Transcript

SPEAKER_01
0:04

Good
morning
today.
How
are
you
today?
Ginger,
ginger,
here
we
are.
Here
we
are.
Possible
smith
ice.
Um,
you
know
what?
We're
not
gonna
talk
about
weather
anymore.
No,
we're
done
with
it.
It's
nice
right
now.
Um,
but
I
do
hear
you're
taking
a
little
bit
of
a
well-deserved
break.
Are
you
getting
excited
for
that?

SPEAKER_02
0:24

I'm
so
excited.
I
I
will
be
so
excited
to
cross
the
border
into
Canada
for
a
couple
weeks.

SPEAKER_01
0:30

Yeah,
you're
going
into
one
of
Joan
Mice'
favorite
places
up
in
Quebec
City.
It
is
stunningly
beautiful.

SPEAKER_02
0:37

And
Montreal.
So
we'll
spend
a
we'll
spend
a
we'll
spend
a
good
amount
of
time
there,
and
I
can
I
can
do
my
French
speaking.
I
was
gonna
say,
are
you
just
gonna
speak
French
the
whole
time?
Absolutely.

SPEAKER_01
0:48

I
mean,
that's
where
I
learned
with
the
Quebec
was
awesome.
I'm
ready
to
well,
you
know
what,
Denise?
The
new
news
today
um
is
I
try
to
just
diligently
work,
and
I
actually
switched
out
a
report
from
Deloitte,
which
our
guest
speaker
is
going
to
know
who
that
is,
uh,
to
something
different
that
I
thought
might
be
a
little
more
applicable
and
especially
to
maternal
health.
The
the
Deloitte
report,
which
I
like,
is
really
about
community-based
organizational
power.
Um,
and
William
Urey
talked
a
little
bit
about
building
coalitions,
and
I
might
still
put
the
report
up,
but
this
one
really
moved
me,
and
um
it's
it's
from
health
affairs,
which
a
lot
of
midwives
I
don't
think
pay
attention
to.
Uh,
we've
had
some
midwife
authors
like
Brie
Thumb
has
published
in
health
affairs,
but
it's
an
important
journal
to
watch.
And
this
just
came
out
a
couple
weeks
ago.
Okay.
So
here's
the
title,
and
I'm
gonna
read
just
a
few
of
the
key
points.
The
title
is
Black
White
Inequities
in
Pregnancy,
related
mortality
in
the
US.
What
will
it
take
to
move
the
needle?
Um,
and
this
is
a
really
well-written
article
in
a
different
slant
than
how
we
have
been
reading
about
black
maternal
mortality
in
the
past,
I
would
say,
couple
years.
So
a
different
researcher
lens.
Well,
first
of
all,
they
document
that
more
than
a
century
ago
we
began
documenting
the
inequities.
So
a
little
bit
about
the
past
history,
but
they
also
bring
up
the
strengths
and
limitations
of
three
different
surveillance
systems
for
tracking
national
and
state
level
trends
that
form
the
evidence
of
how
the
strategies
for
improvement
should
roll
out.
We're
gonna
get
into
Medicaid
real
quick.
Okay.
Um,
the
top
drivers
of
pregnancy-related
deaths
differ
by
race
and
ethnicity,
we
know
that.
And
prevention
must
address
inequities
and
take
these
differences
into
account.
So,
this
this
author
posits
that
although
policymakers
and
researchers
tend
to
focus
on
clinicians'
biases
as
a
primary
cause
of
racial
inequities
in
pregnancy-related
mortality,
the
evidence
suggests
that
intervening
on
upstream
factors
such
as
health
and
social
policies,
will
likely
be
far
more
impactful
than
focusing
on
a
clinician's
behavior.
And
I
really
paused
on
that
one
uh
because
I
think
you
can
have
all
the
rules
you
want
that
clinicians
have
to
do
the
Harvard
implicit
bias
test
every
year
and
it
ain't
gonna
do
anything.
Right,
right.
It
might
make
a
momentary
sort
of
internal
self-reflection,
but
I
don't
know
that
it's
gonna
change
the
outcomes.
And
so
their
recommend
recommended
strategies
for
reducing
racial
inequities
in
the
long
term
include
implementing
universal
health
care.
Wouldn't
that
be
nice?
Oh,
increasing
monitoring
for
cardiovascular
conditions
during
the
prenatal
and
postpartum
periods,
eliminating
barriers
to
abortion
care,
and
addressing
the
effects
of
structural
racism
and
other
forms
of
inequality.
It's
a
fantastically
written
article.

SPEAKER_02
4:24

Okay,
I
have
my
homework.
I
have
to
go
read
it
now.
By
a
non-clinician.
Yeah,
that's
great.
I
mean,
I
do
think
I
think
having
different
lenses,
different
perspectives
really
to
shift
this.
I
mean,
I
think
we
need
to
constantly
be
looking
at
it
from
all
viewpoints.
So
that's
exciting.

SPEAKER_01
4:41

Yeah.
I
mean,
one
thing
that
I
would
add
that
this
author
didn't
include
is
a
more
culturally
congruent
workforce,
which
there
is
a
fair
amount
of
work
going
on
in
that
area.
Um,
but
again,
I'm
not
sure
that
alone
is
going
to
move
the
dial
on
the
wide
discrepancy
that
social
determinants
of
health
and
other
issues
being
addressed
is
of
importance.
Um,
I
was
just
um
on
a
call.
We
had
a
podcast
last
night.
You
were
on,
Denise,
talking
about
the
new
27
ACOG
AMA
OB
codes
that
are
all
changing
in
January
and
how
Arden
and
I
were
on
one
of
those
panels.
We
were
invited
to
be
on
the
panel.
Arden
stayed
on
it
longer
than
me,
but
we
were
invited
to
be
on
a
discussion
and
structural
determinants
of
health
came
up
as
a
high
risk
criteria
for
higher
coding.
And
I
questioned,
I
questioned
them,
and
I'm
like
you're
telling
me
that
a
a
black
woman
living
in
the
South
with
poor
housing
is
going
to
be
considered
medically
high
risk.
Uh
and
what
are
the
implications
of
that
diagnosis
versus
other
issues
that
we
need
to
address
outside
of
the
prenatal
care
and
birth
care
to
help
this
person
have
a
good
outcome?
I
was
thrilled
to
hear
they
remove
social
determinants
of
health
as
a
risk
factor
for
them
to
get
paid
more.
I'm
just
gonna
say
it
like
that.
It
was
almost
like
using
that
terminology
to
increase
their
reimbursement
rates.

SPEAKER_02
6:23

It
makes
me
think
like
more
labeling,
right?
Um,
so
I
I
don't
think
anybody
needs
more
labeling
for
high
risk.
So
I
think
that's
a
good
that's
a
good
thing.

SPEAKER_01
6:33

Why
don't
we
just
treat
everybody
the
same
way
for
all
the
things
we're
doing?

