for one second. When we hear about dividing the CDC, what does that mean and why should we be worried?

Speaker 16 So this is very much focused on

Speaker 16 some of the conversations we've had around COVID and vaccines. That's really where this is coming from.
So there's a desire by some some to divide the CDC into a scientific data gathering institution

Speaker 16 and then an institution that makes the recommendations and policies.

Speaker 16 The idea being recommendations and policies may be more political because you are talking about values at that point.

Speaker 16 How do you value life?

Speaker 16 at what cost financially, what implications it has on society.

Speaker 16 And so there's a desire to create a firewall, so to speak, between who publishes the data, gathers the data, and who is making the policy recommendations.

Speaker 17 When I think about all of these agencies and how they intertwine, one of the conversations then is how easy is it to do this?

Speaker 17 And I know you focus on public health and not necessarily the ins and outs of congressional action, but how easy would it be to divide the CDC or to allow the FDA to rescind the

Speaker 17 polio vaccination authorization? Are those things that take a lot of time? Are those things that are imminent? Is it something that happens by executive order?

Speaker 17 Can you talk a little bit about how public health actually gets changed in this country?

Speaker 16 Yeah, so some of this would need to be congressional action. Some of it could be done by the Secretary of HHS and by executive order by the President.

Speaker 16 This is a very heavy lift to do something like this. You've had a number of CDC directors who've tried to reform the agency numerous times, and it is a very time-consuming,

Speaker 16 very challenging thing to take on.

Speaker 16 You know, in terms of congressional action,

Speaker 16 you would need that in order to split off certain functions from the CDC and to fund these things independently.

Speaker 16 In terms of the FDA rescinding authorization for polio vaccines, it really depends on to what degree the incoming president and HHS secretary and FDA commissioner follow what have been institutional norms.

Speaker 16 Now, do they have the power to

Speaker 16 single-handedly do some of these things?

Speaker 16 Yes, but that would be really extraordinary to see an FDA commissioner or an HHS secretary taking that kind of action and that there are processes for withdrawing an approval.

Speaker 16 you would definitely see lawsuits from the pharmaceutical companies that produce these products if there was threat of rescinding of an approval.

Speaker 16 And they would have standing in terms of is there actually science to support whether these actions are evidence-based and warranted.

Speaker 17 Yeah, and I would also throw out there that there are budgetary implications and that means Congress gets involved.

Speaker 17 And when someone, let's say Mitch McConnell, flags that he is very unhappy about the threat to the polio vaccine, his lever of power is whether or not something moves through, even though he's not going to be the majority leader.

Speaker 17 He has a vote in the Senate and a little bit of influence.

Speaker 17 So I want folks to understand that the straightforward demand for action does not necessarily translate into the immediacy of that action being taken. Would you agree?

Speaker 16 No, I do agree. Because right now you have budgetary lines for the CDC.
You do not have budgetary lines for these separate agencies that they're proposing.

Speaker 16 So you really do need to have congressional action to implement that kind of split.

Speaker 17 Fantastic.

Speaker 17 So health is not simply the ability to know what diseases and threats are out there. You know, it's also about the ability to get help.

Speaker 17 And that means we also have to pay attention to the healthcare access side of things.

Speaker 17 So for example, Project 2025 proposes to roll back the progress that the Biden administration has made in reducing drug prices.

Speaker 17 It also wants to accelerate the privatization of Medicare, which older and disabled Americans rely on.

Speaker 17 And they want to break up Medicaid into block grants, which will set fixed amounts that go to states regardless of the actual cost of health care or the size or needs of the population.

Speaker 17 What are you concerned about when it comes to this administration's impact on healthcare access?

Speaker 17 And how would you process this information as a layperson?

Speaker 16 Well, if you read

Speaker 16 Project 2025, they literally spell out that the cost of Medicare and Medicaid combined since 1967, which is when these programs were started, is about $17.8 trillion.

Speaker 16 And the U.S. deficits for that same time period are $17.9 trillion.

Speaker 16 So in other words, they are pretty clear in that they think that Medicare and Medicaid are the principal principal drivers of our national debt.

Speaker 16 And if we want to eliminate our national debt, we need to dramatically scale back, if not eliminate, Medicare and Medicaid. That's essentially what's implied in what's written in Project 2025.

Speaker 16 And

Speaker 16 There are several strategies to try to scale back spending, one of which is, as you mentioned, privatization of Medicare.

Speaker 16 A lot of people who have Medicare Advantage plans may think they're getting a very good deal.

Speaker 16 they get dental vision benefits, maybe other perks thrown in, and it's great until they need to see a doctor, they get hospitalized, and then realize that their coverage is actually really inferior to what they might have had if they had traditional Medicare.

