The Fifth Branch: Convincing the Cops

Hey, it's Dan Goranstein, host of the Health Policy Podcast Tradeoffs. Welcome to the Fifth Branch. Three part series produced with the Marshall Project examining what happens when a city dramatically changes how it responds to people in a mental health crisis. If you like the Fifth Branch, we hope you'll check out our weekly show, where we combine data, evidence, and storytelling to help you better understand the complicated, costly, and often counterintuitive world of healthcare. Subscribe to Tradeoffs, wherever you get your podcasts. If you're already a subscriber, thanks. The phone rings a little after six, a sunny August evening in 2022. Police Chief Patrice Andrews picks up. One of my deputy chiefs said, "So we have a barricaded person?" The deputy tells Patrice the man had a history of mental illness. The family is worried he might hurt himself. They're asking officers to force him to go to the hospital. Officers are now camped outside the house, and the man is making threats. He said, "I'm not coming out, and if you come in, I'm going to shoot you all." The deputy tells Patrice a hostage negotiator is now on scene, and he's about to call the SWAT team. And I said, "Well, wait a minute, wait a minute. Let's hold on. Let's talk about this for a second." Patrice takes a breath. A cop for more than 20 years, she wanted everyone to take a breath. Whether he would have shot an officer or officers would have shot him. I didn't. I don't have a crystal ball, but I tell you there were the makings in that for maybe it not to end well. Patrice knew what she wanted to do. I said, "Let me call Ryan." Ryan Smith headed up a brand new department in the city, a radical experiment in public safety. Patrice knew the last people Ryan would send would be a SWAT team, Ryan would send a social worker. I'm Dan Gornstein, and this is the fifth branch, a special series from Traderoffs and the Marshall Project on what it looks like when one community dramatically changes how it responds to people in crisis. Police in America have shot and killed 1,939 people in the middle of a mental health crisis since 2015. That's 20% of all police killings in the last decade, one of every five. Those numbers are helping fuel a movement, cities like Denver, Albuquerque, Houston, Louisville and New York have launched what are called alternative crisis response programs instead of armed police, a new generation responders. EMTs and social workers now handle 911 calls involving mental illness, addiction or suicidal thoughts. These programs have kept popping up as we reported on America's mental health crisis, and we wanted to know whether they're working. So about a year ago, we gave Traderoffs producer Ryan Levy an assignment, find a city doing this work. We wanted to find a place that experts thought could be a model for other cities. They needed to be serious about data and be willing to let me spend a bunch of time with them. I talked to several interesting programs, New Orleans, Denver, Rochester, New York. In the end, we went with Durham, North Carolina, and its holistic, empathetic, assistance response team, what locals call heart. National experts were big fans. They did it the right way, thinking, designing, assessing, researching, evaluating, and then they went to work. And heart was willing to give us a lot of access. I interviewed their leaders. I knew that it would be hard. I knew that it would be messy. Thousands of their responders. Is there a level of risk in this job there is? Do I consider it an acceptable risk I do? I wrote along on 911 calls. Are you guys here for the guys at the top of the street? Yes. Okay. This meant the middle of the driveway when I got me knocked out. Interviewed their critics? I mean, I thought it was going to be a disaster. I thought it was the worst idea ever. And met with people who called heart in crisis. The police, they have to be the law, you know. And this is love and mercy. That's a difference. Ryan and I agreed. It made sense to tell this story out of Durham. In the two years since the program launched, curious officials from 50 cities around the country have reached out to heart with lots of questions. Over the course of three episodes, we're going to focus on a few of the biggest. How did heart get off the ground? Does it keep people safe? How big should heart be? Today. Ryan will begin at the beginning. Now Durham pulled off what many cities struggle to do, getting the police bought into a new way to treat people in crisis. From the studio at the Lender Davis Institute at the University of Pennsylvania, this is Trade Ocros. You're going to hear from a lot of people I talked with during my five trips to Durham this year. There are three folks in particular I want you to meet. Patrice Andrews, I am the Chief of Police for the Durham Police Department. My name is David Prater. I'm a peer support specialist with the Durham Community Safety Department's heart team. I'm Ryan Smith. I'm director of the Durham's Community Safety Department. Patrice, David and Ryan stand out to me because they're the ones who best help me understand why the city is transforming the way it responds to people in crisis. How they're doing it and whether it's working out. We'll hear from them a lot throughout the series. They all told me that the story of heart begins in late June, 2020. Hundreds march through downtown Durham. I understand your anger. See us, black people, let me