SPEAKER_02
6:37

Why
don't
we
just
treat
everybody
well
and
give
them
everything
they
need,
right?
Exactly.

SPEAKER_01
6:43

Which
brings
me
to
the
great
honor
of
of
introducing
our
guest.
And
I
tell
you,
we
use
the
word
serendipitous
a
lot,
but
I
now
think
there
is
a
purpose
behind
what
we're
doing
on
the
Possiblist
Midwives
here,
Denise.
Yes.
Um,
one
of
the
things
that
I've
I'm
really
embracing
is
getting
out
of
our
silos
and
finding
people
who
care
about
the
midwifery
profession
and
health
outcomes
related
to
maternal
child
health,
but
are
not
clinicians.
And
how
could
they
help
us?
And
so
let
me
just
tell
you
who
this
person
is
and
then
briefly
how
we
met.
We
are
we
are
so
honored
Ellen
Breslin
is
with
us
today.
She
has
35
years
in
health
and
human
services
management
at
the
state
and
national
level.
She's
very
well
known
in
the
state
of
Massachusetts
and
in
the
Congressional
Budget
Office.
She's
a
strategic
consultant.
She's
a
researcher,
quantitative
and
qualitative
for
all
of
our
research
nerds
out
there.
And
her
focus
area
is
on
Medicaid
payment
and
care
delivery
reform,
integrated
programs,
health
disparity
measurements,
behavioral
health,
rural
health
innovations,
everything
going
on
in
maternal
health
changes
today.
Ellen
has
intersected
conversations
with,
but
how
much
do
we
hear
Ellen
Breslins
talking
to
midwives?
And
I'm
so
thrilled
that
we
have
her
today
because
Ellen
is
one
of
our
main
speakers
in
July
at
our
conference.
But
the
really
cool
thing
about
Ellen
is
we
met
in
a
restaurant
in
Boston.
Nice.
Nice.
We
were
at
a
dinner
that
Kim
Amsley
Camp,
who
is
the
nurse
midwifery
director
at
Cambridge
Health
Alliance,
took
um
took
a
few
of
us,
uh
Leslie
and
Nard
and
I,
out
to
this
really
cool
restaurant.
In
walks
Ellen
and
several
of
her
colleagues,
and
Kim
about
flies
out
of
her
chair.
And
I'm
like,
what
the
heck
is
going
on
here?
Which
led
to
many
conversations
where
Ellen
and
I
just
it's
like
lost
sisters.
Um
we
met
and
and
we
immediately
valued
one
another's
uh
professional
roles.
And
so,
Denise,
any
thoughts
about
Ellen
being
with
us?

SPEAKER_02
9:03

Well,
I'm
actually
very
excited.
Um,
it
is
nice
to,
you
know,
it's
really
nice
to
move
outside
of
all
things
um
midwifery,
but
that
touch
midwifery.
Um
to
really
have
somebody
that
knows
about
policy,
which
I
think,
you
know,
the
midwife
working
in
the
clinic
doesn't
isn't
aware,
doesn't
have
the
time
to
always
be
aware.
So
to
have,
you
know,
kind
of
pointed,
focused
attention
on
anything
related
to
health
policy
is
really
great.
I'm
looking
forward
to
really
hearing
what
Ellen
can
share.

SPEAKER_03
9:34

Yeah.

SPEAKER_02
9:34

Um
and
I
just
think,
yes,
building
our
coalition
is
really,
really
important.
We
have
to
create
a
huge
team.
Yep.

SPEAKER_01
9:43

Yep.
So,
Ellen,
we're
thrilled
you're
here.
Uh,
what
we'd
like
to
ask
our
guests
is
is
tell
us
a
little
bit
about
yourself
and
your
journey,
maybe
to
this
conversation.

SPEAKER_00
9:56

Oh,
uh
you
know,
so
you
say
35
years
of
work.
And
I
think,
well,
over
those
35
years,
it
gives
a
lot
of
time
to
get
involved
in
a
lot
of
different
projects
and
meet
and
learn
new
it
learn
things
from
new
people.
And
uh
I
have
to
say
you're
constantly
learning
as
long
as
you're
living.
And
so
um,
so
Denise
and
Ginger,
I'm
I'm
gonna
learn
this.
Is
really
an
organic
conversation
today,
but
I
would
have
to
say,
I
mean,
if
I
can
tell
you
a
little
bit
about
myself,
I
I
kind
of
pride
myself
on
having
uh,
you
know,
integrity
and
make
trying
to
make
decisions
based
upon
what
I
think
is
good
for
humanity
and
good
for
quality
of
life.
Um,
so
a
lot
of
my
career
has
been
in
health
and
human
services,
the
state
legislature
in
Massachusetts,
you
know,
in
in
control
of
budgets
and
uh
working
on
a
program
purchasing
housing
in
the
community
where
folks
have
to
fight
that,
not
in
my
backyard
syndrome.
Um,
so
there's
something
about
the
underdog
uh
that
I
really,
really
like.
And
I
like
fighting
for
justice
and
health
equity,
reducing
disparities.
And
uh,
you
know,
what
we're
trying
to
do
while
we
live
in
this
world
is
make
an
imprint
and
say,
how
do
we
to
get
back
to
the
Deloitte
report?
How
do
we
move
the
needle
in
that
direction,
in
hum
towards
humanity,
towards
justice,
equity
for
all?
So
my
congressional
budget
office
days
were
very
interesting.
And
one
of
the
key
findings
from
a
major
report
is
I
found
that
military
healthcare
system
surgeons
were
doing
a
third
more
uh
C-sections
on
young
women.
And
it
was
because
the
surgeons
probably
needed
to
sharpen
their
skills.
And
that
was
an
old
report.
I'd
love
to
see
what
the
C-section
rate
is
today,
uh,
to
see.
But
many
years
at
MassHealth
and
where
I
set
capitation
rates
and
risk
sharing
arrangements.
And
that's
the
ticket.
You
want
the
payment
to
provide
the
flexibility
that
um
you
need
in
the
system
to
decide
where
you
deliver,
what
you
know,
what
setting,
who
provides
the
care,
and
to
keep
it
really
person-centered.
And
there's
a
lot
of
rigidity,
I
think,
in
your
business
currently.

SPEAKER_03
12:31

Yes.

SPEAKER_00
12:32

Um,
a
lot
of
regulatory
uh
restrictions,
and
that's
not
really
person-centered
whole
person
care.
You
know,
not
wrong.

SPEAKER_01
12:40

Thank
you
for
saying
that.