Speaker 16 You mentioned the

Speaker 16 Medicare's authority to negotiate drug prices under the Inflation Reduction Act. This is an area where the incoming administration is under pressure to roll back that authority.

Speaker 16 And this has very tangible impacts for people. One of the drugs that was likely going to be in the next round of drug negotiations is semaglutide, also known as Ozempic or Wickovi.

Speaker 16 A lot of people are desperate to get access to that medication.

Speaker 16 Currently is very expensive.

Speaker 16 The Biden administration has recommended or has proposed new guidance that Medicare can cover these medications, also known as GLP-1 weight loss drugs, for people even if they don't have diabetes or cardiovascular disease, but simply because they have obesity.

Speaker 16 And it will be up to the incoming administration to finalize that rule, whether they will or not, we don't know.

Speaker 16 But then if they do and they don't make use of that lever to negotiate down drug prices for,

Speaker 16 you know, including the GLP-1 drugs that would have huge cost implications for Medicare

Speaker 16 so it's a little hard to know how each of these pieces will play out

Speaker 16 with respect to Medicaid you mentioned block grants to the states that's a great way if you're looking to cut your Medicaid costs federal spending on Medicaid to do so What we're also seeing are conversations about reducing the federal

Speaker 16 amount that's being provided for that. So both states and the federal government put money in for Medicaid.

Speaker 16 But if we see a reduction in the federal contribution, some states that have expanded Medicaid may reverse that decision.

Speaker 16 We've seen more and more red states expand Medicaid, North Carolina, for example.

Speaker 16 And that's because there was an understanding that this actually was good for their bottom line. And it had an impact not only on patients, but also on rural communities where

Speaker 16 prior to expansion of Medicaid, many rural hospitals were really in financial trouble. Many still are.

Speaker 16 But we've seen many of these facilities close and Medicaid was a lifeline, expansion of Medicaid was a lifeline to many of these facilities to keep them open and also to keep many of those jobs at those health facilities still available.

Speaker 16 So those are some of the things that we could anticipate with respect to Medicare and Medicaid.

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Speaker 17 So, So you know a lot and

Speaker 17 you have been all over the world, all over the US.

Speaker 17 You've decided to take your experience in epidemiology, but you've really channeled it into sharing information in a way that is extraordinarily accessible.

Speaker 17 You and I met actually in the midst of the COVID pandemic.

Speaker 17 and you invited me to be on a podcast, but it was such an important conversation because you're just a really fantastic communicator on really complicated issues.

Speaker 17 Was there an inciting incident for you that made you decide, I not only have to know what I know, I need other people to understand what I know?

Speaker 16 Yeah, so it was a process of years really to come to this point, but I think some of it was what I experienced working in southern Africa.

Speaker 16 I started my career working in global health and tuberculosis and HIV.

Speaker 16 Was often asked to moderate town hall meetings, meetings with patient advocates, informing policymakers both overseas as well as on the Hill in the U.S.

Speaker 16 So that sort of planted the seed, but then I had pivoted from global health to domestic health around 2012. I was an assistant commissioner of health at the New York City Department of Health.

Speaker 16 And we were dealing with massive cuts to public health funding in the aftermath of the 08-09 recession.

Speaker 16 And in year one on that job, I was tasked with having to cut essentially 20% of my bureau of 250 people. So 50 people out of 250.
That's huge.

Speaker 16 And what I realized coming out of that was we will not fund public health if people don't even understand what it is. People at least need to understand what it is.

Speaker 16 And then you can decide, is this something valuable or not? But I would argue that coming out of the pandemic, people still don't understand what public health is.

Speaker 16 They often confuse public health and health care.

Speaker 16 And so that's really what motivated me: I wanted people to be armed with the facts, to be informed citizens, and then to make decisions, you know, however they want to, based on that information.

Speaker 17 Okay, so here's your platform. Tell people the difference between public health and healthcare

Speaker 17 and how they should describe it when they're sitting around the dinner table. Yeah.

Speaker 16 So healthcare is what people are more familiar with, right? It's what happens in the clinic, in the hospital. It is very individual patient-focused.

Speaker 16 Public health is largely funded by the government, which is in contrast to health care. Much of health care is in the private sector in this country.
Not all of it.

Speaker 16 You know, Medicare is a great example. Medicare, by the way, is socialized medicine, which people don't want to hear, but it is.

Speaker 16 So you have

Speaker 16 largely taxpayer money, some philanthropic foundation money, maybe some public-private partnership, but most of public health is taxpayer dollars.

Speaker 16 It is looking at health from a population, public, hence public health perspective. And so it's not decision-making for an individual patient.

