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Faculty Viewpoints

Dr. Esther Choo: The View from the Emergency Department (Health & Veritas Ep. 46)

On the Health & Veritas podcast, Yale physician-professors Howard Forman and Harlan Krumholz talk about the latest news and ideas in healthcare and seek out the truth amid the noise. In this episode, Harlan outlines his new study tracking excess mortality over the course of the pandemic in the highly vaccinated state of Massachusetts; Howie discusses how the Inflation Reduction Act will tackle drug prices. They’re joined by Dr. Esther Choo to talk about life as a doctor on social media and the crisis facing emergency departments.

A crowded emergency room

An emergency room in New York City in March 2021.

David Grossman/Alamy Stock Photo
  • Esther Choo
    Professor of Emergency Medicine, School of Medicine, Oregon Health & Science University
  • Howard P. Forman
    Professor of Radiology and Biomedical Imaging, Economics, Public Health, and Management; Co-founder, Pozen-Commonwealth Fund Fellowship in Health Equity Leadership, MD/MBA Program, and MBA for Executives Program
  • Harlan M. Krumholz
    Harold H. Hines, Jr. Professor of Medicine and Director of the Yale Center for Outcomes Research and Evaluation

Listen now:


Esther Choo: “Covid-19 is pushing doctors to the brink. Medicine needs to recognize they’re human and need help.”

“Uncoupling of all-cause excess mortality from COVID-19 cases in a highly vaccinated state”

“New York Governor Lifts Mask Mandate for NYC Subways”

White House Fact Sheet: The Inflation Reduction Act Supports Workers and Families

Learn more about the MBA for Executives program at Yale SOM.

Learn more about the MD-MBA program at Yale.

Email Howie and Harlan comments or questions.

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

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This week—

Harlan Krumholz: And, Howie, we’re back from summer break. We’re back from summer break.

Howard Forman: I know. It’s our first August hiatus, and this week we’re going to be talking to Dr. Esther—

Harlan Krumholz: It’s our first August hiatus!

Howard Forman: It is.

Harlan Krumholz: I hope you’re rested up and are all ready for the new season.

Howard Forman: I feel energized and ready to take on the world right now. Here we are.

Harlan Krumholz: All right, so who are we talking to today? Who are we talking to today?

Howard Forman: We’re going to talk to Dr. Esther Choo, our alum from Yale Medical School and Yale College, an emergency medicine physician. But we usually want to just start off with current health news, so what’s on your mind?

Harlan Krumholz: Well, a lot’s on my mind. And by the way, my daughter got married, so that was amazing.

Howard Forman: My daughter went to college for the first time.

Harlan Krumholz: Oh, congratulations.

Howard Forman: That was similarly exciting.

Harlan Krumholz: I wanted to just talk for a minute about a paper that we published. I know that sometimes I maybe perseverate on my own papers, but I think people might be interested in this. Published a paper in Lancet Infectious Diseases that asked the question, over the course of the waves, how have we been doing with regard to excess mortality? Is there any evidence that we’ve made progress? And we looked particularly at a highly vaccinated area—we looked at Massachusetts.

And the thesis, the hypothesis was that given the history of prior infections, the nature of the current variant, the high degree of vaccination within Massachusetts, there’s a possibility that we can actually quantify less mortality impact, less risk of dying as a result of the pandemic than what we’ve seen in prior waves. And in fact, perhaps infection has been what we called “uncoupled from mortality risk” because of the way things have evolved.

And we’re very interested in this measure of excess mortality. In fact, we’ve pioneered some of the refinements that CDC has adopted from what we’ve done to try to come up with a metric that says, if we compare the current mortality rates, the current death rates, versus what we would’ve projected would’ve been the death rates based on historic records. So we basically look in the several years before the pandemic, and we look at the patterns of deaths within a geographic region. And then we fast-forward it ahead and say, given that and given changes in the population, the deaths that have occurred that’s in part by COVID, the changes in immigration, the immigration’s different now than it was before. So we try to come up with a refined estimate of the population and we say, “How does the current mortality rate compare with what we would’ve predicted it should be?”

And very early in the pandemic there were a lot of excess deaths. And the reason we think this is a good metric is because if you just look at deaths caused by COVID, it gets really tricky to label what’s a COVID death. Somebody could have COVID and then they have a heart attack. Is that a COVID death? It gets hard to be very accurate about what exactly was the result of COVID. But you can look at excess deaths as a sort of net, a summation of the exact impact from all causes during this period.

