Ep. 5 | Dr. John Ayanian - Understanding Medicaid Expansion and Its Real-World Outcomes

In this episode of Voices from the Field, we speak with Dr. John Ayanian, a practicing internist and leading health policy researcher at the University of Michigan. He is the Director of the University of Michigan Institute for Healthcare Policy and Innovation and the Alice Hamilton Distinguished University Professor of Medicine and Healthcare Policy.

Dr. Ayanian joins Neil Nakkash to discuss Medicaid expansion and what it has revealed about real-world health outcomes. Drawing on his leadership of the long-term evaluation of Michigan’s Healthy Michigan Plan, he shares insights into how Medicaid expansion has impacted healthcare access, financial security, and population health. He also reflects on the gap between policy design and patient experience, the challenges of evaluating large-scale health reforms, and what his work reveals about the broader forces shaping health in the United States.

For students interested in health policy, healthcare delivery, and population health, this episode offers an in-depth look at how major policy changes translate into real-world impact.

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Transcript

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Welcome to Voices from the Field, the Namine Exchange Podcast. I'm your host, Neil Nikash. As conversations about healthcare access and affordability continue to shape our understanding of health in the U.S., few researchers have done more to study how health policy affects people's lives than Dr. John Aanion. In this episode, I speak with him about the intersection of medicine and public policy, what we've learned from expanding Medicaid, and why health insurance alone is not enough to improve population health outcomes. Dr. Anyon is the director of the Institute for Healthcare Policy and Innovation at the University of Michigan and the Alice Hamilton Distinguished University Professor of Medicine and Healthcare Policy. A practicing primary care physician, he has spent decades studying healthcare access, quality, and disparities with a particular focus on how public policies shape health and well-being. He also led the long-term evaluation of the Healthy Michigan Plan, which is one of the U.S.'s most closely watched studies of Medicaid expansion and its effects on patients' health, financial security, and quality of life. We're just so honored to have one of the nation's leading voices in healthcare policy research with us today. So here's my conversation with Dr. John Ainian. Thank you so much for joining us, Dr. Ayanian. My pleasure to be with you. So I just wanted to start us off by asking us about what really drew you to this intersection of clinical medicine, health policy. Because you know, you're someone who's trained in medicine, public policy, health services research, um, and especially at a time when those fields were um often more siloed or less integrated than they are today. So when I was a college student and uh pre-med student, you know, I knew I was interested in becoming a doctor, but I was also interested in the larger forces affecting how healthcare is delivered, um, how doctors interact with patients. I was actually a history major and political science major in college as an undergrad duke. And so when I was thinking about going on to medical school, you know, I wanted to think about ways that I could combine a career taking care of patients as individuals, but also try to make a difference in terms of how healthcare is delivered in the larger healthcare system, how we pay for health care, how we organize health care. Uh so when I went to medical school, I uh combined it with a degree in public policy and understanding more about some of those broader forces in healthcare. And uh, and I've carried that through in my career. You know, I finished medical school and completed a residency in internal medicine. Uh but after my residency, I did a fellowship in general internal medicine where I learned some of the research skills that I've carried forward in my career, uh, how to study, for example, uh in healthcare economics, or how to conduct surveys of patients and doctors to understand how they're making decisions together, uh, how to work with large healthcare databases, for example, insurance claims in the Medicare program or the Medicaid program or private insurance data, uh, and how to work with statisticians and economists and social scientists who study how healthcare is delivered, and you know, bringing my clinical knowledge as a physician together with some of the social science skills and economic and statistical and out uh analytic skills that those colleagues have to uh really think together both what's happening in the individual interactions that doctors and patients have with understanding some of those larger societal forces at work, you know, when we look at how healthcare is delivered more broadly uh in the way that our system is structured. So you you really speak on this aspect of you completing that fellowship in general internal medicine and bringing integrating both the sort of social science kind of knowledge with the more clinical knowledge that you have. Um but considering that you are an internist and you've you know spent much of your career caring