COVID-19 Webinar Series Session 20 – Tensions, Tradeoffs, and Takeaways: What’s at Stake for America 100 Days into the Pandemic  and Where We Go From Here

12:00 p.m. – 12:05 p.m.     Welcome and Introductions

Sarah J. Dash, MPH, President and CEO, Alliance for Health Policy

@allhealthpolicy

Rachel Nuzum, MPH, Vice President, Federal and State Health Policy, The Commonwealth Fund

@raenuzum

12:05 p.m. – 1:00 p.m.       Moderated Discussion

David Blumenthal, M.D., MPP, President, The Commonwealth Fund

@DavidBlumenthal

Nancy Chockley, MBA, Founding President and CEO, and Foundation Board Member, NIHCM LLC and NIHCM Foundation

@NIHCMFoundation

Reed Tuckson, M.D., FACP, Managing Director, Tuckson Health Connections; Board Chair, Alliance for Health Policy

@DrReedTuckson

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.) 0:07 Good afternoon, everybody. And good morning to our friends on the West Coast. I’m Sarah Dash, President and CEO of the Alliance for Health Policy. Welcome. The 20th event in our … webinar series. For those who are not familiar with the Alliance, welcome. We are a non partisan resource for the policy community, dedicated to advancing knowledge and understanding of health policy issues. 0:29 The Alliance for Health Policy, gratefully acknowledge as the National Institute for Health Care Management Foundation and the Commonwealth Fund for Supporting our coven 19 Webinar series. You can join today’s conversation on Twitter, using the hashtag … live, and follow us at all health policy. 0:46 We want you to all be active participants in today’s interactive conversation, so please get your questions ready. 0:52 Here’s how you ask them. You should see a dashboard on the right side of your web browser, with a speech bubble icon with a question mark. And you can use that to submit questions you have at anytime. We’ll collect them and address as many as we can during the broadcast. You can also use that icon, in case you’re experiencing any technical issues. 1:10 Check out our website. All health policy dot org for background materials, and a recording of today’s webinar, which will be made available there soon. 1:18 Just over, 100 days have passed since the coven 19 Pandemic was declared a national emergency on March 13. Since then, over two million people in the US have been infected by the virus, and more than 120,000 people have lost their lives. 1:35 On March 18th, the Alliance, the Fund and the NIHCM Foundation launched this series to provide insight into the coven 19 response and shed light, on remaining gaps in the system. That must be addressed to limit the severity in the United States. During the first webinar, we heard from an epidemiologist about the urgent need to flatten the curve at the time. There were 5000 cases in the US, and we were just starting to understand what that term met. Since that time, we’ve learned as a health policy community and as a nation in real time, as the ramifications of the virus have shown us on issue after issue, just how inter-connected our health care system is with nearly every aspect of our society. 2:14 Today, I’m so pleased to be joined by leaders, prominent health policy leaders in their own right, and leaders of all three of our partner organizations to reflect on lessons learned three months into the crisis, and lay out consideration as we all work to stem the tide of the pandemic and recover and rebuild, not only a more resilient healthcare system, but with it, a more resilient nation. And now, I’m pleased to turn it over to my co moderator, Rachel Newsom, Vice President of Federal and State Health Policy at the Commonwealth Fund to introduce our panelists and open up the conversation. Rachel, over to you. 2:51 Thanks so much, Sarah. And thanks to all of you for joining us. The Commonwealth Fund is so pleased to have partnered with the Alliance for Health Policy and our Code of 1900 series. 3:00 When our organizations began this effort in March, we had no idea we are embarking on the 20th Session series to address the critical issues brought about by the covert 19 pandemic. 3:10 We hope you take away a few key messages today. First, the culvert 19 pandemic crisis is not over. It’s far from over whether we in the we’re in the first inning or the third inning remains to be seen. But given the move to re-open our nation’s economy and our communities, it seems like a good time to pause and reflect on. What we know about the role of covert 19 and its implications for coverage and access, our delivery system and our frontline providers, and the effort to address system inequity. 3:39 The Commonwealth Fund has been addressing these issues for 100 years, and our panel will help us address these issues in more depth today. 3:47 First, I’m pleased to introduce doctor David Blumenthal, president of the Commonwealth Fund. 3:51 He’ll be followed by Nancy …, founding President, and CEO, and Foundation Board member of the National Institute for Health Care Management. 3:59 Finally, we’re joined by doctor Reed Tuckson and managing Director of Tuckson Health Connections and the board chair of the Alliance for Health Policy. Once again, thank you all for joining us today, and thank you for your active participation. 4:12 I’m going to open with an opening question for all of our panelists, and then I’ll turn it over to David Blumenthal to kick us off with his his response and his opening thoughts. 