Michelle Rathman: Hello and welcome to another episode of The Rural Impact. We're so glad that you joined us again. Really, really happy that you decided to tune in. Before we get started on today's episode, I want to share something with you. One of the most compelling reasons why we started The Rural Impact is because we really wanted to understand more about what people like you and organizations that you might be working with or serving are doing to really make a difference in the rural space.
So whether it's healthcare, whether it's, Building capacity, whether it's investing in economies whether it's innovation in technology or farming, agriculture, education, climate, whatever it might be. We want to know the kind of work that you're doing on the ground that truly is making an impact.
And so, what we're asking you to do is follow us on Twitter, LinkedIn, Facebook, even Instagram. You can find us very easily at The Rural Impact and just share your news with us. Share a link, give us a little bit of information about what it is you're doing. We'll check it out. And then in future episodes we'll be reading about you and sharing that with our listeners and our viewers on YouTube.
So be sure to do that at The Rural Impact. We really appreciate the follow. We would love it if you would subscribe. Of course, that would be wonderful to rate us as well. We really do value your feedback. So, with that, let's dive right in, okay. So you'll remember on the first episode in our Rural Health on Life Support Series, I spoke with Alan Morgan.
Alan is the CEO of the National Rural Health Association, and of course they are I don't know any other organization in this space that's doing what they're doing in terms of the advocacy work, really working to put the brilliant minds of their team and all the members together and say, these are some things that we think really need to be considered on a policy level with our federal government.
And of course, the work has to happen on the ground in our states as well. As we say often on this podcast, you'll hear it. All roads to quality of life are indeed paved by policy. With that said, we are now in our second episode in the series, and today we're going to focus on maternal mortality. It is in my view, and not just mine, many others, the scholarly writers who are sharing this, the statistics and the data with us say it's true.
We are facing just an unbelievably terrible maternal mortality crisis in this country. In fact recent data absolutely shows it. Of all developed countries, of all countries with the economies that we have we have the highest rates of maternal mortality. And where rural is concerned, it's nearly double that of urban maternal mortality rates and of course we've got all sorts of challenges that are related to that hospital closures. We'll talk a little bit about, of course, you've heard us talk about workforce shortages. Those are just a few of the influencers. But today, the guest that I am really privileged to have with us, this is an, an individual who has done a whole lot of research.
I mean pages, and pages and pages of, the research papers and white papers, and. All the things that she has done. So with that said, I had a conversation a little bit earlier with Dr. Julia Interrante and she is a research fellow and statistical lead at the University of Minnesota's Rural Health Research Center.
Dr. Interrante holds an MPH in epidemiology from Emory University and a PhD in health services research from the University of Minnesota. Dr. Interrante's research examines the effects. My favorite subject right now of policy on maternal health outcomes and access on maternity care services with specific focus on geographic and racial equity.
And her research includes such topics as disparities in severe maternal morbidity and mortality, changing access to rural maternity care, and the impact of payment policies on maternal and postpartum care. It's one thing to be able to even provide prenatal care and delivery OB services. It's another thing for postpartum care and I, really don't believe that subject's getting enough attention because if we want healthy children we have to have healthy moms and healthy babies and access to services.
So with that said, I'm really honored again to share my conversation with you, with Dr. Julia Interrante. Thank you again for listening. Here we go.
Dr. Julia D. Interrante: Thank you so much for having me.
Michelle Rathman: It's great to have you here. You have done quite extensive work and, I guess I'm going to dive right in because that's what the introduction was all about. The rate of US maternal and infant morbidity and mortality are higher for rural residents. And so, the numbers I read were across the United States, but for rural in particular, and people may not recognize that, but compared to urban residents and access to care during pregnancy and childbirth is declining.
Michelle Rathman: As a matter of fact, I printed out before we came on here, this is an headline from 2017. Maternal healthcare is disappearing in Rural America. Let's do the math how many years ago that was? We haven't gotten any better, have we? So, can you just talk to us about what your research reveals and why this is so?
Dr. Julia D. Interrante: Yes. Happy to talk about this and, as you mentioned, we see rates of severe maternal morbidity, mortality increase in both rural and urban areas, but it's consistently higher among rural residents. And we know there are differences between rural and urban residents in terms of clinical characteristics that may increase their risk.