for patients um while also you know leading large-scale health policy initiatives, you know, how is just continuing to practice medicine shape the kinds of questions you choose to study in in the policy field? Yeah. So after I completed my clinical training, and for my career, I've I've practiced as a primary care physician. Uh so as a general internist, I take care of adults of all ages, really from you know, older teenagers, adolescents, up through adults through the end of life. And so uh, you know, as a primary care physician, I take care of people with a wide range of health care problems, uh, you know, delivering preventive services as well as taking care of people with chronic conditions, heart disease, diabetes, kidney disease, chronic lung disease, uh, mental health problems. Uh so I uh and I also have throughout my career worked in academic medicine, so uh working with residents and medical students and fellows in internal medicine. Uh and so I, you know, have had that opportunity to see a wide range of physical and mental health problems that people are living with. And that experience uh has uh uh really shaped the kind of research questions I'm asking. Uh, you know, why do people uh present uh to uh their physicians uh or to hospitals and clinics at different stages of illness? Uh why are they treated differently once they uh arrive into uh into the health care system? Uh why do they have different health care outcomes? And you know, uh uh our public health colleagues often talk about the social determinants of health, but in my career, I've often been working with colleagues and studying what we call the social determinants of health care. Uh why do factors like uh people's uh gender or their race or ethnicity or their level of education or income or their immigration status or their language skills or their insurance coverage, um, why do those social and economic factors uh influence um how they access the health care system, how they're treated within the healthcare system, uh, and then how they recover or fail to recover in when they have healthcare issues and medical problems. Uh, and how do we um uh shape the health care that we provide in a way that that helps people to achieve the best possible healthcare outcomes? So, you know, that's how I've brought my um clinical experience and what I've learned from my uh work in internal medicine and delivering healthcare together with my research experience, you know, and collaborating in research teams with this uh colleagues in other uh research disciplines uh to try and improve the healthcare that we're delivering uh here in the US. And as my career has progressed, also working with colleagues uh studying healthcare in other countries as well. I think that's really interesting how you specifically focus on the social determinants of healthcare access, because we know that healthcare access itself is a social determinant of health, but of course, each determinant has its own determinants going in. Um, and sort of on that point of healthcare access and socially determining it, we know that a large segment of uh Americans rely on healthcare access um through programs like Medicaid, Medicare, et cetera, chip. Um and you know, you helped lead that long-term evaluation of Michigan's, you know, healthy Michigan plan, um, which allowed Medicaid to be expanded in our state. You know, for listeners who might not be familiar with that work, uh, could you briefly just walk us through what your team set out to study and what findings really stood out to you? So uh the Medicaid expansion was part of the Affordable Care Act. Uh back in 2010, uh, President Obama signed the Affordable Care Act that had been passed by Congress back in March of 2010. And that expanded health insurance coverage in a number of ways, uh, one of which was the expansion of Medicaid for adults between the ages of 19 and 64 who had low incomes. Medicaid is a partnership between the federal government and state governments, and uh, and that's a program that dates back to 1965, actually was originally enacted when Lyndon Johnson was president back in the mid-1960s. And it had been a program that was uh varied quite a bit in states across the country. Each state was able to set uh very different levels of income that patient the individuals were eligible for Medicaid. Uh it often uh covered people with different levels of disability, it covers many older adults who need nursing home care, and then lots of children are covered under the Medicaid program as well. But for uh working-age adults, it was a very uh program that was very uneven across states, across the country. And what the uh Affordable Care Act did was uh set a more uh even income standard. Basically, uh starting in 2014, uh. Now, what the Supreme Court said in 2012 was the Congress could not force all 50 states to uh adopt that same standard, that they had to allow states individually to decide whether they wanted to accept uh that standard. And the Federal Government, uh, as part of the Affordable Care Act, was going to pay the full cost of the Medicaid expansion for the first three years, and then about 90 percent of that cost uh for uh all years after that. And so Michigan uh decided, as did uh now 40 other states across the country in the District of Columbia that they would accept