Abbe Gluck: The Legal Determinants of Health

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This week, we’ll be speaking with Professor Abbe Gluck of the Yale Law School. But first, we like to check in on current hot topics in health and healthcare. You have this very well-received opinion piece in The British Medical Journal this week. Can you tell us about the piece and why it’s so important?

Harlan Krumholz: Well, it’s an area that I’ve been pondering a lot lately, which is this issue of trust in medicine, and how do we make sure with the changes that are occurring in medicine and healthcare, that we’re able to maintain that trust, that trusted relationship between a patient and the caregiver? One of these areas that is a potential threat to that is something that has the potential for great good, which is the digital transformation of medicine, that we can actually access information, it can flow more freely. It can help us so that your records are where you need them, when you need them. But also there’s something that’s changing in medicine, which is that trust that you can have that you’re sitting across the bed from someone and they’re disclosing information to you, maybe very private information, maybe information that they’re only willing to tell you after years of building a relationship together.

Once they tell you and you document it in the record, all of a sudden it’s no longer private information. This can be something someone feels is quite personal, something that they don’t want to share. A paternalistic medical system will just say, “Well, we need to know everything about you, no matter whether we know you or not so that if you come and we provide care that we can take this into consideration.” But another view of this is that people may have information about themselves that they really don’t want widely known. They may recognize that there may be some risks that someone caring for them doesn’t know it, but they only want to give it to someone that they really trust. So this manifests itself in many ways. One way is just that by documenting it, anyone who takes care of you can have access to that information.

That’s the way the HIPAA works. So when you go and see another doctor that has nothing to do with that very private piece of information you may have disclosed to someone you know, they can see it. But it also happens that through business associate agreements, these kind of agreements that health systems have with private companies, that data can be shipped off every day to third parties. So for example, at Yale, Smilow Cancer Center had an association with Flatiron, a company that provides quality reports back to the system, but Flatiron’s a part of Roche, which is a large pharma company, so that every day we’re shipping all of the information from Smilow to a pharma company, who by the way, deidentifies and sells it to other companies, and by the way, that Flatiron also bought an electronic health record system purely for the reason to monetize that information without the explicit consent to the people whose information they were using.

Then it became obvious to me, by the way, another case was a lot of these pop-up COVID testing sites were having you sign a piece of paper that you never paid attention to so you could get a free COVID test on the corner of the street. Now they were claiming that they are part of your provider network, and they could go out and obtain all of your medical records through another third party who had obtained it from other sources and then monetize and sell it to others. So I’m just writing about this problem that we have in medicine today, which is that this idea of data privacy is a bit of an illusion. The moment anyone documents something about you, there’s a potential, even with our system of HIPAA, the protections of privacy for patients, for that data to go far and near to places that you didn’t explicitly allow it to.

You and I have talked about this. I understand people, doctors who are saying, “But I need to know everything about patients.” I’m saying, I’m more on the side of saying, “Then just ask them whether you can have access to all of their information.” I’m not talking about the place where someone’s unconscious or unable to give consent to maybe we can make an assumption that in a lifesaving moment that all that information should be available. But can people opt out, say, “There’s certain information about me that I want to keep private unless I’m willing to share it”? So anyway, in this piece in BMJ, I opined about this and talk about whether or not we need to be focusing on, how do we maintain trust and what expectations do they have about their data?

Howard Forman: Yeah, no, we certainly should have the ability to opt out. It shouldn’t just be if we aggressively try to opt out, it should be an option every time we come into the hospital. I agree with you on that. I think in the past we never thought much about it. Even before electronic health records, we had paper records that were voluminous, captured a lot of information. If you happen to have that record in front of you, you had access to a lot of information. This is not necessarily a new problem, it’s just exaggerated by the fact that now we have digital data, and it flows so freely and so quickly.

Harlan Krumholz: Which can be good, but also has this other side to it.

Howard Forman: Yeah, no, you’ve convinced me on the topic that we should be focusing on, how do we give people the ability to opt out and then make sure they know they have that option?

Harlan Krumholz: And explicitly share. But anyway, I think it’ll be an ongoing issue, and I hope one that’ll elicit some public conversations and maybe some movement on the policy side. But hey, let’s get to our guest today, Abbe Gluck.