And so what we found was early in the pandemic in those waves, there were spikes in excess death that accompanied the waves. But the bumps were getting smaller, until we got to the wave in the spring, which was the last wave for which we had data. And actually there was no evidence of excess mortality in Massachusetts. There was just a minimum amount, versus the prior ones where there was a pretty profound amount of extra deaths. And what this we thought was telling us is, like I said, given the situation has evolved, the pandemic in Massachusetts, in that time, was not actually causing excess death. And again, we have treatments now, we have prior infections, we have vaccinations and the variant’s evolving.

But this was reinforcing the idea that the kind of strategies that had been undertaken in places like Massachusetts, Connecticut, the Northeast, tends to actually look very much the same, had neutralized the mortality risk that we had seen earlier in the pandemic. And I think, conveyed this sense that society had, began to embrace that we could get back to a more normal existence. That doesn’t mean that people who are particularly vulnerable shouldn’t be careful. It doesn’t mean that we shouldn’t use common sense when we’re going around, but it just tells us where we are in the course of the pandemic. Now things can change with new variants, waning immunity, lots of things can be different, we need to keep monitoring this. But this was, in my mind, really good news.

Howard Forman: Let me ask you just one quick question about you personally, if you’re willing to tell us. The new bivalent vaccines are out, Pfizer, Moderna. People are allowed to get them as early as two months after the last booster. You told us that you got your booster, I think if I’m not mistaken, in May or early June, so you could be getting it soon. Have you made a decision yet about when you’re going to get the bivalent booster?

Harlan Krumholz: Oh my God, I’ve been trying to duck this question because I don’t want to get involved in the politics of it. But I will tell you how I’m thinking about it, which is that in a hiatus period, and I think we’re in a hiatus period right now, infections are dropping, the excess deaths, particularly in places like where we live, Connecticut, are very low. The risk of major complications at this point for someone who’s otherwise healthy, has been previously vaccinated, I don’t know that I’ve been previously infected, but I know lots of people who have been and vaccinated.

I think it would be a good case to say that I’m going to wait until it seems like there’s a wave that’s coming that’s got some potency to it with regard to risk. And it’s predicated on the notion that we’re probably going to get some warning. We have every time before, that there’s a wave creeping up that looks like it’s going to be a problem. Now obviously it always starts somewhere, but I do think that I’d rather get boosted in a time when it’s just before a period where it looks like there’s some risk, as opposed to waste an early period of extra protection at a time when I don’t think that it’s not as dangerous.

So that’s I think the case. I know very smart people who feel otherwise or rushing out to be boosted. I understand that case. And I’m not anti-vax by any means, I’m pro-vax, but I’m just trying to...And lots of people, by the way, say you shouldn’t time it. I hear you, but I’ve already gotten three shots. And I also believe cellular immunity, some immediate immunity, besides the antibodies, provides some protection. Anyway, that’s how I’m thinking about it right now. But there’s lots of opinions and that could change, but that’s what I’m thinking right now.

Howard Forman: I’m aligned with you on that. And I’m trying to also think about, I know timing, we shouldn’t be doing, but I’m in the same boat basically. So let’s hope we get it timed right if we’re going to try to time it at all.

Harlan Krumholz: Yeah. Yep. Great. So Howie, let’s get to our guest.

Howard Forman: All right. Today we welcome Dr. Esther Choo. She is a full professor of emergency medicine, Oregon Health and Science University. Her research interests include opioid and cannabis use, women’s health, health policy, and health services. Outside of her role as a physician and professor, Professor Choo speaks and advises on improving equity in the workplace in the provision of healthcare and is published in The Lancet, Washington Post, NBC Think, Self magazine, and USA Today on these topics. She’s a founder of Equity Quotient, which advises companies on building equitable cultures, and is a health columnist for MSNBC. She earned her undergraduate and medical degrees from Yale and an MPH degree at the Oregon Health and Science University.

First of all, welcome to Health & Veritas. Esther, you are a true, quadruple or even a quintuple threat. You have an amazing record of scholarship, you’re an outstanding clinician. You teach, you run programs. And you’ve been a leading source in the fight against misinformation during this pandemic. And quite frankly, always effectively using social media, lay media, scientific media, et cetera, to communicate. Is it association or is it causation that emergency medicine physicians in particular seem to be so successful at marrying these elements?

Esther Choo: Well, Howie and Harlan, thank you for having me on. It’s just such an honor to be on with two people I admire so much.