that federal funding and expand Medicaid. So uh starting in 2014, uh Michigan expanded Medicaid in what's called the Healthy Michigan Plan, like you referenced in your question to me. And uh but when Michigan expanded Medicaid, it required a bipartisan agreement. At the time, uh Michigan was one of the few Republican-led states. Uh, here in Michigan, we had a Republican governor and Republican legislature. And in the decision to expand Medicaid, they decided to add some uh Republican uh favored provisions such as health savings accounts and financial incentives for healthy behaviors, uh, a strong focus on primary care and uh uh and and uh so because of those Republican features, it required a waiver from the federal government, and that waiver required an independent evaluation. So our State Health Department came to a team of us here at the University of Michigan uh and and uh and asked us to lead an independent evaluation of the Healthy Michigan Plan. Uh and so over the decade from 2014 to 2024, uh we've been evaluating uh that expansion of Medicaid. Uh and what we found basically is that for about 700,000 adults who enrolled in the Medicaid expansion, which represents about 7% of the 10 million uh population of Michigan, that access is improved, that uh the enrollees in the Healthy Michigan plan tell us that their physical health, their mental health, their dental health have all improved over the time that they've enrolled in this plan, uh, that many more of them are getting primary care and that they're using primary care and less frequently using emergency departments uh for their medical care, which is generally a good thing because people uh generally have their health needs met more effectively if they're going for care in a primary care office. Rather, you know, emergency departments are important when people need them for true emergencies, uh, but they're not the best place to get your preventive care or your chronic disease management, for example, for diabetes or high blood pressure. So uh, you know, those are some of our key findings. Um, we've also found that um people's employment opportunities have improved, and that's important because for both Democrats and Republicans, uh supporting Medicaid expansion, that's been an important goal. So uh, you know, those are some of the key findings. Uh, you know, we've uh published uh, you know, several dozen peer-reviewed articles and a number of reports to the state and federal government. Uh uh, you know, and it's been a real team effort. We've had about 15 faculty and a similar number of staff from uh different schools, the medical school, school public health, the business school working together, uh, school of social work and the school, the Ford School of Public Policy on this evaluation and partnering with our colleagues at the state government and federal government uh uh to uh generate this evidence. And, you know, and it's helped other states decide whether they wanted to expand Medicaid as well over the past decade. You covered a lot of the ways that you know the Medicaid expansion positively improved um outcomes just beyond people's physical health, also just in terms of labor the labor um that they were able to complete. Um and I think this really challenged a lot of people's preconceived notions about Medicaid expansion, about uh the Affordable Care Act itself. Um back in 2010, 2008, 2009, 2010, there was a lot of um, I guess you could say there was a battle to get the ACAA pass on the federal level. Um, and there were a lot of these questions um brought up. Um but you were someone who really had that unique experience of you know evaluating the impact of Medicaid expansion um, you know, as it was unfolding in Michigan. So, you know, looking back now, um, you know, what surprised you about that, you know, the gap between how policymakers imagined the expansion would look like and how it uh impact the population versus how patients have actually experienced it since? Yeah, I think you know, one area that uh we could have expected, but I think it was um uh uh somewhat surprising is just uh how important Medicaid is to improve people's employment prospects. Uh you know, oftentimes uh we think about uh Medicaid, maybe people are using it instead of working, but what we learned is how important it is to keep people working. Uh that, you know, uh the most people on Medicaid actually are working. Uh well over half are you know working full-time or part-time. And when they have their Medicaid coverage, they tell us how important it is to help them keep working. Uh you know, uh many adults with low incomes uh you know need their Medicaid coverage in order to stay healthy enough to keep working. Uh you know, oftentimes they work in jobs that either don't offer health insurance or the health insurance is too expensive. You know, they're working minimum wage jobs or part-time jobs, uh, for which it's very difficult for them to afford the health insurance, even if it is offered, you know, or they're seasonal workers, you know, they may uh work jobs that are only available to them, for example, in the summer months. Uh so uh so it's very difficult for them to afford health insurance, you know, given the rising cost of health insurance. And so, you know, Medicaid really fills a crucial gap. And, you know, for example, if