Who the Health Cares? Season 3 episode 2

*MUSIC*

 

Hi, I’m Michael Sparer, the Director of the Center for Public Health Implementation at Columbia University. You’re listening to “Who the Health Cares,” a podcast about the US public health system: what it is, who does what, and why all of us should care about it.

 

On today’s episode, I’m sitting down with my longtime friend and colleague Larry Brown.  Larry’s a political scientist by training who has spent decades studying the politics of healthcare and health policy.  Larry’s a professor here at the Mailman School of Public Health, and also the Interim Chair of the school’s Department of Health Policy and Management. 

 

In our conversation, Larry and I talked about whether public health can ever really be separated from politics – and whether it should be. We also discussed what the midterm elections might mean for public health, why so much of public health ultimately comes down to what happens at the local level, and what the next generation of public health leaders need to know about coalition building, reading the room, and even the art of improvisation.

 

Here’s my conversation with Larry Brown.

 

Michael: Hey, Larry, thank you for joining me on this, uh, conversation here today.

Larry: Thank you for inviting me. It's a pleasure as always to talk with you.

Michael: You know, it's interesting, we've known each other a long time. In fact, you were the person who hired me here at the Mailman School in the Department of Health Policy and Management over 30 years ago. So we've known each other a long time. We've worked together for years and years. You're my favorite person to work with, I'll, I'll tell you that right now.

Larry: And vice versa, believe me.

Michael: But, you know, we've never really talked about what drew us into the fields that, that we've worked on for the last 30 years, and I know you were a political scientist from early days at, at Harvard and then Michigan and Brookings and, and then came here. What, what drew you into the field of political science, and then from there into the field of the politics of public health?

Larry: Well, what, what drew me, it's, it's sort of the, the Peter principle at work. When I, uh, was an undergraduate at Harvard, I majored in philosophy, and then discovered two things in the course of that few years.

One is Harvard didn't have the kind of philosophy that I wanted to study. I wanted to study phenomenology, existentialism, Jean-Paul Sartre, all that kind of stuff, and they had symbolic logic and English analytical philosophy, which was not my cup of tea. But also, I entered as an undergraduate in 1965, right in the middle of the Great Society, right in the middle of the civil rights revolution, and all of that.

And got kind of caught up in it, at least spiritually, if you will, and intellectually. And I've always been very interested in cities. You know, New York, Paris, and even great cities like Binghamton, where I grew up. We actually then talked about the urban crisis and the problems of inner cities, and it looked like there was reason to believe that the federal government was serious about federal urban policy.

I mean, it seems almost quaint and hallucinatory to talk about- ... these things in today's perspective, but there was a time, and- Yeah ... we, we really-

Michael: There was a time ...

Larry: we talked a very good game.

Michael: Yeah.

Larry: So anyway, getting a little bit ahead of things, I decided that I would try to get a PhD in what Harvard called government, which it still does, political science, because I wanna study urban policy.

I wanna study... And I wanna study the politics of urban policy. How did government go about creating and then implementing programs to try to improve the lot of the disadvantaged populations in cities? And so I, I applied to and got accepted in the government department at Harvard and began to specialize in, in that way.

And I got an internship for one year from the Brookings Institution to go and do my dissertation, which I did. And so I spent a year, in those days, just driving around and no GPS and getting lost doing interviews, interviewing people in, in three cities and in three issue areas. I, I decided that was a good way to look at it, and they were education, housing, and health.

The only trouble was when I actually looked at the program- It talked a great game. We're gonna concentrate all kinds of federal resources in coordinated fashion on the most disadvantaged communities of disadvantaged cities, and there were gonna be five of them and a huge concentration of resources.

Well, politically, that wasn't really doable, so we ended up taking what was a fairly modest sum of money, dividing them among 150 cities. And then by the time you, you divided it up and you bring in the citizen participation, what do you really wanna have? Well, I wanna have... We want better schooling, we want better housing, we want better healthcare, we want better transportation, and you fragment all the priorities.

