Katherine Baicker: Rigorous Thinking about Hard Problems

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. We’re excited to welcome University of Chicago provost Katherine Baicker today. But first we like to check in on current hot topics in health and healthcare. And Harlan, what’s top of mind for you today?

Harlan Krumholz: Well, Howie, I was very interested in this report that came out. It was from the Peterson and the Kaiser Family Foundation group, that was really looking at life expectancy and, again, comparing it to cost. Look, this is the same old story you and I’ve talked about for a while, but this is really updated and with good information. And so, in the U.S. they’re describing a period where life expectancy continued to decline, while rebounding in other comparable countries between 2020 and 2021. And this was, I think, the important thing about this report was that it was comparing us with other countries and also that the life expectancy gap between men and women has widened more in the U.S. than in any other country. The U.S. gap increased to 5.8-year difference in 2021, up from 5.1 in 2019, and in other countries it’s just a little more than four.

So our life expectancy is dropping more than comparable countries. Our gap between men and women is enlarging, and is maybe the largest among comparable countries. And we have the lowest life expectancy compared to other wealthy nations, while spending, continuing to spend, not even just a little bit more than these other countries, but 2x more than these countries, 3x more than Japan, who has the longest life expectancy. And all this to say one thing, I want to get your view on this, but in 1980, as recently as 1980, life expectancy of birth in the U.S. and in other sort of comparably large and wealthy countries was pretty similar. So this wasn’t like something that’s always been. In 1980, pretty close. And since then there’s been this separation, separation by life expectancy and separation on the other side by cost as we continue to outstrip the rest of the world. And I don’t know how, look, you teach health policy, you’re an expert in what’s going on in healthcare and healthcare spending. You tell me what’s happening here.

Howard Forman: Yeah, so I mean, look, I think there’s a lot of things happening, and I don’t have all the answers at all, but for the last decades we’ve always said that probably only about a third of the improvement in life expectancy over the last hundred years is due to healthcare. And that most of it is due to social determinants of health, public health, things like that, education, sanitation, all those other measures.

And I just wonder whether the same is true in reverse. Is it because of the excess gun violence in our country? Is it the excess of opioid deaths which are dramatically higher in this country than most other countries in the world? Is it the higher levels of alcoholism and other types of even motor vehicular trauma? We’re high on most of these measures compared to the other developed nations. Some of that is our libertarian nature of this country. But I wonder how much of it comes down to that.

Harlan Krumholz: It’s not. There was another recent study that came out that was looking, those are contributing factors, but our major causes of death, cardiovascular disease for example, continues to be a central reason that we’re different from everyone else. And so it’s not just those things.

Howard Forman: But cardiovascular disease does rely on nutrition and exercise and livable and walkable communities.

Harlan Krumholz: Oh, for sure. I just meant just taking accidents and homicides and—

Howard Forman: No, I’m adding them all up. I’m just saying there’s a lot of things in there and very few of them, I mean, look, I don’t want to say that we shouldn’t blame healthcare providers, but just as we’ve said that most life expectancy improvements have not been due to healthcare but due to other things, I think that we spent so much time with the $4 trillion on healthcare. We’re back to Betsy Bradley and Lauren Taylor’s Healthcare Paradox book. We may be spending the money in the wrong category.

Harlan Krumholz: And I just wonder, a lot of people want to argue that if we start decreasing or slowing spending, we’re going to inhibit innovation. And I just ask, what has the innovation brought for us if at a population level there’s so much separation?

Howard Forman: I agree.

Harlan Krumholz: And just to end this, I just want to be really clear about this, because I mentioned this thing about, and you may think that Japan’s not a proper comparison for us, but it just is like a remarkable thing that we spend per capita something like $12,000 on each person for a life expectancy of 76.4, and in Japan, they’re spending $4,000, $5,000 essentially, for a life expectancy of 84.5.

Howard Forman: I know, I know. It’s striking. Look, these are the first slides in my class. These are the first slides in my class, and we spend a lot of time in class trying to tease out why it is, and nobody has great answers. It just is.

Harlan Krumholz: I’m, during this next interview, I’m going to ask our guest, who’s one of the foremost health policy people in the country, what her solution is for health policy. So we’ll see what she says.

Howard Forman: I look forward to it.

Harlan Krumholz: Yep. Great.