4:21 Covered 1009 was declared a national emergency, as Sarah referenced on March 13th, a little over 100 days ago. There’s still so many things you don’t know. 4:30 Given that we are nowhere near the end of the pandemic, what can we say about how our health system responded? What’s working well? What do you see as the next immediate area for action? What are the longer term steps needed to move the US towards recovery and rebuilding? 4:45 We’ll start with you. 4:49 Thank you so much, Rachel. 4:50 And I want to thank our partners at the National Institute for Health Care Management, and the Alliance For they’re working on putting on this touristic series of webinars and of course, to Rachel and Sarah for their leadership. 5:05 I must say that as I look back over the last few months, it is almost certainly the most challenging difficult period during my 45 year career as a primary care physician, as a health professional, as a policymaker and as a scholar of health policy, we are watching a train wreck of public health train, wreck in slow motion, advocacy, frustrating, and perplexing. 5:32 Now is the time to stop dwelling on the past to start looking forward, to ask ourselves how we can seize the moment learned from experience and make things better. 5:46 This is a moment of choice for policy makers for the country as a whole, about how to make sure that we learn from our tough recent experiences, and learn how to make sure that what we’re experiencing now does not happen again. 6:01 I think, to do that, we need to understand that we are in the midst of soar, simultaneous intertwined, health care crises, that the pandemic illustrates and compounds, but has not created de novo. 6:17 The first of these is a coverage crisis. 6:21 We know that about many people with employer sponsored insurance have lost jobs about assis. 6:33 Those have insurance in the workplace, and they important fraction of those laws are now when insured, when they were previously insured. 6:45 The financing of our healthcare system has revealed to be, has been revealed to be incredibly fragile. 6:50 It depends on the volume of fee for service work That is done by our critical healthcare institutions, especially our small practices. Primary care practices and institutions are incredibly vulnerable. Is this a way to support a vital national health infrastructure, especially during times of crisis? 7:13A third crisis has to do with equity. 7:17 Our long history of racism and discrimination against persons of color has risen dramatically to the floor, twice as many african americans as whites have died of covert 19. This is not new, but it’s staring us again in the face. 7:33 And, finally, we’re now learning that we have a public health crisis. 7:38 We have no effective Public Health Institute system in this country. 7:43 We cannot say that. 7:45 Without a public health system, we don’t have one. If we don’t create one going forward. We will be a victim of the next pandemic just SBAR this week so I’d be happy to talk more about each of these crises as we go forward and about options to deal with them. 8:06 Thanks so much David and Nancy. 8:11 Hi. Thank you Rachel and and Sarah. I’d like to add my thanks to this incredible job that you have done with these rapid response webinars. I think they’ve proven to be a very valuable resource, resource to decision makers, and I just want to thank you all for your hard work, and leadership on that. 8:31 I’d like to start my remarks today by recognizing the heroic efforts of people across the country as they face this pandemic the health care workers and the essential workers, the millions of people who’ve stayed home. And those that shuddered their businesses, including many medical providers. 8:52 There’s a lot to celebrate and how Americans have responded to the pandemic, despite the many, many well documented failures, which, I know you’ve covered in depth in many of the, the previous session. But I think it’s important to recognize what has gone right. 9:12 Today, we’re at a pivotal moment in the pandemic probit 19 Cases are surging and more than half the state. 9:18 Leaders are under incredible pressure to re-open, given the economic devastation, and as people grow fatigued of social distancing. 9:28 And as Rachel said, we’re still in the early innings, and of course, this fall, we’ll also be dealing with the flu season. 9:36 You know, we talk about testing, contact, tracing, and recent advances in therapeutics. 9:43 But it really seems that we are largely counting on the arrival of a vaccine and why there’s lots of reasons to be optimistic about the discovery of a vaccine for covert 19. The history of vaccines for viruses is actually a cautionary tale. So it does give me some concern as we addressed some of these forward looking issues. 10:05 But as David has alluded to, one of the things that pandemic has done is laid bare the flaws in our health care system and in our society, especially around health and equity. 10:18 The human stories of the pandemic are of the fortunate majority. 10:22 Those of us lucky enough to be able to work from home, enjoy time with our families, and Marvel at how productive the Zoom meetings are. 10:32 And it’s also the stories of the unfortunate minority. 10:36Those that can’t work from home don’t have reliable childcare and our contracting Kobi 19 at high levels and suffering severe health consequences and even death. 