they have diabetes or high blood pressure or asthma or depression, where we know you know medications and good primary care make such a difference to keep them healthy, uh getting that medical care through the Medicaid program uh keeps them healthy and allows them to keep working uh you know and contributing both to their families and to their local economies. Uh so you know that was, I think, uh, you know, somewhat of a surprise just how important it is to help. And we saw that in our data, that it helped people uh to stay working, uh, sometimes to get better paying jobs because they were able to maintain their health. Uh another surprise was just how important the dental coverage is to people within Medicaid. That was a feature. States have an option whether to offer dental coverage through their Medicaid program and their Medicaid expansion. And many of the people that we surveyed and interviewed uh had not had dental coverage for five, 10, or 15 years uh before they uh enrolled in the Healthy Michigan Plan. And that dental coverage uh was very important to their overall physical health and oral health. Uh and that was also important to their mental health and and their ability to work. Uh uh people uh just uh you know their quality of life is much better when they're getting good dental care, uh, not just to help them, for example, with chronic pain uh that they may have from uh you know uh dental problems, but uh it also helps their overall sense of well-being, uh and you know if their physical appearance is better because they're having their uh dental problems taken care of. Uh they feel more confident, for example, when they go out for job interviews and uh and and they're able sometimes to get better paying jobs because of that. So we, you know, we heard those stories and you know, we found it was important, for example, uh when talking to policymakers and political leaders, you know, to share. That was another, I think, important finding, not just to collect good quantitative data, but to collect some of the stories of the Medicaid enrollees. And you know, that's very important to combine good quantitative data with good qualitative information and the narratives and the stories of the people affected by programs like Medicaid expansion. Uh, you know, that that you know, when we whether we were talking to reporters or political leaders or community leaders, uh, that combination of good quantitative data and and good stories, uh, you know, you know, the the the stories of the people affected by the programs or the people delivering the healthcare uh to new Medicaid enrollees are important to share. Those personal anecdotes definitely play a role um at you know the levers of power, you know, just they're what's often cited and they're often what I feel resonate the most um with a lot of policymakers, which you know, of course, data is important and people should be looking at data, but it's it's great that you guys are able to both capture quantitative and qualitative um pieces in that work. And I heard you talking about work requirements, you know, sort of the impact on labor. Um so in a bit we'll get to work requirements because I think that's a very interesting conversation uh for our current moment. Um, but before we get there, um, I want to talk about another finding in in your research, um, just more broadly, which is, you know, that insurance coverage alone has not erased, you know, the sort of disparities that we see in health outcomes, um, you know, especially here in the United States compared to other peer nations. Um, so what do you think this aspect of your research really revealed about the deeper forces um shaping healthcare in America um and health outcomes generally? Well, that uh, you know, brings us back to you know the larger social determinants of health, that you know, people need good access to medical care, but they also need good education, uh, they need employment opportunities, uh, you know, some of the structural forces that affect people's health. Uh you know, we know that where people live uh can affect their health uh as much or more than uh you know genetic factors uh uh that that often are important. Uh you know, we want to uh understand biologic forces, certainly, but social forces often and environmental factors can be uh as important as as some of those biologic factors in determining people's health outcomes. Uh so it it you know and that's why you know we have to think about uh you know uh for example, early childhood opportunities, making sure that uh children have you know good nutrition, uh you know, opportunities for early childhood education uh that are as strong as possible, uh that families are supported, uh that uh you know that uh employment uh you know opportunities are there for young adults and you know and and middle-aged and older adults as well. Uh those are all critically important and uh uh you know that and and you know and and that mental health is supported. Uh you know, these are uh you know critically important that it's not just enough to give people insurance to deal with problems after they've developed. You know, ideally we want to have a focus on prevention and uh you know a community orientation that you know is is is it is uh it's not just a matter of treating people as individuals, but but