White House Minority Health Forum

Welcome to the White House. It's really wonderful to have you all here to work on some work that really, really matters. President Biden has said something that I really treasure, which is that America is an idea unique in the world, an idea of hope and opportunity, of possibilities, of giving everyone a fair shot, and as he likes to say, he knows we've never fully lived up to it, but we've never walked away from it, either, and we will not walk away from it now. Everyone here knows that health outcomes in America are simply unacceptable for the richest country in the world. That's true across our country, and it is especially true in our minority communities, in our ethnic majority communities and our racial minority communities. You all know the examples well, I'll just give you one. It turns out, we now have gotten to where we can prevent nearly every case of cervical cancer if we get the screenings and the HPV vaccines in place. (01:05) But when people lack access to those vaccines, and to the healthcare that they need, the outcomes show what happens. Hispanic and Latino people in the United States are over 30% more likely than White people to die from cervical cancer. Mortality rates are over 50% higher for American Indian and Alaska native people than for White people, and Black women, too, are much more likely to die from cervical cancer than other women in the United States. That's unacceptable. It's a status quo that we're not going to accept, because we have a big aspiration, and that aspiration is for a future in which everyone in America can live a long and healthy life irrespective of zip code or of income level, irrespective of gender identity or sexual orientation, irrespective of race or ethnicity. That's what we've got to live up to. We've got a lot of work to do, and we are making progress with this President's leadership. (02:03) In this Biden-Harris Administration, we've made a whole host of important steps. I'll just share a few with you. Under President Biden's Inflation Reduction Act, that legislation, we got legislation in place that has capped the cost of insulin at $35 a month. Think about what that means for making treatment accessible for Medicare D recipients. That means more than 150,000 Black Americans, more than 130,000 Latino Americans, more than 30,000 Asian Americans now have an affordable access to this critically important insulin. Those are communities that all have higher rates of diabetes, and it's essential that we make this accessible. It's critical that we get upstream of where health problems start, and we know that chemical plants have been disproportionately built near lower-income communities, communities of color. That's a long-standing problem. We know that the toxic emissions from those plants cause cancer, and that they cause respiratory illnesses. The Biden-Harris Administration has now released a rule that will cut 6,200 tons of certain types of air pollution, of those toxic emissions every year. (03:16) And when that happens, we're going to be reducing the related cancer risks by 96% in communities near chemical plants that are covered by this rule. This is how you get ahead of the problem, is nip this problem in the bud by making sure that people can live in healthy communities. Annabella mentioned the President and the First Lady's Cancer Moonshot. I think everyone here knows that it's personal for them, but they know it's personal for every family across this country, and that's why it's been such a passionate focus for them for so many years. We are making real progress under the Cancer Moonshot. When they reignited it a couple of years ago, they set two critical goals. One was to cut the cancer death rate in half over these next 25 years. That's about twice the rate of progress we've been making. That's 4 million deaths avoided in that period. (04:06) That's a huge deal. Equally important, they made a commitment to change the experience, and to improve the experience for people that are going through this, the individuals, but their families and their caregivers as they go through this. We're making progress on many fronts under the Cancer Moonshot. Another one that's key to prevention is, just recently, we just announced the first ever legally enforceable standards to keep people safe from PFAS, which of course, are these forever chemicals, to keep PFAS out of our drinking water. We know that this is linked to a whole host of health issues, including cancer. It's an important step. Of course, just this fundamental idea that clean water and sanitation is fundamental to keeping people healthy, and because of that, if you look at the President's bipartisan infrastructure law, BIL is investing $3.5 billion to improve water wells, to improve wastewater systems on tribal lands, and that includes homes for 71,000 American Indian and Alaska native people. This is a huge deal. (05:10) We all understand that there's a lot more work to be done, but I can't tell you how much hope and how much courage it gives me to see the progress that is possible when we start moving out on this work. This administration has made such an important start in such an important direction. We know what all of you do to make this possible. I want to thank you for the work that you're doing, for the partnership with us, and let's get at it, because we've got a lot more to do to get where we need to go. Thanks for having me.

I worked as a nurse in the emergency room at the start of the COVID-19 pandemic in New York City. For many Americans, the COVID-19 pandemic laid bare the health disparities that we will discuss today. For many of us, these were longstanding, well-known health disparities. Like I was told in nursing school, when America catches a cold, the Black community gets pneumonia. I am grateful to be here today standing on the shoulders of those who have always been fighting for equity. We are here to recognize National Minority Health Month. The foundation of National Minority Health Month was laid by educator, author, and civil rights leader Booker T. Washington in 1915. What he began over 100 years ago resonates with equivalent urgency today. This month serves as a powerful reminder of the importance of recognizing and addressing the unique structural challenges faced by racial and ethnic minority populations, including disparities in access to quality healthcare and disproportionate exposure to environmental hazards. (07:18) It is also important to acknowledge that these challenges are compounding in nature. That means that people from these same populations who are living with a disability or are a member of the LGBTQI plus community may experience even greater disparities in health outcomes. I applaud each of you and those on the livestream for the work that you represent, and the actions big and small that you take every day to advance equity. Your passion, your vision and commitment to this work is shared by the Biden-Harris Administration. In recognition that advancing equity is a generational commitment that will require sustained federal leadership and partnership with all communities, President Biden has signed two executive orders to build equity into the everyday business and operations of government, and continue the work to make the promise of America real for everyone. Everyone includes communities of color, tribal and indigenous communities, rural communities, lesbian, gay, bisexual, transgender, queer and intersex individuals, people with disabilities, women and girls, and communities impacted by persistent poverty. (08:35) Like Dr. Prabhakar just said, we have a lot of work to do, but that is how we live up to the unique idea that is America. Thank you, thank you, thank you for being here today. We do have a tremendous program for you, so I want to jump right into it. We have brought together esteemed experts from dynamic backgrounds, from government and the private sector, to help us understand both the problems and the solutions that are needed to advance equity for vulnerable communities. It is my privilege to invite to the stage our first panel, to discuss environmental justice and health outcomes. Please join me in welcoming Dr. Jalonne White-Newsome, Chief Environmental Justice Officer, Ana Mascarenas, Senior Advisor for Environmental Justice at the Department of Health and Human Services, and Michele Roberts, National Coordinator for Environmental Justice Health Alliance for Chemical Policy Reform.

Good morning.

Good morning.