Howard Forman: Abbe Gluck is the Alfred M. Ranking Professor of Law at the Yale Law School with a joint appointment as Professor of Internal Medicine in the Yale Medical School. She founded and runs both the Yale Law School Solomon Center for Health Law and Policy as well as the Yale Law School Medical-Legal Partnership, a law clinic that provides legal services to those in need. Professor Gluck has served as special counsel to President-elect and then President Biden between November 2020 and November 2021 as lead legal counsel for the COVID-19 Response Team of the White House and worked on healthcare litigation and policy for the White House Council’s Office. Before coming to Yale, she held positions at Columbia Law School and worked for New Jersey’s governor, John Corzine; New York City’s mayor, Michael Bloomberg; and the U.S. Senate. Her expertise is wide-ranging and covers multidistrict litigation, federalism, and the intersection of law and healthcare.

Professor Gluck has been published in many distinguished journals and has written several books, including the soon-to-be released book, COVID-19 and the Law: Disruption, Impact, and Legacy. Professor Gluck graduated from Yale University with a BA and obtained her JD from Yale Law School. So first of all, we both welcome you to the Health & Veritas podcast. We’re really excited to have you here. We all talk about social determinants of health, and Daniel Dawes talks about the political determinants of health, but really a lot of your work delves into the legal determinants of health and how the law impacts our health and our standing. I’d love to hear you expound on that a little bit so the listeners understand what that means.

Abbe Gluck: Oh, that’s a great question. I think what you’re getting at is that in the last 10 to 15 years, particularly with the passage of the Affordable Care Act, people are really focusing on the way in which the structure of our healthcare system and the laws that surround it affect access to healthcare. So you’re right, I never thought about myself in that precise way, but I do think about the way in which we legally structure our system, how that affects issues of access, equity, cost, et cetera. That’s what makes our Yale Center pretty unique. Most people don’t focus on the intersection of public law, government statutes, and healthcare.

Howard Forman: As a quick follow-up to that. When I hear MLP, I think “master limited partnership” or something and medical-legal partnership is unfamiliar to me, quite frankly, and it’s unfamiliar, I think, to many of our listeners. Can you explain what that means and the different types of medical-legal partnerships that you’ve established in New Haven and been replicated more widely?

Abbe Gluck: Yeah, you’re asking all of my favorite questions, Howie, so thank you. Medical-legal partnerships are one way in which hospitals address social determinants of health by working with lawyers and social workers at the bedside in the clinic. Many clients, especially low-income clients, undocumented immigrants, those returning from prison, are not the type that eagerly seek out legal counsel. But they need help and they need benefits. They’re being discriminated against. There are a whole host of reasons why they need legal counsel or referrals for legal services. What MLPs do is they integrate the legal and medical teams. Physicians screen patients for health-harming civil legal needs, and then the lawyers work on them. There’s a lot of research just showing that a medical-legal partnership, for example, might reduce emergency room readmissions. Right?

Howard Forman: Wow.

Abbe Gluck: So to your question: Yale, what are we doing at Yale? Starting in 2012, we founded a major Yale medical-legal partnership program in conjunction with the Yale New Haven Hospital and a couple other local partners. We now have more than eight medical-legal partnerships in New Haven, making us the largest academic medical center to have an MLP. Just quickly, the populations we cover: pediatrics, veterans, those returning from incarceration, undocumented immigrants, oncology patients, palliative care patients, the elderly, and more. It’s a really fantastic program, and we’re so happy to be partnering with Yale New Haven on this.

Harlan Krumholz: I have a lot of questions I want to ask you. Howie, one of the great things being at Yale is that you get to meet these rock stars like Abbe—

Abbe Gluck: For sure.

Harlan Krumholz: ... and the fact that we’re in close enough proximity that it can foster collaborations and interactions. We’re so lucky really to have someone like Abbe here. But just to go back to this medical partnership, can you just explain what exactly is it? So is it that when someone comes in the emergency department, there’s actually lawyers available who can help patients because some of the things that are impeding their health happen to be the legal structures around them? How is that different than what the social workers do? Can you just explain with a little more detail?