Howard Forman: Katherine Baicker is the provost of the University of Chicago and the Emmett Dedmon Professor at the Harris School of Public Policy. She’s a nationally recognized and highly accomplished health economist, and her research includes analyzing healthcare policy, public economics, and the effects of private and public health insurance. Before being named provost, she was the dean of the Harris School. She has also worked at the Harvard T.H. Chan School of Public Health as the C. Boyden Gray Professor of Health Economics.

Dr. Baicker is internationally renowned for running the Oregon Health Insurance Experiment, a large-scale study on the effect of healthcare outcomes and healthcare utilization in Oregon after its Medicaid expansion. In addition to her teaching and researching roles, Dr. Baicker is a National Bureau of Economic Research Research associate and serves on the board of several national health related organizations, including Eli Lilly and as a trustee for the Mayo Clinic.

She also holds several editorial and advisory positions, such as for JAMA Health Forum, the National Institute for Healthcare Management Foundation and Health Affairs, and was a commissioner on the Medicare Payment Advisory Commission. She has served as a member of the President’s Council of Economic Advisors and is on the Congressional Budget Office’s Panel of Health Advisors. She completed her BA in economics at Yale University almost exactly 30 years ago before pursuing a PhD in economics at Harvard.

I want to first welcome you to the podcast, and both Harlan and I know that you are much, much more than the Oregon Health Insurance Experiment.

Harlan Krumholz: Much more.

Howard Forman: But it is a tremendous contribution to our understanding of so much. I wonder if you could start off by just explaining to our audience why it was so important, and maybe some of the basics of how it was constructed, and then I’m going to follow up with a couple of questions and hand it off to Harlan.

Katherine Baicker: Well, thank you so much for that kind introduction. And if I were known only for the Oregon Health Insurance Experiment, I would feel pretty proud about that, because it’s, I think, one of the most important studies I’ve had the opportunity to work on, and here’s why: there are crucial questions in health policy that are still roiling the federal government and states today. What does it mean to cover people with public programs like Medicaid? What does it do to healthcare costs? What does it do for their health? What does it do to wellbeing overall? And these are foundational questions about programs that are more than 50 years old. So you’d think that we would know the answers, and it’s not for lack of trying, it’s that it’s very hard to separate out the effective insurance itself from all sorts of other things.

So for example, if you wanted to know what the effect of being on Medicaid was for mortality, say your state considering covering more people in your state with Medicaid, how much would that change mortality rates? Well, you might start with a very naïve comparison of looking at the mortality rate for people on Medicaid versus the uninsured. And you might discover that people on Medicaid have a higher mortality rate than the uninsured.

Well, it would certainly not be the right conclusion to say, “...therefore Medicaid is killing people. It’s a terrible program and we should discontinue it.” Rather, you have to understand why are some people on Medicaid and some people aren’t. One of the ways you get on Medicaid is by being low-income. That in and of itself is very hard on your health for lots of reasons. Another way you get on Medicaid is being disabled, in and of itself a health challenge. So if you don’t take those into account, you’re going to get a very mistaken idea about the effect of your policy on your residents’ wellbeing.

Howard Forman: And quickly tell us how is it that you structured this? I mean, how did this happen? What was the natural experiment that presented itself to you?

Katherine Baicker: The state of Oregon before the ACA, or Obamacare, had decided to expand Medicaid to all low-income adults. And I should say that I think it was surprising to a lot of people to learn around the ACA debate that most low-income adults who don’t fall into a particular category are not eligible for any public insurance, or weren’t before that law change.

Oregon was one of the states that had chosen to expand Medicaid beyond those mandatory categories of the disabled, pregnant women, low-income children, but they ran out of money for their program and couldn’t enroll new people until 2008 when because of attrition from the program, and because of some new revenue sources, they had enough money to enroll 10,000 more people. And they decided the only fair way to do that would be through a lottery. They thought about lots of other mechanisms. You could say, “What about first come first serve?”

Well, that might advantage people who were better connected to the social safety net, who had more access to a computer, for example. And they didn’t want to advantage those people over all of the others who might want to take up the program. So they held a lottery, they got a waiting list, they signed up 90,000 people on that waiting list, and then they drew names by chance, not because they were looking to set up the perfect natural experiment, although that is in essence what they did, but because they wanted to be fair to residents in Oregon.