Good morning. All right, that sounds good. All right, well thank you so much for the kind introduction, Annabella, and thanks to everyone for being here. This is the first panel of this lightning round event, and I want to appreciate our partners at the Office of Science and Technology Policy for hosting this event and creating this space to talk about environmental justice. Since day one, it is no question that President Biden and Vice President Harris have made us set forth on the most ambitious environmental justice and climate justice agenda ever, because the core belief is, regardless of who you are or where you come from, everyone deserves to live in a healthy, clean and safe environment. When we think about the reality that there are communities with environmental justice concerns across this country, where that healthy, clean, safe environment is not their everyday situation. Folks are being disproportionately impacted, leading to health concerns like anxiety, cancer, my goodness, lead poisoning, the list can go on and on. (11:11) It's important for us today, again, in honor of Minority Health Month, to talk about that intersection between health and environmental justice. We have a fabulous panel to do that in the little time that we have, so with that, I'm going to jump right in. Again, welcome to Michelle and Ana, and thank you for offering your experience and wisdom. The first question, over the last month, there's been a lot of activity. The Biden-Harris Administration issued the first ever nationally, legally enforceable drinking water standard to protect communities from PFAS, or forever chemicals, a ban on asbestos, stronger clean air standards. From where you all are standing, what do those rules really mean for communities? We'll start with you, Michelle.

Thank you for having me, and for having us, the Environmental Justice Health Alliance for Chemical Policy Reform here. Those who know me know I come with my communities, and when I say us, I just brought us into the room. For us in the Environmental Justice Health Alliance, we span across this nation, and our fence line to some of our nation's, many of our nation's most egregious industrial operations. Many of our communities did not have access to clean drinking water, but then, there were communities who did have access to clean drinking water, however, failed regulatory processes, ideas, get rich ideas, quick ideas, new ways and advanced ways of doing business, incorporating toxics co-opted their water. It prevented them from having access to clean water. These particular policies will help many communities try to gain access to clean air, clean water, clean soils. However, it's a beginning, it's a start. For decades, they have been appealing to local, state and federal regulatory agencies to bring the justice that we are beginning to see in this administration.

Thank you. It is really an honor to be sitting next to you amazing leaders. I am working at the U.S. Department of Health and Human Services, and I'm so privileged to be in this role. I also stand with my family and my community at my back. My mother and family, generations in California's Central Valley working as farm workers, and that instilled from me from an early age that the environments we live and work in affect our health, affect our families, and in fact, have generational effects. When we're thinking about the environment, and environmental actions, and I've been privileged to work in communities, alongside communities, in governments, environmental actions really are primary public health preventative actions. I think that's what's really important in the recognition of some of these regulations coming to fruition, in helping make sure that this administration, many examples of enforcing existing rules and regulations to help build back some of that trust where there has not been enough enforcement over time. (14:54) I think this particular set of regulations are extremely important in recognizing at the fence line, and especially as we heard in the opening, Dr. Prabhakar, that there are 64,000 tons of pollutants that will no longer be released when these come into effect. That is real impact in communities, bringing down cancer risk levels that we know are there. The science is still catching up as to how many of these chemicals interact with each other, and what we hear all the time is, we're concerned about the cumulative effects. For these actions to happen, while we know that more research is needed in certain areas, while we know that we need to look at policies, how they're implemented, it is, I think, a good step forward to see this, and to also be working towards clean air, clean water for many communities. (15:42) I'll just end by saying that this administration is also put forward a focus on civil rights enforcement, and that is important in the context of environmental justice for many, many reasons, and really lifting up the good work of movement leaders alongside Michele, Martha Dina Arguello and Catherine Coleman Flowers, who worked alongside our agencies, and Department of Justice and Health and Human Services, in putting a path for clean sanitation wastewater systems in Alabama. That is a civil rights case using our authorities. I just really want to bring them into the room here, too, because we have so much work that is ongoing, new tools that we're implementing, and it is, I think, a way to open up the conversation of how these environmental actions will also be followed up and connected to our primary prevention strategies, and also ongoing public health needs. In many cases, there hasn't been enough of a conversation in the community about long-term effects, and we know that our experts in the room will need to be stepping in, and continue to be present in that space.

I appreciate you both, and I think what's so interesting is that when we talk about this moment, along with all the actions, and all the tools and levers that we have in place, it is definitely on us to make sure that what we're doing now will have impacts on the generations that come. What's also top of mind is that we have legacy pollution across this country. We have orphaned wells, we have coal mines, we have all these things that communities have been dealing with for decades and decades. Part of the President's Invest in America agenda is to address those coal mines, to address those orphaned wells. What do those investments mean to communities?

That means a multiplicity of things. Just like it takes an all-of-government approach federally, it will take an all-of-government approach locally, and we would do a disservice if we did not go directly to communities upon leaving the room today, because communities, for decades, have been holding up all governments. In the absence of anyone hearing what they had to say, they have continued to build. What do we mean by that? We have been educating ourselves on the solutions. We have been addressing the impacts of the issues. We have even looked at and addressed how it has even impacted our children's learning abilities, their performances in school, the mental health, the criminal justice system, the economics, all of that. All of that is all interconnected, and what we need is to have the moral and political will to be, again, addressing a different way, a systems approach. That systems approach has to address the systemic impacts and issues affiliated and associated with racism. (19:06) That systems approach must begin with the impacts of the legacies, the legacies within this. As brother Booker T. Washington told you way back in the day, we must address, and have the moral political will to address the negative externalities associated over time with legacy as it goes from the banking to the boardroom, to the school board, to the health boards, to that organic chemistry class that was put in place so that some of our brothers and sisters would not get into medical school, to that of those who have ADHD, like me, who possibly couldn't even pass a LSAT score if I wanted to, to that of our brothers and sisters who are still struggling with and wondering and understanding why they can't get out of communities that they told you were overburdened with pollution. There was a deal made to move them out to another home, but no health coverage to make them whole, like Delma and Christine Bennett are saying in Mossville, Louisiana. We must have the moral and political will and courage to hear about the legacy, to face the legacy, to confront the legacy, to overtake the legacy, and

... Then to flip the legacy into precaution, wholeness, well-being, all of that. Are you ready to ride? Are you ready to go? And when we do so my brothers and sisters, because see, this just isn't a color thing. This will help my poor white brothers and sisters in Appalachia. And as my dear sister friend Martha [inaudible 00:21:35] told me in LA, that de-restrictive covenants kept out drilling and fracking from Hollywood Hills. But when our dear Swooner went over the Baldwin Hills, you know Nat King Cole, my grandmother loved him. But he was subjected to drilling and they're still subjected to drilling in Baldwin Hills. (22:04) So we have got to really look at how it is, we have the moral and political courage, and I give thanks to two amazing people, Jacqueline Dickerson Roberts, my mom, who was able to continue to move forward when her mother died at age 16, who had TB and cancer and they wanted to put her in a separate unequal facility to die from the TB. And I want to also give a shout-out to my dearly departed Leslie R. Roberts Sr. my father, who was always broken by the fact that his brother, David Roberts, was also separate but unequal TB. But my grandfather drove him from Delaware back to Indiana where he eventually died. We have got to stop these types of disparities. We have solutions.