SPEAKER_00
12:42

Yeah,
yeah.
You're
not
wrong.
So
um
I
but
you
know,
my
career
has
had
a
lot
of
uh
interest
in
integrated
care
programs,
people
with
disabilities,
and
I
see
so
many
parallels,
so
many
parallels
between
medicalizing
their
care
and
medicalizing
uh
care
for
for
women.
Um,
and
you
look
at
the
triple
aim
or
quadruple
aim,
you
know,
and
what
you're
trying
to
do
is
consistent.
And
I
really
like
the,
you
know,
the
triple
aim
is
the
you
know,
the
the
cost,
the
uh
patient's
benefit,
the
cost
benefit,
as
well
as
population
health.
And
so
that
all
has
it
baked
in.
I
like
the
quadruple
aim
because
you
bring
in
the
provider
experience,
and
you
won't
maintain
a
workforce
unless
you
you
actually
have
provider
satisfaction
and
you
know,
provider
support
because
it's
just
really
hard.
Um,
my
understanding
is
you
know,
midwifery
is
a
tough
profession.
It
is
hard
to
be
a
midwife
today.
And
um,
I
listened
to
a
um
uh
a
person
at
Mount
Auburn
Hospital
about
a
month
ago,
and
um
she
said
it's
really
hard
for
midwives
to
work
within
hospital
settings.
So
we
need
to
support
them
if
that
is
the
setting
of
choice
for
a
woman.
And
I'm
all
about
women's
choices.
My
mom
had
12
kids.
I
have
six
sisters.
Um,
so
you
can
imagine
we
had
a
lot
of
our
bodies
ourselves,
you
know,
around
the
house.
And
we
had
a
girl's
bathroom
and
a
boys'
bathroom,
right?
You
know,
the
two
shall
never
meet,
um,
because
that
was
that
era,
you
know,
worth
World
War
II
uh
generational
parents.
So
I
think
I'm
shaped
by
this
kind
of
pragmat
pragmatism
belief
in
equity.
My
Catholicism
is
important
to
me,
and
uh,
but
that
means
love
thy
neighbor.
So
all
this
stuff
about
immigrants,
all
this
stuff
about
transgender,
it's
very
it
that's
just
hate.
And
yeah,
um,
so
I
think
if
you
come
from
a
place
of
love
and
mix
it
with
public
policy,
uh
you
end
up
being
on
the
right
side.

unknown
15:02

Yeah.

SPEAKER_00
15:03

Like
your
side
right
now.

SPEAKER_01
15:06

Well,
you
know,
the
pro
the
problem,
you
know,
persists,
Ellen.
And
I
actually
went
back,
I
think
it's
2017
or
maybe
19,
of
a
Vimeo
PowerPoint
I
found
of
you
uh
with
some
co-presenters
on
Medicaid
and
social
determinants
of
health
as
it
was
rolling
out
for
Medicaid
plans.
And
this
is
just
in
my
mind,
we
haven't
moved
the
dial.
We
have,
in
fact,
in
in
in
childbirth,
it's
worse
than
it
was
10
years
ago.
What
is
going
on?
Like,
why
can't
we
move
the
dial?
If
Medicaid
really
is
designed
to
improve
outcomes,
they're
not.

SPEAKER_00
15:51

Uh,
two,
I
mean,
there,
it's
like,
ooh,
you
know,
I
I
can
try
to
unpack
that,
but
what
I
would
say
is
let
me
just
give
you
an
example.
We
had
uh
a
standoff
in
our
country
where
institutionalization
was
the
way
to
go
for
people
with
disabilities
for
older
adults,
and
home
and
community-based
services
uh
in
Medicaid
was
always
it's
an
optional
benefit,
right?
So
that's
why
Trump's
Medicaid
budget
cuts
are
so
dangerous
right
now,
because
um,
when
states
really
have
to
manage
their
Medicaid
budget,
they're
going
to
have
to
keep
the
mandatory
benefits,
which
are
largely
institutional
benefits.
And
those
home
and
community-based
service
benefits
are
all
optional.
And
so,
how
did
we
rebalance
the
system
through
very
specific
intentional
demonstrations
from
the
federal
government?
And
from
the
federal
government,
they
said,
states,
we
will
sweeten
the
deal
and
give
you
higher
federal
match
if
you
move
the
needle
on
uh
moving
the
number
of
users
and
spending
from
the
institutional
side
to
the
home
and
community-based
service
side.
And
so
we
have
been,
as
a
country,
very
successful.
However,
as
you
know,
state
Medicaid
programs
mean
that
it
is
every
state.
If
you've
seen
one
state
Medicaid
program,
you've
seen
one
state's
Medicaid
program.
Right.
That's
right.
So
on
average,
you're
in
the
low
60s.
Uh,
I
think
about
that
in
terms
of
rebalancing
spending
in
our
country.
Yeah.
This
has
been
going
on
since,
well,
as
you
know,
the
ADA
was
passed,
and
then
you
had
the
Olmsted
decision,
which
gave
people
the
rights.
Now
I'm
kind
of
chronicling
a
little
bit
of
the
civil
rights
history,
and
that
took
advocates
chaining
themselves
to
the
doors
in
Congress
to
clamor
to
have
their
voices
be
heard.
And
so
if
you
bring
lived
experience,
but
literally
they
did,
they
they
protested,
they
started
rolling
out
the
independent
living
centers.
So
it
started
changing
the
culture,
but
we
still
have
stigma,
discrimination,
bias.
Um,
you
look
at
the
outcomes,
Dr.
Lisa
Iazzoni
at
Mass
General
Hospital
wrote
all
of
these
articles.
And
she
said,
if
I
am
a
person
who
goes
in
to
an
emergency
department,
what
is
the
doctor's
perception
of
your
life
worth
living,
your
white
life
worth
keeping?
It's
pretty
dim.
And
so
how
do
you
that
so
with
all
this
change,
uh
juxtapose
that
with
perception
of
the
value
that
I
place
on
your
life?
Now,
midwifery
has
another
uh
set
of
issues,
but
to
kind
of
look
at
a
cascade
of
or
a
portfolio
of
things,
and
you
can
do
some
concrete
things,
take
federal
action,
take
state
action.
But
how
do
you
change
perception?
And
I
think
midwifery
has
a
lot
of
the
same
parallels
in
terms
of
perception.
Is
this
safe?
Is
this,
you
know,
and
da-da-da-da?
But
on
the
health
equity
front,
uh
it
is
hands
down
uh
the
one
of
the
most
popular
chassis
right
now,
mid-wifery,
to
address
health
equity.
So
isn't
that
like
a
slam
dunk?
Shouldn't
that
be
everywhere?
Shouldn't
we
all
be
educating
um
our
children?
Uh,
shouldn't
we
our
our
doctors,
everyone,
because
that
is
ultimately
coming
back
to
the
triple
aim
and
quadruple
aim
and
adopters
uh
do
no
harm.
You
know,
I
mean,
if
you
really
start
to
invoke
all
of
the
different
principles
we
live
by,
uh
that,
you
know,
uh
we
have
supposedly
equal
rights,
equal
voting
rights,
equal
rights
to,
you
know,
life,
liberty,
and
the
pursuit
of
happiness,
then
we
uh,
you
know,
then
that
if
that
can
move
the
needle,
if
mid-wifery
can
move
the
needle
on
saving
one
life,
black
life,
one
mother,
one
child,
then
that
it
that's
worth
it.
That's
worth
it.
And
so,
but
what
is
it
gonna
take?
Yeah,
and
and
Ellen
are
a
bunch
of
the
issues.
No,
no,
no.