Dr. Julia D. Interrante: But even after controlling for all those factors, we still see 9% higher odds of severe maternal morbidity and mortality for rural residents compared to urban residents. And as you mentioned a lot of rural communities are losing access to obstetric services, and this has been happening for decades.
Dr. Julia D. Interrante: So by 2004, only 45% of rural counties had no access to obstetric care.
Michelle Rathman: That's nearly half. I just want everyone to recognize that 45%, that's startling.
Dr. Julia D. Interrante: Yeah, and that was in 2004.
Dr. Julia D. Interrante: Our latest estimates are in 2018 and now 56% of rural counties have no obstetric care. So we're getting closer to 60% not having any access to obstetric care.
Dr. Julia D. Interrante: And what we see too is that these losses are really concentrated in rural communities. That are the most remote. So, it's not like you can just drive over to a urban community that also has access. A lot of these areas that are losing obstetrics services are very far away. People are driving one hour, two hours, four hours to give birth.
Dr. Julia D. Interrante: And that's not. Attainable for many, many people, especially people who are low income, have childcare barriers. It just incredibly challenging and increases the risk when you are in the middle of giving birth and driving hours away to go to a place where you can have your baby.
Michelle Rathman: Yeah. You say that I'm actually working with a hospital. I won't say exactly where, but it's in the state of Washington, and so many hospitals are closing their OB units, and what really is startling to me, and I understand it, I get it, is because it's a money loser. Okay. And it's also not safe.
Michelle Rathman: I've been talking for years about, I worked with a hospital in Illinois that we tried to bring academic, rural medicine track and ob and quite frankly, the head of the department of the Academic Medical Center said, "You need more than 200 births a year." And so when a rural hospital has 20 or 30 or 40 births a year, I know we talk about it in such, kind of cold numbers.
Michelle Rathman: But again, these are policy decisions. They're not insurmountable. But when a hospital cannot afford it, whether it's medical malpractice or insurance or whether it's because they don't have the staff that's doing enough of these births. I would imagine that plays a huge factor in the disparities that we're talking about.
Dr. Julia D. Interrante: Yes.
Michelle Rathman: Your research shows that not all rural communities are equally affected, as evidenced by the number of that show rural US counties with majority black and indigenous populations. And I think this is something that, again, certainly doesn't get enough attention. They've higher rates of premature death.
Michelle Rathman: And again, I'd like for you to provide our listeners with some examples of why this is so. What are the distinct differences between the disparities within these different populations?
Dr. Julia D. Interrante: Yeah, so I think this is where intersectionality really comes into play here. A lot of these rural communities with a high proportion of people of color, especially black and indigenous folks also have high rates of patients who are insured through Medicaid, and we know that Medicaid pays much less for childbirth than private insurance does.
Dr. Julia D. Interrante: So you get a bit of that intersectionality going on there along with systemic racism in communities that have been chronically underfunded and under supported in terms of nutrition services, childcare access, all of these issues that impact people's quality of life and access to services.
Dr. Julia D. Interrante: We also see what's happening as communities that are losing obstetric services are those in lower income and with a higher proportion of residents who are on Medicaid. And again, a lot of these states we see the lowest rate of access in the south. Again, where you have less generous Medicaid programs where Medicaid's also either not covering or reimbursing at lower rates for things like midwives and doulas and other support personnel. And all of this stuff really compounds when it comes to access for rural residents of color.
Michelle Rathman: Yeah, that was my next point is that we're not really connecting the dots here. We know, I've seen map after map. It's so interesting, Julia, because we talk about data-driven decisions, we talk about it a lot, and yet what we're really seeing are outcomes based on policy-driven decisions.
Michelle Rathman: And to me that is, that's at the crux, that's the heart of the matter. And so when we are looking to help people connect the dots between those states. One of the things I heard this week, it is not about politics, it's about the policy, but the politics are driving the policies and so those states that chose chose not to expand.
Michelle Rathman: Let's just talk a little bit about some of your research and maybe some more of the specific things that you're seeing in the states that have chosen not to expand and how that impacts the outcomes for women who are, pursuing starting a family, I mean by choice. And then we'll talk about, not by choice, because we are going to talk about that today as well.
Dr. Julia D. Interrante: Yeah. Medicaid expansion we know is important for increasing access and maintaining hospitals in general in rural communities. But our research has also shown it's really not enough. Medicaid eligibility rules differ for people who are pregnant. One of the things though that we see is a lot of patients who gain Medicaid because of pregnancy then lose it 60 days after childbirth, which is also a problem.