Abbe Gluck: Yeah, I would love to. I always worry about going on too long, so I’m happy to talk more. Since you mentioned rock stars, you have to know Harlan knows that I call him the Bono of healthcare. So he opened the door to that question. So I have to use my Bono joke on Harlan. We all know it’s true.

Harlan Krumholz: Oh, no, no, no, no.

Abbe Gluck: So what happened? So for example, the amazing Transitions medical partnership, which is run by the fantastic Dr. Emily Wang and Lisa Puglisi here at Yale New Haven Hospitals, one of our partners, we founded the “L” in that MLP. They had a medical clinic for those returning from incarceration. They screened their patients for medical needs. Sometime around 2014 we added a legal component. There are lawyers in the clinic in the same physical space, Harlan, when patients come in. Emily’s team screens for patients on the medical side, but they also ask questions about things like housing and nutrition.

Then they send all their patients, not just the ones that the doctors think deserve one, to our lawyers. James Bhandary-Alexander is our head lawyer. He has a team of law students who are also helping him. They then screen the patients. What’s different from the social workers, who do an incredible job and are an integral part of many MLPs, is that the lawyers can actually engage in the practice of law on the spot, whether that’s helping patients fill out forms, engaging in referrals, or actually taking them on as clients. There’s a literature that shows that merely giving patients referrals to legal services doesn’t necessarily get patients legal services, ‘cause it’s hard to get in, and also—

Harlan Krumholz: This is such an incredible idea, and it’s an idea about how there are actually teams addressing various facets of people’s life that are interfering with their ability to achieve healthy lives, and just amazing—

Abbe Gluck: Lisa Puglisi has an article coming out now that’s coming out in the journal that we’re putting out coming out of the recent conference at Yale Law School where she’s collecting studies showing how social determinants of health, things like lack of access to housing or non-medical regular debt, actually have significant correlation with cardiovascular health. So she’s actually showing how having these interdisciplinary teams really could make a difference on nutrition. You also think about things like access to benefits or people who have been discriminated against at work. Those things add stress to people’s lives, but they also affect their ability to adequately sleep and eat and care for their families.

Harlan Krumholz: So you were the lead lawyer for the COVID-19 Response Team of the White House during the Biden administration in one of the many ways that you’ve served the nation. What do you think are some of the most impactful initiatives or cases or issues that were raised by the pandemic and that will continue down the line to be very important for us to be paying attention to because there were so many legal challenges during the pandemic? Really, this did bring law right into public policy in a way that not just in the crafting of public policy but in the combating of public policy. So I’m curious, so what did you think were some of the key areas that were most important that will continue to have legs in the future?

Abbe Gluck: So it was the privilege of my professional life to work in the White House during this historic moment. We did bring new legal ideas to the table under enormously trying circumstances. One of the things that we had to navigate, which is an enduring question, is the role of the federal government vis-à-vis local governments, in emergency response. So the Trump administration actually made significant headway in getting the vaccines but had made very little headway in getting them out. We then had to figure out the way in which legally the federal government could exercise some muscle. In a healthcare system that likes to think of itself as mostly local, the local governments were really not up to the task. So one of the key areas of my legal work was figuring out what levers of federal power we had to push, sometimes softly and sometimes not so softly.

One of the first things that we did that’s an example was you might remember in the beginning of the response, different states had different prioritizations for different populations who had access to the vaccine. People wanted to get their kids back to school. Teachers were not willing to go to school until they had access to the vaccines. One of the first legal announcements the Biden administration made apart from the whole slew of day one announcements like masking on trains and all of those things was basically requiring the states to give teachers access to vaccination in priority fashion. That was a very big strong legal move and one that was actually very complicated to figure out. But Harlan, your broader question about what are the legacies of this pandemic? So many. One, obviously health equity, and health inequity is really the right term. So what we saw across the pandemic was intolerable disparities in access to care.