Michelle said everything. I really do see this recognition and acknowledgement of legacy of harm and investing and working together as the critical moment that we're in. And so I think that the investments on cleaning up the legacy pollution opens up these conversations, opens up all of our expertise in all of our experiences to see how we can jump in and partner and be meaningfully a part of the solution.

Thank you. That's a lot. And I know we have a little bit of time left, but I want to just ask the question. When we talk about legacy Michelle, we have to acknowledge the legacy that we're dealing with right now, but we also have this opportunity to make, like you said, flip the legacy, leave a different legacy. When we talk about the potential of the Justice40 Initiative and really the goals of delivering 40% of the overall benefits of all these gazillions of dollars to disadvantaged communities, we can change that legacy. So very succinctly, what does that mean when we talk about public health?

The good news is we have this Justice40 Initiative and in the great state of Delaware, I want to lift up Representative Larry Lambert who put together just quickly a Justice40 oversight committee that includes the Department of Health. Unfortunately, we came to our people and said, "We have a problem in Delaware." But the health department said this was pre-President Obama, and now President Biden said, "Oh no, it's the people's Health, it's their lifestyle." Just very quickly now, we are utilizing the Justice40 oversight work to really hold the state health department accountable. And now communities are able to engage in this process and say, "Yeah, it may have been our lifestyle, but it's also these things too. And how do we address cumulative impacts and come with a solution to move forward?"

We're really looking at these place-based structural drivers of health in a new way, and I think in a way we're putting the resources to help reverse those legacies to come up with those solutions together. I just want to emphasize for the vast experience and passion in the room that when we are looking at structural drivers of health, to look upstream at environment as so critical. When we continue to see those disparities and those gaps continue along the whole life cycle, but keep looking upstream to what we know as pollution exacerbated by climate change. Really important to bring into the conversation. So many of these, of the health disparities, chronic disease, lack of access to safe drinking water and sanitation, climate change is a multiplier effect. And as we know, it also disproportionately adds in communities of color. (26:43) And so I think when we look at the hot summer coming up, when we look at all of these health conditions that are going to be exacerbated, we also look to the investments that are being made right now and how we can build them so that it makes our communities in partnership more resilient together and helps reverse those legacies. So I really appreciate being able to be part of this panel. It really is an honor. I'll pass it back to you Dr. [inaudible 00:27:14] .

So again, thank you Michelle for your work and advocacy. Thank you Anna for your work and advocacy on the inside. And I just want to leave with the note that we cannot have healthy communities without achieving environmental justice. They're hand in hand. So thank you for folks that are working in this room and are working outside of this room and let's get there because it can become a reality and a legacy that we can all be proud of. Thanks so much.

That was such a powerful panel. Thank you. Thank you. So to speak with us next about access to care and social drivers of health, I'm thrilled to invite our next panel to join us on stage. Please join me in welcoming Christen Linke Young, Deputy Assistant to the President for Health and Veterans Affairs, Dr. Aditi Malik, Acting Director of the Office of Minority Health at the Centers for Medicare and Medicaid and Dr. Robert Winn, Director of the VCU Massey Comprehensive Cancer Center.

Hi everybody. It's great to be here with you today and I look forward to a discussion with a really incredible panel. I want to dive right in. We only have a few minutes to talk about a lot of ground, and I want to start on the idea of access to healthcare and what that means. The President places such a high priority on making sure that Americans have access to the healthcare system and the health that comes with it. We are incredibly proud of the fact that more Americans have health insurance than ever before today, thanks to our work to build upon and really deliver the promise of the Affordable Care Act. (29:06) We are working to make health insurance more affordable and we are also working to make healthcare more affordable. Medicare is at the negotiating table right now for the first time in history, trying to get a fair price on 10 of the most expensive prescription drugs so that our seniors have better access to medicine. But we know this is just the beginning and there is so much more work to do to make health and the healthcare system accessible to the American people. So I'd love to hear from you Aditi a little bit about what access to healthcare means at CMS.

Thanks, Christen. And can folks hear me? Yes. I'll just add my quick thank you to the OSTP folks for having us, convening us today. Access to healthcare. I'll take that in two parts. First is coverage, and you said it. Coverage is necessary but not sufficient for access to healthcare. Many of us in this room I will assume carry health insurance cards in our wallets or have them at home. What we take for granted is that that is a gateway to be able to see a primary care doctor for those of us that are caretakers of people, big and small, to be able to take care of our families with a peace of mind that again, I think, many of us take for granted. Because of historic investments, historic legislation that has happened during this administration, CMS, which is the Center for Medicare and Medicaid Services now covers over 160 million people in this country. That's one in two Americans that are covered by Medicare, Medicaid and CHIP or the marketplaces that were established by the Affordable Care Act. (30:43) And alongside that healthcare coverage, I think the second part of that question is helping make sure that people can actually do something with that healthcare coverage. And things like, first of all, making it easier to enroll in the program. If any of you have tried to enroll in Medicaid or Medicare or social services programs, it's not that easy and simple things like being able to take your eligibility in one program and use that as a basis for eligibility in another program based on the rules that exist. Simple things and sort of common sense solutions that this administration has really championed, that will make it easier for eligible people to access those programs. (31:26) And now again, that's the second piece of access. That idea that, "Okay, once I have this card, what does it get me?" That's things like ... This administration has pushed on things like appointment wait times, provider directories. "How do I know if this person takes my insurance?" Or, "Okay, I can call this doctor's office, but now they're telling me it's six weeks till I can get to see someone." So really putting in place guardrails and standards so that it means something to carry that card. (31:57) And then to the point about affordability, the ability to have insulin capped at $35 a month, for example, or for folks that are on blood thinners or life-saving, life-changing medications for a variety of diseases can now access those medications in a way that will not break the bank so families aren't having to choose from putting food on the table or splitting pills so they can make their medications last longer. So I think in ways both big and small, access really means that in the spirit of America or the idea of America that Dr. [inaudible 00:32:33] shared, that everybody's got a fair shot, a fair shot to get coverage and that that coverage actually means something when they have it.