The notion of concentrated resources just fell apart. And I became then, and have remained since, sort of a skeptic about so-called place-based policies. It occurred to me hell would freeze over before you could get enough federal commitment to actually move the proverbial needle in these communities.

And what struck me was you wanna do something about these so-called urban problems, don't address them as urban problems. Address them as universalist welfare state problems. I mean, sure, great, have the neighborhood health centers and add to their numbers.

Michael: That's great.

Larry: But better still, get universal coverage and broader policy to make the rental and purchasing of housing more, if not universally available, at least more inclusive. And so I switched from a focus on federal urban policy to a focus on, on welfare state policies.

Michael: Okay. Yeah.

Larry: Particularly federal. But also, I mean, uh, state and local, because I could see from what I l- looking at model cities that place-based is just too hard to do in terms of concentration of resources.

And so therefore, I favor more centralized policies, welfare state policies. But now I gotta say, in light of what we're talking about right now, I feel rather the opposite. That, that you can only do so much- In terms of public health leadership. Now, when you get into coverage and things like the Affordable Care Act and-

Michael: That's different.

Larry: And that's another story altogether. Right. But when you're talking about public health- '

Michael: Cause you're talking about balancing individual rights and- Yeah ... community needs, et cetera. Yeah. Well, it's interesting too, 'cause when I think of universal coverage and the history of the efforts to get... Which has failed in the United States.

That's right. We, we don't have it. But I can think of... There are figures I can think of, either at a federal level or state level. At a federal level, I can think of Ted Kennedy, you know, as someone who devoted his career, arguably unsuccessfully, probably regretted for much of his life that he hadn't worked out a deal with Richard Nixon in, in, in, in the early '70s, et cetera.

Larry: Exactly.

Michael: Uh, here in New York you can think of Dick Gottfried, you know- Yeah ... longtime state legislature. But when I think about sort of the, the champions for public health, you know, sort of a public health icon, I have a harder time thinking who's that person that's really gonna take the lead for the public health community to try to rebuild and strengthen and stabilize the community at a, at a national level anyway.

Larry: You got me. And the, the question is, is this a deficit of vision and leadership, or is it a case where the inherent nature of public health is such that it doesn't easily lend itself to that? 'Cause you can say all you want, "We know prevention works, and we'd save... We can save lives a million at a time through vaccinations and so forth."

You can say it- But how you rally people behind it as a, as a, you know, it doesn't hold a candle politically with, with universal coverage. What people are concerned about, I get sick and I have to go to the doctor. Am I gonna be driven into medical bankruptcy? That I care about in a very salient and urgent way.

I know prevention works. Well, fine. I'll stop eating hotfoot Sundays day after tomorrow, and I'll watch my diet.

Michael: Unless I sneak one in, then, uh-

Larry: Right. Or, you know- Yeah ... I'll stop smoking. But, uh-

Michael: Well, and as they say, you know, the success of public health is invisible until something goes wrong, and then public health either fixes it if there's an outbreak or gets blamed if it gets worse than, uh...

I mean, take the foodborne outbreaks that we've had recently. You know, the fact that we haven't been able to, to truly- That's right ... you know.

Larry: And that might be one thing that if the Democrats could do if, when they get back into power is, is restore some of these inspection and, uh, food safety type of things.

But consumer protection seems to be... That- that's even fold, I think, into a broader agenda of consumer protection, where maybe you get an Elizabeth Warren or you something. But public health is tough. I mean, there are areas. You, you know, I mean, the, the anti-smoking campaign, the campaign for mandatory seat belts, the drinking age up to 21.

There are some areas where what looked like an impossible political quest, which was denounced as trampling on sacred individual liberties, and yet we, for better or worse-

Michael: Mm-hmm ...

Larry: made progress, but it's not easy to do.

Michael: Yeah. Yeah. Well, we do have midterm elections coming up. How important do you think these midterm elections are? I mean, for public health, is it gonna make much of a difference? Is it all still state and local? I mean, what, what's your thought on that?

