Joseph Sakran: Confronting Gun Violence

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

Howard Forman: And I’m Howie Forman. We have 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 Dr. Joe Sakran. But first, Harlan, you had a great paper come out yesterday. It’s been widely covered in the press. Tell us your view on what’s important about it?

Harlan Krumholz: Thanks, Howie. I had the privilege of working with some really remarkable investigators from around the country and in a paper that was led by a research associate at CORE, César Caraballo, and we really took a close look at issues around health equity. Many people are aware that Black people in this country have a much higher mortality rate than White people do. And people have described that difference for a long time and actually for hundreds of years. We’ve been a aware of this tragic difference. And what we did was sort of reframe an understanding of this, looking at this difference not as a difference but as an excess. I mean, there’s no natural biological reason that White people should have lower mortality rates than Black people, that Black people should suffer health disadvantage.

It’s a social phenomenon. I mean, race is a social construct. And these social determinants impart the legacy of a long, unfortunate history in this country and the reality of today puts people who self-report as being a Black person in this country—this is a substantial health disadvantage. And so we took a look at this excess mortality—“excess” with regard to what would’ve occurred if their mortality rates have been the same as White people—and in sort of characterizing this as both tragic and preventable, like I said, there’s no reason biologically for there to be these differences. And then we were interested in looking at this over the last two decades and to try to understand whether there’s been any progress at all. And then to look at this among different age ranges and to look at it by different causes of death and by men and women comparing men and women also. And what we saw was that over the last 20 years, there was a period starting about 20 years ago where there was some gains that were being made, some closing of this gap, but then that stalled.

And then with the pandemic, you saw an extraordinary increase in this gap, not just in mortality in the country, which did increase. Of course we know we lost a million people to COVID, but in the excess number of deaths among Black Americans compared to White Americans, leaving us in a position no better than we were two decades ago in showing that that improvement that we did observe early in that two-decade period wasn’t robust. It couldn’t be sustained when the system became under pressure and we started adding up how many actual excess deaths occurred over this two decades, and it was 1.6 million. But more than that, again: everybody dies. So these are age-adjusted rates, hard to wrap your head around. So we translated these into actual years lost among people in the Black community that occurred only because the rates are much higher than those who are in the White community in this country who self-report as White.

And it was over 80 million years lost. These are years lost from the dinner table, lost loved ones. These are people who can’t contribute to society because of premature death. And we saw it occurring, the most years of life loss were in this infant mortality period but also was accumulating among people in late middle age and in the early elderly period. And when we looked at causes, it was really the usual high-flying causes of death in this country. Cancer or heart disease were also contributing to this excess.

So it’s not just that these were the leading causes of death, but they’re the leading contributors to the differences in the mortality between Black people and White people: stroke also, pulmonary disease. And part of the message here is that one public health crisis is ending, but another one that’s been with us for hundreds of years persists. And the toll is extraordinary, and it really is time for us to invest in and focus on health equity in new ways and recognize that the current approaches just aren’t working. They’re not producing sustainable progress in that we have to begin to think about new approaches that are really going to help solve this problem. Probably stretching across medical care, communities, built environments, economics, I mean, there’s a whole range of issues here, air quality, but this is just isn’t working well. We’re not making the progress we should.

Howard Forman: The loss is just staggering, and it’s just so disappointing to see. But it’s important to document it and for people to start to explain what we can do to actually make measurable gains.

Harlan Krumholz: And our hope is actually that these metrics we’ve developed could be adopted by the federal government and be reported on a monthly or quarterly basis that we could hold ourselves accountable to them and that they would be in front of us in bright relief as to what the real toll is and the recognition, you know there’s a lot of emphasis on biology in healthcare and medicine. There needs to be an equal emphasis on social determinants and what really is causing a toll that’s separate from just being sort of what you’re born with but by really the social context of lives that ends up robbing people of years.

So hey, let’s get on. You got a great guest that you scheduled, a friend of yours, and I’m so eager to meet him. Joe Sakran. Let’s get going.