Just looking in New York the month of March, looking at the difference between the outer borough hospitals and Manhattan hospitals, people who died, people who didn’t get care, the amount of services that were there, that is something we absolutely have to address. Our wonderful colleague, Marcella Nunez-Smith, was the equity coordinator for the COVID response and really drove the effort to try to get the vaccines out to rural, low-income, and minority populations. There are also a whole host of populations that we saw were left behind—the elderly did not have adequate protections; those in prison did not have adequate protections. So one thing that the book does is it actually looks across a slew of populations and a slew of issues and identifies a whole host of issues that were existing before the pandemic, but that the pandemic exacerbated and shown light.

Harlan Krumholz: At the White House, was there ever a consideration of saying by pushing federal power on these states, especially in areas of red states, they were actually creating a political backlash, and what we should do is stand ready to provide services but not to impose our will to say that “our way is the best way” for Florida? Instead of having someone like the governor of Florida and the secretary of health pushing back on the government, where was the decision made that we actually need to do this for Americans regardless of what the local governments there want to do?

Abbe Gluck: You can look at the arc of the pandemic, and I’ve written about this in the book. My chapter’s actually about this, and in fact, the arc of regulation. So you see that the regulatory response of the pandemic started out with incentives, not mandates, and over time, mandates emerged as something that was viewed to be necessary. That actually took quite a long time. So one of the first real mandates was the Healthcare Emergency Temporary Standard, the requirement from OSHA that you have to take extra precautions including wearing masks but a lot of other things in healthcare settings. But that didn’t even come that quickly.

The Trump administration actually started with a very loose response that was basically sitting back and letting the states do what they wanted. That was viewed as wildly ineffective by pretty much everyone who was watching it, not just in the White House but across the country. If you look at the arc of the Biden pandemic, you’ll see there was a very slow arc toward mandates, and it was something that the administration took very seriously. It wasn’t really until the summer of ’21 and the fall of ’21 when you started to see things like the Air Force vaccination mandate, and the mandates that came were mostly in the vaccination space once it was entirely clear just how absolutely effective and safe the vaccines were.

Howard Forman: Well, I wanted to just point out for our listeners that not only are you involved in the practice of health law, but you’re a constitutional scholar. There are a lot of ways in which our health healthcare delivery system, our policies are continuing to be under attack. So even now, there’s a ruling, I believe, out of Texas—it always seems to be out of Texas—trying to strip parts of the ACA, the preventive care provisions. Then separately unrelated to the ACA but related to FDA regulations is the very big issue of making mifepristone unavailable to literally tens of millions of women in this country. These are constitutional issues that will eventually reach the Supreme Court. Can you give our listeners a little understanding of how you and other constitutional scholars work to support the health access and well-being of the population through health law?

Abbe Gluck: Okay, so it’s great to talk about these cases. The FDA case has gotten a little more attention, so I’m going to start with the other one, which is a very important case called Braidwood. It is out of Texas. Both of those cases are out of the federal court in Texas. Most listeners probably don’t remember that not that many years ago, slightly more than a decade ago, if you took your child to the pediatrician to get a vaccine, as I did with my twins, you got a very big bill. I remember getting my bill and thinking, “Why am I paying all this money for my children’s vaccines?” I have great insurance from Yale, and I was told that vaccines aren’t covered by health insurance. Vaccines are just one of more than 200 essential preventive services that include breast and colon cancer screening.

It includes statins for heart disease. It includes hearing screening for children and adults. It includes lots of elderly services, many things that people ... PrEP for HIV prevention. Many different services that never had coverage before were covered by the Affordable Act, benefiting more than 100 million people, it is estimated. So after seven challenges to the Affordable Care Act and the Supreme Court in a pandemic where we saw the Affordable Care Act safety net swell to really benefit and protect us. By the way, let me just say, the fact that we all got the vaccine for free is because of these very same provisions that are being challenged in Texas. It’s the preventative care provisions that allowed us all, no matter who we were, to access that vaccine for free. There is now a challenge to that. The challenge actually stemmed from two prompts. One is the desire to take the statute down. The other is, quite frankly, a moral attack on LGBTQ populations, more by people who have homophobic tendencies. In other words, there’s no other way to say it.