Howard Forman: And just one last question before I hand it off to Harlan. There’s an article in the Atlantic from 2013 that I think summarizes the discourse on your study so well, and the title is “How to Use the Oregon Medicaid Study to Your Ideological Advantage,” and it is the best title I’ve ever seen. Can you give a couple of examples of how people use this study to their ideological advantage?

Katherine Baicker: I’m really glad you highlighted that, because that’s one of my favorites too, and I use it in a lot of slides when I present about Oregon, because the answers that we got from the study were very nuanced. It was a mixed bag, as any study of a multifaceted program with lots of different effects for lots of different people is likely to produce.

So people who were in favor of expanding Medicaid could say, look, people are much happier when they have Medicaid, they have much lower debt, they’re more likely to get access to care that they value, depression rates are much lower. Self-reported, health is much better. Look, it’s a great program.

On the other hand, people who were not in favor of expanding Medicaid could say, look, there were no effects found on physical health conditions like high blood pressure, diabetes, cholesterol, obesity. And people spent a lot more on the program. Not only did they go to the doctor more, but they went to the emergency room more. And so the program cost a lot of money, and that’s the reality of almost any public program. It comes with benefits to the people who are enrolled, and it comes at a cost to the taxpayers who have to finance it. And because those are often different people, it sets up a real political conundrum for policymakers.

Harlan Krumholz: This is really, I think, one of the best examples of studying public policy in a rigorous way. It’s just extraordinary. I think that the thing that really did surprise me about it was that there was no improvement in physical health. And you look for, you know, two years after the lottery, and tried to detect these changes. I mean, a lot of people who are promoting the idea of Medicaid expansion sort of have this assumption that people are going to die if we don’t expand Medicare. We’re going to save lives, or we’re going to vastly improve health. And your study, this Oregon Health Experiment, you and many others really failed to demonstrate that that was true.

Now, it did show, like you said, that interestingly, there were more hospitalizations and more ED visits, but that also proves something which was that increase in healthcare utilization, at least in the two-year timeframe, didn’t translate into a meaningful benefit by physical health. It did raise the level of diabetes detection and management, and lower rates of depression, reduced financial strain, all those things are good. But mostly when you’re thinking about the policy side, we’re thinking about how to improve physical health. How did you, as you thought about this, piece this together, because it sort of seems so important that people have this insurance coverage, but yet the coverage by itself, it didn’t achieve that better physical health.

Katherine Baicker: Well, there are a couple of threads that I want to pull on in that great question.

First of all, I don’t want to downplay the improvement in depression. We saw a really marked improvement in depression, where we screened people in-person interviews and found a 30% or nine-percentage-point drop in depression. And this is a serious unmet health need of the population. So I wouldn’t want to minimize the importance of that, nor of the financial wellbeing. There was a 25% drop in bills sent to collection, and having bills sent to collection is a terrible outcome for the people whose finances are then disrupted. It’s also bad outcome for the healthcare system, because those bills are almost never collected upon. So it shows providers giving care that’s not being reimbursed. So those are important benefits, but I don’t think it should be as surprising as it was to many that Medicaid alone did not cure diabetes or high blood pressure.

When people got access to Medicaid, they got access to the health that our healthcare system provides. We also have uncontrolled hypertension in Medicare populations and in the privately insured. And so I think this study doesn’t speak to why that is, but in many ways I think it’s representative of our failure to adequately address chronic physical health conditions in our healthcare system today and suggest that we need to have a better system-wide approach to addressing those chronic physical conditions.

Harlan Krumholz: Yeah, I think that just what you’re saying, it’s like if we’ve got a broken system, giving people, sort of relieving the financial toxicity of the system doesn’t necessarily make the system more effective. And there need to be different... that I wondered on the depression side whether you were thinking that this wasn’t because they necessarily got access to mental health services, but when you relieve the financial strain, when you give people more secure access to healthcare, maybe that’s also helping with depression? Or did you think this was because our mental health services are so effective that when you reduced the financial barrier and they got it, that actually that was what produced it? Which did you think it was?

Katherine Baicker: I think the latter is very important. So surely people were much happier when they were insured than uninsured. When we did follow-up qualitative interviews with people, they described the stress of being uninsured, the psychic burden it placed on them and their families.