Thank you so much for that. Robert, I'd love to hear from you about what in there resonates with the experience of your patients and how you would elaborate on what access really means day to day on the front lines in the healthcare system.

Yeah, thank you for that. I was thinking that we need to broaden out this conversation around access. And what I mean is we certainly need to be functioning and working on solving the problems of how to get people to us. But in the spirit of Jack Geiger and the spirit of John Hatch, which were the founding fathers for us of the community health, we have infrastructure. The issue is I think we've under-imagined what we have already put in place since the 60s about maybe going back to the closet and figuring out how we can make these things more robust. For example, the question is not only right care, right time. So that means sometimes they'll have to get to us, but the question is how can we use what we already have in place to reimagine what's possible? So I think of access as not only people getting to us, but what can we use right now to make sure that the parts that we know survivorship with cancer patients, that we can do in the community. (33:46) The second part about that is that you cannot talk about access without quality. I think those two are linked and sometimes we have the conversation around access without understanding that quality matters too. And I'll just quickly say that I learned that from my eight-year-old when I took him to a bike shop. No, seriously. I was trying to give him this bike that was on sale because it was saving me some money. But he understood, he was like, "Well, what about that bike?" But that's what our patients are, in some ways in the communities. The reality is when we talk about quality, there is getting standard of care and there's getting really the standard and the access to all the miracles that we have driven from the molecules that become medicine. (34:25) That's the conversation I think that we could also start having about the payment's going to be important, but also access. It's not just them getting to the mothership or getting to the shiny academics. Why are we thinking what the ACCC and other things about how to move robustly, get things out to people and their workplaces by the way, just saying. Just saying.

Thank you. Thank you so much for that. And I think it resonates with everybody in the room how the healthcare system needs to do more to meet people where they are and deliver care in ways that are focused on population health. And I think that's a great segue to a little bit of a discussion about the social drivers of health. Over the last 20 years, we've seen increasing recognition that where we live, work, play, worship, these things are just as important, if not more important to our health and wellbeing than what happens inside the four walls of a hospital or a doctor's office. And conversations about the social drivers of health have gone from something that happened in rooms like these to something that is becoming more and more woven into the fabric of the healthcare system and conversations that are happening in boardrooms of insurance companies and hospitals and on the front lines with healthcare workers across the country. (35:47) And we are seeing increasing recognition that access to healthy food matters a great deal for our health. That access to a stable place to live is one of the most important things when it comes to so many chronic conditions. That exposure to interpersonal violence, that protection from chronic stress and the challenges of persistent poverty are so much more important than almost anything that happens inside a doctor's office to our health and well-being. But we still have a long way to go from that recognition to systems that recognize that and fully build it into the way we treat people in the healthcare system and we address population health system-wide. So Robert, I'd love to hear from you about some of the work that you are doing in this space and where you see the real opportunities in policy and in care delivery over the next 5 to 10 years.

And I'll try to make this as quick as I can, but it is absolutely true that your ZNA is a much bigger driver on your [inaudible 00:36:50] outcomes than your DNA. Although much of the research has been focused on our biology and DNA, I'm hoping for a day where we can stop blaming people from neighborhoods saying that African American men are going to do worse with prostate cancer because they're African American without recognizing that the structures, the particulate matters that they're associated with, the stress that drives cancer, which we know is now a real science, that we actually also are re-putting some money into that research. (37:14) So getting right down to it, I have to say that there are two things that come to mind immediately that outreach and engagement and particularly navigation aren't just nice things. They're going to be critical things to actually making sure that people stay healthy. And by the way, when I say outreach and engagement and navigation, I actually want us to rethink about how we think about those. Because right now we think about those as activities as opposed to science and new knowledge that gets brought about how to come up with new approaches. So if I had to put my money down in addition to the next miracle drugs, which are important, the immunotherapies and stuff, it really will be in how the science of outreach and engagement and how the business of navigation, how we can level that up to get people to where they need to be. I do think that and diversification of workforces and things are going to be important.

Can you talk a little bit more about what you mean by navigation, what that looks like when you see it working?

I'm going to get a little Drake up in here, but you know, bring a little Drake energy. So let me tell you what navigation isn't. And I work with groups and I think that this is a perfect opportunity to talk about how we are not so much dysfunctional as we are disconnected. We have activities within the AON, which I'm a proud board member on, and which we have nurse navigation. But we also know that sometimes people don't trust you if you're not in a neighborhood. We know that from Harold P. Freeman. We also know from the work from Dr. Geiger and Dr. Hatch, that putting people and having community activators to get you connected to navigation at the different levels to the game. We think navigation is simply getting you through the health system, but there is the navigation and crossing that bridge of activating the system for you in the first place so that you can be navigated through the health system. (38:58) And yet when we talk about navigators, we're still stuck in a very 1980s, 1990s sort of model. I think it's time to actually add levels to the game, which is why I say there is a science actually to navigation as well as an activity. And so from my perspective, we're working in Virginia and at VCU in creating this connectedness between what I call community activators and navigators. And one quick example is that with most of our designated cancer centers, if you are a donor or if you are the namesake of that building, you know what you do? You get on the phone, you call somebody and you activate a system that you then get navigated. Why don't we do that same thing for people who are living in the areas of poverty? That's what I'm going to try to be about. That's what we're at least starting.

Thank you so much for that. Aditi, can you talk a little bit more about the policy levers and the work going on inside the federal government to try to bring more care that looks like that gold standard to communities across the country?

Yeah, I love that. This is the question of how do you pay for it? How do you connect the dots of what we think it should look like? And then how do you connect the dots so that it actually gets funded and reimbursed in a meaningful and robust way? So I'm going to wind us back to give you some overarching view on this. And then I promise to come back to that payment piece that I think is so critical. Paradigm shift, I think in the last 5 to 10 years around the importance of social drivers of health. It is no longer a thing that we write in the medical chart of housing unstable. This is the reason the person is in the hospital. They're here because they don't have a roof over their head. They're here because they don't have food to eat. And so we just can't ignore it anymore. And I think that that's the real paradigm shift that's happened clinically. Communities knew this decades ago and we're just catching up. And I think the policy is just catching up, which I am so excited about. (40:58) So from a CMS large payer perspective, that means a couple different things. It means requirements around screening. Before, heretofore, it's been, "Well, if I happen to ask whether you have a healthy food to eat." It might come up in conversation. It might not. And again, in recognition of the fact that we can't really ignore it anymore, we are now screening across a number of settings with standardized tools to really understand what is the incidence, what is the prevalence of food insecurity, housing instability, lack of access to transportation across the populations that we're trying to serve? Treasure what you measure. And if we can't measure it, we can't fix it. And so starting with screening. (41:40) Then two, really important to this navigation point is the idea of making investment in life-changing, life-saving services and supports. And so I'll start with care navigation where we've kind of kicked off this thread. As of the Medicare physician fee schedule just

... within the last year. It's a billable service. So enrolled providers in Medicare can provide a navigation service, and I sure hope it looks like that, can provide that service and bill for it and be compensated for that time, because for too long it's been the add on, it's been the accessory, right? So people get paid... We have a healthcare system, by and large, and this is changing, that gets paid for doing things to you, not that gets paid for doing things for you-

Come on.