tell you something. We are tired. We've seen these protesters hit the streets here in Durham for almost 10 days now. I had to keep some quote unquote good cops. But if you're letting the bad ones keep doing what they're doing, you're just as bad. The protests here look a lot like they do across the country following the murder of George Floyd by a Minneapolis police officer. Signs, chance, calls to reform the police. Protesters paint the word defund in bright yellow letters on Main Street with an arrow pointing to police headquarters. A few blocks away, the word fund in the same crisp yellow with an arrow pointing toward the department of social services. These protests spark city hall to launch an independent review of Durham's 911 data. They find that violent crime represents less than 2% of all calls. Trespassing, verbal disturbances, and mental health crisis calls make up much the rest. So to respond to those calls, city leaders earmarked $3 million in June, 2021 to create the community safety department. They tap Ryan Smith to run it. This work in part is about, you know, helping people imagine something that they may not have imagined. This new agency gives Ryan a chance to solve an old public safety problem. Your house is on fire, we send fire, you're having cardiac arrest, we send EMS. There are shots fired, there is violent crime or criminal activity, we need to send law enforcement. But people call 911 for a whole bunch of other reasons. And most of those reasons because we haven't had another branch to sort them into have gone to law enforcement. For decades, Durham had four branches of public safety. 911, answering the call, police, fire, and EMS. City leaders want Ryan to build a fifth branch, where 911 dispatches social workers and other mental health workers instead of armed officers. They give them 12 months, one year to design this new branch of the public safety tree, and convince his town that it'll be safe. I think most communities are afraid that if they're sending social workers and others that someone's going to get hurt and killed. An armed response in the US has actually been around for a while. The first programs to send mental health workers to 911 calls, date back to the 1980s. 27 of the country's 50 largest cities have now launched or piloted alternative response programs. To build his, Ryan talks with several of them. Denver, San Francisco, Albuquerque, and he learns how safe this work can be. This work in part is about helping tell the story of what this is looking like in other communities. These are the calls they're already sending, these types of responders to all the bad things that you're worried about. These were not seeing evidence of that. Ryan designs a program with four parts. Put a mental health worker inside 911 who will resolve some calls over the phone. Many teams of unarmed social workers, EMTs, and people with lived experience to respond to nonviolent calls involving mental illness and homelessness. For crisis calls that involve the threat of violence, 911 would dispatch a clinician and especially trained Durham cop. The last piece, heart teams would work with people to connect them to longer term help after a crisis call. Ryan knows this is audacious. No other city he'd found had a model this comprehensive. If what we're really doing is about, you know, sending the most appropriate response, then I want that to be available for as many people and as many moments as possible. To do that though, Ryan has to figure out how to deal with this. I'm like, this is going to be a disaster. I said, it is not going to go over well. A whole lot of officers in the Durham Police Department, like Sergeant Dan Leader there, see this new department as an attack. Ryan understands their point of view. The idea of this new branch came from the defund protests. Based on what he learned from other cities, Ryan believes getting police buy-in gives the whole enterprise its best shot. One thing that I've noted is the inability to get law enforcement buy-in can lead to programs like ours being much smaller than they need to be or is warranted. A quick word about why Ryan seemed up to this challenge. He's called. The 45-year-old is quick to empathize and slow to anger. Behind his khakis and button downs Ryan has this quiet intensity to him. A spirit that just keeps pushing. Finally, and this is random but it'll make sense in a minute. He's got a bird name. My bird name is Chikity. That's an important part of our identity in the department. Actually, everyone at heart has a bird name. Ryan's assistant director came up with the idea, the kind of department bonding thing. Ryan got Chikity. He gave me the shirt version of why Chikity for you. Here, let's go. I'll read it to you. Ryan reads to me from a colorful printout. Chikity is moving a small group called a banditry and forged together. It decreases their chances of a hawk taking them by surprise. It's taped to his office window in City Hall. By example, the Chikity shows us how working an cooperative team means more eyes and ears and fewer opportunities for predators. Ryan is good at seeing problems and finding solutions. If you can get Durham's police leaders on board, he thinks they can help him persuade all the skeptical rank and file cops. For the police chief to say, yes, this is good work. To me, that was the dream. Can I make that happen? Turns out, Ryan was lucky. Are you ready? Chief? It's December 2021. I. I. I. Stage your name. Patrice