But I think that we uncovered more than that. I think the clinical episodes of depression dropped substantially, and that’s not just about feeling less stressed. People used more medications for depression. They were more likely to have their depression diagnosed by a healthcare provider, and there was huge unmet need in the population for diagnosis and treatment of depression. So the fact that we saw an improvement there, I think speaks to the removal of financial barriers, allowing people to have access to care, getting medications, and having medications available that worked. That’s always very important. And one of the reasons we studied the conditions we studied is that for each of them, there was some treatment available that could, if taken consistently and prescribed appropriately, improve the condition.

So let me come back for a second to hypertension where there was much hand wringing when we discovered that there was no detectable effect on hypertension in this study. People suggested, well, maybe you just didn’t wait long enough.

Well, as you noted, it was about two to two and a half years after people gained access to insurance. They were no more likely to have their high blood pressure diagnosed, and they were no more likely to have a medication in their possession at the two-and-a-half year mark, those who had insurance relative to those who were uninsured. So the idea that somehow if we just waited six more months, somehow that train would’ve gotten back on the tracks, to me, doesn’t seem quite plausible. And in fact, when people take those medications, they work within a number of months. And so I would have expected if we were going to see anything, it would have shown up in that period.

But of course the study stopped after about two and a half years, because more people in Oregon got insurance. So the control group gained access to insurance, and thus the experiment ended. So I cannot say definitively what the effect at five years would be, but not seeing anything at two years does not make me optimistic on that front.

But again, people were much better off being insured. They reported their healthcare needs were more likely to be met. They described their health as being better, when you asked people, what’s your health? Excellent, very good, good, fair, poor, people were much more likely to say that their health was good or better. And that’s a pretty good predictor of people’s long-term health outcomes.

So the fact that we didn’t see the chronic physical conditions improve, to me, doesn’t mean that the insurance wasn’t providing meaningful health benefits as well as financial and wellbeing benefits to those who were enrolled.

Harlan Krumholz: And just to say what you said, I wanted just for listeners to know, that the prevalence of undiagnosed depression being reduced by 50% and untreated depression by more than 60%, those are huge numbers. That’s not—

Katherine Baicker: Yes, this is the most effective antidepressant ever invented, in fact. So I think we don’t want to put that aside. And I think sometimes the mental health outcomes are made secondary to the physical health outcomes, and both are very important in people’s quality of—

Harlan Krumholz: Well, yeah, that’s amazing. And the number of respondents reporting unmet mental health needs being unmet dropped by 40%. Those are huge numbers. Yeah, Howie?

Howard Forman: You are not afraid to push back against dogma on a number of issues. But one of them that always catches my eye, is the fact that earlier in your career you were involved in a paper that supported the fact that workplace wellness programs help people, and later on, you have another natural experiment that sort of disproves that. I just wonder if your thoughts on workplace wellness programs, because that’s almost dogma, there are people that are still to this day saying employers need to invest more in workplace wellness.

Katherine Baicker: Yeah, that was a very interesting experience for me. The way that project started is, I was sitting with one of my colleagues at Harvard, David Cutler, and one of our then stellar graduate students, Zirui Song, who’s now a faculty member at Harvard as well. And David and I were thinking about studying workplace wellness programs, because there wasn’t a lot of robust evidence about whether they worked or not. And we realized that there was no synthesis of the existing literature.

We set out first to say, what do we know about these programs? And we realized that there was a lot of scattershot discussion, but we had no place to take away a good overall synthesis estimate. So we got our graduate student then, Zirui, to help us pull together a lit review, and presented that lit review to say, if you look at all of the published studies, it looks like they work. It looks like there’s a return in terms of reduced absenteeism, improved worker wellbeing. And so this is promising. But, as we said in that paper, there may be bias in what studies are done, who participates, what things are published. Very few of these have robust identification strategies, meaning teasing out cause and effect.

So we discarded the papers from that review that had no control group or comparison group strategy, and left the ones that we thought were the best, but we noted that really there was a need for gold standard evidence on whether these worked that was not subject to the kind of selection biases that most natural quasi-experimental or observational studies were.

So then we set about to do that study, which took many years. We found a wonderful partner in BJ’s Wholesale Club, and a vendor who helped us implement a representative program at scale. And we randomized different stores of BJ’s their employees into having the program or not, and waited to see what the results were. And after two years, and then again after three years, we found that there were no detectable improvements in those health conditions, in absenteeism, or in spending on healthcare.