Dr. Julia D. Interrante: And one area of focus for policy has been on extending that to a year postpartum. And we know that is going to greatly impact rural residents. I think it's one in four rural residents of color would be assisted by that postpartum Medicaid extension, along with one in six white rural residents who would be impacted by that, who lose Medicaid after childbirth.
Dr. Julia D. Interrante: But again, all of that it's all important and it's still not enough. So we. You also have to increase reimbursement rates. Like I mentioned earlier, the rates are very low for Medicaid for covering all the fixed costs that low birth volume rural hospitals experience in
Michelle Rathman: That are rising, right?
Dr. Julia D. Interrante: that are rising
Michelle Rathman: That are going up and they're not coming down anytime soon.
Dr. Julia D. Interrante: Yeah. And we do have lower birth volumes in these rural communities. But it doesn't mean just because you have less people giving birth there doesn't mean that no one is going to get pregnant and give birth in those communities. So you still need some sort of access to care. We have a very fragmented healthcare system, which sometimes makes it really hard for rural hospitals that are still around with and without obstetric services to have relationships set up between urban hospitals where maybe patients do need a higher level of care, and for clinical safety, it makes sense for them to transfer. But again, that requires relationships that are already set up, insurance that covers patients in both of those areas that accept Medicaid. And so again, it's just it's quite complex and requires a multifaceted approach, I think, to dealing with some of these issues.
Michelle Rathman: In our first episode I spoke with Alan Morgan, who's the CEO of the National Rural Health Association, and we dove into the whole Rural Emergency Hospital Program. And where that's happening is mostly in those states that did not expand. And so we were talking about, okay, it's a band aid for a problem that's, for a gaping head wound is kind of the, the way that I look at it because rural emergency hospitals, community health centers, as vitally important as they are for prenatal care, they're not designed as birthing centers, nor are the back of an ambulance, which we know are dwindling.
Michelle Rathman: And so I wonder if you have any thoughts about any research that you've done where the supports, where there's there where people dare to go and they're innovative, what have you seen in terms of addressing that at a policy level that you think would be valuable for others to learn when they are vulnerable and have lost their obstetric services? What are some of the things you're seeing out there that are really making a difference for those women who have now have positive outcomes as a result of good policy? Anything you can share on that front?
Dr. Julia D. Interrante: Yeah. I think I'll start first with the emergency care. So, we did a study a few years back where we talked to emergency department physicians and administrators in hospitals that did not have obstetric care. And 80% of the people that we surveyed told us that they didn't feel like they had enough training and resources to handle those emergency birth situations.
Dr. Julia D. Interrante: So, there are policies that specifically train rural emergency departments on how to handle things like cardiac arrest, but not on emergency births. So having training programs like that and resourcing people, again, it doesn't solve the problem, but at least you are getting a basic understanding of how to deal with the situations that are going to arise.
Dr. Julia D. Interrante: We know that not every community is going to get back the obstetric services that they lost, but we need to have something in place to help people who are still giving birth there. In terms of examples of where places have been innovative and have done well, we have done a series of case studies about this, where we've interviewed providers and administrators at hospitals who have been really creative in, in how to handle these situations.
Dr. Julia D. Interrante: We've seen places, like in Wisconsin, there's a hos, like a rural hospital where they've tried to actually draw patients to them from urban communities by offering things like VBAC. That's vaginal birth after cesarean and things like water births things that are more accessible in urban communities, but not every hospital does that.
Dr. Julia D. Interrante: And so trying to expand some of that to increase their birth volume and attract patients. We also see things like, there's a great example out of Alaska. Where, there's lots of parts of Alaska that are very
Michelle Rathman: Very remote.
Dr. Julia D. Interrante: Very remote. There is a community that is largely made up of different indigenous and tribal populations where there are no roads.
Dr. Julia D. Interrante: So it's not like you can just hop on a road and drive to the hospital that's hours away. Where Medicaid actually pays to fly patients in before their birth and stay at a like mother baby center with their peer members who are also giving birth around the same time. So that's a really cool example.
Dr. Julia D. Interrante: Not sustainable everywhere. And again, it's very unique circumstances and they don't pay for partners to come also, which is I think another challenge there. But I think a very creative
Michelle Rathman: Because you're asking women to sacrifice so much of their lives just to have access to the care that is essential for a positive, healthy outcome. And I get it. Once again, it's like an innovation to plug a hole that could burst again at any moment.