I agree with you on the emergency medicine physician thing and yeah, is it correlation or causation? I’m not sure. I do think that people in emergency medicine are drawn to it because we like to be at the leading edge. We like dynamic, fast-changing environments. And I think we also like to be...There’s a canary in the coalmine kind of aspect to the practice of emergency medicine. I mean, whatever is happening in the community tends to emerge in the emergency department. So we tend to be there when we see, say, outbreaks of a new recreational drug or a new infectious disease, as in the case with COVID. So I think people who choose emergency medicine naturally like to see things they don’t understand and have to be quick on their feet in responding to it.

And so I think that’s some of the reason that you saw a lot of ER doctors out front when the pandemic hit. Just when we didn’t know much at all, being at least available to talk about what we started to see, what patients look like, what this disease look like. And then I think there is that short attention span thing that is cultivated in emergency medicine.

I mean, there’s a study...was it a Yale study? There was a study that showed that our task interruptions are something like every six minutes in emergency medicine. I mean, you can either thrive in that environment and embrace it, or you can at least tolerate it. But I think we’re used to being pretty nimble and switching from topic to topic, not spending a long time focusing on things. So I think that is, if you think of the way that, say, social media is or just general news media, I think that kind of brain is good fit.

Harlan Krumholz: Yeah, I was thinking that too, Howie. Some of the people I admire most who are on the front lines of trying to bring about positive change are in emergency medicine. I’ve always thought that being on those front lines, seeing people from all cuts of society, in many cases the most vulnerable and in positions where they need help, and really being tuned into what the social determinants that are driving the kind of health challenges that we’re seeing within our health systems. I mean, maybe help tuning people in. And I think we should all be spending more time in the emergency department, probably, if we want to really understand what people are facing in those challenges.

Well, one of the things I wanted to ask you, Esther...Or I don’t know, what do you think of that? I mean that that’s—

Esther Choo: Yeah, I agree with you. I mean, I think, my husband and I were talking about this recently because we have both changed a lot over the course of our careers. I mean, I would say going into medicine, initially I was a pretty traditional thinker in terms of what my life would be like. I’d go into an office and see a patient and do medicine, whatever that entailed. And then it only took a few months into my residency...I did my internship at Yale New Haven Hospital as a medicine intern and then I went to Boston Medical Center as a resident.

And it was really that second year as a resident in Boston’s biggest safety net hospital that I started feeling totally different about what my job was here. Because we do this teeny tiny bit of healthcare, and yet our patients had to go back to whatever environment they had, often very socially disadvantaged. And it was clear that that was our responsibility too. And that’s when all the literature around the revolving door of emergency care was really coming into our consciousness.

And it’s not to say that every ER doctor feels very strongly about addressing some of these social issues, but I think a lot of us do. And it’s really our experience in the ED. I don’t think you cannot take that home with you and start to think about what it is you want to do in this world so that people could have better and healthier lives.

Harlan Krumholz: Yeah, I think that that came to...I guess, brightest relief for me when discharging somebody who’s homeless, and you’ve just spent all these resources trying to get them well, and then now you’re putting them back on the street without really having any sort of plan about that. It is really true that...our training, we’re socialized into thinking hard about the narrow medical problem, but these health issues are rarely just circumscribed within a medical construct. And that’s where I think the leadership from the emergency medicine is so strong and so clear and so important, so needed.

One thing I wanted to ask about is, gosh, I really admire the way you get your messages out and the way in which you’re able to interact with people through social media. And I think for a lot of us we’re thinking that despite all the challenges, it can be a force of good. You can actually engage people in gender-constructive interactions and even potentially change the minds, or have our own minds changed if we’re in that kind of milieu.

On the other hand, it has a dark side, and that dark side can rear its ugly head at a moment’s notice. And I don’t know, you seem to be able to hit just a right tone. And also balance sometimes some reflections that are quite personal with reflections that are social or professional, meaning that they have impact for society or they have impact for your local environment. I mean how are you able to do that, and do you ever find yourself...I mean, do you just do it spontaneously or do you find yourself needing to reflect, like “I wonder how this is going to be received?” and taking time on it. I don’t know, what is your process for how you interact with the public that way?

Esther Choo: Yeah, it’s a good question. And I mean, I definitely am closer to being spontaneous and not thinking too hard about individual posts, because I feel that there is an element of authenticity that people respond to. And if you are super planned out or strategic or trying to do something, I feel like that comes across too. And so I think there is this element of, if it’s forced, people just don’t hook into it because they feel that is what you’re doing. So I do try to be authentically myself.