10:48 These human stories are playing out across an unfair healthcare system, rooted in an economy experiencing historic levels of wealth and inequality. 11:00 People who are black, Hispanic, Native American, and Asians are 2 to 3 times more likely to die from the virus, depend on work that places them on the front line or suffer pandemic related economic hardships. 11:17 So one of the key questions is, will this crisis push us to meaningfully address the underlying structural issues in our healthcare system? 11:26 And in our society, Coven 19 has changed Life for Millions of Americans. 11:32 And even after it is controlled, it threatens to accelerate a mental health, substance abuse, and loneliness crisis in America. 11:41 And we need to ensure that our healthcare system is equipped to deal with this, both in the short and medium, and long term. 11:50There are many reasons to be optimistic, our system is adjusting, telehealth is here to stay, the speed of innovation is changing and learning communities have sprung up everywhere. And we begin to use techniques like virtual clinical trial. 12:06 Care is being safely shifted to less intensive settings, we’re doing less low value care. 12:15 So there are many things that, that we can capitalize as we move forward. But, as David alluded to, many, many problems remain. 12:24 So now more than ever, we must work towards a more equitable healthcare system and society, and that means protecting the most vulnerable, as we recognize and address racial and other forms of discrimination. So I’m very much looking forward to today’s discussion. Thank you. 12:44 Thank you so much, Nanci, doctor … 12:47 good will extend on David’s admonition as we look to the future. We have to learn from the past so, I see the good and the bad. The good news about what we’ve seen is, number one, the values, a physician and health professional professionalism, I have stood the test of time that, the commitment that the young health, professional students, make, when they graduate. They, are Hippocratic Oath that those are enduring values that inform our society, and our profound, and were profoundly demonstrated through this. Crisis number two, the ability to flex and expand the hospital delivery system. With remarkable innovativeness. The capacity that so many of our hospitals demonstrated to create new wards to create new ICU capacity and doing it with a rapid turnaround was, I thought, extraordinary and, praiseworthy, number three. 13:40 The ability to create a real-time learning laboratory, which facilitated identifying novel clinical insights from the provision of care, even in a chaotic environment that we had with rapid real-time dissemination of those insights. And continuous modification and adjustment of treatment protocols, are, our journals responded, well, Our professional societies responded well. And we learned a lot and used in knowledge, continually upgrading, and changing and modifying clinical performance. I thought that was extraordinary, Useful number for the advancement and adoption of Telehealth is a watershed moment in the future. 14:16 In the history of health care, the bad things are number one, we don’t really have a health system. So, to talk about how the health system performed, it’s probably a non-sequitur. What we have is a broken system where not only as David has indicated with the brokenness or public health, but the connection or the interconnection between public health and clinical medicine, that part is clearly broken. 14:38 Something that really needs to be attended to. We also know that the slowness not only of testing as a problem but what is not getting enough attention is the sub optimal capacity of contact tracing. And it’s not just a capacity of contact tracing, but the ability to gain the trust of the American people in being able to to to get at that. Number two, what is really bad? Is the politicization of science and public health. The inability to overcome the legacy of distressed by people of color and other populations, the attacking of public health officials and the intimidation of them, through the politicization is important much of this is outside of the control of the health system, but let us remember and not take ourselves off of the off of off of the scrutiny table. 15:31 Be clear that we have failed in our health system to maintain or build those trusting relationships that could have withstood the challenges at the moment. So while exacerbated by the behavior of too many public health public officials, political leaders, making it worse. But unfortunately we did not have the resiliency built into the system that we should have had. number three, what is bad, is the unpreparedness, not only of testing but the unwillingness to document. Subpopulations epidemiological trends so that we could identify hotspots early. 16:06And then lastly, I think the bad from what we’ve learned is and we’ll talk about this I’m sure one a few moments the new challenges that this provide provokes for affordability to care and access to care. So, it’s a picture of good news and bad news, unfortunately, more on the bad than good. 16:34 Thank you so much. And now I’m going to turn it over to Sarah Dash for our next session. 16:43 Great, thanks Rachel. Well, thank you to each of you for really outlining just just a tremendous scope of, you know, really the good, the bad, and the ugly as we as we look over the last few months. And look forward. 