And of course the promise to employers is often, you’ll save money because you’ll have fewer missed shifts, and more healthy workers who are more productive for the company. We didn’t find any evidence that that was the case. Now does that mean that those programs are a waste? Well, it depends how much employees like them, and whether employers want to have it as a benefit just like they’d have any other benefit that employees value. But if employers are under the impression that they will save money by implementing one of those programs, this study certainly gave pause to that.

And just to bring the question back to where you started, in this case, as in the Medicaid study, it’s really important for researchers to hew closely to the findings of the study rather than have their own views and preferences flavor that reporting. And that was particularly fraught in the Medicaid study, where I described this nuanced set of findings, some things that would give comfort to those looking to expand, and some that would give pause, and policymakers and reporters, journalists would say, “Okay, so does that mean we should expand Medicaid or not?” And the answer is always, “Well, that depends on what your preferences are. Here are the costs, here are the benefits. You have to decide if you think that those are worth it.”

That is of course not the answer that a lot of them want, but if I want the evidence to be taken seriously, then I have to be an unbiased reporter of that evidence. And I tried very hard throughout to be the voice for the evidence, not the voice for my own views.

Harlan Krumholz: I think people listening already have a sense of what an extraordinary investigator you are, and the fact that you took on, and have taken on, questions with great practical significance so that the answers actually have a welcome group of people who want to act on them. And I think that every time I look at your work, I think like, wow, that’s just so important to be asking the kind of questions that people care about.

But you’ve decided, over the last several years, for sure, to actually I would say balance your interest as an investigator with an interest in administration, and have gone on to become the dean of the Harris School and now provost of the University of Chicago, a real, one of the great leaders within academia today. What was it that sort of led to that idea that you had that aspiration? I can actually remember when we actually went for a walk, when you were even looking at the Yale School of Public Health years ago, and why have you had that interest, and what have you hoped to accomplish on the administrative side?

Katherine Baicker: These are deep questions, and it does go back to my original motivation, in studying economics in the first place, which is I came to economics from the perspective of public policy, and I was always interested in safety net programs, and in using public resources to address challenges in society. And when I took my first economics class, I realized that it was the toolkit that made the most sense to me, in thinking carefully about trade-offs, costs, and benefits. There are very few policies where everyone’s a winner and it’s free. And that means you have to both develop estimates that are implementable. How much does it help people? Sure, these people are better off. How many people? How much better off? Because you have to weigh those costs against the benefits to make good policy decisions. So that’s what brought me to economics, and why I’ve always tried to study questions that have practical import, but what I realized in some of my stints in government, especially, is that the evidence doesn’t speak for itself.

You as a researcher have to take the time and energy to translate them in a way that’s meaningful to policymakers. And that doesn’t mean overly simplifying things, or that people who are digesting the evidence aren’t very smart people. They’re coming from different backgrounds. And as academics, I think we can get a little insular in our jargon, the way we talk in shorthand about our results, and also lose sight of the parts that really matter for policymakers.

And the idea that you could just hand off your research to somebody else who would interpret it for you, I think is misguided. That you as the researcher, if you care about correct interpretation, and if you care about it being accessible in close to real time to people who are trying to make decisions that affect millions of people, you have to invest your own energies in that.

For me, the Oregon Experiment was the height of that, and after that experience and after having spent some time in Washington, I thought I would really like to have the opportunity to amplify that translational work for a wider set of people.

I also really like solving problems in a practical way. And I started as chair of the Department of Health Policy and Management at Harvard before becoming dean and then provost. And of course you have to have big-picture vision and goals and priorities, but you also just have to clear away the things that are making it harder for people to do the work they’re doing, and there’s a real reward to that as well.

So I enjoy the mix of getting to think about what’s exciting, and where we can be investing and supporting, and also just unleashing the vast talent of our students and our faculty, both on the transformational educational informational side and on the research with real world import side. And that’s a feature of my job.

Howard Forman: I want to just read you a quote really quick, and then come back to you with a question. In 1993, a Yale undergrad was quoted by the president of Yale at the baccalaureate ceremony.

And here’s the quote. She said, “While here, I have grown enchanted with the idea of a university, not just Yale, but all universities. I plan to be in academia for the rest of my life. That is not something I planned before coming to Yale but something that developed here. I’m going to go to Harvard next year to study economics with an eye on an academic career. My goal is to drift back and forth between academia and policymaking and government, to be one of those academics who is called upon to create economic policy, and then return to teaching and research.”