I will say my authentic self is fairly private, and so when I share pieces of myself, there...there’s this, I often feel a little bit uncomfortable. But I think sometimes, I just think in this day and age, I think people need to know why you’re so engaged in a topic. And so sometimes it is just much more helpful, and actually part of the process of raising awareness, to be vulnerable.

A year or two ago, for example, I shared that we were having so much terrible mental health among healthcare workers. And over the course of the pandemic I’ve lost three friends to suicide. And I thought, “Well, such a big part of this is stigma and this feeling that you cannot pursue treatment.” So I decided to share how I had been depressed during residency and I sought treatment from a psychiatrist and was on medications for a while.

And that was one where everything I put out was totally spontaneous, and then I just paused because I had never shared some of this with my family members. And so I mean, the way that my closest cousin found out that I’d ever been treated for depression, and she’s a psychiatrist, was that I wrote a piece for The Washington Post. And I think there’s always that potential to be actually hurtful to your loved ones by being so open in the public space, whether because you’re talking about them or sharing things that feel like they’re so personal and dear that they really were not meant for a bigger audience.

I think I’ve had a hard time figuring out what the balance is, but I try to err on the side of, is this helpful for the topic? or are we overcoming taboo and stigma about talking about some of these things? And the same thing actually goes with gender bias and racial bias, and a lot of these things I try to talk about. We’re so uncomfortable talking about these things and our personal experiences, failing or succeeding with them, that it’s very difficult to feel like we can ever engage in meaningful solutions, because we’re not even talking about the problems directly and our role in it. I guess that’s how I try to do my decision making.

Harlan Krumholz: Just to say quickly, I thought that was really brave. I mean, I know people.... Maybe “brave” is used a lot, but putting yourself out and I’m sure it helped a lot of people. I mean that kind of willingness to share. People look at you on a pedestal, they see you, they listen to you, paying a lot of attention to you.

And when you are willing to make that kind of share, I think it really helps a lot of people that these are the kind of problems that most people experience at some time or another. And it’s not something to be ashamed of, but rather it’s something that people can talk about and feel okay about. Anyway, I thought that was amazing and really appreciate that you did that.

Howard Forman: I’m curious, Esther, the advice that you would give either a younger version of yourself or some of your trainees now about how to use social media effectively. Because I find myself starting off any discussion about this by telling people, “Don’t do what I do.” I’m at a point to my career where I don’t worry about—

Harlan Krumholz: I tell that people too, “Don’t do what Howie does.” I tell them.

Howard Forman: Exactly.

Esther Choo: I love what Howie does!

Howard Forman: No, I think it’s wise.... No, it’s wise. But I’m wondering—

Harlan Krumholz: Literally, Howie stepped into it in a way that I just can’t even imagine anybody should do, but …

Howard Forman: We can go into that in another podcast one day. But I’m curious to know, with the accumulated knowledge you have, and you have faced some offensive attacks at times, and you are a successful woman who is at the top of her career so you can do certain things now. But what do you tell junior faculty and residents and medical students, what is your advice for them?

Esther Choo: Thinking of where you are in life and power dynamics and things like that is so important. I mean, I think it is very different from this end. I mean, I’m a full professor and later in my career, and just at the age where you start to run out of...I feel like I was about to wade into bad language there. You start to run out of as much caring as you had before about what people think about you. But I do think early in your career, I think it’s okay to actually just lurk for a while and look at accounts that you admire. And think about all the people who are reading it, including your future employer, your grandmother, anyone who could look at that and just think about who you want to be online.

And then I do always emphasize the authenticity piece. I just think, whoever you are, if you want your voice to resonate and to be true and to have impact, I think you just have to figure out...I mean, the thing I like about both of your social media accounts is, whether you regret it or not, I do think both of you are very true to your voice. My impression of you, from the overlap we’ve had at Yale, is how you come across on Twitter. And I think that’s how you can be there and be there so often and show up for things.

And some of these things can really come back and have outsized importance. I mean, you’ve seen, I think it was one tweet that was so influential when Vivek Murthy went up for Surgeon General the first time. Literally one tweet about gun safety that I thought was really benign but that had such outsized importance. I’m not sure that was something he shouldn’t have put out there. But still, I think it is true that, whether or not you delete, things are out there, and so being thoughtful.