SPEAKER_01
20:54

At
the
point,
uh
your
points
are
so
important
to
understand,
as
Yuri
would
say,
the
balcony
view.
And
then
we
have
the
clinician,
Denise
here,
who's
working
very
hard.
I
think
she
has
19
midwife
colleagues
at
a
huge
hospital.
They're
so
busy
saving
those
lives.
And
at
the
same
time,
our
professions
experiencing
devaluation,
barriers
to
care,
exhaustion
because
there
aren't
enough
providers,
and
how,
you
know,
what
we're
trying
to
think
about
here,
and
not
Denise
can't
do
this
alone,
but
how
do
we
rally
our
coalition
of
people
to
help
the
midwives
break
through
the
political
quagmire,
the
policy
quagmire,
the
payer
quagmire
of
not
paying
attention
to
our
voices
because
they
don't
want
to
they
they
want
to
espouse
they
think
midwives
and
doulas
can
help
and
birth
centers,
but
they
don't
want
to
hear
from
us.

SPEAKER_00
22:00

Well,
I
mean,
I
always
think
of
it
as
side
by
side.
So
I
sat
on
the
board
of
the
Disability
Policy
Consortium.
I
um
rarely
do
projects
now
without
somebody
with
lived
experience
of
the
condition.
Very
good.
And
so
the
great
idea.
You
know,
and
then
the
research
and
the
voices
that
we
need
to
lift
are
those
who
have
had,
you
know,
uh
delivery
by
midwife
with
midwife.
And
that
the
that
lived
experience
speaks
way
more,
I
think,
than
a
provider's
voice
because
you're
believing
the
consumer.

SPEAKER_03
22:43

Yeah.

SPEAKER_00
22:43

The
consumer
is
saying,
and
I
I
I
honor
and
respect
all
of
your
voices,
but
the
person
you're
trying
to
convince
to
is
in
some
cases
the
other
people
who
need
to
clamor
for
delivery
by
midwife.
You
so
it's
something
like
11
or
12
percent
of
births
are
by
midwife.
So
it's
you
know,
economics,
right?
Think
about
economics,
it's
price
and
quantity,
it's
supply
and
demand.
Yeah,
and
so
what
we
I
mean,
it's
multifactorial,
your
coalition
building.
So
part
of
it
is
demand.
We
as
people
demand
it
and
not
just
the
person
giving
birth.
And
it
has
to
be
families,
and
so
it
has
to
be
families
clamoring
for
midwifery,
it
has
to
be
coalition
building,
such
as
you
know,
there
are
so
many
different
coalitions
that,
and
I'm
not
up
to
speed
on
all
of
the
various
coalitions
in
in
your
uh
in
this
specific
field,
but
I
will
be
by
July.
But
it's
really
it's
really
bringing
together
those
folks
to
create
a
sense
of
shared
values.
When
you
do
that,
for
example,
you
know
everybody
agrees
on
health
equity.
You
I
mean,
and
maybe
some
people
don't
too,
um,
you
know,
in
in
our
country,
sadly,
right
now.
Um
you
know,
when
you
see
some
of
the
evidence
uh
of
their
health
systems,
it's
it
might
be
poverty
aligned.
It
also
means
money.
And
so
right
now,
hospitals,
uh
given
uh
OB3,
um,
they
stand
OB3
in
Massachusetts,
we
call
it
OB3,
the
one
big,
beautiful
bill.
And
um,
because
nobody
can
bear
to
say
it's
big
and
beautiful.
Um,
and
so
uh,
but
hospitals
are
really
up
a
creek,
and
healthcare
costs
are
really
up
a
creek,
and
health
insurance
premiums
are,
and
people
in
our
country.
So
it's
looking
for
alignment
with
all
of
the
problems
that
we
have.
People
can't
afford
health
insurance,
people
um
are
you
know
medicalizing
mid-wifery
because
that's
what
our
culture
seems
to
embrace
medicalizing
uh
health
conditions
and
making
it
into
a
health
condition
and
disease.
And
so
it's
looking
at
all
of
the,
I
would
say,
um,
like
the
Achilles
heel
of
our
health
system,
which
is
that
we
have
a
workforce
shortage,
we
have
a
housing
shortage,
we
have
health
premiums
going
through
the
roof,
we
have
a
direct
care
uh
workforce
shortage
to
um,
you
know,
uh
to
support
older
adults
and
people
with
disabilities.
We
have
uh
health
inequities
that
if
you
do
cost
out
health
inequities
in
our
system,
sadly,
that
uh
I
hate
to
think
of
it
from
a
quantitative
perspective,
but
that
justifies
doing
something
about
it
because
it
is
costing
us
millions
and
billions
of
dollars
to
perpetuate
poor
health
outcomes
and
discrimination.
And
so
one
of
the
reasons.

SPEAKER_01
26:17

I'm
gonna
stop
you
there
for
a
second,
Ellen,
because
we
look
at
the
population
health
data
in
the
southern
poverty
block,
and
that
has
been
true
across
all
health
indices
for
decades,
and
yet
there
seems
to
be
very
little
will
or
public
understanding
of
what
you
just
said.
Uh,
that
that
the
cost
to
the
society
by
the
willful,
intentional
um
act
to
not
improve
access,
housing,
health
care
is
costing
those
states
not
just
lives
of
the
people
who
reside
there,
but
of
their
entire
state
budget.
Yeah.
What
is
what
is
what
is
the
disconnect?
Is
it
still
is
it
historical?
I
mean,
it's
it's
it's
like
I
don't
I
don't
get
it
as
a
white
privileged
woman,
you
know.