Howard Forman: Dr. Joseph—Joe—Sakran is a trauma surgeon currently serving as the director of emergency general surgery at the Johns Hopkins Hospital. He’s associate professor of surgery, associate chief of the Division of Acute Care Surgery and vice chair of clinical operations in the Department of Surgery. Dr. Sakran is renowned for his gun violence prevention advocacy, his coalition building, and his policy response to the gun violence public health emergency. Since surviving a near-fatal gunshot wound when he was in high school, Dr. Sakran has made it his life’s mission to treat and advocate for the victims of gun violence. He is a founder of the online community @thisisourlane, which brings together the medical community in finding solutions to gun violence. He has previously worked in the U.S. Senate providing medical and public health counsel during the earliest stages of the pandemic. Dr. Sakran graduated with a bachelor’s degree from George Mason University before completing his medical training at Ben-Gurion University of the Negev. He completed a fellowship at the hospital of the University of Pennsylvania in traumatology, surgical care, and emergency general surgery and received an MPH from the Johns Hopkins Bloomberg School of Public Health and later attended the Harvard Kennedy School of Government, where he obtained an MPA.

So first of all, I just welcome you to the podcast. Even reading that exhausts me to realize how much that you have done and accomplished at this point. And I wanted to start off by—

Harlan Krumholz: Howie, first of all: traumatology?

Howard Forman: That’s what it said.

Joseph Sakran: You know what? It’s funny, Harlan, because people, and when I first saw that, when I went to the University of Pennsylvania and it was on the walls, it says Division of Traumatology. I’m like, “Oh, is that actually a word?” I’m like, okay. So, people say that a lot. But, yeah.

Howard Forman: I trained at the University of Pennsylvania, so I feel like I understand the pretentiousness that they try to embody at times.

Harlan Krumholz: No, and so for listeners, really this is the study of trauma focused on trauma surgery or trauma at large, even bigger than surgery?

Joseph Sakran: Yeah. So, I think the way to think about it is because I was literally doing an interview earlier and there was the same conversation with the reporter. He was like, “Are you an ER doc? Or what are you, exactly?” So I think the way to think of trauma surgeons, right, we’re general surgeons, so I did five years of general surgery and then I spent two years of trauma critical care at the University of Pennsylvania where we take care of trauma patients, but we also become intensivists. And so if you think about our practice, our practice is taking care of those that are critically ill. So you come in with a gunshot wound or maybe you come in with appendicitis or a bowel obstruction. And then we also, some of us do elective general surgery, and we’re also intensivist. So it’s kind of a very comprehensive, broad-based answer.

Howard Forman: And we have a fairly large program here at Yale in this because these are the people I deal with on a regular basis in the ER. So I mean, I thank God for you people because quite frankly, when you have an emergency in the middle of the night, it’s not your private surgeon that’s taking care of you. It’s you guys. So I’m thankful for that. But I want to start off by asking you to tell us that story because I’ve heard it before. It is a compelling story of how a young man toward the end of high school finds himself with a life-threatening injury that he just randomly happened upon.

Joseph Sakran: It was 1994, and it was literally the first high school football game of my senior year. And I had just come back actually from an SAT prep class. My parents—

Harlan Krumholz: Where’d you grow up? Where were you?

Joseph Sakran: In Burke, Virginia. Northern Virginia.

Harlan Krumholz: Yeah.

Joseph Sakran: And my parents, immigrant parents, were all about education. I mean, that was their primary focus. So they had just started sending me to SAT prep class, and I’d just come back from the class and my friend was actually already at my house waiting for me to come with him to go to the game. And I remember rushing in, and my dad’s trying to ask me questions about, “Hey, how was the class?” And I’m quickly changing to get out of the door. And as he always does, before I walk out, he says, “Be careful and don’t come home late.”

And we go to the game. The game was great. And then after the game, the way high school students typically do, I was hanging out with some friends at a nearby park and a fight broke out that we had nothing to do with, and a guy pulled out a gun and started firing into the crowd.

I knew something was wrong, but I didn’t know exactly. It happened so fast. It’s just even almost hard to describe. I remember just almost in slow motion watching this crowd disperse, and I felt entirely numb. And I was like, “Okay, something is not right.” And I happened to be wearing all white that night. I had white jeans and a white shirt, and I got to the curb and my friend saw me and I was just soaked in blood and they tried to lay me down, but I was like, because I had a ruptured trachea, windpipe, I was choking on my blood. So they had to sit me up.

And then I ended up going to Inova Fairfax Hospital, which was the trauma center that was closest. Interestingly enough, Harlan, if you fast-forward now, when I came back to residency, actually that’s where I did my general surgery residency.

Harlan Krumholz: Oh, my God. This is an incredible story. So was it that they were on the side of you, so this bullet just kind of hit you in the front of your neck? How did it not go through back to your spine and—

Joseph Sakran: Now, as a trauma surgeon, we’re always, it’s like The Matrix, right? It’s like, how does the trajectory of this bullet actually end up where it did.