Larry: I think until we get new leadership, Democratic or left of center leadership in the executive branch- Public health is gonna have a very uphill struggle, it seems to me. If we get back the House but not the Senate, the House is gonna have various priorities, but I find it hard to believe that public health is going to be a very high priority.

Michael: Even in a Democratic House.

Larry: Even a Democratic House. Now, moving toward restoring the subsidies in the ACA and offsetting some of the cuts in Medicaid, those, those kinds of things that speak directly to affordability of healthcare- Right.

Michael: They'll still face a Trump veto there, though.

Larry: Well, they, they will. Yeah. But I think in terms of at least trying to-

Michael: Trying, yeah ...

Larry: fight the good fight- Right ... and do what your constituents expect, I think that'll be the priority. I mean, in fact, I've- I'm thinking as you speak, what would be the areas of a renaissance for public health, uh, in a Democratic agenda?

I, I don't know what it would be except maybe to repopulate the CDC, uh, and restore research grants in public health, but also biomedical research, NIH, uh, that have been cut back. I, I don't think it's gonna matter that much, and probably even if we get back the Senate, aside from repopulating decimated agencies, what would be the agenda that they would want?

Michael: I mean, President Trump's been able to achieve much, if not most, of his agenda through executive orders as opposed to congressional action anyway. Uh-

Larry: Well, that's right. That's right. And I would hope that if we had the House and the Senate, you'd invalidate some of those executive orders, but I don't know how easy that is to do at this point. So I think we have to ... I mean, the longer perspective takes us out to 2028.

Michael: Right.

Larry: And, uh-

Michael: Right ...

Larry: but then again, when you say, all right, so it's, um, John Assaf or it's, um, Roy Cooper or, or somebody who's the, you know, good, comfortable left of center, not so far left of center, but good kind of mainstream Democrat who wants to use government for the good of the people, what are they gonna do with public health exactly?

Michael: Yeah. I mean, our former faculty colleague here at Mailman, as you remember many years ago, one of the faculty in our epidemiology department was Abdul El-Sayed, now running for Senate, uh, on sort of a Medicare-for-all framework. What's your take on how that's gonna play out?

Larry: My view is that the most important thing with respect to Medicare for All and single-payer is the fact that since the late '60s and the '70s, when the question is asked in public polling, "Do you trust the federal government to do the right thing all or most of the time?"

You used to get something in the 60% range, and it's gone down, down, down, down, down steadily to about, what? 15% now. How on earth are you going to achieve a single-payer system or Medicare for All by handing the healthcare system over to a federal government that is so distrusted? It doesn't work. Um, Vermont went through a big exercise.

You know, a pretty liberal state. Said, "We're gonna figure out how to do it. We're gonna, you know, work out all the different nuances and bells and whistles, and then we'll figure out how, how we pay for it." And they did. They put all the things together, and then they sat down to figure out how to pay for it, and they quickly discovered it would be enormously expensive, and they bagged it.

Michael: Right.

Larry: No state has come close to enacting single-payer.

Michael: For years, we've heard public officials really at every level, federal, state, county level, say their job is to, quote, unquote, "Follow the science and stay out of politics." You know, we, we heard this during COVID-19. We heard it just a few weeks ago when, uh, Dr.

Erica Schwartz was being confirmed as the, you know, the director of the CDC. I mean, she sat in her chair and she said, uh, "I will never betray the science. I will go where the science leads us." Is that her job? I mean, and what, what does she get right- Yeah ... and what does she get wrong in, in saying that?

Larry: Well, there's, there's a problem there, I think, that- The science is often ambiguous. COVID, for ex-- It, it was a, a n-novel virus. Um, we hadn't seen its likes before. So the-- all eyes are on the CDC and on the government. If they then, Fauci or whomever, came out and said, "You know, it's a new virus. We don't really know what to make of it exactly, and our best guess or our guesstimates are this," they would've looked deficient in authority and lost legitimacy.

So I suppose as a practical matter, they have to say, "This is what we think the science suggests." But then it could come back to bite you, uh, as it has w-with the CDC and COVID. I think public health for too long, in my view, has taken that, that view to an extreme. We're the professionals. We're the scientists.