Speaker 16 And I think this is one area where people got frustrated during the pandemic because you had these blanket recommendations for how do we reduce disease and death at the population level?

Speaker 16 And some people would say, yeah, but that's not me.

Speaker 16 And so

Speaker 16 they would not see themselves as being at risk, for example, and are not necessarily thinking about not just what, say, COVID infection means for them, but what it might mean for the people around them.

Speaker 16 And so those are just different ways of how do you weigh risk and benefit of certain different things.

Speaker 16 Another way to think about public health is it's all the stuff that does not happen in a clinic or hospital.

Speaker 16 It's all the stuff like what's your air quality, your water quality, what is the safety of your neighborhood, is it so violent you can't go out for a walk and exercise in your neighborhood?

Speaker 16 What is your access to healthy food? You know, those are the kinds of things we think about in public health. And that's not something you address with a prescription pad or a surgery.

Speaker 16 A lot of our levers in public health are really about policy and how do you shift the needle through policy.

Speaker 17 Which brings us to the doing section of this conversation.

Speaker 17 You have been such a thoughtful partner to powerful people, but as you pointed out, you've also been doing that work

Speaker 17 with local organizations, with town hall meetings, helping citizens understand their power.

Speaker 17 How do we as individuals push back and meet this moment? We know there has been a recent tragedy where vigilante justice seemed like a solution to someone.

Speaker 17 But we know that that's not the answer. So how do we think about what else we can do? We know we talk about voting, and for some, that didn't seem to work this time.
It does work.

Speaker 17 It just doesn't work all the time in the ways we want it to work. But how do we talk about starting at the local level, using public health as the point of entry?

Speaker 17 Give us our marching orders. What do we do?

Speaker 16 You know, with respect to the United Healthcare CEO's assassination murder,

Speaker 16 I found that profoundly disturbing because it speaks to how disempowered even this highly educated, privileged young man, how disempowered he felt in fighting the issues with our healthcare system.

Speaker 16 And yes, our healthcare system is horrible. We spend more than any other country in the world.
We have the worst outcomes of any high-income country.

Speaker 16 And by the way, healthcare itself only predicts about 10 to 20% of life expectancy of people's health outcomes. And so a lot of what needs to be done to improve people's health is not in health care.

Speaker 16 Again, it's in public health. It's about 80-90% of the game is in public health.

Speaker 16 What really upset me about that incident was people are so disempowered that they feel like they have no choice but vigilante justice, but political violence.

Speaker 16 And that's a very scary place to be when people don't believe in voting, in government institutions, in meeting with their local officials. Yes, all of that takes time.

Speaker 16 It does take time to get informed, to understand the issues, to reach out to those people and to talk to them.

Speaker 16 But I think that is where we really need to be encouraging people to get involved is do those things.

Speaker 16 DC might seem very far away. And again, a lot of the action is not in DC for these issues.
It is in your state. It's in your city.
Get involved at that level.

Speaker 16 In New York City, for example, we have these community health boards and I've met with a bunch of them over the last couple of years during the pandemic to educate them.

Speaker 16 These are concerned citizens who are really trying to do what they can to make their communities healthier.

Speaker 16 And yes, that, again, takes time, it takes lots of people, but that's where you can have a very tangible impact.

Speaker 16 So that's really the level at which I would encourage people. The powers are there.
These are really

Speaker 16 kitchen table concerns people have. Like it's what's happening, I don't know, with pollution near the school where your kids goes to school.

Speaker 16 It's what's happening with gun violence in your neighborhood. It's the opioid overdoses.
you know, your neighbors, you're talking about so-and-so lost their son.

Speaker 16 These are things that are very tangible to people where you can get involved and it doesn't have to be a partisan thing.

Speaker 17 Dr. Celine Gounder, thank you so much for joining us here and informing us here at Assembly Required.

Speaker 17 At Assembly Required, we encourage the audience to be curious, solve problems, and do good through a segment we call our toolkit.

Speaker 17 Now, we're going to fight the allergy to science and information by being curious. During my time in the Georgia State Legislature, I relied heavily on KFF News, and it's still my go-to.

Speaker 17 KFF News is an independent source with news and health policy research, so sign up for their newsletters at kfff.org slash email.

Speaker 17 For regular listeners, you're going to notice that today I'm doing things a little differently.

Speaker 17 You see, we've gotten quite a few listener questions that have a running theme. First, Ed Bog wrote an email titled, How to Be an Activist with Social Anxiety.

Speaker 17 He writes, since the election, I felt energized to help defend human rights, but severe social anxiety has been a major barrier for me.

Speaker 17 Even when it's just low-stakes small talk, my throat gets so dry that I can barely speak, and years of customer service work hasn't helped me overcome this.