Harlan Krumholz: It’s a miracle! I’m just thinking—and it’s not because I’m even technically as interested, is just thinking—this is, I mean, it’s both a tragedy and a miracle that you’re in the wrong place at the wrong time. All these things could have happened. I mean it’s incredible.

Joseph Sakran: A hundred percent. And I always think about that because we take care of patients that instead of it missing the spinal cord, it goes right through the spinal cord and they’re paralyzed and they’re quads [quadriplegics] for life. So, if I was turned a little bit differently or whatever, I mean, maybe it would’ve even been higher and been a head wound, who knows? I’m just, every day that I see these patients coming through our trauma center, I’m like, “Man, I am so blessed.” Even though it was such a terrible moment in many ways, like you said, I’m pretty blessed to have come out with....

Harlan Krumholz: Well, and incredible for them to have you as a doctor because you don’t just see them as a body. You see, you have this visceral feel for what they’re experiencing, in a way.

Joseph Sakran: Yeah, and I think I remember there was this moment, it was after I had left the hospital, I had the tracheostomy tube in, and that was for a 17-year-old, I mean, I remember just looking at the people that had those were the smokers that you saw on TV that they were trying to scare you from that. But here I was, 17 with a tracheostomy tube and these beet-red scars up and down my neck. And I remember my dad, he said, “Joe,” he said, “what happened to you was terrible, but you have two options. One is you can feel sorry for yourself.” And I think that’s tough love, especially from an immigrant dad. “Or the second is you can take this terrible incident and turn it into something that impacts the lives of other people.” And that really was like the aha moment and—

Harlan Krumholz: Wow.

Joseph Sakran: Yeah, inspired me to go into medicine to become a trauma surgeon, and now working at this intersection of medicine, public health and public policy.

Howard Forman: And you’ve done a lot of work now. I mean, first of all, you’ve done the coursework. I mean, you have these two additional advanced degrees. You’ve now worked in the Senate. You were particularly activated when the NRA told doctors to “stay in their lane” about five years ago during one of the unfortunately way too many gun violence events that occurs. Do you want to just tell us about that and how you responded?

Joseph Sakran: Yeah, so the NRA came out and essentially said to doctors that they didn’t have any business being part of the solution as it relates to gun violence prevention. And I think we were incensed, and let me just say, it wasn’t just doctors. I mean, yes, they were targeting doctors, but what ended up happening is in that moment, there was a coalescing of healthcare professionals. The docs, the nurses, the techs, the researchers, everyone that said, “No, actually we do have a role to play.” And it was the first time that I really saw from a grassroots perspective, really, people come together. And I think one of the reasons, Howie, that that happened was because it wasn’t that we were just kind of telling people, oh, over 40,000 people die a year of gun violence. No, it’s not the data and the science. It’s the stories that we told. It’s the pictures that we showed.

And I think that was a very important lesson for people because we’re kind of wonky as healthcare folks. The data and science is important to us, and I’m not minimizing that, but the data and science doesn’t change the hearts and minds of people. And so we learned the power of storytelling, the power of narrative, if that makes sense? And so that’s when kind of people came together, and it was an incredible moment. And it’s even to this day, I think continues to inspire and give energy to healthcare professionals to figure out how to have their voice beyond the bedside.

Harlan Krumholz: By the way, I just want to say a pleasure for me to be on with two Rob Wood Johnson Health Policy Fellows. So actually you, Joe, took advantage of the foundation support to take a physician and enable them to engage in policy and substance voice. And our own Howie Forman actually had a critical juncture in his career, spent a year in Washington and also was, I think, both a major contributor but also learned a lot. And it’s really remarkable, and as Howie said, you’ve done a variety of things that have prepared you to participate in policy in meaningful ways.

This Roger Sherman Lecture that you gave I thought was really interesting. I mean, you end up giving an impassioned call to action for healthcare professionals to not only provide care at the bedside but to drive broader social change. And I think it’s something that a lot of young doctors in particular but maybe all of us could benefit from reading and thinking deeply about because we make contributions to individual patients in the ways in which we provide individualized care. But the idea of trying to put ourselves out of business.

I mean, I think one of the best things about being in medicine is the very best doctors actually try to put themselves out of business because we want to see people healthier, sort of prevent the problems that we’re often treating. And you are just one of the very best examples of someone who has engaged like that.