Andrews. Patrice Andrews stands on stage at North Carolina Central University. The same historically black school in Durham she attended 30 years earlier. Dressed in her black ceremonial Durham Police Department uniform, she takes her oath, becoming the city's 33rd police chief. There are a few things I want you to know about Patrice. She comes from an old Durham family. Her dad integrated city schools. She worked as a beat cop here for 20 years. But here's the most important thing. She's taking this job at 48, in part because she wants to reduce the harm police can cause. Patrice grew up hearing stories from her parents about the racism and harassment they faced. Law enforcement was an extension of an oppressive government. I mean, just in a nutshell. Patrice worried as a black woman what some people in the black community might think about her being a cop. Patrice's dad gave her some advice. You have to do the work. And if what you're trying to do is make law enforcement better, you're trying to make an impact, then you have to stay focused on that. Not worry about how people view you as a black woman in this field. Patrice determined all those years ago to be the kind of cop that would make everyone feel safe. She struggled sometimes though to find her identity in the uniform. There were times where I knew that some of the force that I saw and participated in was excessive, right? But how do you call that out? How do you. It's very hard to call that out when you don't necessarily feel like you would be supportive and supported in doing that. That I will endeavor. To support. To support. She prepares to become Durham's top cop. Patrice understands law enforcement's opposition to heart runs deep. But she also understands firsthand how hard it can be for cops to respond to a person with mental illness. I remember responding to a call and there was a woman that was seeing things in her home. Patrice had been on the force for a few years by this point. She and her partner had driven to the home of a woman who had repeatedly called 911, saying there were intruders. It quickly became clear. There were no intruders. She'd point to a lamp and she'd say they're behind the lamp and so we'd go over there and say, "You're trespass, you can't be here." Patrice and her partner hoped chasing these figures away. These figures only this woman could see would bring her some peace. But she called 911 again. And again. And we kept saying, "You can't call us anymore for this. You know, we've told the people to get out of your home and they're out. You can't call us anymore. Don't call us anymore." She kept calling. We didn't know what to do. We didn't have the knowledge, the professional knowledge on how to work with someone that clearly was going through a moment of crisis. The only thing we knew to do was take her to jail because for us, that was solving our problem. It felt so wrong. You know, you hear the word "ic"? It was the biggest "ic" one of the biggest "ic" I've ever had in this career. Patrice never learned what happened to that woman. Just that the call stopped. I often wonder, did we harm her? Did we harm her mentally? More? And doing that? Did it serve a purpose aside from our wanting her to stop calling 911? Patrice spent 20 years seeing the limits and the abuses of policing. I knew right from wrong, but I didn't necessarily know how to change a system that had seemingly always done it the wrong way and had gotten away with it. She had learned change could come through policy by becoming a supervisor, a leader, a chief. And now she's ready to be that change. I am going to be unapologetic about saying, "You're wrong, that's wrong, and we're going to fix this." The ceremony ends, crowd thins. As she heads home, Patrice thinks to herself that heart. This new, unarmed public safety response offers her and really her whole department a chance to do better. For cops to do their best work and for heart to do something different. We can do both. We can have a wonderful professional police department. We can also have amazing public safety partners in heart. Now she just has to convince a few hundred deeply skeptical officers. After the break, Patrice and Ryan Smith map out a plan to get rank and file cops bought in. Is there more to this story? Help us tell it. We want to hear about your experiences with crisis response teams. What advice would you give to someone considering calling a response team for themselves or for a loved one experiencing a mental health crisis? Go to tradeoffs.org/thephifthbranch to share your story. And join us for a virtual discussion on August 15th where we'll answer your questions and share your insights. For more information at tradeoffs.org/thephifthbranch Welcome back. Tradeoffs producer Ryan Levy has spent much of the past year on the road, more on the phone, talking with people in cities that are trying to find new ways to respond to mental health crises. In Durham and more than two dozen of the largest cities in America, that means sending unarmed social workers rather than police. As we heard before the break, cops have often been skeptical of alternative crisis response programs. Police chief Patrice Andrews and Ryan Smith, the head of heart, hoped to chip away at those fears. A tall task. Again, here's Ryan. Cops were pissed. Nothing is ever 100 percent but it was darn close. That this was a bad idea. Police Sergeant Dan Leiter spent one Saturday in the fall of 2021 with some