... right?

Come on.

And so this is a real opportunity to say, well, navigation is something for a person, right? We can throw all the chemotherapy in the world at you, but if you don't understand or have access to the supports that get you to appointments, it's meaningless, right? And so care navigation, it's called Principal Illness Navigation, there's actually a number of different codes, but Principal Illness Navigation for those that want to Google it now or later. (42:59) The other thing I'll highlight is Community Health Integration, very similar, for folks that are trying to navigate, "I don't know how to call a food bank. I don't know how to get myself on a Section 8 housing voucher list," right? "I'm taking care of children and trying to work full-time. I don't have time for these things," right? And so the ability for a clinical enterprise, whether it's an oncologist, a cancer center, or a primary care doc or whomever, to invest in building the staff, building the infrastructure, building the community connections, and be compensated for those time and efforts. (43:39) And then another, in the interest of time so I'll just highlight, in addition to those supports, services that directly address unmet health-related social needs, right? So an individual says, "I don't have food to eat." There are a number of states now through a variety of Medicaid flexibilities that for high-risk eligible individuals can directly offer food to that person as part of an individualized care plan. The same with housing navigation services, right? (44:11) So we work very closely, and I see some partners in the room and I hope some are listening from the Department of Housing and Urban Development, the US Department of Agriculture, in the spirit of a real whole of government effort to say these factors, influence peoples' health, and we need to come together and build the bridges across our silos to be able to address those things, and now we see that happening through payment.

Thank you so much for that, and I think this is some of the most exciting and energizing work going on in partnership between the government and payers and health systems across the country. I also think there's a really important next generation of this work to make sure that we don't over-medicalize things that-

There's just so many.

Yes.

... shouldn't be over-medicalized. And it's great to be turning on payment flows and letting dollars move, but we need to make sure that this continues to stay in the spirit of representing communities and speaking to communities in a way that feels culturally competent and representative, and I think there is such an important new generation of this work to come. (45:14) So I think that just about wraps up our time. Thank you so much to our incredible panelists, and I look forward to continuing the discussion today.

I don't know how else to say it, but these panels are fire. Thank you so much. It is my pleasure to welcome last, but not least... I'm too animated. Last, but not least, our third panel to discuss research innovation for health equity. They have already come to stage, but from right to left, please join me in welcoming Dr. Cameron Webb, Director of Health, Policy, and Equity at the University of Virginia School of Medicine; and former Senior Advisor to the White House Office of Covid-19 Response, Dr. Carmen Guerra; Associate Director of Diversity and Outreach at the Abramson Cancer Center, University of Pennsylvania; and Dr. Eliseo J. Pérez-Stable, Director of the National Institute on Minority Health and Health Disparities. Sorry about that.

Thanks so much, Annabella. And I think it's great to be here. They weren't playing when they said lightening panels, were they? Really important. Our panel here is talking about research innovation for health equity, and when you think about research and health equity, so often a lot of us in the room and on the livestream will say we've studied the problem enough. Studied the problem, studied the problem. When are we going to act? (46:38) But we actually, I think, want to take a second for this panel to talk about how critical it is to continue that ongoing work to study the problem as you just heard, "Treasure what you measure," right? And as we say in healthcare often, "You can't treat what you don't see." If we go back and think historically, I want to frame this as the past, present, and future in this research space. This isn't a new conversation, researching for health equity. If you go back to 1899 it was W.E.B. DuBois and the Philadelphia Negro, right? Chapter 10, really studied it. It's a sociological study, but looked at those health outcomes and the differences between Black Philadelphians and white Philadelphians, and saw some clear differences in mortality that were critical. (47:19) You can fast-forward, and we know that in 1988 it was what was known as the Heckler Report, but it was the Secretary's Task Force on Black and Minority Health that was out of the Department of Health and Human Services that really again shines a light on those conversations around health outcomes for communities of color. You move forward, and, of course, so many of us know unequal treatment from the institutes of medicine that, again, shines a light onto those issues. These studies are critical, because at each point it accelerates our work. It leads in some instances to legislation, in some instances to the creation of offices and institutes that help to lead this work. (47:56) And so I want to start the conversation just by asking if that's our past, where are we right now? What's the present? When we talk about research innovation and the current state of play, where are things in terms of measuring for health equity?

I'd be happy to start. Thank you, Cameron, for the great question, and thank you for the invitation to be here today. If you look at past, what you see is that a lot of the interventions that we were trying to implement to reduce health inequities, health disparities, have often been uni-dimensional. What I mean by that is that they target one specific social need, for example, or social determinate, and they often were targeted at the individual level. So target that population or this group in the community. (48:42) And I think where we need to go in the future is actually to develop more multilevel, multidimensional interventions that address multiple social determinates of health at once. And we need to address them at the more upstream level. And I think the NIH recognizes that, because in 2022 Frances Collins made the announcement of the first ever research awards. They were called transformative awards for addressing health disparities and advancing health inequity, and there were about 11 awards made over $58 million. I believe your institute was part of that group that was funding these awards through the common fund at NIH. And there are some really creative, really wonderful projects that aim to do this work. This work is hard. (49:38) I'll give you an example from my own institution. We have two investigators at UPENN that were fortunate enough to apply and receive this award, Gina South and Atheen Venkataramani. They proposed a multilevel intervention to address the large inequity in lifespans that we have in Philadelphia in communities right nextdoor to each other. The Black community and white communities of Philadelphia can have 20-year lifespan difference. And so what they proposed was an intervention to address the community level by turning vacant lots into housing and also gardening and trash cleanup. At the individual level, they develop interventions to empower individuals to develop wealth. And at the organizational level, they developed strategies to help individuals take advantage of public programs, public benefits for example. And so what they're going to study is how does that impact health? They're going to measure health at the individual level, blood pressures for example, stress levels, psychological distress. They're going to measure community level connectedness, and then they're going to measure wealth creation. (50:56) So these are the kinds of upstream interventions that we hope will improve many diseases, because I think that's the approach in the past. We've been very disease specific, and we need to increase the research that we do so that it reduces disparities in multiple diseases at once. So that's one example.