Here’s a question I wanted to ask you, though, is like many areas of today’s society, this issue of firearms has become so contentious and almost religious. Which side are you on? Where were you born or what’s your political party? And you’ve talked about the attempt to separate policies and politics, but as I’ve seen people try to do that, it keeps getting sucked back into the politics and to the entrenched positions that exist there. What’s your strategy about actually trying to make progress and navigating this in a way? Because I’ll just say one other thing that really impressed me about what you said, which is your effort to build consensus and in which you differentiate consensus building from consensus documents or why papers that come out. But you’re really talking about this consensus building.

So, I think we would all agree with you that that’s what we need. We need to be able to say, what can we agree on here? But what’s your strategy? How are you actually trying to achieve this in actual practice?

Joseph Sakran: Yeah. Well, let me first say that I’m always trying to follow in Howie’s footsteps. I don’t think I’m doing a great job of it, but—

Harlan Krumholz: Yeah, me too. Me too.

Joseph Sakran: Honestly, Harlan, none of the stuff that you mentioned was necessarily planned. I didn’t have this—my actually grand plan was to try to give other people the same second chance that I was given. And the reason I have this kind of nontraditional path down academic medicine is because I started to realize despite how good you may think you are as a trauma surgeon or despite how amazing the Johns Hopkins Trauma Center is, if someone comes in that’s shot in the head, there’s very little that you can do to save their life. And so it got me going down these alternative paths to develop the skill sets to try to hopefully be part of that social fabric of our communities and society.

And I think a lot of this stuff, as you talk about, when I think about the consensus piece, there’s a couple ways to think about that. And I saw this firsthand in the Senate that as Americans, we have a lot more commonality than most people recognize. And I think I have witnessed that personally in going around the country talking about this very emotionally charged issue, even in places like Oklahoma and Kansas, where gun owners will come up to me and say, “Joe, we actually agree with the majority of what you’re saying.” And when you start to think about that and you start to think that how much similarity there is, it makes you realize that the strategy and the approach of what you do is just as critical as having the right idea. There’s a lot of people with the right idea that don’t take the right strategy and they fail.

And so my approach has really been trying to listen with the intent to understand the perspectives of other people. And when you talk to most responsible gun owners, they want the things that we want. They want expanded background checks. They want extreme risk protection orders. They want minimizing hundred-round drums and assault weapons. There’s a lot of consensus that exists there.

And so that’s what we have tried to do is to, of course, number one, phrase this in a way that doesn’t really push away people and allows them to come to the table so we can have those conversations and then combine that with the typical public health approach that we have taken for seatbelts and car fatalities, clean water, I mean so many other things. And that’s what we’ve been doing, Harlan.

Howard Forman: I want to make sure that, give you a chance to tell us about what hope you might have given that you’ve worked in the Senate, you see how things are done. It’s slow, but sometimes we make big, bold moves. What are your thoughts about these commonsense gun reform measures that you’ve talked about that most people, including most gun owners, seem to agree on?

Joseph Sakran: So two things about the hope, because I think, Howie, there’s a lot of people that are like, “God, nothing is ever going to change. Oh, look, it took nearly 30 years to pass the Bipartisan Safer Communities Act.” And I want to say two things. One is, when I was in the Senate, here’s what I found, and you don’t see this, is that both Republican and Democratic staffers, they come in every day, I think really trying to make this country a better place. A lot of the end results are not so different. The difference is, how do we get there? And that’s where some of the ideological kind of components come into play. Now, specifically about gun violence, right? Yes, it took nearly 30 years to get that federal piece of legislation, which is only a first step. But let’s not forget that our country is different than where we were 10 years ago.

And in fact, in America, most governing happens at the local and state level, which is why over the past decade there’s been over 500 pieces of commonsense legislation that’s been passed in cities and states across this country. And when you think about, “Well, why is that?” It’s because it’s the moms going to the state houses wearing the red shirts. It’s the healthcare professionals raising their voice. It’s all of these individuals that are pounding the pavement to do that work in the communities, which we often forget are so critical.

And that has led to a cultural transformation that has allowed us to push the needle and move the needle forward as it relates to kind of what’s happening at the federal level. Is it happening fast enough? No. Right? Because we just saw the leading cause of death for children and adolescents in America is gun violence. It’s not poisoning, it’s not cancer, it’s not car fatalities—it’s gun violence. So, that has to really be something that it’s about time we put our children first and we think about where we’re headed as a nation.