other cops at headquarters listening to heart director Ryan Smith make his pitch. He was in a very tough spot. The director had to try to convince a bunch of cops that there's something you need to buy into and it wasn't going on really well. Police chief Patrice Andrews had started to notice rank and file a reaction to the new department. I-rolls, officers muttering about agendas, the woke generation. Once your officer asked Patrice, what's this BS about being defunded through heart? That's why Patrice had invited Ryan to these meetings to come talk with every single patrol officer, hundreds of cops. She wanted to give them a chance to get into it. You had to break down perceptions. You had to break down feelings and you had to create environments where people could speak openly and honestly. The officers had plenty to share with Ryan. I said I just want to make sure I understand if there's a disturbance call and I'm around the corner. We have to wait for the clinician who's across the city. I did not think it was going to work out. I thought it was a very bad idea. The cops had lots of concerns. Most of them came down to fear. Fear for residents, fear for their jobs, fear for the safety of the new responders. If they're going to deal with some of the same people that we've had to deal with, like if we're getting assaulted, what's going to happen to them? Ryan Smith expected this big blue wall. In the meetings, he could feel the existential dread in the air. The city was hemorrhaging officers. 58 left the department between June 2020 and the city. and the end of 2021. 8% of their total staff driven away largely by the pandemic and the protests. Sargent Dan Leader said plenty of rank and file felt unfairly lumped in with the Minneapolis officer who murdered George Floyd. What did we do? We're good cops. We didn't do anything wrong. Why are we having to go through this? First, there'd been that huge defund arrow spray painted on the street and now all this about new responders. Things are changing and this is a train that is not stopping. No matter how much you don't want to do this, guess what you're doing it. There was a lot of trepidation about, well, what does this going to mean for us? You know, how is this going to affect what we've been doing for years? The cops were right. Heart was happening. Ryan wasn't showing up for these weekly pummelings to cut some kind of grand bargain. He wanted officers to be prepared for this change and maybe earn a bit of goodwill. With police, we needed to build confidence that we could do this and not get someone killed. Point blank. But building that confidence, Ryan knew, was going to take time. That was true for community activists too. To convince them that heart was truly an alternative crisis response program, he co-hosted virtual town halls with the advocates and held smaller in-person focus groups in English and Spanish. It was clear to me that it had to be a very intentional effort. It had to be consistent. You weren't going to do it with a few words or small gestures. These steps, the town halls, the focus groups, the meetings with cops, this was Ryan trying to live up to his nickname. The chickadee shows us how working an cooperative team means more eyes and ears and fewer opportunities for predators. Throughout the end of 2021 and the first half of 2022, Ryan Smith and Chief Andrews, address rumors, tried to reassure officers. We just needed to make sure that our officers knew that this is not, we're not replacing you. You still have work that you need to do as a law enforcement officer. They used data to walk through officers' fears that heart would put people in danger. Everyone's going to have that, well, I remember this time when this one trespass call ended in a gunshot and an officer was hurt. That's a valid thing, we name that and then we look at the data and put that into context so that happens on like less than 1% of 1% of the time. Ryan and Patrice agreed to ditch the plan to have the social workers and cops arrive on scene separately. And still, they were a long way from getting most rank and file officers bought in. On June 28th, 2022, heart launched. Hello, Durham, I'm one one. Clinicians started answering 911 calls. Unarmed social workers, DMTs and peer support specialists jumped in vans and hit the streets. They respond to homeless people panhandling. People thinking about suicide. He acknowledged that he attempted to kill himself. Parents passed their breaking point. It's all screaming and hollering and throwing stuff and kicking stuff. Sergeant Dan Leader listens to it all unfold on his police radio. He's going to hear social workers screaming for the cops to come save them. That's not what he hears. So I hear these calls come out, I'll hear the co-responders or the hard team responding to it. And you don't see it come back. Trust after a planet fitness 1010 MLK. I mean, the calls been handled. Whatever it is they're doing, they're doing it right. And the call doesn't come back again. Much to Dan's surprise, these new teams seem to be doing just fine. But there was still a bunch of skepticism and suspicion. Some officers would swoop in and respond to calls meant for heart. Others would ignore orders to wait for heart before engaging with a scene. This lingering pushback from officers frustrated Chief Patrice Andrews. She wanted them to see that heart can make their jobs better. Safer. Which brings us to that August night in 2022. Heart's been