thinking about you know healthy communities and and uh public health approach to uh you know maintaining health uh you know in the larger society so that we're uh thinking about things uh you know from an upstream uh uh sense of uh trying to uh prevent problems before they develop, but you know, rather than just addressing them with insurance and and access to good medical care. Uh you know, obviously we want people to get good treatment after they're developing health problems, but the more we can you know think about sort of what are the drivers of of of uh health issues and illness before they develop, uh, you know, that that will pay big dividends. And you know, so that you know, uh a lot of the you know, concern we have about vaccine preventable illnesses right now is uh you know a good example. Uh obviously we want people uh to have the best possible information. Uh you know, we you know. We believe in people to have the you know freedom of choice uh when it when it comes to uh medical information and and making personal decisions. Uh but we also want to make sure that people have accurate information and uh you know and um you know the children are protected, you know, particularly, you know, children who uh may have medical problems uh that you know make them particularly vulnerable to vaccine preventable illnesses. So uh, you know, that's a good example where a public health approach, you know, remains critically important. But why do you think relative to our peer nature nations, other OECD countries, we spend so much more per capita on healthcare, yet our outcomes continue to be, you know, while the gap has closed a little bit, but they still continue to be worse? Well, there are a few reasons for that. One is that we've created a healthcare system where we pay more for a lot of the healthcare services that we offer. You know, we pay more for uh most of the, you know, the pharmaceutical uh uh uh uh drugs that we provide and biologic therapies. Uh, we pay more for most of the uh hospital services and physician services that we provide. Uh, you know, and that's just a you know a legacy of the past 50 or 60 years. Uh in you know, that that it wasn't always that way, but it's you know uh largely, you know, in the last uh 50 to 75 years, uh that's how our healthcare system has developed. And um it's you know, in part because you know, we don't have a single payer healthcare system like most other countries that heavily regulate the prices of healthcare that they pay through the government. Uh and then uh you know, partly it's because uh you know we have uh you know uh a lot more income inequality and uh so you know I think uh and less uh fewer social services uh for lower income people in this country. So uh uh, you know, and that I think you know creates more poverty-related illnesses in the US um than in other high-income countries. And uh uh, you know, for a long time I think we also had more smoking related illnesses. We made a lot of progress on that. In fact, uh, you know, now, you know, that that's actually a kind of you know, a public health uh I think a lot of public health progress has been made uh in reducing smoking rates dramatically in this country in the last 50 years. But at the same time, we've developed a lot more obesity related illnesses and we're seeing the effects of that. So I think you know, those are you know a few of the four, you know, the effects of the high prices we pay, um, you know, the poverty-related illnesses that we experience in this country more so than other countries, and then uh, you know, more recently, you know, uh effects of the you know rising obesity rates and in the last 15 years or so, you know, the opioid epidemic, you know, have all kind of combined to uh you know cause a lot of the kind of worsened health outcomes that we see in this country relative to other high-income countries. I'm gonna pivot us back to what we were talking about earlier about you know, labor in particular. Um, so you know, in your work evaluating the Healthy Michigan plan, you really showed that many Medicaid enrollees were already working or they were in school, caregiving, some are even doing like volunteer work. Um, but there's a sort of renewed conversation now about Medicaid work requirements. What do you think it is that policymakers continue to misunderstand about the the realities of you know Medicaid uh populations or you know, people on Medicaid generally? Well, some of it's just a fundamental disagreement about um you know how long people should rely on Medicaid. I think many Republican lawmakers believe that uh Medicaid should be a more short-term uh solution for people uh you know, and would like them uh you know to transition to employer-sponsored insurance. Uh uh but I think in part that's um uh you know kind of a misplaced um uh uh understanding that uh you know that people can get jobs in which employer-sponsored insurance is affordable. Uh you know, certainly some uh you know younger uh Medicaid enrollees uh uh early in their careers will uh uh you know end up in jobs where they can uh afford insurance, but uh many kind of middle-aged and older adults on Medicaid just are you know do not have the employment prospects where they're likely to uh end up in jobs where they have health insurance that they can afford. You know, they're