Harlan Krumholz: I wanted to just tick off some quick stats here just so people have some things I saw from in an article that was published a couple years ago by David Hemenway and a colleague. This is one: unintentional firearm deaths in the United States compared to all other countries, about six times higher overall firearm death from all causes that was unintentional, but from all causes, 10 times higher. And then they estimated that 90% of women, 91% of children 0 to 14, and 92% of youth aged 15 to 24, and 82% of all people are killed by firearms are from the U.S., worldwide are killed by firearms, this vast majority of them. It’s a real U.S. problem. And yet some of the ideas here, I just want to also invoke Art Kellerman, someone who I look up to a public health advocate, emergency medicine doctor who did a really interesting piece of work that was published in The New England Journal of Medicine, looking at what happened to people who had firearms in the home? And how that was associated with increased risk of homicide and risk. You know, he get widely criticized by the people who were gun advocates.

And then ultimately, Congress in 1996 passes the Dickey Amendment, which says that basically federal funds can’t be used. The CDC can’t use federal funds for looking at firearms, taking it out of the realm of public health and saying, you can’t do research in this area.

So we’ve got a lot of issues, I think, to mediate. But let me end by, I just wanted to put that in context to say how important the area that you’re working on is, because everyone can see that in the headlines of the, when multiple people are killed within a... but it’s more, much more than that too. Those are horrible tragedies, but it’s the mundane everyday that where this stuff is just happening that somehow we’ve turned our eyes from.

But you talk about the four P’s: purpose, passion, patience, and perseverance. I wonder if you could just as we get to the end of this, just riff a bit on what that means to you and what you’re looking ahead to.

Joseph Sakran: Yeah. And let me just say if I can first, Harlan, because the point that you just made is so critical, that the media often covers the mass shootings, which are like 3% or even less than 3% of the entire public health problem. But every day in cities like Baltimore, you have young Brown and Black men that are being slaughtered on our streets. And so we have, I think, the opportunity and the responsibility to tell those stories.

Now, as it relates to the four P’s that I use this with students, I use this with some of the residents, and honestly it’s been kind of some guiding principles for me. And the first one is purpose over position. And I think about this often because look, if we’re being honest, everyone has ego. Ego is innate to us as humans. I think the difference is is that you shouldn’t be driven by ego.

And when you think about purpose, purpose to me is the “why.” If that is your foundation, it will keep you grounded. There’s a lot of red shiny lights out there, and it doesn’t mean you have to grab all of them. And I think sometimes as you’re kind of taking this path down your career, it’s easy to be distracted. And that’s why I always have that foundational purpose and think back to what that is to help guide me down this path that I’ve taken.

The second is, in any of the work that we do, you need to be passionate about it. But the interesting thing about passion is passion alone is not enough. You also got to be patient. And funny enough, I know you mentioned I mentioned this in the article that I wrote in the Sherman Lecture, but most passionate people are not patient, and most patient people are not passionate.

And you need that combination because, and this gets to the last P, we all are going to face adversity, and you have to be patient in order to persevere and to transcend those challenges that are going to exist. That will allow you, hopefully, to figure out how to carve out your own path. And guess what? The next generation of healthcare leaders in America are not thinking about healthcare the same way that maybe a lot of us thought about it coming up through the ranks. And so they’re really wanting to have a more authentic approach to the issues that we’re facing in this country.

Harlan Krumholz: That’s terrific. Yeah. Thanks so much. I think you’ve given me and Howie and the listeners a lot to think about. And just so appreciative of the kind of deep commitment you have to make progress.

Howard Forman: Thanks for all that you do, Joe, and thanks for being a great friend. We appreciate you.

Joseph Sakran: Well, thank you all so much for having me. It’s really such an honor and I appreciate all the effort y’all put into this, and hopefully this is one of many interactions.

Harlan Krumholz: It’s a privilege to have you on, Joe. It’s a privilege to have you on.

Joseph Sakran: Thank you.

Howard Forman: Thanks, Joe.

Harlan Krumholz: Well, that was a terrific interview, Howie. I really enjoyed listening to Joe and he’s really a source of great inspiration. And yeah, man, actually, I’m so glad that you know him and that you brought him on and it’s terrific. By the way, you two are both Robert Wood Johnson Policy Fellows, but let’s get to another favorite part of the podcast for me is listening to you. So, what’s on your mind this week?