lied for less than two months when Patrice gets the call about that barricaded man making threats. He said, I'm not coming out and if you come in I'm going to shoot you all. The commander outside the home is reposing a SWAT team. At that moment Patrice knows, busting down the door could lead to violence. Exactly what she wants to avoid. So she gets Ryan on the phone. I said, look, this is what I have. I know that you all are done working for the day and is there any way that someone can go out. She called me and I told her that I would reach out to Abbin and Abbin is one of our clinical managers. So I get the call from Ryan. I was with my children. I had just picked them up from school and we were ahead at home. I knew something was going on because it was after hours. Heart in the early days shut down for the night at five. I got home, got my children's settled and my husband though kind of what was going on. And then I called chief Andrews to get a little bit more information and details on the situation. Patrice tells social worker Abbin of Mediaco, cool the temperature down. Convince the man to go to the hospital. Abbin has done this job for 20 years. She lives for moments like this. Some of the officers were already like, yeah, he's not really going to talk to you. But you can try and I smell because I'm like, okay, I'll try. The five foot one social worker digs it. She calls the barricaded man's father. Dad tells her that his son has been hospitalized before. Abbin calls the man. He was just angry. And so, okay, you can be angry. You can curse and you can yell, it's fine. Her calls keep getting interrupted. Dad calling son, son calling dad. Up and down the street, Abbin of Paces. Some of the officers would come and be like, you know, how is he? And I'm like, no, we're still talking. Because sometimes people just need to talk and need to be validated. Abbin on the phone keeps repeating herself. You're okay. Let it out. It's fine. And we're going to be with you. After Abbin, I guess, is about an hour of calls. The man relaxes. She gives officers the thumbs up. Officers eye Abbin, like, oh my goodness. He let officers come and start his room to make sure that, you know, he was okay. The man cooperates. He asks Abbin, can I stay tonight? Go to the hospital tomorrow? Abbin calls chief Andrews. Abbin said, well, he's not a danger to himself. He is intoxicated. Let's give him a moment. Let's check back in with him. And so we went about it a different way. The next day, Abbin drives the man to the hospital. A police escort follows. The man checks himself in. Crisis averted. This was a huge moment for the young department. The idea that heart was useful to cops was spreading. Patrice saw it. Officers said, oh, so we can call them for this is great. This is great. So that means that we don't have to do this. We wouldn't have to do that. And they can help us. Sergeant Dan Leader saw it too. When I'm wrong, I'm the first one to raise my hand and say, you know what? I was wrong. These people are going to help you. They're going to make your job and your lives on this job easier. For Ryan Smith, this incident captured what he'd been saying to officers for the last year. Most people do not think that story can end with that person just walking out without any hand cuffs on with no use of force and be transported to hospital because he has threatened to hurt officers and hurt himself. The idea that a different type of response might be successful that is hard to imagine. For Abda, the story of the barricaded man is important because it's so unremarkable. I'm a social worker. So this is what I do. Heart has now responded to more than 15,0911 calls. Cops in Durham. People in Durham. No longer have to imagine what their new branch of public safety can do. They're seeing it every day. Trados producer, Ryan Levy. Back in a minute. We've always seen the fifth branch as bigger than the story of just one city. That's why we've partnered with another nonprofit newsroom, the Marshall Project, which reports on our criminal justice system. While Ryan Levy has devoted a lot of time to Durham's heart program, Marshall Project's staff writer, Christy Thompson, has interviewed researchers, advocates, and other leaders in the field to get a more national perspective on the alternative crisis response movement. At the end of each episode of the fifth branch, Christy will join me to put that show's theme into a broader context. Today, again, we're talking about buy-in. Christy, thanks so much for being here. Thanks for having me. So Ryan Levy shared a stat with me that when heart first launched, just 37% of Durham police officers thought heart would be helpful on mental health calls. Now, that's 66%. We know the cops around the country are skeptical about programs like heart. How are other cities, Christy, trying to get them on board? Yeah, I talked with people at the Law Enforcement Action Partnership, also known as LEAP, which is an organization that works with cops and prosecutors and correction officials who are interested in criminal justice reform. And they said, like in Durham, officers really do seem to be getting on board once they're able to see what these programs can do in the field and how it can free them up to work on more serious calls. One thing that they said was really important. important is that the messenger really matters here. If somebody from within law enforcement, like you had in Durham, is able to pitch this program