motivated workers, they're just not, you know, they're in lower wage jobs or, you know, or they where they won't afford insurance, or they have chronic health problems, you know, at age 55 or 60, um, where they're just not going to be able to work sufficient hours to uh to afford health insurance on their own. Uh, even though they probably can work 15, 20, 25 hours a week, it's just not enough to afford health insurance on their own. But you know, they they can work a reasonable amount and earn some income uh if they can keep their Medicaid to help them, you know, afford their medications for high blood pressure or diabetes or whatever other health conditions they have. Um it's um you know, and that's where you know the uh good data can help, but I think also you know sharing the personal stories of uh people affected in you know, uh with those chronic health problems uh hopefully can make a difference. The other area where we're you know seeing make Medicaid make a big difference is helping to support rural hospitals. And you know, certainly in some of the more uh conservative states that have chosen to expand Medicaid, uh that has swayed a number of Republican uh lawmakers. And it'll be interesting to see as Medicaid work requirements are implemented, uh is that going to threaten uh some of the rural hospitals if if many people start to lose their Medicaid coverage, uh, you know, how that affects uh uh rural communities uh, you know, with Republican uh legislators. Uh because, you know, in states that did not expand Medicaid, we've seen a number of rural hospitals close. And those are really anchors in their communities providing a lot of vital services. I hear you communicating a lot of these different um aspects about what made Medicaid expansion so impactful across um different states, different environments. And you know, this is largely in part due to your work in academic medicine. Um and you, of course, were the founding editor-in-chief of JAMA Health Forum. And for those of you who don't know um what that is, it was the JAMA Open Networks um journal focused on health policy. Correct me if I if I you know stated that incorrectly. But um, you know, one challenge in academic medicine really has been, you know, how can we translate research into policy change? Um, so you know, from your experience, what have you learned about how researchers can more effectively communicate um to policymakers or to the public um, you know, these changes and what the research is showing? It's a great question. You know, here at the University of Michigan, I I lead the Institute for Healthcare Policy and Innovation, and that's something uh we encourage our faculty to really develop the skills to communicate their work more effectively, to think of their research as a starting point and their their academic publications not as a starting point, not an end point. That it's it's really important to uh try to translate the the work that we are doing uh as uh academic researchers, uh, not just to our peers, to other researchers at universities and academic medical centers, but uh to uh folks in the media, in government, in community organizations, in the private sector, uh, to the general public. Uh and we can do that by uh trying to speak in in ways that people can understand, uh, not just in sort of uh the way we would write for an academic journal, but in the way that that people talk in in everyday terms. And uh obviously, you know, there sometimes you know these are sort of complicated sort of research methods, uh, but we you know it's important to try to translate that into language that people would use in everyday conversation and and and uh and and to use um you know examples uh that people experience in in in everyday life. And you know, and we're talking in the kind of research that I and colleagues do, you know, we're talking about healthcare, we're talking about public health, we're talking about uh you know everyday uh health conditions that people experience in their lives. So uh you know, it's it's it's it's uh something that that uh you know is we can readily do if we put our minds to it. And uh, you know, and and uh and and that makes it more relatable and uh and it makes it more actionable uh for, for example, for policymakers if we can do that well. And I think the other thing is uh a big challenge is not just to describe the problems that we're seeing in the healthcare system or in public health, uh, but to be working towards understanding what potential solutions are and and evaluating those solutions uh and providing options. And you know, and uh, you know, we have it's a fine line. Uh we don't we you know we're not advocates, uh, you know, we can have our personal opinions that, you know, as as citizens, as voters, uh, but our role as researchers is to ask tough questions and try to come up with the best evidence for uh you know what works and what doesn't work, whether it's in terms of uh you know individual um healthcare options or sort of policy solutions in terms of how the healthcare system is working or terms of community health or public health solutions. So um, and then you know, going back to an earlier point in our conversation, you know, bringing together sort of data with stories, you know, often what we call mixed methods, bringing quantitative