And then I did get called into the principal’s office here once, the president of my hospital called me in once after a tweet that got a lot of attention. And he didn’t actually have specific things, but he just said, “My advice to you is to try to always be respectful of people.” And it wasn’t in reference to anything specific, but he said, “You’ll never regret being respectful to people.” And I’ve always kept that voice in my mind as well.

Howard Forman: Good advice. Yeah, I’m just curious, one more question that’s a total pivot now. While we were sitting here, I got a text from one of our emergency medicine colleagues about the boarding issue in the ER now. And I’m not asking you about that specifically; I’m asking you what do you see as the biggest challenge right now in emergency room care delivery? If it is boarding I’d love to hear more, but I’m curious to know what you see as a challenge in your clinical practice.

Esther Choo: Oh boy. Yeah, so I mean I can start by just talking about what boarding is. If you come to an emergency department right now, mine, I think most major emergency departments, actually pretty much all of my peers are facing the same thing, where the beds we have in the emergency department to see acute care patients are not accessible to us. Because there are patients who were supposed to be admitted to the hospital who never made it upstairs because those beds are not available, and so we don’t have acute care beds. So our ability to take patients out of the waiting room and put them into actual beds, or out of the ambulance bay and put them into actual beds and take care of them, and all that entails...If you imagine, if you don’t have a bed, you can’t actually undress a patient, do a full physical exam, have the privacy and luxury of time with them.

And so all those things are being pushed out. And we have a ton of patients in the waiting room, and I would say even outside. So the last few shifts that I worked, there was, at some point, I stepped outside to examine a patient in front of the emergency department, which is, I mean, you can imagine you’re coming and not feeling well and imagine if that’s where you’re examined. If you want to do a pelvic exam, sometimes it’s like a work of God to figure out a place where you can do that.

And so this is something that we’re struggling with at the emergency department. And what is causing boarding? It’s a million things. And so I mean, I think in the emergency department we are experiencing the big care gaps that are happening right now. The fact that people still often don’t have access to a routine medical provider. Those medical providers are totally overwhelmed. We have a huge healthcare staffing issue. We’ve lost, what, 25% of our nurses, maybe more, and other ancillary staff. Where are they coming from? I don’t know.

Clinical training of nurses, even if we can recruit them in this era, has a bottleneck in clinical sites to train, which have not grown. And there’s a shortage of every...I mean, every shift you walk in and you just hear the list of things that are in shortage that day. IV tubing, green top tube, a lavender tube, the ability to run a troponin, IV contrast dye. Ativan was the last thing, something you use multiple times a day. And so every time you get one of those, it slows care a little bit.

And so I think our ability to provide good and timely care is so curtailed right now. And some of that is COVID catch-up care. It’s a ton of, a very complex illness. It is still COVID, believe it or not. I realized we’re talking as if the pandemic is over. We’re still routinely seeing COVID patients, some very sick still. And then enormous staffing and supply shortages. So I’m no longer a mid-career physician. I think I’ve been an ED doc for coming on 20 years. And we always complain about boarding, we always complain about crowding and throughput times, but this is something very special and different that we’re having a hard time seeing our way out of.

Harlan Krumholz: Yeah. I mean, it’s just reprehensible really that we’re in this situation. And all the things you’re talking about, the shortages in the United States, the richest healthcare system in the world, not necessarily most effective but the richest healthcare system, where we can’t allocate resources in a way that makes sense for this. I don’t know, it’s crazy.

I wanted to take you one level up as we get to the end of the podcast. I think of you as someone who seeks large-scale change. I just wonder, what are you prioritizing right now in terms of what you think are the most important areas to push? And if you had a wish about what things are going to look like a decade from now in an area that’s made change, where do you think it’s going to be and how will it be?

Esther Choo: I mean, I think my focus right now and for a while has really been on issues surrounding health equity and equity in the delivery of care and public health. And I think what I wish we could fundamentally change is thinking of health equity as foundational. I mean, I think the way that I’m used to hearing health equity talked about, the way that we hear it talked about all the time, anytime you see any pronouncement about the pandemic and next steps, I feel like I hear in it this tone that’s, “Here’s what we’re going to do for the majority of people, most of whom have a lot of privilege. And then we’re going to sprinkle a little bit of health equity at the end, if resources allow.” And I mean, that is really what’s going to happen this fall as we lose funding for a lot of pandemic measures, vaccines, testing, and as we drop the less costly measures like masks and distance work.