What about you, Eliseo? What do you think in terms of where we are right now, how we've grown in our approach to research innovation, and what's the current state of play?

So I'll mention two big picture issues, and thank you for having me here today. This is really great. First, we need to have community engagement. We need to know what our target population, what the community around us is interested in. And that includes, then, both a population health approach from healthcare systems and research groups, and also a partnership approach. So we're not just going to go to the community, take them what we know, and say, "Here. We're here to help you," but we're going to go to the community and say, "Let's talk about what the problems are and let's look for solutions in common." That's one of the approaches. (52:09) And you mentioned before the common fund. We have a big initiative called Compass that is directly funding community organizations, but required to partner with researchers. The Community Engagement Alliance that I co-chair at NIH along with Gary Gibbons, Director of Heart, Lung, and Blood Institute, also has that as a principle, with community organizations receiving a required amount of funding of the awards that are being made. Then a second aspect on the research side is we need to figure out what we're all going to use for measures and be consistent with it, because great that social drivers or food security is going to become more incorporated into healthcare, but the researchers I talk to that we fund say, "We don't really know yet which one is the best way to do it." We have to do some research about this in order then to identify how we can influence that. (53:13) Healthcare is really critical especially when you have a chronic disease, but half the population, they don't need much healthcare, right? They can get by with information, occasional going to get vaccines and doing lifestyle and getting advice. But when you have a diagnosis and you have to take a medicine every day to keep yourself out of the hospital, to keep yourself going, that changes things. And the community needs access to quality healthcare, which was mentioned earlier, but also we need healthy communities doing those structural interventions to get there. And so innovations in research really require a healthy community. We need standardized metrics, and we need partnerships between the researchers and the people that we're trying to help.

I love that. And I also love how it dovetails on the previous conversations we've had, kind of centrality of community in so many of these conversations. If we were going to take a step back and think about it from a basic scientist standpoint, the development of new medications, new therapies, and just looking at health outcomes in general, from a research standpoint, what's missing? What are we missing in our current paradigm in terms of how to effectively study what we need to study to make sure that we're creating opportunities for everybody to achieve their best health?

I can start. We had a lovely conversation on our panel about genomic data and how it lacks representation from all groups, that we'd like to see that, but another example comes to mind, which is in the immunotherapy field. That's an exploding new group of therapies for a lot of diseases, including cancer. And there's some really interesting research that I've read recently that shows that many of the targeted therapies that are being developed for immunotherapies rely on the specific HLA allel that is actually very prominent in mostly white populations in the Americas and Europe, but doesn't represent the rest of the population in the world, Asian populations, African nation populations. And so, as it turns out, this is going to get worse, because of all the therapies that are being studied, somewhere along 80% are specific for that allel in Anglo populations. And so I think we're going to see health disparities continue to widen, and how do we fix that, which is what your question is. And I think the datasets that we use, the samples, the bio- samples that we use, they really need to have the representation that we need of all populations in order for us to not develop therapies just specific for one group, which stands to widen inequities.

Well, a party is not a party until we mention HLA haplotypes, and well known. Anything now?

I would add when I started at NIMHD, I went to a meeting in Atlanta on cancer, and it was a presentation by a scientist from the Cleveland Clinic who said he had made some observations about African Americans and colon cancer, and he goes, "I've got to dig into this some," and he went to the genome atlas to see how many samples, genotypes, of Black patients with colon cancer. There were three available. This was 2015. So I think that's a challenge. And he went on again. NCI said, "We're going to change that," and they have been slowly changing it. We at NIMHHD also help fund a group in California to genotype... this is somatic mutations, they're not mutations in your blood, but mutations in the tumors, in the cancer themselves, on 150 Latina women from California with breast cancer. And they tripled the number that were available in the genome atlas with that one particular effort. We did the genotyping and they did the actual analysis and research. (57:29) So I think there's a lot of work to do in this, but part of it is around communication as well, and we need to also do science on innovation in basic things that we take for granted. How many clinicians who are trained worry about, "I've got to communicate better. I've got to be a better clinician in how I talk to my patients and how I care for them, show empathy." No, they're worried about knowing the facts or missing the diagnosis, which are important. Don't get me wrong, these are critically important. But we just take communication for granted, and yet there's a science behind it. It's a learnable skill. You get better at it the more... Like writing, like these other things, you do get better at it if you work at it and we really prioritize it and value it, which is not built into our system.

In both instances, you kind of allude to the role of race and ethnicity, or at least our approach to measuring that in healthcare settings, and how that's a primary issue, right? We know that so much of our health data is based on subjective impressions of race, and that's challenging, right? And especially in healthcare settings. But how can we get to a point where we do have the data sources that we need to effectively research a lot of different health outcomes, and particularly taking note of the disparities there?

I'll start. Well, race is a social construct. That's a starter. And my colleagues at NIH all, I think, accept that. It has biological components, like it has behavioral and environmental ones, as well, and I think that's the starting point. So what I identify as is what I am, and that's how we should operationalize it and standardize the way we ask it. There are errors, primarily actually in populations that are more mixed, like Latinos, American Indians, Alaskan Natives, people from certain parts of Asia or the Pacific, the South Pacific, but I think we can get there. We know enough that we know how to do it. (59:41) The other is socioeconomic status. We never ask about social class. We don't know where people come from, whether they come from a very sophisticated background or whether they come from a very poor background, first in their family to go to college or persistent poverty has been mentioned a couple times. Most clinicians don't have a sense of that when they take care of patients. And I think in research it's also not measured systematically. In clinical research, I should say, not in population research. (01:00:13) And then the other is geography. We have tremendous disparities, differences, by geographic location, like centers, big urban centers, rural areas, remote areas, suburban areas. So I think these are factors, and others, I'm sure, that I didn't mention that are important.

And I would say your question is very timely, and there's actually a National Academies Committee on this topic. And I agree wit Eliseo that race is meaningless biologically because it is a social construct, but it does have consequences that we need to investigate when we're measuring biologic phenomena. So the real question is what is... If race doesn't have a biologic meaning, what is it being used for when investigators say, "This racial group has a higher risk of this or higher risk of that." And that's the question that investigators haven't answered. What is race a proxy for? Is it socioeconomics? Is it the genetic diversity that we sometimes see in our populations? It is culture? Is it something else? And so I think we as investigators have not done a good job dis-aggregating what are those variables that race is a proxy for that we're seeing as signals. And that's going to take almost retraining of the scientific mind, all the brilliant scientific minds that we have, and so that might be an opportunity for us moving forward is how do we educate and reeducate scientists to really look at what is this in your conceptual model, race, stands for, what is it representing, and how are you going to measure that more precisely than self-reported race?