16:58 I’d love to follow up. Doctor Toxin just on. your last point around affordability and coverage. And this has been, this has long been, you know, a challenge in the country. we’ve made strides, but certainly are not there yet as far as coverage and affordability and, you know, as you and the other. And the others have pointed out. 17:18 You know, we also have, of course, these tremendous health disparities that that covert has really shined a spotlight on, but that we’ve known about for a really long time. We know those disparities really extend into the realm of, you know, of coverage and affordability. 17:36 How do you see that intersection playing out as we move forward? Any, does this crisis create an imperative to take a closer look at coverage, and affordability, you know, kind of equity, like, will that alone, solve the problem, Can you start us off there? 17:55 So clearly, before …, we had an affordability crisis with extraordinary percentages of the American people unable to afford their co-pay or their fundamental insurance. And the number of people that were in collection for medical debt, clearly those are, again, exacerbated and exemplified greatest by subpopulations, groups, people of color, those who are poor. So those issues were clearly in front of us now. We will have to have a complex equation As we reset what the, what the costs of care will be as we will. 18:32 Will we expect hospitals to maintain the capacity to have excess capacity to meet search not only for the later stages of this, but for the next pandemic. Will we have more capacity and redundancy built into the system or not that’s a decision that would have to make in terms of the bricks and mortar. We have to understand what supply chain dynamics are going to look like and whether or not those supply chain, redundancies will be built in and what the economics will be for. What we’ll compare to pre covert appear to be inefficiencies built in. 19:08 You subtract from that, perhaps the savings that could come from telehealth if used intelligently or will telehealth be an hour augmentative and additional cost and not taking costs out of the system. So those are the unknowns. Inevitably, we are going to certainly see that nothing about this epidemic or this pandemic will lessen the cost challenges. 19:30 And that means then that people who are a dependent who are low-income people or dependent on public funding and public insurance are going to have a very hard time. And I would leave my answer concluded with, in particular, in terms of your question. The real sensitive spot for me is what’s going to happen to Medicaid reimbursement. Because if we find now that Medicaid reimbursement continues to be suboptimal, lilo and providers are unwilling to take Medicaid, which will be a disastrous input implication for so many people in this country, then we’re going to not only worsen disparities. But we’re also going to set ourselves up again for having rebound opportunities for pandemics, such as this. 20:18 Great. Thank you so much, doctor … and doctor Blumenthal, you. You talked about the coverage crisis, the equity crisis, and the delivery crisis also intertwined. 20:30 What are your thoughts on on this intersectionality, and as we think about moving forward? 20:38 Well, Sarah, I think we face a critical choice in the next election about whether we are one country, when it comes to protecting people from illnesses that affect everybody, or whether we’re going to remain divide it the way we have in the past. 20:57 This epidemic has shown that when people don’t have health insurance coverage, don’t get kids they need. 21:04 They don’t get into the system, and they were vain, infectious, and then create vulnerabilities for their co citizens in ways that is now graphically clear. 21:17 So, the question, we, two phases, whether we now see coverage as vital to our national welfare, if we do, there are plenty of options going forward, ranging from the most extreme Medicare for all to modest changes in the Affordable Care Act, expand coverage and affordability. 21:41 With respect to affordability, the, there is a sweet spot where prospective payments, capitation and world variations on that can create more stability of financing for our delivery system while at the same time, keeping a counterfeit fitting accountability for providers of care that will cause them to be more judicious in their use of services and also their pricing of services. So I think that’s one of the great opportunities we have right now. 22:14 which is to say to our providers of care, looks, this has shown that your dependence on fee for service volume leaves you incredibly vulnerable at a time when … are likely to occur. 22:27Wouldn’t you prefer to have a guaranteed source of revenue in, return for taking responsibility or group of patients, exactly incentives for cost control, as well as for stability? 22:47 Could I just augment? one thing that David said, which is extremely important, and I really like is’s response. And that is, in addition to value based reimbursement, models that he described are also a huge incentive for the delivery system to partner with public health. Because there are clear incentives there as you look at the holistic care of the patient and not just piecemeal fee for service to be concerned about the precursors of the illness, the identification of disease early. And being able to mobilize assets and resources to kept the keep the patient from tipping. From risk factor to actual manifestation of disease. So all of those harbor well also in addition to the great points that David has made to stitching together the public health and the clinical care delivery system more effectively. 