Howard Forman: Thanks, Harlan. So after such a sobering interview, I wanted to briefly mention some good news. We’re approaching the 10th anniversary of the implementation of full Obamacare, which is January 2024 will be that 10-year anniversary. And in that time we’ve watched many sustained efforts to undo this historic piece of legislation, mostly failing to disrupt it, and the ACA has been very impactful. The CDC this week released the annual national health insurance interview survey from 2022, and so here are some highlights to consider.

There are now 28 million people, 8.4% of the total population uninsured at the time of this survey, and that is down from 30 million last year and about 49 million or 16% in the year that Obamacare became law. Uninsurance rate has dropped from 7.8% to 4.2% among children in that same interval. Following up on your segment from the intro, Black Americans have seen improvement in the uninsurance rate, but still lag White Americans. The uninsured rate among Black Americans is now 13.3% down from 19% as of the 2010 survey. But the gap between White and Black Americans, while narrowing, remains 5.9 percentage points.

The uninsured rate among non-elderly adults in Medicaid expansion states, those that have expanded under Obamacare was 9.1% compared to 19.2% in non-expansion states, states that have resisted expanding. So, I just want to repeat that. If you are in a Medicaid expansion state as we are, your uninsured rate among non-eligible adults is 9.1%. If you’re in a state like Florida or Texas or the other eight states that haven’t expanded, it’s 19.2%. The percentage of non-elderly adults who are covered on the ACA Obamacare exchanges has increased to 4.3% from 3.7% just four years earlier. So, I don’t want to dwell on the negative today. I mean, I think we’ve talked previously about underinsurance and financial toxicity, and we’re going to keep coming back to that.

I also don’t want to dwell on the threats to this improvement. We’ve talked about efforts to push people off the Medicare rolls before and know that it will continue. So I just want to pause and acknowledge that public policy and legislation can work and seem to have scored reasonably well here, even if imperfectly. We know that insurance coverage does translate into lives and years of lives saved. We know that the impact is greatest on the poorest among us. Income inequality in the U.S. has continued to increase, and the U.S. is the most unequal in terms of income of the G7 nations. We have the great luxury of being able to afford to continue to make progress against poverty and particularly to improve healthcare access for all. At the moment, though, that does not seem to be our national priority, but one can hope.

Harlan Krumholz: Howie, I’m just going to, first of all, I’m always happy to hear good news, but I will say this, with the advent of the Affordable Care Act and Obamacare, we’ve failed to see life expectancy improve. We failed to see health status improve, failed to see functional status improve. We failed to see multi-morbidity go down in the country. I mean, health is, of course, I’m not saying it caused it. When we look at financial toxicity, people most affected by financial toxicity are actually insured, but they’re paying so much in premiums and in their healthcare that it’s hampering them.

I mean, to me it’s like it’s still incomplete because people are underinsured. And I’m willing to celebrate that we’re moving towards greater insurance because as you know, I’m a fan of saying we should actually, no one should be experiencing financial toxicity in this country. And I’m increasingly believing that this is only going to be accomplished through a single-payer approach. But I’m puzzled by the lack of outcome correlation with this good news on the insurance side. And when I look at the global macro picture within the country, I don’t know. My enthusiasm—

Howard Forman: I mean, I think that it’s hard to fight against the counterfactual. We don’t know what would’ve been without Obamacare.

Harlan Krumholz: Yeah, fair.

Howard Forman: We do have very strong evidence that Medicaid expansion does lead to longer lives and healthier individuals. We do have evidence about that. So on the low end of things, if you look at people who have no insurance and give them Medicaid coverage, they do better. I agree with you that we’ve got a lot of financial issues to tackle, but those may very well be confounded by the fact that obesity is getting worse in this country. Substance use disorders are getting worse in this country, and there are other sort of mental illness afflictions that are seemingly getting worse.

Harlan Krumholz: That’s fair. And I don’t want anyone to mistake my... I’m enthusiastic about greater coverage. I just keep thinking, what else do we need to do to be able to reach the promised land here? Health equity, good health for all, and get rid of this toxicity, the financial toxicity, I mean. 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 @H-M-K-Y-A-L-E, that’s @hmkyale.

Howard Forman: And 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 where you can check out 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 researcher, Sophia Stumpf, and to our producer, Miranda Shafer, they are extraordinary and they help us produce an outstanding podcast every week. Talk to you soon, Howie.

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