So we've already touched on it through some of your responses, but we've talked about the past, we've talked about the present. When we think about the future, in terms of research innovation for health equity, what do the next five or 10 years look like ideally in terms of our approach to researching for health equity?

I don't know if it's an ideal approach, but I think that AI, this is the Office of Science and Technology and we haven't talked about AI, stands to transform everything. Not just healthcare, right? But every sector, whether it's education, the military, defense, you name it, it's going to affect everything. And AI has, in my experience, been a wonderful tool that can help potentially change paradigms, and I'll give you a quick example. My colleague, Ravi Parikh, and I are working

... on. I'm a cancer screening investigator and we're using AI to actually predict who's going to have a positive screening test. Because if you think about screening, any kind of screenings, most people are not helped by screenings. They get a negative test. There's a few people that have a positive test and they're helped by screening, right? We found their disease early, we might be able to intervene early, but the majority of people don't benefit from health screening. Maybe they have peace of mind that for another year they might not need a mammogram or whatever the test is. So what we're trying to do with AI is we're trying to identify and predict who are the people that are going to have those positive tests, show that perhaps we can concentrate our limited resources like navigation and healthcare resources on that population that really needs to have that screening test. (01:03:48) But I worry about AI because obviously it has been, many of the machine learning models have been built with very little diversity. And as a result, they're going to just perpetuate some of the discrimination that we already have in healthcare, the structural discrimination. And so the ideal path forward for the next five, 10 years would be a path forward that recognizes the peril of AI and builds in enough protections so that we don't end up widening disparities with AI. (01:04:20) And last thing I'll say is there are examples already in the literature that have been published, which actually strike terror in me as to how AI can be misused. There's a study that was published by two investigators that were using machine learning software to create new therapeutic drugs for different diseases. And they were incentivizing the model for hitting the target and having good bioactivity against a target and decentivizing the model for toxicity. Well, they changed one thing. They incentivized toxicity. They left six hours later, came back, and they found over 4,000 new chemicals, new molecules, that actually can harm individuals. And they didn't know what to do with this data. They didn't know if they should keep it to themselves so it wouldn't fall in the bad hands of people or publish it. They went ahead and published it in Nature Machine Learning. You can imagine the reaction that they got after that. (01:05:24) But AI is a tool and it can fall into hands that don't mean well for us and our healthcare. And so building a system that has those safeguards of who uses that technology and how is going to be really important.

So I'll add in a different direction perhaps. So data science is critical and we don't have enough of people of our communities oriented to data science. And we need more in order to avoid some of these biases and algorithms that we're seeing. However, I can imagine equity in another 10 years, maybe longer or maybe less, where you're really aiming to have healthy communities, communities that address the structural factors we measured, we talked about earlier. Violence was mentioned, green space, the contamination in the air or the water being clean. I think is it Jackson Mississippi that doesn't really have access to potable water in this country? I mean, is that acceptable in the richest country in the history of the planet? (01:06:39) And then you have healthcare that addresses quality in a population basis. And by healthy community, I also mean communities that aren't uniform necessarily. There could be uniform, but I think that there's reasonable empirical evidence from the past that if you have people of different socioeconomic levels, not wealthy because wealthy people are on their own, right? But to avoid this whole persistent poverty syndrome that we've talked about, you have people living in the same community that actually leads to better health and better communities. Now there are examples in the country. They're not talked about a lot, but we can aim for that as a goal.

Well, as we talk about research and innovation, I guess the last question I'll ask, and then we'll close, is just this idea of who are the researchers, right? As we're innovating, where do you think we need the most support and help from a diverse and robust group of young up-and-coming researchers speaking to our future? Where do you think the most need is? And we'll close with that.

Well, I can say that some examples that we've used in Philadelphia have really focused on the public schools in Philadelphia to identify future researchers down the line that might not have had the opportunity. And so I think that that's really important for us, a source of future researchers and for diversification of the research workforce. But you have to reach out to them young and plant that seed because it is a long road to become a researcher. It's an expensive road. So many costs are associated with that decision, both financial and non-financial. And so it's not just merely engaging those populations, but also how can we develop the means to support their retention in that pathway towards becoming researchers.

So the research workforce, if we look at the data, and I'll go the opposite direction, I like to look at people who are in the pipeline, who make it out to the pipelines. How many medical students, how many medical school graduates we have? 14% are from either African American, Latino, American Indian, Alaska native, or Native Hawaiian, Pacific Islander background. And yet those four population groups are about 1/3 of America. We have a problem, and it's not going to be easy to make that problem better given the current legal environment. So we have to look for opportunities to promote the advancement of, in my view, in our institute of the researchers who make it or those who finish medical school, finish a Ph. D. in STEM, in STEM disciplines and make it to that point and then give them opportunities along with everyone else. (01:09:39) Approaching it from a socioeconomic perspective also matters. The University of California years ago made it... Affirmative action was illegal in California based on a referendum. So they changed their strategies about recruitment for the university to do it by socioeconomic perspective and geographic perspective. And overall, it has worked reasonably well. Almost half of the students in the undergraduates in the 10 campuses are first in their family. They have a community college transfer. So how can we think out of the box further down the road to really promote that in the research pipeline?

Well, it certainly starts and continues with conversations like these. It certainly is led in our communities and by so many of you. I want to thank our panelists for joining us today, and thank you all for joining.

I'm so grateful to our panelists. Let's give them another hand. We are so grateful. We're just so grateful to, I guess all nine of you, for both naming the challenges that we must overcome, but also sharing the actionable solutions that will help us overcome them. So really thank you so much. (01:11:04) We are almost at the end of our program. I want to go ahead and introduce our final speaker, a gentleman who does not need an introduction. We are so pleased to have with us today the Secretary of the United States Department of Health and Human Services Secretary Xavier Becerra.