SPEAKER_00
27:18

Well,
it's
it's
funny.
I
don't
get
it.
I
mean,
I
have
to
say,
one
of
12
growing
up
in
Boston,
I
don't
think
I
ever
saw
a
pediatrician.
I
really,
you
know,
I
don't
think
we
had
health
insurance
at
one
point.
And
I
I
so
health
is
much
more
than
health
insurance,
right?
And
it
is
about
not
overeating,
it's
about
exercise,
it
is
about
food,
nutrition,
etc.
And
so
I
don't
place
all
of
my
um,
yeah,
I
I
can't
actually
remember
going
to
the
to
to
the
pediatrician,
but
I
do
remember
going
to
public
schools
and
getting
my
ear,
my
uh
hearing
and
vision
and
teeth
checked.
And
you
know,
that's
where
public
health
comes
in.
And
you
guys
are
on
the
frontier
of
public
health.
What
you're
doing
is
public
health
because
you're
doing
it
without
discrimination,
and
you're
just
giving
it
to
everybody
equally,
and
you're
not
bringing
uh
implicit
bias
to
to
the
delivery
uh
setting.
And
so
I
I
do
really
think
that
we
are
at
a,
I
mean,
hospitals
became
the
the
thing
in
our
system,
and
so
right
now
the
way
to
solve
it
is
through
payment
reform.
And
so
the
you
you
mentioned,
you
know,
social
risk
adjustment
for
payments
to
um
to
go
upstream.
And
the
reason
they
do
that
is
obviously
because
of
discrimination
and
poverty,
um
having
come
out
of
the
Medicaid
arena,
MassHealth,
and
we
call
it
MassHealth
to
destigmatize
the
name
Medicaid,
because
Medicaid
is
aid
for
the
poor.
And
you
know,
you
you
you
don't
need
to
like
you
know
lower
anybody's
dignity
in
life
or
anything
like
that.
And
first
of
all,
it's
very
commonplace
anyway
now.
It's
one
out
of
four
people
in
Massachusetts,
sometimes
one
out
of
three,
you
know,
and
so
thank
goodness
uh
Medicaid
is
such
an
important
payer.
Um
and
so,
but
I
would
say
the
way
to
go
with
you
know
moving
the
needle
is
we've
got
to
have
intentional
congressional
and
federal
demonstration
programs
that
go,
pow,
we're
doing
this,
we're
tackling
this.
This
is
not
exactly
an
easy
environment
to
make
that
case.
So
perhaps
you
make
the
case
that
it's
just
lower
cost.
And
because
health
equity,
um,
and
you
know,
the
other
thing
is
we
we're
trying
to
get
away
from
social
determinants
of
health
now
and
health-related
social
needs.
We're
trying
to
call
them
social
drivers
of
health.
Oh,
yeah.
And
it's
because
and
it's
because
it
shouldn't
be
a
determinant.
No,
just
because
that's
right,
you
have
um,
and
to
your
point
earlier,
we
want
to
level
the
playing
field
here.
I
don't
want
to
have
uh
greater
poverty
in
African-American
communities
than
white
communities.
Uh,
like
I
want
everybody
to
have
a
thriving
community,
have
enough
food,
have
enough
housing,
etc.
And
so
we
do
compensate
that
for
that
now
because
what's
happening
is
CBOs,
can
uh
community-based
organizations,
are
totally
classic,
under-resourced,
do
not
have
the
infrastructure,
do
not
have
the
data
sharing
capabilities.
And
now
we
have
more
big,
huge
platforms
that
do
that,
like
Unite
Us,
for
example.
I
I'm
not
advertising
for
them
and
just
get
that
name
popped
to
mind.
And
but
that
we
have
these
huge
uh
infrastructures
that
support
community-based
organization.
But
I
just
met
a
woman
in
a
rural
community
last
week
and
I
was
house
sitting
for
somebody,
and
she
serves
up
120
meals
a
day.
She's
a
volunteer,
and
because
a
lot
of
the
funds
in
her
community
are
getting
cut,
and
she's
also
getting
the
overflow
very
soon.
So,
like
the
community-based
organizations
are
just
trying
to
get
by
a
lot
of
them.
Yeah.
And
that
when
they
have
been
swept
into
health
care
reform
under
Medicaid
programs,
a
lot
of
what
happens
is
the
hospitals
get
the
money
to
allocate
it
out
to
the
community-based
organizations
rather
than
giving
the
communities
their
due,
or
they
give
the
money
to
the
community
organizations
and
they
forget
about
the
infrastructure.
Yeah,
they
don't
forget
about
it,
they
don't
invest
in
it.
Yeah.
So
unless
you
invest
in
something
and
make
it
stable,
swably,
it's
gonna
go
and
have
interoperability
and
information
and
data
exchange,
yeah.
Then
you're
you
haven't,
you
do
not
want
a
CBO,
a
community-based
organization
to
become
just
like
the
medical
system.
Now
the
hospitals,
who
have
really
gotten
a
lot
of
the
money
over
the
last
couple
of
years,
especially
my
own
state,
now
they
we
don't
have
the
money
to
sustain
this.
So
now
they're
gonna
have
to
do
major,
major
payment
reform.
And
AI
has
also
accelerated
the
use
of
cost
growth
in
our
country
as
well.
Because
rather
than
calling
it
up
coding,
it's
accurate
coding.
So
it's
like
hugely
comprehensive
now.
And
so
when
you'd
use
AI
and
that
gets
fed
into
your
system
of
coding
and
that
drives
payment,
yes,
let's
back
away
and
pay
by
outcomes,
please.
You
know,
then
you've
got
into
a
little
bit
of
a
game,
you
know,
and
you've
seen
it
in
the
newspapers
across
the
country,
Medicare
Advantage
plans,
up
coding,
all
of
that
other
stuff.
Yeah.
So
let's
not
let's
not
get
too
wrangled
up
here
with
the
AI.
And
you
know,
I
always
say
throw
out
the
code
book.
Show
me
the
show
me
the
outcomes.

SPEAKER_01
33:39

I
would
love
for
Arden
to
be
on
this
on
this
call,
Denise.

SPEAKER_00
33:42

Because
I
think
she
agrees.
I
mean,
show
me
a
healthy
baby
born
to
a
happy,
healthy
mother.
Thank
you
so
much.
And
yes,
and
so
that's
the
ultimate
outcome,
right?
What
do
you
pay
for?
And
what
are
you
gonna
get?

SPEAKER_01
33:59

I
don't
think
we
have
data
systems,
even
with
the
new
department
the
federal
government
formed.
Yeah.
I
don't
I
don't
there
is
no
accurate
data
system
in
our
country
to
answer
your
question.
There
is
not
one.

SPEAKER_00
34:17

Yeah,
well,
we
need
to
know.
So,
you
know,
when
it's
delivered
in
a
hospital
setting,
when
it's
delivered
in
a
birth
center.
Yes,
anyway.
When
we
need
the
voices
of
the
people
who
have
delivered
by
midwife,
we
need
those
voices.
You
no
provider
workforce
can
carry
the
water
alone.