23:35 Great. Thank you so much for that. And we want to get into a whole set of questions around delivery system next. I want to just, I want to follow up on something that David said, and then, and then I’ll turn to. Nancy if you have any, any thoughts on this, you know, as it relates to coverage and affordability, obviously? 23:54 We can’t ignore the economic impact of people, you know, staying at home. 24:00 We know we’re in probably the worst economic crisis since the Great Depression with tremendous job loss, and, you know, a lot of job loss among, you know, the folks who just don’t have the opportunity to stay at home and and those those sorts of things. And, of course, job are tied the coverage. So, David, maybe, I know you and the fund have done a lot on this. Can you comment on that? Like, what do we know so far? 24:28 What’s the evidence so far about job losses as high debt coverage. And what are the equity implications there? 24:38 Well, we we know that about two fifths of the folks who have lost jobs have employer sponsored insurance. 24:53 Either they or their dependents are covered under employee plans. 24:59 And of those two sets who have lost jobs, have employer sponsored insurance a fifth become uninsured. 25:11 Some of them have gotten Medicaid, some important, but plants on the Affordable Care Act marketplaces, some furlough and still have insurance while they’re furloughed. So they might lose it if they lose their jobs in the future. 25:26 But assist, those people have joined the ranks of the 30 million uninsured who were uninsured prior to the pandemic. 25:37 So there is a direct in the employer sponsored insurance regime. 25:41 There is the direct link between the strength of the economy and the level of coverage that we have. 25:49 The numbers of uninsured we have, this of course, is a moment when we have to ask ourselves than there are many out answers. 25:57 Is employers plus insurance the basis for a humane and predictable adequate level of insurance coverage in this country. 26:09 Thank you. Alright, so now, I want to ask you what you think of this, And I want to leave a comment. We just back from our audience around, you know, they don’t think the primary issue, is lack of coverage and affordability. But the audience member talked about, you know, it’s more a problem of poverty, education work, conditions, and environmental exposure, food and nutrition long before anyone needs health care. 26:31 And maybe, you know, as you’re as, as you as you think about, know, these, these issues around around health equity and how coverage FRB ability. You know, potentially it. Like how do you think it’s fitting into the bigger picture? 26:46 Great, Thank you, Sarah, and I’ll just build on the previous speakers comments as well as addressing specifically more of the equity. You know, we’ve been dealing with coverage and affordability for a long time, and we’ve made some progress on coverage with the passage of the ACA. But of course, the Supreme Court is hearing the case on it now, where 23 million people might lose their coverage. 27:14 Medicaid expansion didn’t happen the way we wanted it to, to, to happen across the whole country, state budgets are been devastated. So there’s a lot of global issues, but more specifically, in terms of the health disparities. As I think, the questioner Rodin, it’s not enough just to provide coverage. We know people don’t even take up some of the Medicaid coverage that has been put out there, and even if they do, they may not have access to physicians. So, this is a complicated question. 27:49 And then, it’s made so much more difficult by some really specific issues related to inequities. And so yes, there is a great imperative to act. And the pandemic has helped people recognize that it’s not only the right thing to do to deal with health care disparities but it’s actually in everyone’s self interest or health is inter-dependent. And our economic lives are intertwined. And the pandemic has really highlighted that to the general population. 28:27 And I think there’s a growing recognition that we’re still dealing with implicit systemic racism and discrimination, And so, if you can call it good news, the good news is, the problem is clearer and more people know about it. 28:42 But, there. But, this is a very hard problem to solve, and it goes beyond the general discussion of coverage and affordability. We need to address a broad array of social determinants of health, and what, what do we mean by social determinants of health? We’re talking about income and employment, social status, and support, education, and child development, and the environment. And these are very large, difficult structural issues related. 29:13 To the health care disparities. 29:16 So, and many key macro trends are making it harder to solve these problems. For example, the concentration of wealth and vulnerability of low wage jobs to automation. 