So I hear I'm cleanup, but it's not. Sometimes in baseball, that's great, but if it means you're left at the party at the end, it's not so great, right? I hope it's been both the party, but you also feel like we've hit some home runs because we want you to come back. (01:11:50) I think the message is coming not just from Director Prabhakar, but also from the president of the United States and the Vice president of the United States, is this is your place. You need to come visit us as often as possible and we need to go visit you. I hope we're telegraphing that to you. And if we're not, then I'm going to say it again a little bit later on before I conclude because we don't want to stop this. We want it to grow. (01:12:17) At the Department of Health and Human Services, and I see Ana Mascareñas whose part of our team and I know was on the panel earlier, we do something that I learned when I was Attorney General in California. We had implemented the most far-reaching law to protect privacy over the internet because we saw how everyone's private information was being used for all sorts of purposes in ways that they didn't even know. And so we began something after we had passed this privacy law on the internet, for the internet that no data had done. We started what we called equity by design. I'm sorry, privacy by design, so that everything that we did with regard to the internet and everything that anyone wanted to do as a purveyor of internet or high-tech information, and if you were going to access people's privacy, you had to have privacy in the design of your model if you wanted it to surpass us and our enforcement of the new law. (01:13:20) When I came to HHS, I said we're going to do equity by design at the Department of Health and Human Services so that if you want to send out one of the $1.8 trillion that's in the Department of Health and Human Services' budget, show me that you factored in equity at the very beginning of that idea. Show me how it's going to get to everyone. Equity by design. (01:13:52) Now, we did that because so many of you understand, equity has not normally been in the design of our nation. In fact, if you read the Founding Document, it is absolutely not in the design of that document. And so we have to work hard at it. And so the fact that when I came into this office in 2021, mid-March of 2021, and quickly when I was getting the reports because we were in the midst of the pandemic, the height of the pandemic, and I started getting the reports, we had the vaccine now, by May of 2021, the reports that were getting that about 2/3 of white adults in this country had received at least one shot of the vaccine. At that same time, less than 50% of Black and brown adults had received the vaccine. You were already seeing what we always see in this country, the disparity beginning to grow. So we said no. And this is where equity by design comes in. (01:14:52) So when we initiated our programs to tackle the pandemic, we said, "We're not going to wait for communities to come to us. We're going to go to them." And that's what we did. And we enlisted some 19,000 trusted voices because we knew if we were just trying to peddle this stuff, people would say, "You're peddling stuff." And some communities have real apprehension about... I heard it a lot in the Black community. Tuskegee. That's all he had to say, is Tuskegee. And then you understood, "Don't tell me I'm getting something free because I know at the end of the day I'm going to pay a price." And so we had to have the pediatrician, the clergy person, the teacher, the coach, the barber, the beautician. Whoever was a trusted voice in that neighborhood, that's who we try to enlist. And they helped us. (01:15:41) And by the way, have you heard about the vaccines? Let me tell you as they're clipping here, let me tell you what we're doing. And that's why by January of 2022, about nine months later, 90%,, more than 90% of adult white Americans had received a vaccine. 90% of adult Black Americans had received a vaccine. 90% of Latino adult Americans had received a vaccine. Native American, Asian American. 90% of all of our communities had received a vaccine. We were able to erase that disparity, not by luck, not because it was easy, not by coincidence, it was intentional. That's equity by design. We need you to have equity by design in everything we do. And so we want you now and we're trying to reel you in by inviting you here. So you'll continue to come. (01:16:39) Let me give you a couple of other examples of what we're doing, and they can be very simple things. Last month, actually almost precisely 30 days ago, I was at Howard University, just down the street, not far from here. It was Match Day at the College of Medicine at Howard University. Match day is an important day. Probably one of the most important days for up and coming physicians in America. It was the day that they hear where they will be matched to perform their residency program. So I was invited by the university to address the graduates on the day of Match Day. (01:17:18) I'm going to tell you, the energy in that room, they had in a huge hall, obviously the families there, you could see the excitement, as I said, the energy, but it was more than that. It was the pride. Because in many cases, these were the first to actually have a chance to be those professionals. You have the parents who just couldn't believe that their daughter and their son were on the verge of doing something that they could only hope to have access to at some point. And the stories... I didn't drop the mic yet, but... Maybe she actually stop [inaudible 01:18:00]. But the stories are what really killed it. I mean, my wife's a physician. Her family for a time lived in a boxcar while they were out there picking fruits and vegetables in central California. My dad was a farm worker. He got to the 6th grade and then he had to start working to help support the family. These are real stories. There's nothing more powerful than that. And to get to be part of that and say to them what I just said to you, "We want you. This isn't the last time you're going to see me because we're going to marry. We're going to come together. We're going to do some great things." It's like Humphrey Bogart, right? At the very end, this is the beginning of a really special relationship. And so we want folks to know, equity by design requires you. (01:18:56) Second story. Three weeks ago I was in San Diego because we have a really special program called ARPA-H. Maybe you've heard of it, right? The Advanced Research Projects in Health. It's similar to DARPA, the Defense Department's version, which is credited with inventing the internet and GPS. Big stuff. But we do it for health, so we think we're special. (01:19:22) ARPA-H is out there looking for innovators who've got that idea, but just don't have the capital and want to put an idea that research on the ground working not in 10, 12 years the way NIH usually does it, right? They do the basic research and it takes a while. Two or three years, your idea is going to fly or fall. And we don't mind. We expect a few failures, but we want to see if you can fly. (01:19:54) So we were in San Diego for a special reason. We went to San Diego State University because it is a minority-serving institution. We invited people, professionals, students from the various minority-serving institutions in the Southern California to come learn about ARPA-H because we don't want just those who are already in the know, who are already in the circle to know about ARPA-H. We want folks who are still trying to get into the circle who haven't been the beneficiaries of equity by design to be in that room. And so we're going to continue to do little things like that, attend Match Day, hold sessions for minority-serving institutions. Because at the end of the day, some of the greatest discoveries, some of the proudest moments for America are going to come because we included people who have a story to tell that's going to knock your socks off. (01:20:48) And so I hope you're here to make a difference. I hope you're here because you know this is not free. And I hope you're here because you recognize that the president and the vice president have made it an enduring commitment that we serve all Americans and that we serve them with the people that look like them. And so it is in our design, or maybe it's better to say it's in our DNA. We need to continue to have a president and a vice president who have it in their DNA to include all of us from the get-go. And so you are here because we need to have those trusted voices to make that clear. I am proud, proud to serve in this administration. I am proud to stand with you, but I'm going to be more proud when you tell me about the stories of your successes and even more so about your son's and daughter's successes because that is where the real future is. (01:21:46) I may be clean up here today, but your sons and daughters, wow, are they going to be hitting some home runs. So thank you for having attended. Thank you for being committed. Thank you for everything you're doing. Now I can drop the mic. Thanks so much. Have a good day.

So grateful. I really don't want to follow that. So I want to go ahead and conclude our program and just echo the appreciation of the Secretary. Thank you all for being here. You are, and we, represent the solutions that will make this world a more equitable place, so thank you, thank you.