SPEAKER_01
34:37

So,
two
things
you
have
said,
I
want
our
midwife
listeners
to
really
listen
twice
to
you.
It's
very
clear
to
me,
and
I
think
Denise,
you're
gonna
agree.
Data
drives
change.
If
you
are
not
collecting
data
for
your
midwife
practice,
that
has
to
stop.
And
the
other
is
not
just
press
gainy
patient
experience
forms,
but
what
are
you
doing
to
stay
connected
to
the
families
you
serve?
How
can
you
build
a
base
of
a
community?
Let's
just
go
back
to
our
favorite
fan,
William
Murray.
How
can
you
build
that
constituency,
not
just
to
drop
in
when
you're
in
crisis,
but
to
help
be
part
of
your
annual
report
of
those
patient
experiences
that
made
a
difference
in
why
you're
there
in
that
practice?
I,
you
know,
we
gotta
figure
out,
Ellen,
how
to
help
midwives
know
that
they
can
do
some
things
that
they
have
not
been
doing
before
that
I
would
call
leverage
to
this
story.
Because
just
saying
we're
good
or
we
have
good
outcomes
is
not
gonna
work.

SPEAKER_00
35:59

Yeah.
Do
we
have
a
living
video
or
a
uh
big
documentary
on
just
the
voices
of
women
who've
delivered
by
midwife?
And
literally,
we
must
have
the
stories
of
Emily,
the
stories
of
um
Carrie,
the
stories
of,
you
know.

SPEAKER_01
36:20

So
listening
to
Mothers
Four,
listening
to
Mothers
Four
just
came
out
this
week.
I
almost
used
it
and
I
decided
I
was
gonna
go
a
different
direction
with
you.
But
it
it's
sponsored
by
the
National
Partnership
for
Women
and
Families.
They
they
are
a
very
big
coalition,
been
around
a
long
time.
And
Eugene
De
Klerk,
Dr.
De
Klerk
from
Boston
uh
college.
I
you
should
know
that
name,
Eugene
De
Klerk
is
the
Birth
by
Numbers
guru,
um,
started
this
Listening
to
Brothers
survey,
and
they
actually
have
the
stories
in
a
qualitative
narrative
in
text.
But
what
I
hear
you
saying,
Ellen,
which
I
beautiful,
I
think
we
need
them
in
video,
in
a
movie,
in
something
that
is
more
emotionally
tangible
than
reading
somebody's
words.

SPEAKER_00
37:13

Yeah,
there
are
a
lot
of
powerful,
uh,
powerful,
powerful
uh
small
videos
um
that
you
can
do.
People
have
a
nanosecond
attention
these
days.
Yeah,
I
find
that
they
don't
read
anything
longer
than
two
pages.
Yeah,
I
can't
write
a
report
without
a
two-page
executive
summary.
And
it
has
to
be
in
graphics.
It
can't
even,
it
has
to
be
visual.
And
I
mean,
we're
all
from
kind
of
more
of
the
generation
where
you
actually
read
a
physical
book
and
now
we
don't
have
time,
you
know,
etc.
But
I
want
to
also
make
another
important
point
about,
you
know,
I
followed
the
um
autism,
you
know,
debate
here
in
Massachusetts
um
after
I
had
twins
and
I
didn't
go
right
back
to
work,
and
I
ended
up
doing
um
a
report
with
my
colleague
Tony
Dreyfus,
and
we
uh
didn't
really
know
the
area
of
autism,
but
um,
because
I
hadn't
actually
had
uh
a
friend,
or
uh
it
turned
out
one
of
my
good
friends,
um,
her
son
has
autism.
And
anyway,
the
ABA
in
Autism
Speaks
people
were
really
they
formed
a
very
strong
national
coalition.
And
the
legislation
that
I
had
to
review,
analyze,
and
work
with
an
actuarial
firm
uh
up
in
Maine.
Um,
and
we
looked
at
the
evidence
base
and
we
looked
at
the
cost
and
we
looked
at
the
benefit
to
uh
children
who
would
receive
it.
At
the
time,
you
know,
ABA
is
super
controversial
right
now.
And
at
the
time,
that
was
the
only
solution
that
people
were
grabbing
onto
for
hope,
you
know,
really
looking
at
coverage.
And,
you
know,
there
are
definitely
many
camps
within
this
broad
uh
continuum
spectrum
of
autism.
And
but
what
it
was
is
the
legislature
mandated
this
study.
We
did
the
study,
uh,
it
was
the
legislature
passed
it
after
the
study
came
out.
There
was
a
champion
at
the
state
within
Executive
Office
of
Health
and
Human
Services,
Gene
McGuire,
took
this
report,
went
up
to
the
legislature,
said,
we
need
to
help
these
families.
They're
spending
gobs
of
money
out
of
pocket.
And
so
there
are
all
these
different
tools
that
you
can
use.
And
one
of
the
and
so,
you
know,
a
sort
of
strong
report
that
spells
out
the
cost
to
society,
the
um
quality
of
life,
the
evidence-based,
which
was
just
in
its
infancy.
But
you
need
that
clear
discussion,
evidence-based,
and
you
probably
have
to
do
this
state
by
state.

SPEAKER_01
40:09

I
was
just
gonna
say
state
by
state.

SPEAKER_00
40:14

Right,
but
all
you
need
to
do
is
get
about
four
or
five
states,
take
it
to
the
National
Association
of
Medicaid
directors.
Medicaid
is
always
the
first
kind
of
line,
and
then
you
know,
get
them
to
think
about
how
you
can
replicate,
and
then
you've
got
consultants
who
can
tailor
it
to
that
state,
but
but
but
this
is
the
problem
in
a
decentralized,
you
know,
system
in
in
terms
of
having
to
go
state
by
state.
But
at
the
end
of
the
day,
when
Governor
Dabal
Patrick
signed
that,
there
were
so
many
families
going,
I
was
thousands
of
dollars
in
debt.
And
you
know,
fortunately,
we
we
have
iterated
upon
the
um
interventions
and
supports
that
children
with
disabilities
need,
right?
I
mean,
and
all
things
evolve.

SPEAKER_01
41:07

Um
so
yeah,
let's
just
take
it
over
to
maternal
outcomes.
We
we
seem
to
focus
more
on
maternal
mortality
than
maternal
morbidity.
So
if
we
have
900
women
dying
every
year,
but
90,000
women
impacted
by
severe
maternal
outcomes.

SPEAKER_00
41:32

Yeah.

SPEAKER_01
41:33

To
me,
I
mean,
all
of
that
is
important
in
the
conversation,
but
it's
almost
as
if
it's
not
a
problem
because
it's
not
impacting
that
many
people,
and
yet
there
are
many
consequences
from
a
severe
maternal
event.
And
this
idea,
I
love
your
idea
of
finding
championing
states
where
where
maybe
examples
of
I
maybe
California
is
a
good
one
in
Massachusetts.
I'm
just
gonna
say
it,
Denise,
because
both
of
these
states
with
midwives
are
very
organized
and
they're
very
progressive
states.
Um
we
need
examples
like
Ellen.