29:28 So, bottom line is that we need to move the needle on this. 29:33 And, we need to make the healthcare system more accessible, yes, by promoting broader coverage, and by making it more affordable, but low-income people, know, healthcare, they can’t afford healthcare, they, you know, the, the average household mix $50,000 a year, that’s very difficult to afford a regular premium. So, yes, we need to do coverage and affordability, but we also need to. 30:10 give people real access to insurance, and to physicians. And, we also really need to deal with these very tough issues related to social determinants of health. And, also, we need to eliminate implicit bias in the healthcare system. So, yes, give coverage less. Let’s make it affordable. Let’s finance or public health program. But, also, let’s, let’s deal with social determinants of health, but also less let’s eliminate implicit bias. 30:45 And at Nic And we funded, a study recently published in science, that was the, for the first time, documented, the degree to which a spending based algorithm fails, to identify black, patients with high health needs, resulting in significant, significant racial disparities in access to care management services that could improve patient outcomes. And, well, no. one intentionally designed these algorithms to be biased. It still captured systemic under treatment of African Americans. And, of course, once this was recognized, all the parties involved wanted to fix that. 31:24 So, it’s a very complicated problem, yes, coverage, yes, affordability, get better funding and broader access to public programs. Yes, let’s make sure there’s a better connection between physicians and minority communities, but let’s also tackle the social determinants of health and the implicit biases in our healthcare system. 31:53 Thanks so much, Nancy. And this is Rachel. I want to turn the topic a little bit back to the delivery system and frontline providers and just to add, we’re, we’re at about 12 30. We’re going to wrap up just before one. 32:09 We definitely want to talk about economic recovery and some public opinion pieces here, so I’m going to ask our, our esteemed panelists to be short and concise with your answers if possible. You know, it’s really hard and these are very difficult question. But I’m going to start with you on the delivery system. We’ve been talking about how the covert 19 pandemic have really put frontline providers and the delivery system of face-to-face with unprecedented challenges. And the hospitals, in some parts of the country have been both overwhelmed by surges, impatience, and some are dealing with the dual an issue of both overpowering demand as well as the vanishing of profitable services that often provide their fiscal stability really difficult place for health systems and providers to be. 33:05 Given where you stand from your vantage point, what does the evidence tell us about? How are our health system and our providers have been weathering the storm? And what are what do we need to do right now to really ensure the resilience of our health system and our frontline providers? 33:29 Unmute their, Thanks, Rachel. It’s a very important question. 33:33 First, I want to say that on a personal level, our healthcare providers have, as we said, really risen to the challenge, as the father of three physicians who have been involved in caring for patients, I see the cost in anxiety as exact every day for them and their families. But as we said, they swore an oath and they go to work despite the threats. 34:03 But the institutions which they work and often the small practices in which they work has proven unstable under stress. 34:15 And I think we have to look at the fundamental causes of that instability and ask ourselves whether a health system that is so vulnerable in times of pandemic is a health system that is properly slyness, properly organized. 34:34 Is it a vital infrastructure, like our electrical grid, or our communication systems that can’t be allowed to collapse when the wind’s? 34:48 Swift wins. 34:50 Hurricane force winds. Blow us, who are calm if we decide that it is such a vital infrastructure. 34:58 I think we can begin to think about ways of financing it, that are more predictable and more stable, while at the same time, provided the accountability for both cost and quality of care. And that’s where I come back to switching much more to a value based or prospective payment budgeted, prospective budgeting kind of approach. 35:21 So that whether debated this up or whether demand is down, D, predict the financial welfare sustainability. that’s just this protected. 35:32 one can of course add on, Alex, Lots of fun things to create surge capacity, which I do think we will need to do in the future, and might be easier to do that. 35:43 If we have the kind of control over spending. That would be implied predictability of spending that would be applied by more value based prospectus reimbursement than we have had in the past. 35:57 So I think we need to look carefully at another. Also we need to recognize this pandemic before it is over. 36:06 Under even the most optimistic scenarios Is going to knocked the wind out of, threatens the existence of critical services like primary care, behavioral health and our safety of institutions. 36:23 They need help right away. We will not have a functional health care system. 36:28 So, it’s a lot to do, but I think we can get our heads around it. 36:32 Thank you so much, doctor Thaxton, I’m gonna have you follow up on that. You mentioned, Medicaid providers talk about frontline providers, You know, serving communities where we can see the need. And yet, there’s that, there’s a disconnect between recovery dollars that have gone out to support providers and the Medica