We have the evidence. Doctor's orders, we're gonna tell you what to do, and that's how you improve public health. I think they need to be more cautious about it and say, in effect, "Look, it's an evolving situation. We're telling you what we think our best judgment is, is thus and such."

You know, as, as people who are often used to the world of doctor's orders and what they view as unambiguous, double-blinded, controlled trial-type science, I don't think they're comfortable with that degree of uncertainty. And there is uncertainty, but something's gotta change.

Michael: I think you're right, but I'm going back to also thinking about Erica Schwartz's comment, you know, when she was being confirmed, that, "I'm just gonna follow the science." Would it have been better if she had said something like, "Of course, the science is incredibly important.

We're gonna try to develop the best science that we can about whatever the issue is that, that we come up with. But at the end of the day, what we should do kinda depends on, you know, these political decisions, on ethical decisions, on, as they say in politics, who gets what, when, and how." You know, whether or not we should impose a mandate, you know, that everybody wear a mask or not.

Well, the scientists can say, "We think a mandate would be a good idea because to save the health of the public writ large, requiring everybody to wear a mask is a good idea, or take a vaccine is a good idea." On the other hand, if there are parts of society that feel culturally, they don't think it's a good idea, or politically they don't think it's a good idea.

They think it's gonna have adverse economic impacts, um, or they just disagree. I mean, maybe what she said is, "We're gonna give you the best science we can give you, but then we need to have conversations about what to do with the science."

Larry: I agree with that. I think she said, "We, we, as science, will, will tell you what the science says as far as it has something to say and as far as we can understand its implications.

And beyond that, we will try to interpret as best we can what we think would be prudent conduct. And beyond that, I think it's gonna have to be left to the localities," because even if you come to things like cancel your sports events and your church services and keep your kids home, that's gonna have to be locally accepted, locally enforced, locally interpreted. I mean, you can call it a mandate, but somebody's gotta make it, make it happen, and- And

Michael: public health really happens in the 3,000 local

Larry: health departments in the country. Oh, that's right. Yeah. That's- That's what you got, 3,000 local public health departments that have to ... It's an exercise in sense making.

You know, that notion, it's, it, it, interpretation in the sense of what makes sense in the here and now in the context of this local community. And that can't just be the local public health officers. They've gotta be at the table, but ultimately the politicians who in part are raising property tax money to fund a good portion of the local budget of the local public health department, they gotta be included.

And that's why I think public health has gotta be more interactive and, and more e- there should be more dialogue and, and more embracing in the politics of it as a constructive force. And the, the outcome of that dialogue may not be what public health officials think is necessarily the best thing, but there's no real alternative to building legitimacy sort of place by place and issue by issue and day by day in, in a local community.

Michael: And do you think the politics of public health are different at the state and local level than they are at the national level? Or maybe it depends on which state and local, you know, maybe they still vary.

Larry: I think, I think what you say is right. That it depends at what administration and what state. States are highly various, but, um-

Michael: Well, that raises another really interesting issue, which I wanna segue to. Uh, there have been a lot of folks that I think will pretty much define any social ill that we have in this country- ... uh, as a public health crisis. If it's the misuse of social media, if it's loneliness, if it's gun violence, if it's opioid epidemics, if it's obesity, uh, if it's mental health crises.

And these are all... I'm not in any respect diminishing the importance of any of those issues. But what's your take on the scope of public health? Should that also be determined at sort of a state and local level, do you think? Or how do we think about those issues?

Larry: I think if we sit here in the Mailman School, you and I as professors, and say, "Let's delineate," like we're writing a constitution or something, "what in the world of challenges is public health and what isn't?"

I think it's a futile exercise. Potentially everything is public health, but that doesn't mean that public health should be trying to embrace everything. And there's no central public health that could do that because it plays out at the states and, oh yeah, and the CDC and the federal government, sure.

CDC could decide, "Here's our list of social determinants that we think are, are suitable for public health, and here's another list that isn't." Or we could say- You know, go for it. Everything is public health. I don't think that's productive.