So this is probably the most prescient comment I’ve ever heard from an undergrad. And I’m wondering now, 30 years later, do you add administration to that? And is it in your vision, now, to be able to see even a larger institution or at least a larger role? And I say this because ironically, President Salovey was our last episode, and people are going to think there’s a conspiracy theory here, and I just want to tell them that I think that you would be a great president of a university.

Katherine Baicker: Well—

Harlan Krumholz: Which university, Howie?

Howard Forman: Well, it starts with a Y, ends in an E, and has an “AL” in the middle.

Harlan Krumholz: I couldn’t agree more.

Katherine Baicker: You are very kind. I do not know how you dug up that quote. It does sound like something I might have said, but I really did come to that realization at Yale. I had no interest in economics. I’d never taken an economics class before I came to the EP and E major at Yale. And I had never thought about academic administration or staying in academia. I was motivated by public policy.

But what I learned in my economics classes at Yale, that motivated the whole career path that I, apparently, very clearly laid out senior year, was the value of rigorous thinking about hard problems that you can do in academia that is very hard to do other places. And then the opportunity that some academics have more than others. I think economics is one of the fields that goes back and forth more than some others, but the opportunity to spend some time applying what we’ve learned in academia to real-world decision-making, but not be so mired in it that you can’t come back to answer new problems, answer new questions.

So it is absolutely true that that was instilled in me at Yale, and I’m really glad it worked out the way it did. I’m very much enjoying academic leadership, and I’ve always enjoyed leadership opportunities. So I think it’s a great combination for me.

Harlan Krumholz: I wanted to just as we get to the end here, wanted to ask you a question as one of the foremost experts on health policy in the country. So your very close colleague, Amy Finkelstein, has just come out with a book, We’ve Got You Covered, and what she makes an argument for, some people would say Medicare for All, I think of a little bit differently, but it’s like full coverage for people that we need to move in that direction. I just wonder where you stand on this topic, what are you thinking should be the solution for what ails us? We’re spending more, we’re getting less every year now, particularly in the last decade. What economics policy should we be considering to address that?

Katherine Baicker: I am a huge fan of Amy Finkelstein, and her work is flawless, in that she’s answered so many pressing questions about health policy, public insurance, private insurance, how we think about optimal design definitively. So it was a great pleasure to get to work with her. And unsurprisingly, I think have come to similar, although slightly different conclusions.

And I have some work with John Skinner and Amitabh Chandra and Mark Shepherd thinking about optimal insurance design. And I come to something that looks a little more like Medicaid for All than Medicare for All. And what I mean by that is that I think people ask all the time, is healthcare a right? And to me, that’s not the right question, because healthcare is not one thing. It’s not something that you either have or you don’t. It’s a continuum of things from people going without basic lifesaving care to everything under the sun that may have zero incremental benefit to your health at great cost. In fact, some care is actually harmful to health at some point, and at great expense.

And that’s a continuum where we have to choose a spot as a society to say, we think everybody should have at least this much healthcare. That is a much better question. “How much healthcare is a right?” than “Is healthcare a right?” And until we’re willing to have that debate as a society, we’re not going to be able to enact policy that guarantees everyone that minimum floor.

If you say the minimum floor is everything that’s possibly available, that’s more than a hundred percent of GDP. That means no money for schools, or housing, or food. Nobody would say that. But it’s because of the miracle of modern medicine that there is so much that we can do for, or to, people in the realm of healthcare. So if we have a sensible discussion to say, how much are we going to prioritize health relative to all of the other good things that we can do? And then guarantee that everybody has access to that, and then let higher-income people buy more above that if they want to.

Now that last thought is one that comes with serious ethical implications that need serious debate. If you frame it that way, you are in essence saying that higher-income people are going to have better healthcare and live longer, healthier lives. And is that something we’re comfortable saying?

I would note that that happens now, without the minimum access to care that we’re talking about and that there is some societal advantage to having higher-income people paying more for healthcare, because that’s where new treatments come from. And then over time, the cost comes down, with good competition and generic entry, and all of that is of course crucial, so that everybody ends up with access to more treatments and more innovation than they would in a world where there weren’t those extra resources being brought into the healthcare system.