Dr. Julia D. Interrante: Exactly. There are also examples like in New Mexico where they've been very innovative in terms of really building up maternity care workforce specifically for indigenous midwives and like rebuilding that workforce to provide really culturally competent and appropriate care for patients in the way that they want to give birth and provides more options.
Dr. Julia D. Interrante: Obviously not every birth is going to be appropriate for a midwife or a birth center because there are patients who have complications, but a lot of births are not complicated, are as a natural part of life. Right. And so just. Again, providing more options different types of providers who help attend births is really important.
Dr. Julia D. Interrante: And again, expanding the workforce to include providers of color. So again, this is where, especially for indigenous and black providers who can treat patients who are also diverse.
Michelle Rathman: Yeah, we've seen so many news reports about how important it is to have providers who are culturally aware, culturally sensitive and empowering to, to their patients. So I'm going to, I'm going to put out a little subject here that I'm not afraid to talk about I, I tell people at this stage of my life now as a grandmother we need to talk about the elephants in the room when they're there.
Michelle Rathman: And so I take a look at, again this podcast is all about connecting the dots. So I want to connect, we'll connect the dots a little bit. Okay, Julia? So we've got increasing number of rural hospitals closing their doors, an increasing number of rural hospitals going away with their obstetric services for all the reasons that we've talked about.
Michelle Rathman: And now we open up another door here and connecting another dot. And now we're talking about the laws across this country in many states. In particular, those not being judgmental just laying out the facts that did not expand Medicaid. But besides that, you have huge swaths of the south.
Michelle Rathman: For example, in Texas there is, I think, I talked about last time we were on about maybe the size of Connecticut that doesn't have a single OB provider, and now we have restrictions on women's reproductive care. So if you could pull out your brilliant researcher, put your researcher mind in your crystal ball if you have one in, at the forefront, what do you predict is going to happen?
Michelle Rathman: In this regard what do you predict in terms of our numbers? What? What do you foresee if we don't address this in a meaningful way immediately?
Dr. Julia D. Interrante: Yeah. So I will caveat this with the fact that my research doesn't specifically focus on abortion care access, but we have heard stories of Providers. So, clinicians who are afraid to practice obstetric care in states that have had really strong restrictions against abortion care. And again, we already have workforce shortages in a lot of these communities.
Dr. Julia D. Interrante: A lot of these states have really large rural populations. So when you're already having workforce challenges when again, a lot of these places they have one, two, three clinicians who are doing childbirth care. You lose one of those and that could close the entire service. And that's also for nursing support staff as well.
Dr. Julia D. Interrante: Yeah. Yeah. And again, also when you don't have access to abortion care, when sometimes it is medically necessary, both mentally and physically. That's there's, I don't see how that doesn't increase our rates of maternal morbidity and mortality.
Michelle Rathman: Yeah. And then on top of that, we go in, so we know about our abysmal rural, maternal and infant health outcomes, but they're connected to a host of other policy choices. And I read you've got this long list of all this great research in the papers that you've written, we're talking about, why do we have poor outcomes?
Michelle Rathman: Well, nutrition assistance. Housing, those other social determinants of health. But let's talk about that and how that influences, because the outcomes that you talk about, the research that you do is beyond the numbers, there's a root cause behind some of these outcomes. And let's just talk about any policy work or research that you've done around an increase and an interest in increasing access to these really important services that help to ensure a pregnant person's health and wellbeing throughout her pregnancy.
Dr. Julia D. Interrante: Yeah. Again, I think a lot of these. Policies or lack of policies is really intertwined and intertangled with systemic racism. A long history that we have had on not providing care and reducing access, or not covering specific services for rural populations of color. Again, the whole issue with like scope of practice laws and midwifery care access has been driven by systemic racism.
Dr. Julia D. Interrante: Back in the day, midwives were the majority provider of childbirth care and a lot of midwives were women of color. And again, we see in other countries, most people are giving birth with midwives. In the US it's like only 20% of births are attended by midwives and it's complete opposite. In England, it's 80% who are at having births attended by midwives. It's just completely opposite. And a lot of that has to do with our long history of how these professions have evolved and who has been prevented from entering that space, that professional space that we've created policy barriers to accessing and working in.