that goes a long way. I'm curious, Kristi. Have you found any places where a lack of buy-in from law enforcement has stifled or even shut down a program? That's actually a more complicated question than it seems. I think that skepticism from law enforcement has slowed down maybe in multiple places the expansion of these programs, but it's hard to say exactly how big of a challenge that has been because people are inclined to talk about the success and not focus on the struggle when they're still trying to gain more support for these programs. Something that I did see in my reporting and in local reporting across the country is that police unions can be a limiting factor in the expansion of these programs. So I live in Seattle and here are crisis response teams are primarily sent out alongside police officers. Part of that is because it was specified in the Seattle police contract that these responders would not be replacing police officers on certain calls. What about community activists? Heart director Ryan Smith was worried about losing their support if heart seemed too close to law enforcement. Is that a concern that you've heard in your conversations? Absolutely. That's why some programs they've chosen to be housed inside the fire department or an albacurky they've chosen to create an entirely separate public safety agency. But even then, these teams are being mostly dispatched by 9-1-1. But a lot of people are still really wary of calling 9-1-1. That's why in some places like Atlanta for example, they've decided to use 3-1-1 for people to call to send out their responders so that even if a crisis responder can't come, the caller has the discretion to say, "I don't want to be transferred to 9-1-1." And they're never going to get a police response that they didn't consent to. You talk about 9-1-1. And we call this series the 5th branch, in part because Ryan Smith was so adamant that 9-1-1 was just as important a partner as the police, maybe even more, because every single call heart responds to involves 9-1-1. Absolutely. What experts were telling me was that the part that we have not talked enough about is getting buy-in from these dispatchers. And they are the gatekeepers, right? They're the ones who decide whether to send these teams out. I talked to one former dispatcher who said the motto was "win and doubt send them out, them being cops." That's really what they've gotten used to. In Chicago, they're sending out a regular update to dispatchers with the outcomes of the calls that they send people to to say, "Hey, you sent our care team and this person got connected to services. I've heard of other cities who invited dispatchers on ride along so they can actually see the teams in action." So they're always that they're trying to get the 4th branch 9-1-1 dispatchers on board because I think they can really be the missing piece of the puzzle in these programs expanding as much as they want to and having as big of a presence as they could have within a city. Final question. I know there's some lawsuits out there that are raising the issue of whether buy-in as we've been talking about it will even really matter going forward. Can you tell us a little bit about these lawsuits? Yeah, there's two ongoing lawsuits right now that claim that to keep sending armed police to a mental health crisis is actually a violation of the Americans with Disabilities Act. And the Justice Department has said similar things as well. They've been investigating policing in places like Louisville Kentucky, in Minneapolis, and most recently in Phoenix. And they've found that those police departments were discriminatory against people with mental health disabilities by the way they were cops were responding to people in crisis. So we're in a really interesting place right now where so far cities have been adopting these programs voluntarily but it seems like there might be increasing legal pressure for them to have some kind of response like this available. Kristy Thompson thanks so much for taking the time to talk with the Sun Trade Offs. Next week does heart make Durham a safer place? A lot of the calls that are in crisis the people can turn on them in a heartbeat and there's nobody there to protect them they're going to get hurt. What happens when a social worker shows up on the scene instead of a cop? If we sit in the heart scene please. I doubt 911 and I ask for the heart scene. 911 calls are unpredictable and heart's first responders are on the front lines. Do I consider it an acceptable risk? I do. Is heart making Durham a safer place to live? Part 2 of the 5th branch drops next Thursday. Check it out wherever you get your podcasts. I'm Dan Goranstein you're listening to the 5th branch a special series from Trade Offs and the Marshall Project. The 5th branch was reported by Ryan Levy with help from Mark Maximoff and edited by Kate Kahan our partners at the Marshall Project include Kristy Thompson and Manuel Torres. The 5th branch is supported in part by Just Trust and the Sozoze Foundation. For a full list of credits visit our website tradeoffs.org/the5thbranch. Thanks also to all our listeners who helped to support our work including Naomi Fener, Lee Moss and James Wong. Our media partner is SideFX Public Media based at WFYI. Trade Offs is supported in part by the Robert Wood Johnson Foundation Arnold Ventures West Health the California Healthcare Foundation and the National Institute for Health Care Management Foundation.