So that’s something I think we ought to consider more seriously, and I think it’s more realistic than an unlimited Medicare for A threell approach. Now of course, what’s realistic today? I am a simple economist, not a politician, and I find it often baffling what can get done and what can’t get done. So if you ask me, do I think we’re going to have a plan that looks like this in the next 1, 2, 3, 5 years? I’m not optimistic about that. But I think if we can change the discourse to focus on how much healthcare we want to be sure everyone has, I think we’re in a better position to make sure that we have a sustainable system that delivers that.

Howard Forman: I want to just, on behalf of Harlan, but also with Harlan, thank you so much for joining us today. You bring clarity to so many topics, many more than we got to discuss today, but I just thank you for all that you’ve done for the profession, and look forward to seeing more of your work.

Harlan Krumholz: What a great pleasure to have you on. Thank you so much.

Katherine Baicker: I’m grateful for the chance to talk with you, and I’d love to come back anytime.

Harlan Krumholz: Well, Howie, that was a terrific interview, but hey, let’s get to your part this week. So what’s on your mind?

Howard Forman: Yeah, so I just wanted to come with something that’s, to me, a little uplifting in a sense. The President’s Emergency Plan for AIDS Relief, which we call PEPFAR, is a 20-year-old program first created by President George W. Bush in 2003, reauthorized three times, it has always had widely bipartisan support. Estimates are that it has saved 25 million lives globally, increased vaccination rates, decreased childhood and maternal mortality rates, had other positive effects on health and healthcare, including about infectious diseases like malaria and tuberculosis. It has cost over a hundred billion dollars over its history, but it is widely regarded as one of the most impactful and successful global health initiatives ever, and in the context of 25 million lives saved alone, this sum is actually modest. Four thousand dollars per life, if you wanted to try to quantify that. Rare have we seen interventions that are that cost-effective.

So Congress, which right now is as we speak, so dysfunctional as to be almost paralyzed, was already holding up this successful program because of abortion politics. In short, Congress would like to legislate that any organization that performs or promotes abortion as a means of family planning should not receive PEPFAR funds. There’s no question that PEPFAR neither supports nor funds abortion. This is about using the leverage of U.S. funding to prevent nongovernmental organizations in other countries from performing or promoting abortion.

President Trump had banned this use of the money. President Biden undid that by a separate executive order. And I would just point out, to put it a little different way, we are imposing on other countries a standard that we ourselves don’t adhere to, and I really hope that cooler heads will prevail, because the bipartisan support has been something that we’ve pointed to with pride, the number of lives saved has been great.

Harlan Krumholz: Did you say cooler heads will prevail in our Congress?

Howard Forman: Well, they can’t get hotter. Can they get hotter? I don’t know.

Harlan Krumholz: I don’t know. PEPFAR is one of the most amazing programs that has ever been put into place. I know many of us didn’t always agree with George W. Bush on some things. I know other people did agree, but this is one thing I think everyone can come together and say was a real triumph. Someone who I knew through my residency, Eric Goosby was head of PEPFAR from 2009 to 2013. And Eric, who’s a remarkable guy, really transitioned it from this emergency response to sustainable program.

But it’s got an illustrious history and much more work to do. It’s a tragedy to not continue it. And for people interested in diplomacy, isn’t this how a perfect example of soft power?

Howard Forman: That’s right.

Harlan Krumholz: Where it’s not like we go in with troops, but we actually go in with help, and—

Howard Forman: A hundred percent, Harlan. I mean, we talk about giving governments money for weapons, munitions, which may very well serve our national interest, but here is something that we can do to save lives, make people’s lives better. And to your point earlier, in the beginning of the podcast, you look at South Africa as an example of what life expectancy is. It bottomed out around 2003, 2004 when PEPFAR started, and since that time we’ve seen an improvement. A lot of it just has to do with the medications. A lot of it has to do with PEPFAR.

Harlan Krumholz: Yeah, I love when we exert our soft power like that. I really wish we would do more of this around the world. And yeah, this is not a time to pull back on that kind of work.

Thank you, Howie, for bringing that up. It’s just such an important point.

You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can continue to follow us on Twitter or X or email us at health.veritas@yale.edu.

Harlan Krumholz: On X I’m @ H-M-K-Y-A-L-E, that’s @HMKYale.

Howard Forman: I’m @TheHowie, @ T-H-E-H-O-W-I-E. Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the healthcare track, founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs, you can check out our website at som.yale.edu/emba.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and to our producer, Miranda Shafer. Amazing work, week in, week out.

Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. I’ll talk to you soon.