Michelle Rathman: I'm from Illinois and I have two children, but they're 38 and 34. And I had a nurse midwife for both, but I ended up having emergency C-sections for both as well. And I think about my time way back then when things were very different and had I not had access the likelihood cuz they were both emergencies, I could have been in the shoes of somebody else, even though I wasn't in a persistent poverty county or what have you, I do understand how supportive and how important they are even to be a part of a woman's prenatal care and experience. The time they take. It just makes so much sense to me and apparently it makes a lot of sense to a lot of other countries too.
Michelle Rathman: But somehow we're not there. And then I wonder because I think that we would be remiss if we didn't talk about payment policies. That's another huge piece of this, specifically the impact on maternal and postpartum care. Because we've seen in the last few months where we sit today on this date, we've got so many people.
Michelle Rathman: I think the numbers as of yesterday, this is now the six, the 15th of June, we're recording this. I think a million people, and I don't have the breakout of how many are women and children have been unwound kicked off Medicaid. And I wonder how you foresee that being, both the insurance piece and moving on from the social determinants, but what do you predict is going to happen there?
Dr. Julia D. Interrante: Yeah, obviously maintaining access to care is really important and any kind of transition in access to insurance around and after the time of childbirth is really, really impacts what's happening, right? Like you either going from having Medicaid to having no insurance or going from Medicaid to having to find and afford private insurance is really complicated. And can decrease access to actual care.
Dr. Julia D. Interrante: And again, the finding providers in hospitals and clinics that accept your insurance can be challenging. So typically in the us the way like Obstetric Care is paid for, is in a bundled payment, so all of prenatal, childbirth and postpartum care is paid for at a set rate.
Dr. Julia D. Interrante: This is both within private and private insurance and Medicaid. And it's paid at the time of childbirth. So again, if you're transitioning different places, it makes the payment really complicated and it really decreases the incentive for clinicians to ensure that patients come back for postpartum care. And it also disincentivizes additional needed care.
Dr. Julia D. Interrante: The American College of Obstetricians and Gynecologists and the World Health Organization have had recommendations for years now that postpartum care consists of more than a single checkup at six weeks, which is still pretty standard.
Dr. Julia D. Interrante: And that's what we pay for, right? We don't pay for additional care. We don't pay for these other services that are also really important in terms of saving lives, right? Because half of maternal deaths occur after childbirth. And so in having contact with a healthcare provider before six weeks is really important.
Dr. Julia D. Interrante: But also in terms of quality of life and feeling like you have support and that there's someone that you can talk to when you are having breastfeeding challenges or urinary incontinence or things that really impact your quality of life and things like sleep, right? Like it's really challenging having a newborn.
Dr. Julia D. Interrante: I've done this twice and I'm about to do it for a third time. And it's just, even when you have resources and support in terms of like family or friends that are nearby, which a lot of people don't have, there's still questions that come up that you might need to talk to someone and it's sometimes unclear if that's going to be covered by your insurance or not.
Dr. Julia D. Interrante: And that's, that
Michelle Rathman: It's so frustrating, Julia, because then we shift the focus away from mom and we put it on baby, and even then, we're not doing a really good job at that, at well as well either. And there's it in, it really upsets me to think about the fact that, I know that, so the majority of births just go swimmingly and so forth, but, you can't put it in a box and you can't, not every heart surgery goes the same way.
Michelle Rathman: Not every procedure, not even dental procedure goes the same way. It depends on the individual and we're not taking into account. And so I guess I would, I wonder because we talked earlier about the fact that so many of these decisions are policy driven versus data driven, but your research is so compelling, and I know that we've got some really astute members of Congress.
Michelle Rathman: I was fortunate to serve on Congresswoman Lauren Underwood's Health Advisory Committee. And she's extremely passionate about this. The Momnibus program. There are legislators who are listening to this, so, How do you think that we can, any ideas you have, how we can we take your research and the research of your colleagues and the data that we know?
Michelle Rathman: How can we get into the heads and more importantly, the hearts of our lawmakers to stop making this a disconnect? So they create a policy that creates an domino effect, an adverse effect on moms and infants. What do you think it's going to take for us to finally not say, our numbers are worse than they were in 2004.
Michelle Rathman: In 2017. We are in 2023. When is it going to get better? How's that going to happen through legislation if they're not listening to us, if they're not feeling the need, the passion to. To write this and turn it around and make it sustainable, because we can't just keep going back year after year and trying to see if we can get things in the budget and then hope that they say, oh, this is good, we can sustain it through, sustained funding.