data together with qualitative stories or narratives by the people experiencing the health problems or the solutions. Uh uh, you know, that's often kind of the most effective way to communicate our research. You know, what are what are the stories behind the numbers that that kind of really bring uh the data to light? Um so you know, those are some of the ways I think we we do our best when we're kind of communicating the research to to the broader community. I really like that view of you know qualitative data or qualitative findings because oftentimes you know they're used to inform research questions, but here's another way they can be used, sort of to inform the public, the different segments um that make up our population. Uh I find we like to always ask our guests um for some book recommendations, media recommendations. It could be related to your work, or it doesn't need to be. You know, what are some books, um, shows, media that you'd recommend to our audience? Well, uh I I have three in mind that I would share and maybe uh kind of a brief explanation for each. Uh the first would be, you know, one that you referenced, it's the journal JAMA Health Forum. Uh, you know, I served as the founding editor. We launched it back in 2020, and I served as the editor-in-chief for the first five years. And it, as you mentioned, it's uh it's the health policy journal of the JAMA network, and it's an open access journal. So uh uh it's available to readers anywhere in the world uh for free. It does not require a subscription. Uh and uh you know it's its goal is to publish cutting-edge health policy research and commentaries, and uh uh and uh you know, we try to uh publish uh uh research and commentaries that you know is accessible to a wide range of readers, both you know, physicians and other health professionals and academics, but also folks in the general public and students at all levels. So uh, you know, that's one that I would recommend. And there's also a podcast that goes with it. So uh you know that that would be my first recommendation for people interested in health policy and uh both in the US and uh as well as globally. Um the second, in terms of a media recommendation, I guess would be the the streaming show, uh The Pit, uh, which captures uh you know uh sort of what's happening in emergency departments, uh uh, you know, and uh uh while most of it's uh a lot of tough clinical problems that land in emergency departments, uh they've actually uh captured uh a lot of health policy challenges. For example, what happens to people uh when they have no insurance or inadequate insurance and they they land in an emergency department, or uh you know what happens to people with uh you know um tenuous immigration status who need health care or people with mental health crises or people who need end-of-life care that uh you know may not be um uh you know readily available. So uh a lot of difficult health policy issues in an emergency department uh that uh you know uh you know come to a head, let's say, when people are having health crises uh would be uh kind of a media um recommendation I'd have. And then a book recommendation I'd have um is actually one that was uh uh a book written about a close friend of mine, uh Dr. Paul Farmer. It's the book Mountains Beyond Mountains, uh, written by uh Tracy Kidder, an acclaimed author who who uh uh unfortunately passed away in the past year. And uh my good friend Paul passed away a few years ago. But Paul and I were friends back in college at Duke as undergrads and uh went to medical school together at Harvard, and and Paul just had a tremendous career. And uh um, you know, I'd recommend that for some of your listeners who are uh students now, undergrads or or health professional students, because Paul just had such a passion for his work, and you know, that began uh for him early in life, and uh, you know, his passion carried him forward through uh such an amazing career. And uh, you know, and I think that uh passion can is so inspiring, and and the the story of his life's work told in the book Mountains Beyond Mountains, I think has been so inspiring to so many people, uh, many of whom have uh themselves had uh uh impactful careers in global health. But I think it's an inspiring uh uh life story for people in in many different uh uh careers. And uh so that would be my recommendation for a great book, uh a book of inspiration. I have to second all three of those phenomenal recommendations, um, but especially Jam Health Forum. You're the one who told me about it. And since you did tell me about it, the written articles um along with the podcast have just been incredibly helpful for me, especially when you know learning about those areas that I don't have much understanding of or don't have, I don't want to say expertise, but you know, a high-level understanding of. So, you know, thank you so much for those recommendations. Thank you so much for joining us, Dr. Aanian. I think this was an incredible conversation. And take care. I appreciate the invitation. Thank you, Neil. Thanks for listening to Voices from the Field, the Naminexum Podcast. If you enjoyed this episode, please make sure to follow us on Instagram, Spotify, Apple Podcasts, and YouTube to stay updated on our upcoming episodes. We'll catch you next time on Voices from the Field.