The attack was basically on this HIV prevention drug called PrEP, which is one of many different preventative care drugs that covered Affordable Care Act. The allegation is that the Constitution requires expert bodies to be basically supervised closely by heads of departments and those confirmed by the Senate, and that the Affordable Care Act structure, which by the way, relies on expert medical bodies for good reason. We do not want political people telling us which medicines are essential, that the Affordable Care Act structure is not adequately supervised. That case is now on appeal in the Fifth Circuit. It could take down a huge number of preventative care services, including by the way, full birth control. All right? So it affects everybody. It doesn’t matter if you’re gay or straight or old or you’re young. Everyone is benefiting from these preventative care services. Should I go on to the for mifepristone case, or do I want to stop there?

Howard Forman: Yeah, no, I would love to hear that. Yep.

Abbe Gluck: Yeah. These are multi-pronged attacks on the administrative state. So one thing to step back for listeners to keep in mind, court followers in general, what is happening right now in conservative legal circles and the court is a full-frontal attack on the apparatus of government. The idea, we want to shrink what the government does, going after the Affordable Care Act is one way to do that. Going after the FDA is another way to do that. Both of these cases have broad structural policy strategies going after big government. They’re also about specific drugs like PrEP and like mifepristone. Mifepristone, as most of our listeners probably know, is one of two drugs that are combined to induce abortion.

Even before the Dobbs decision that overturned Roe v. Wade, more than 50% of women receive medical rather than surgical abortions, largely because they’re cheaper. Some view them as less traumatic, a whole variety of reasons, easier to take a day off and they’re equally safe. This lawsuit basically says the FDA’s original approval back in 2000 of this drug was not fully reasoned. So it is the first time in history that opponents have gone after a drug two decades after its approval and challenged the fairness and rationality of the process. DACA [Deferred Action for Childhood Arrivals] is also on appeal on the Fifth Circuit and will have obviously devastating implications for women whose healthcare is already, access is already threatened with the overturn of Roe v. Wade.

Howard Forman: Yeah. Am I allowed to say “Chevron deference” now? I feel like that’s the term I’m supposed to say whenever we talk about the administrative state, but it’s the only legal term I know.

Abbe Gluck: Well, Chevron was the big case that for 40 years has been used by court after court after court. It’s, by the way, the top-cited case in the U.S. report, so the number one case that is cited more often than the others, which says, “When in doubt, we defer to the expertise of the agency.”

Howard Forman: Right. Right.

Abbe Gluck: That is what is being challenged right now.

Harlan Krumholz: I wanted to first of all, thank you so much for being with us, and I know everyone’s going to really appreciate the kind of insights you ever bring. I wanted to ask you here at the end, so you clerked for legendary justices like Ruth Bader Ginsburg and Ralph K. Winter. Interestingly, Winter’s nominated by Reagan, Ginsburg by Clinton, you’re on with judges who come in different directions, both remarkable individuals. I just wonder if you could just share a little bit, particularly about Ginsburg, since everyone’s so familiar with her, what was it like to be a clerk with her? Maybe is there an anecdote or story that hangs with you about your time with her?

Abbe Gluck: I’ve spoken about Justice Ginsburg a lot in public, and so it’s always hard to know what to say about this marvelous person. She was the most hardworking person that I’ve ever worked for. She worked through the night. I wrote somewhere that her famous faxes came across the airwaves all through the night, and that is true. She demanded excellence, so she taught everyone who worked for her to be extraordinarily careful. She also always thought about the consequences on the lives of everyday people of her legal decisions. So I think that’s something that really mark Justice Ginsburg. There’s a great example of one case I’ll give that will resonate with physicians, I think.

There’s a case about a strip search of some high school girls in a gym, and some Advil was found on a teenage girl because she had PMS. They basically made her take all of her clothes off in front of everybody else as a punishment for hiding Advil in her clothes. At oral argument, there’s a lot of talk about, “Well, this is just fun locker room games,” among all the male justices. Justice Ginsburg was the only woman on the court at the time, and her reaction was, “This is anything but locker room talk. This is a teenage girl,” so she’s thinking about the effect. Similarly, in the many cases that challenged the ACA’s increased access to birth control medication, Justice Ginsburg was constantly aware of the effects on everyday women of access to those drugs.