Dr. Julia D. Interrante: That is a great question. I wish I had a complete answer for how to make that work. I think just again, continuing to, to talk about our findings with media, with the public to increase awareness, disseminating our findings directly with lawmakers and state and federal government agencies who have the power to make some of these changes.
Dr. Julia D. Interrante: And I do think we have tried our hardest to bring awareness to some of these issues, but we are so limited in the data that we have to even discuss some of this stuff. So, I think for me, one of the big areas that I think is important and some of these bills do like the Rural Mom's Act and Momnibus Bill is doing better data collection. So having more consistent data collection around maternal health outcomes.
Dr. Julia D. Interrante: Obviously we want to prevent maternal deaths. That's like the worst outcome you can have. But there are so many other things that we should also care about preventing that we need to collect data on so we can even talk about what's happening that we don't collect data on or talk about.
Dr. Julia D. Interrante: And again, it's not just creating a data collection burden, but also paying for those things to be collected and analyzed in a way that takes a intersectional lens. So talking about okay, we implemented a policy, did we also mandate that policy be evaluated in terms of did it help or not? And what are the equity considerations in that too?
Dr. Julia D. Interrante: So a lot of policies passed where no, no funding is included for analysis of it, of if it worked or not. So it's having the data before to talk about all these issues, but also after, right? And and being okay to say, okay, some, maybe this policy that had good intentions didn't work. Maybe we should try something else, is also really important.
Michelle Rathman: The last question I have for you is because, we look at a lot of times in our world, we take a look at federal policy and I know the Federal Office of Rurall Health Policy and HRSA, they've got the RMOMS program, and we'll be talking with it RMOMS network if you will that we're working on for the next episode.
Michelle Rathman: But just anything that you might be able to share from a state level, and even local level, because in this case, sometimes it does go up the chain. And if it's important at a local and a state and a regional level, maybe we can get some traction on a federal level. So is there anything that you're seeing in terms of how the research you've done and the data has influenced local or state level change? I'm just curious.
Dr. Julia D. Interrante: I definitely think so much stuff happens on the state level that's incredibly impactful for people's lives. We've talked about already in terms of what Medicaid covers in state, like scope of practice laws that can be done on the state level, reimbursing for doulas, like decreasing barriers to entry to having diverse workforce for all types of maternity care providers.
Dr. Julia D. Interrante: And again I think just thinking about all of that and there, there are lots of states that are doing innovative things, but on a small scale. And I think actually doing something with those results that have been positive in some states are important.
Michelle Rathman: And listen to our listeners out there. If you are a part of a network, if you are affecting change, we want to hear about your best practices and how are you're making an impact on this subject matter because we're happy to share it. I think about, what COVID did in terms of expanding telehealth there, telemonitoring programs, and we can get this, we, we put people in space, we can get this right.
Michelle Rathman: I just think the clock is ticking and we need to to get moving on this because the problems are not going to get I think they're just going to increase for rural in particular because of what we're seeing the trend in, in rural hospital closures and the lack of access to all these services and so forth.
Michelle Rathman: My goodness. Julia, I just want to thank you so much for your research. We're going to keep following you. And we're going to put some of your research up on our website as well. I just I'm willing you the best outcomes for yourself. Very excited to hear that you're on the verge of of a new joy in your life.
Michelle Rathman: We really appreciate your work and I, I can't believe how fast the episodes go, but I also want to make sure that I thank those who are responsible for helping us put all this together. And that includes Brea Corsaro, who is our Associate Producer and Sarah Staub, and she is our amazing Creative Director.
Michelle Rathman: And then also for Jonah Mancino for the great original music that he's produced for this podcast. If you are interested to learn more about how you can become a part of this conversation, join us, share your rural impact, please go to theruralimpact.com. Pretty simple. You can follow us on social media.
Michelle Rathman: And next up on our last episode of this particular series, we're going to continue the conversation and we will be talking about Medicaid expansion. As well as those who are being, dumped off the roles and talking about exactly what the implications are for that. And then, as I said, we'll be talking to an RMOMS participant network and just hear some of the positive outcomes because we don't want to, what we've talked about here today is not a light subject, but we hope that it has enlightened you.
Michelle Rathman: So thanks for joining us and we're going to talk to you on our next episode of The Rural Impact.