Michael: A number of states now, as, as, as you know, are requiring counties to basically do an assessment of their community, of the health of their community, and then pick a couple of priority areas that they say they're gonna focus on.

Maybe it's substance abuse in one community, maybe it's mental health, maybe it's gun violence- Yeah ... maybe it's opioids, whatever it happens to be. Um-

Larry: That makes sense ...

Michael: and then try to create partnerships around that, locally driven, you know, and politically plausible or pragmatic, I

Larry: think. Well, I think that's the best way to make operational the notion in public health.

I, I wouldn't say public health is everything. I, I would say public health could possibly be everything- Hmm ... or could possibly be many more things than you might imagine.

Michael: Well, public health could be everything, but that doesn't mean that every public health agency could-

Larry: Try to do everything ...

Michael: could take everything on.

Larry: I completely agree. That, that says it well.

Michael: I argued, and I'm... I think I still believe this, but I'm not sure if I do or not. You know, during COVID, I sort of had an argument in an article one time in which suggested what we really needed was a, uh, secretary of public health in the cabinets. Yeah, I

Larry: remember that.

Michael: Yeah. Uh-

Larry: Yeah. Good idea ...

Michael: part of the reason I think there needs to be that kind of leadership, even at a national level, mixed in a federalism way with state and local- Yeah.

Larry: Yeah ...

Michael: is because public health is just remarkably under-resourced-

Larry: Well,

Michael: that's right ... you know, underpaid, undervalued, uh, still to this day, even more so maybe after COVID, which is one of the reasons they need so many partners.

I mean, you compare, you know, a local health department with the big academic medical center in a community. I mean, as we've talked about, you know, you have a $6 trillion healthcare system, and the CDC gives out, what- Just- ... 11 billion a year ...

Larry: which is a commentary on how much we value the evidence that public health provides, you know?

Michael: I mean- Not very much ...

Larry: not very much.

Michael: Yeah, yeah. So what is a public health director in Nebraska versus Texas versus Florida versus New York? What are the kind of skill sets that public health leaders in state and local governments need that they don't necessarily... They may have 'em now, they might not have 'em now, but, you know, what kind of skills should we be teaching them?

Larry: Well- I think they have to have a sense for coalition building. I mean, they need a politician sense. Uh, how do you read the room, if you will? You... Okay, I were the public health commissioner of a new county, I'd wanna know, okay, how do people get their healthcare around here? And what's the attitude of the medical community?

Are there members of the medical society that are really interested in public health, or is there an adamant kind of opposition, "Stay away from us and leave us alone. Don't trespass on anything that we do"? What's the climate of opinion? Also, are there political champions here? Have, have we got county executives or county commissioners, certain number of them are receptive to doing things with a larger public health budget and tackling tasks that come under our purview, or is this a kind of a diehard attitude to public health as a challenge or, or, or, or a not an efficacious way of, uh, of using your, your local budget and your political capital? So you start to read the room and figure out where you have allies, and figure out what do people really want from public health.

Michael: Yeah. Let me ask just one or two more. I'm just... You know, we're in a school of public health. We've been teaching and researching in a school of public health together for a long time.

What should we be teaching our students who are gonna go into the field of public health about the science... I don't wanna say science versus politics, but the science and politics, the fact that public health is, in your words I think and from your writing, inescapably political. How do we sort of convey that, and what do we try to get over to our students as a result of that?

Larry: I would say what we can give them in a classroom context, university context, we can give them facts. We can give them knowledge. We can give them analytical skills. We can tell them descriptively and otherwise how the world works out there, what are the disparities and what are the numbers of the people covered, and what are the, you know, where, where we stand in terms of healthcare outcomes and all that stuff, and that's useful to have.

Secondly We can give them explanations and interpretations. We can try to... You know, we can instill in them how the world works with respect to healthcare and broaden their knowledge and deepen their knowledge. We can also try to get them to understand why healthcare systems work the way they do. And you bring different perspectives to bear.