Speaker 17 How do I get involved and make a difference when so much of the work is about connecting people?

Speaker 17 Number two,

Speaker 17 Mu Yan Chen wrote about wanting to be politically engaged even though she just has a green card.

Speaker 17 I came to the U.S. from China more than 10 years ago and now work as a researcher in a national lab.

Speaker 17 Being a foreign national with a green card now, It's been quite stressful to watch the events unfolding, but it seems difficult to do anything about it legally.

Speaker 17 I'm wondering if there are anything such as volunteer opportunities that I can contribute to.

Speaker 17 And number three, a caller whose name I didn't quite catch called in and left a voicemail responding to the Heather Cox Richardson episode.

Speaker 17 She writes, I've been getting myself and my small online community to call our representative every day and leave messages with them as well as an email.

Speaker 17 Just kind of letting them know, you know, what we think and what we need from them. And so I'm just wondering, are there specific folks folks we can be calling and writing?

Speaker 17 I like the idea of a bunch of us doing this kind of small thing together.

Speaker 17 We've been calling individual members that we can, also writing and calling our senators about Trump's nominations to his cabinet, but just looking for any other ideas for folks to call.

Speaker 17 Now, normally this is where I'd either answer your questions or give you resources on what to do about what we just discussed, like public health. But today, we're going to begin a capsule course.

Speaker 17 In grassroots organizing, Ed's social anxiety means we just find a different way for him to contribute to the cause, like setting up agendas or coordinating resources.

Speaker 17 For Muyan, her expertise can be a major asset in finding information and developing communication systems.

Speaker 17 And for our phone warrior, you're in the midst of convening advocates to push our agenda for good. Because here at Assembly Required, we know we can start solving problems by showing up and taking

Speaker 17 Over the next several episodes, we're going to use this segment to talk about concrete steps that we can take towards insisting that political leaders do their jobs.

Speaker 17 Federal action will obviously matter and absolutely it's important. But what I hope you've heard over these many episodes is that we're here to win.
However, winning won't be fast.

Speaker 17 and it will require many of us across the country to take on different parts of the problem and combine our successes.

Speaker 17 And that means often working at the local level so we can one day have federal impact. This is not in lieu of federal action, it's in addition to.
Let's get started.

Speaker 17 Our first step is identifying the issue that matters to you most. Is it your state's refusal to expand Medicaid? Book bans in your local school district, a food desert that seems to be growing.

Speaker 17 Do you need to launch a tenants union? Pick one as your tester pancake, pancake, the issue that you want to start with. So over the holidays, your task is to decide on the issue you want to tackle.

Speaker 17 Be as specific as possible about the problem. And also, be as local as you can with the solution.
If the city council can solve it, start there. If it's the county commission, know it.

Speaker 17 Does the state have jurisdiction? If so, that's your target. Take the time to know who's in charge and who can make the change you want to see.
This is called power mapping.

Speaker 17 So find out as much as you can about the issue, who's responsible, and who else is already working on it. Check social media and Google to see if anyone else is talking about this issue.

Speaker 17 Write it all down, and let's get ready to go to work.

Speaker 17 As we close, I want to share one last listener comment, and this is from Emily Drake. She writes, I wanted to thank you, first of all, for answering my question a few weeks ago.

Speaker 17 After hearing your answer and listening to this week's episode about the education system, I have decided to go back to teaching public school and to get involved as much as possible.

Speaker 17 I taught public school for seven years and I've had a few years off staying home with my kids. But I think it's a good time to go back and use my skills for good.
So thank you.

Speaker 17 I appreciate all you do. Well, thank you, Emily, for sharing and for telling me how you're getting to work.

Speaker 17 And if any of you want to tell us what you've learned, how you've solved a problem, or how you've rejoined the fight, send us an email at assemblyrequired at crooked.com or leave us a voicemail.

Speaker 17 Your questions and comments might be featured on the pod. Our number is 213-293-9509.

Speaker 17 I wanted to say thank you. Thank you for listening.
Thank you for engaging. Thank you for letting us know that we're coming together and we're getting to work.

Speaker 17 That wraps up this episode of Assembly Required with Stacey Abrams. I'll meet you here next week.

Speaker 17 Assembly Required with Stacey Abrams is a crooked media production. Our lead show producer is Alona Minkowski, and our associate producer is Paulina Velasco.
Kirill Polaviev is our video producer.

Speaker 17 This episode was recorded and mixed by Evan Sutton. Our theme song is by Vasilius Vitopoulos.
Thank you to Matt DeGroote, Kyle Seglin, Tyler Boozer, and Samantha Slossberg for production support.

Speaker 17 Our executive producers are Katie Long, Madeline Haringer, and me, Stacey Abrams.

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