So she was extraordinary in that regard. The other thing about her that I always like to leave people with was that Justice Ginsburg was a consummate optimist about the Constitution and the court. There was an opera that was written about Justice Ginsburg and Justice Scalia, her famous best friend. It’s called Scalia/Ginsburg. Her favorite aria from the opera goes, “We are different. We are one,” where they both sing this basically love aria together, talking about how they see the world differently but they both share consummate faiths, Constitution and the rule of law. So when you asked me why I clerked for Ralph Winter, a Republican judge, and Justice Ginsburg, extraordinary liberal lion of our time, they were different, they were one. They both saw a belief in the country and the world where the law could help people who are less fortunate and ensure a more just and equal society.

Howard Forman: Well, you are a worthy legacy to Justice Ginsburg, and we are so fortunate to have you as a friend and colleague, and we look forward to having you back on the podcast.

Abbe Gluck: My pleasure. I feel the same way about both of you guys, Bono and Bono sidekick.

Howard Forman: Bono sidekick....

Harlan Krumholz: Thank you. Well, that was a terrific interview. I’m so grateful that Abbe joined us today. But let’s get to your part, another favorite part of the show for me, so Howard, what’s on your mind this week?

Howard Forman: Yeah, thanks. So on our January 19th episode, we talked about the changes that would be coming to Medicaid with the pandemic emergency coming to an end. We indicated that as many as 5 to 15 million people might fall off the Medicaid rolls. Many of these individuals no longer officially qualify, but many do. Just a brief reminder to a listeners, Medicaid, which is the program for the poor and indigent in our country, grew enormously during the pandemic from 64 million individuals up to 86 million individuals earlier this year, February of this year. Medicaid had a continuous enrollment provision during the pandemic that limited who could be thrown off of Medicaid involuntarily during that time.

Those rules have now changed or reverted back, and states are now making highly variable efforts to disenroll those individuals who may not longer qualify. So to give you an idea of how variable this can be, 50% of those whose eligibility is being checked in Arkansas have been disenrolled already; 54% in Florida, while in Virginia, the number’s only 10%. All states have 10 months to complete this process. Ideally, in a perfect world, only those who are no longer eligible would lose coverage. But for various reasons, hundreds of thousands, if not millions of others will find themselves without coverage despite still being eligible. So for instance, 250,000 people have been kicked off Medicaid in Florida alone.

Florida and Arkansas are also leading the reporting nations in what are called procedural disenrollment, which is to say that the vast majority of those disenrolled are not necessarily ineligible, just they don’t have all their paperwork lined up properly. Florida has 82% procedural denials, Arkansas 88%. In Pennsylvania, a very different state politically, the figure is only 43%. At the end of the day, it is prudent to make sure that individuals who are receiving Medicaid benefits are actually eligible for those benefits. It’s hard to quarrel with that. But if we’re going to be disenrolling vast numbers of individuals who ultimately do qualify, we’re imposing harm on the most marginalized, minoritized, and under-resourced populations, and that’s a collective failure of policy and government.

Harlan Krumholz: Well, and Howie, let’s be clear, there’s going to be a big domino effect here because this is also revenue to hospitals that’s cut off. This is not just affecting those people, and I agree with you, that’s number one, what effect is it having on people’s lives? But we’re going to see that this is going to have an effect on the healthcare systems at large because they’ve changed over time to accommodate this greater coverage and actually revenue so that they don’t ... people can talk about it—

Howard Forman: It’s going to create work for what Abbe Gluck just talked to us about. It’s going to require people to dig in quickly and help get these people back on Medicaid when in many cases, it was our administrative bureaucracy, sometimes benignly but sometimes maliciously, throwing people off the rolls when they shouldn’t have been. So it’s—

Harlan Krumholz: Yeah, in a time that our life expectancy continues to go down and the health of the nation continues to decline, this isn’t—

Howard Forman: Doesn’t help.

Harlan Krumholz: It doesn’t help. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can find us on Twitter.

Harlan Krumholz: I’m @hmkyale, that’s H-M-K-Yale.

Howard Forman: I’m @thehowie, that’s @T-H-E-H-O-W-I-E. You can also email us at health.veritas@yale.edu. Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs, or you can check on our website at som.yale.edu/emba.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and to our producer, Miranda Shafer. They are absolutely out-of-this-world amazing. Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan, and talk to you soon.