That's where sociology, economics, political science, history, et cetera, et cetera, law, you can bring those perspectives to bear, and that will enrich their thinking. But then you have to tell them, "Look, you're gonna have to improvise." If you think you're gonna come out of here with your degree and your head full of all these factual and explanatory variables, and then when you take a job and you're f- faced with a decision situation, you're just gonna go back and pull out the mental file about what you learned at the Mailman school, forget about it.

You're not gonna be able to do that. The situations are distinctive, and you have to use your raw materials you get in being educated here to improvise, to interpret, to look at this situation and say, "What is the basic nature of this situation in the context in which I'm confronting it in this organization, in this part of the healthcare system at this point in time?" Now, you don't learn how to improvise. I think you just, you do impro- You learn and you improvise.

Michael: And I guess you have to learn how to develop allies, and you have to learn how to-

Larry: Definitely ...

Michael: you know.

Larry: Definitely. I think we should be teaching our students less about leadership, which is a term that's almost devoid of meaning these days, and more about championship.

How do you get people that are willing to go to bat in terms of budgetary allocations and time and trying to bring people in line with, with, with your agenda? Those are skills I think they need to have.

Michael: Well, I think I, I wanna thank you and also tell you that as a educator, as a champion, as a researcher, as a mentor, you've done that-

over these last 30-plus years, obviously for me- Well, I, uh- ... uh, but for so many of our faculty, for thousands of students that have gone through this school over the years, and for so many in the public health and healthcare community more generally. So anyway, Larry, it's just been a pleasure to get to chat with you a little bit today.

Uh- Pleasure's all mine ... as I said, thank you for everything, and, uh, to be continued, this conversation.

Larry: Thanks for inviting me to do this. It's great fun.

*MUSIC*

 

That was Larry Brown, Professor of Health Policy and Management.

 

Couple of thoughts before I close out today’s episode.

 

First, Larry’s take on the potential impact of the Congressional midterms was depressing but seems right on target: strengthening the nation’s public health system is unlikely to be a high priority for a new Congress, even one with a Democratic majority.  The reality is that public health happens in local communities and it is in those communities that we need to forge coalitions in support of public health work, and it is in those communities that we need to rebuild trust.

 

To be sure, public health leaders often note, correctly, that infectious diseases do not respect borders.  That is also a reality, one which becomes an argument for national, perhaps even global responses to epidemics, much less a pandemic.  But here again, even in such a crisis it is local public health leaders that need to build the trust and the legitimacy needed to make any infectious disease response work.

 

Second, there is a lot of talk these days among Progressive Democrats about different versions of Medicare-for-All.  These proposals are a response to the nearly universal unhappiness with our current health care system.  As Larry noted, however, it defies political logic to believe that we might enact such a proposal in an era in which only 15% of the American public trusts the federal government to do the right thing most of the time. 

 

In my view, the most plausible path forward for a reformed US health system would be one in which we more effectively regulate the price and quality of the system we now have.

Third, Larry noted that we increasingly call every social ill a PH crisis, from the misuse of social media to loneliness to gun violence, and more.  But as Larry also noted, just because every social crisis could become part of a public health agenda doesn’t mean that public health agencies can address every social ill.  Instead, local communities should assess their community needs and focus on those problems that are local priorities and on which they can have a real impact.

 

Finally, Larry had an interesting and thoughtful response when I asked him what we should be teaching our public health students.  He started by noting that these students need to learn facts, theories, and analytic skills.  But he then added that students also need to avoid being overly rule bound, that they learn how important it is to improvise, to adapt to whatever unexpected item is suddenly on the agenda. 

 

And with that useful advice, we come to the end of this episode of Who the Health Cares, a podcast that is doing its best to get the word out about what public health does and why it’s so important. We’ll be back in two weeks with another conversation, this time with Avenel Joseph, the Vice President of Policy for the Robert Wood Johnson Foundation.

 

Till then, this is Michael Sparer, signing off from the Center for Public Health Implementation at Columbia University.

 

The “Who the Health Cares” production team includes: Zoe Denckla, Rachel Ferat, Grace Rubin, Rebecca Sale, and Alex Weaver. Thanks to all of you!