SPEAKER_00
42:17

The
advancing
health
equity
that
that
Governor
Healy
signed.
Yes.
Uh
Governor
Healy
is
uh,
you
know,
uh
a
woman
who
very
much
believes
in
choice
and
very
much
believes
in
women's
rights,
etc.
And
um,
and
we
also
have
uh
two,
it's
environmental,
right?
I
mean,
we
have
a
health
equity
compact
in
Massachusetts
led
by
executive
director
Michael
Carey.
Um,
he
has
a
health
equity
conference
every
single
year.
He
elevates
the
issues
of
health
disparities,
and
people
do
uber
focus
on
mortality
and
morbidity
is
also
incredibly
important
because
as
you
look
up,
as
you
look
down
the
line,
longevity,
right?
The
the
folks
who
experience
morbidity
outcomes
during
they
have
a
you
know
a
worse
trajectory
lifelong
of
health,
better
health
outcomes.
And
so
what
happens
is
those
folks
become,
you
know,
if
you
look
at
the
pyramid
and
the
top
high
cost
people,
they
many
of
those
folks
will
likely
become
the
very,
very
high
cost
people
on
Medicaid
or
Medicaid
and
Medicare,
duly
eligible.
And
so
once
people
start
realizing
the
implications
from
multiple
perspectives,
because
what
speaks
to
me
is
quality
of
life.
And
even
though
I'm
a
numbers
person,
what
also
speaks
to
me
is
does
it
does
it
make
sense?
Absolutely.
You
know,
we
shouldn't
be
toy,
we
shouldn't
be
uh
uber
focused
on.
Price
and
quantity
for
what
you
really
need
is
a
value-based
outcome.
You
really
need
these
morbidity
rates
to
go
down,
and
that's
incentive
payments.
And
sadly,
you
don't
want
to
reward
people
for
systemic
implicit
bias
and
systemic
bias
in
the
system.
But
you
can
use
payments
to
close
the
gap,
to
bridge
that
gap
and
the
extra
resources
needed.
And
I
do
not
know
how
you
can
change
perception
overnight.

SPEAKER_03
44:35

Yeah.

SPEAKER_00
44:35

And
how
you
can,
but
if
you
are
being
paid
more
and
the
hospital
is
and
they
are
up
a
creek
right
now
to
um
to
in
in
rural
my
fear
with
the
rural
health
transformation
funds,
unless
directed
and
saying
X
percent
of
the
money
has
to
go
to
free
birthing
centers,
or
we
don't
know
how
this
money
is
going
to
get
allocated.

SPEAKER_01
45:03

And
so
that
it's
it's
it's
it's
like
the
the
the
tech,
I
was
on
a
call
with
a
maternal
health
advisory
board
for
Heartland
Forward.
This
is
an
initiative
of
the
Walton
Foundation.
Uh,
and
and
the
conversation
about
rural
health
transformation
funds
and
maternal
health
specifically
was
how
how
can
the
stakeholder
group
help
influence
those
people
on
how
they're
going
to
spend
their
money?
Because
there's
a
physician
who
runs
an
organization
called
NEST,
which
is
home
care
for
rural
health
families.
She
said
she's
at
a
conference,
and
the
exhibitors
are
all
all
these
tech
gadget
people
trying
to
sell
to
the
purchasers,
you
know,
Uberings
and,
you
know,
apps
and
you
know,
high-tech
things
that
aren't
necessarily,
you
know,
DaVinci
robots
that
aren't
gonna
that
aren't
what
is
needed,
and
yet
it's
a
quick
spin
and
it's
flashy.
Yeah,
yeah,
yeah.
It's
so
I
have
a
question
for
you
because
you
mentioned
you
mentioned
Tima.
We
had
a
podcast
uh
a
few
uh
months
ago
with
someone
who
has
as
a
midwife
an
in-road
to
Tima
in
Alabama.
But
of
the
15
states
and
and
the
people
we
have
found,
the
midwives
we
have
found
so
far,
um,
there
was
a
call
a
few
weeks
ago
with
as
many
as
we
could
find
in
those
15
states,
Minnesota
and
Alabama
are
the
only
two
of
the
15
where
we
know
midwives
have
been
contacted.
Like
in
Kansas,
nada,
nothing.
I
had
to
write
a
letter
to
the
governor,
the
insurance
commissioner,
the
Medicaid
office,
and
the
DOH
to
get
a
meeting
to
ask,
what
are
y'all
doing
with
Pillar
One?
Do
you
have
recommendations
in
the
world
you
live
in
of
how
to
get
the
attention
of
the
very
people
who
are
who
are
administrating
the
funds
and
are
supposed
to
be
in
this
pre-planning
phase?

SPEAKER_00
47:11

Yeah,
whoa,
that
is
it
is
it
is
a
mystery.
Um
so
not
not
specific
to
this
state,
but
so
and
when
you
say
Tima,
can
you
just
the
transform
the
transforming
maternal
health
grant?

SPEAKER_01
47:29

Okay,
17,
yes,
17
million.
You
might
not
be
as
familiar
with
it,
but
it's
17
million,
15
states,
value-based
payment
reform
for
maternity
care.

SPEAKER_02
47:41

Yeah.

SPEAKER_01
47:42

And
pillar
number
one
is
to
do
a
workforce
assessment
and
integrate
midwives,
dualism,
birth
centers.

SPEAKER_00
47:51

So
if
I'm
I'm
just
gonna
put
myself
in
a
situation
of
being
you
and
not
knowing
perfect
what
is
what
the
heck
is
going
on,
yes,
and
so
like
someone
give
me
the
skinny,
how
do
I
get
engaged?
Where
are
the
engagement
work
groups
happening?
Who's
doing
what?
Um,
so
I
must
say,
because
I'm
one
of
those
people,
I
would
probably
go
straight
to
the
secretary
of
the
health
and
human
services
department
and
to
the
Medicaid
director
and
the
uh
Department
of
Public
Health.
And
I
wouldn't
let
up
until
I
know
where's
that
RFR
or
you
know,
request
for
research.

SPEAKER_01
48:38

Do
you
know
do
you
know
what
I
was
told,
Ellen,
for
Kansas?
They
didn't
have
permission
to
let
me
see
it.

SPEAKER_00
48:44

Okay,
well,
I
would
say,
what
does
that
say?
Are
you
going
to
be
engaging
not
only
people
who
are
midwives
to
inform
and
shape
the
program,
but
also
midwives
to
read,
review,
evaluate
the
quality
of
the
proposal?

SPEAKER_03
49:08

Yeah.

SPEAKER_00
49:08

And
then
the
third
part
is
oversight
and
implementation,
what's
the
plan?

SPEAKER_01
49:16

Yeah.

SPEAKER_00
49:16

And
so
I
from
start
to
finish,
that
whole
thing
should
have
mid-wiffery
and
people
who
are
a
part
of
the
system.
And
then
they're
always
procurement
rules,
right?
So
if
you're
sitting
on
the
oversight
panel
informing
and
shaping
the
development
of
this
implementation,
guess
what?
You
can't
really
bid
on
that
as
an
organization.
So,
how
do
you
get
objective
folks
who
aren't
doing
it
too,
you
know,
in
any
business,
right?
Pocket,
right?
Pocket
the
money,
get
the
benefit
of
shaking
a
certain
certain
way,
like
small
group
who's
situated
in
this
town
and
da-da-da-da-da.
Yeah,
and
you
can
you
always
have
to
be,
you
know,
um,
you
know,
ethical
and
honest
about
those
engagement
practices,
or
you
you
askew
that
process
and
you
just
have
open
public
forums,
convenient
around
the
lives
and
you
know,
your
hours
and
midwives.

SPEAKER_01
50:18

They're
not,
they're
not,
they're
not
doing
it,
Ellen.
And
they're
in
nearing
the
end
of
year
two
of
a
three-year
planning
phase
and
a
10-year
grant.
And
so,
you
know,
we
you
just
said
you
just
said
an
oversight
group.
Like,
I'm
mad
now.

SPEAKER_00
50:32

I've
I've
had
my
always
oversight
because
what
are
the
what
are
the
metrics
you're
managing
too,
right?
And
how
are
you
paying
them?
And
that
that
is
how
you
how
you
ensure
that
programs,
right?
Yeah,
in
the
government
where
the
money
is
spent
on
the
things
you
want
to
spend
the
money
on
for
the
outcomes
you're
aiming
to
achieve.
It's
really
simple.
Public
policy
has
to
be
about
making
good
policy
to
spend
the
money
the
right
way.
I
get
that.
You
not
being
at
the
table
is
quite
frankly
up
very
upsetting,
very
disturbing
because
you're
the
folks
on
the
front
lines.
Are
they
enlisting
the
um
you
know
communities
of
color?
Are
they
at
the
table?
Are
so
when
policy
happens
in
a
vacuum,
as
we
know,
it
it
never
quite
works
well
when
the
rubber
meets
the
road,
because
the
people
who
experience
it,
the
people
who
are
in
charge
of
doing
the
work,
the
people
who
benefit
from
the
work,
the
consumers,
none
of
that
actually
may
fit
with
reality
on
the
ground.
And
it
always
has
to,
you
know,
fit
with
the
assessment
of
the
capability
and
understanding
of
the
assets
of
the
people
who
are
going
to
be
providing
the
change.

SPEAKER_01
52:01

I
think
the
problem
here,
as
and
I
agree
with
everything
you're
saying,
is
this
roadblock,
similar
to
the
rural
health
transformation
grant,
of
which
some
do
have
34,
35
have
maternal
health
initiatives,
maybe
not
midwife
specific.
We
can't
get
to
the
table,
Ellen.
And
so,
you
know,
my
my
my
my
next
move,
which
I'm
strategically
doing,
but
underground,
not
so
much
now,
is
to
get
all
these
states
together,
the
midwife
voices,
and
go
to
the
federal
government
and
say,
what's
going
on
here?

SPEAKER_00
52:36

We're
in
the
dark.

SPEAKER_01
52:39

Yeah.
I
mean,
I
don't
know
any
other
pathway
for
our
voices.

SPEAKER_00
52:44

Yeah,
it
is,
and
that's
what
I
thought
at
first
uh
when
you
were
saying
that
uh
what's
interesting
is
every
so
they
have
an
urgency
to
spending
the
money.
Yes.
Right.
And
so
a
lot
of
people
feel
that
this
is
a
huge
win
for
tech,
right?
And
digital
platforms
and
everything,
because
how
do
you
spend
money
fast?
Yeah,
yeah,
you
know,
you
use
technology,
Project
Echo
is
a
win-win,
you
know.
I
and
so
spending
it
fast
and
getting
outcomes,
and
you
have
to
prove
that
you're
doing
a
good
job
with
the
rural
health
transformation
fund.
So
almost
if
you
can
think
about
all
change
is
incremental,
and
boy,
you've
been
waiting
for
that
change,
and
it's
been
incremental,
and
so
you're
probably
sick
of
hearing
that
word.
But
where
do
you
intersect
with
the
ones
who
are
getting
the
money
with
project
echo?
And
so
I'd
be
knocking
on
their
door
and
saying,
How
do
we
then
provide?
And
you
can
you
can
intersect
with
Project
Echo
to
find
out
a
little
bit
more
what
all
those
pathways
are
for
you,
but
also
you
don't
want
the
train
to
leave
the
station,
which
is
your
obvious,
like
it
is
a
real
concern.
But
I'd
also
be
going
to
the
legislatures.
I
I
would
also
be
going
to
the
champions
in
your
state
who
like
we
have
uh
Catherine
Clark
in
Massachusetts.
She's
the
she's
amazing.

SPEAKER_01
54:27

Like
go
to
the
established
coalitions
and
the
powerful
voices
and
let
them
know
the
situations
we're
in.

SPEAKER_00
54:35

Yes.
I
and
and
right
now,
not
having
a
seat
at
the
table
means
that
this
thing
goes
forward
and
you
don't
know
that's
right
to
what
extent
it's
gonna
encompass
and
who
does
have
a
seat
at
the
table.
Right.
And
people
who
do
have
a
seat
at
the
table
don't
like
to
give
up
their
seat,
and
some
people
don't
like
to
share
it,
and
some
people
use,
you
know,
like
Harry
Potter,
you
know,
the
cloak.
And
so
I
don't
want
to
let
you
know
what's
going
on,
yeah.
And
so
then
it
becomes
super
secret.
So
are
you
saying
we
need
to
get
more
intentional
and
savvy,
and
our
voices
need
to
not
be
so
they
can't
be
quiet
and
uh
like
uh
Katie
Elizabeth
Katie
Stanton,
Eleanor
Roosevelt,
none
of
those
women
got
anywhere
without
ruffling
feathers
and
maybe
even
being
seen
like,
oh
god,
that
I
mean,
women
get
it
all
the
time.

SPEAKER_01
55:38

I
I
have
another
t-shirt
logo
here,
Denise.
Are
you
ruffling
feathers?

SPEAKER_00
55:44

Yeah,
and
I
mean,
are
you
making
good
trouble
too?

SPEAKER_01
55:47

I've
liked
that
one.
I've
always
liked
that
one.
Yeah,
but
you
know,
we
I'm
thinking
back
on
on
our
conversation.
We're
we're
not
at
an
hour,
but
man,
I
have
heard
so
much
from
you
in
this
time
that
I'm
just
like
on
overload
because
no,
no,
no.
Uh
no,
please
don't,
because
it
shows
information
is
good,
and
it
shows
our
listeners
how
much
we
don't
understand.
We
might
we
might
like
know
up
here
that
it's
complicated,
but
when
it
comes
to
your
world
and
the
complexity,
the
data
that's
required,
the
analytics
of
the
data,
it
is
crucial
to
the
leverage
that
we
are
trying
to
espouse
with
a
very
small
N.
Very
small
N.