And so I think time and again, we really start to focus on, what can very well resourced people do. And I think we’re forgetting the foundational things that are so important to public health. Things that are inclusive, that protect the entire community, that don’t leave our elderly or disabled and other socially disadvantaged people behind. And so my thinking on that has completely changed because I used to be a “sprinkle on afterwards” kind of person. And now we see the very structure of healthcare is built in an inequitable way.

We’ve learned about pulse oximetry, that’s really titrated to people with lighter skin. It turns out our temperature probe, there was just a study that came out I think in the last day or two, temperature probes, we’re finding out, may not calibrate well with darker skin. And I mean, some of these things where it’s like it’s because we didn’t even build the basic things that we use to provide healthcare. We didn’t build them with any sort of inclusive or equitable framework. It pulls down our accomplishments in everything we do.

If you look at data from the Commonwealth Fund, it’s like, our measures of equity are so bad. The distance between those who have the most and those who have the least are so bad. That’s really what drags us behind other wealthy countries in terms of our accomplishments with regard to important health outcomes. And if we learn how to narrow them and bring the top-achieving health access to more of our population, that’s what will bring us within range of other countries that we consider to be our peers in every other respect. So I think we have to start turning around, completely turning around the way that we think about achieving health equity.

Harlan Krumholz: And those that we punish, the financial toxicity, that they come and see us and then they’re burdened with bills. And we’ve got to address this idea that in this country, that what you make and how much you have in terms of resources is determinative of whether or not you’re going to be harmed financially by your interactions with the healthcare system. It’s just unacceptable. But look, it’s been a—

Esther Choo: Yeah. Yeah, I totally agree. And I just think we have to stop pretending that we can just do our piece and then ignore the rest. Yeah, “You’re going to get a huge bill from this that you cannot afford that will crush your family financially. But I’m just going to do my piece as a physician and write all the tests and the treatments that I want.” That has to be at least a little bit on us as well.

Harlan Krumholz: We can’t pretend like that’s not part of it, yeah.

Esther Choo: Yeah.

Harlan Krumholz: Well, look, it’s been delightful to have you on. I’m so excited that you accepted and so happy that you’ve spent some time with us today. And you continue to be an inspiration. Look forward to whatever you’re going to do next, and we’ll continue to follow you closely. And thanks so much.

Howard Forman: Yeah, I hope you’ll come back again because I love hearing this, and there’s so much more we could have covered today.

Esther Choo: Thanks for having me on. Thanks to your whole team.

Harlan Krumholz: Thank you.

Howard Forman: Take care, Esther.

Harlan Krumholz: Howie, that was a terrific segment with Esther. I’m so glad that she was able to join us. Let’s pivot, let’s go to you. And so what’s on your mind lately?

Howard Forman: Yeah, so for a change I have really good news to report on. While we were on hiatus, our Congress passed and our president signed into law the Inflation Reduction Act, which had, as one of its central planks, a prescription drug bill. And if you and our listeners recall, we talked about whether prescription drug legislation could pass Congress 11 months ago, in fact, in episodes 3 and 4 of the Health & Veritas podcast. At the time we pointed out that this was wildly favored by voters—I think it was about 83% from both parties—but also acknowledged that the prescription drug industry would be vigorously fighting this. And I was maybe pessimistic or at least cautious that this could even happen. But to quote our current president, “This is a big effing deal.”

So what’s included in this, and what should our listeners know about? Number one, it immediately forces rebates, and by that I mean next year rebates. If drug companies raise prices faster than inflation, it caps the cost of insulin for Medicare beneficiaries at $35 per month. It improves vaccine costs and coverage for Medicare. It limits out-of-pocket costs and beneficiaries in Medicare in 2024 and caps them at $2,000 a year in 2025 and beyond. And it begins the process of Medicare negotiating drug prices, starting with the 10 most expensive. And by that I mean total volume of spending drugs starting in 2026.

We’re still hopeful that a cap on insulin prices for non-Medicare beneficiaries can pass Congress in the final months of this congressional session. But from the point of view of major prescription drug legislation, this is long overdue, and it’s also surprising, in a good way.

Harlan Krumholz: Howie, I was just wondering, so who are the losers with this bill?

Howard Forman: Yeah. The main loser, if you want to think of it that way, is on the margin one might argue that innovation will be curtailed a little bit. There are estimates that are I think 0.81% or 1%. They’re very small estimates that would suggest, from a pure finance point of view, that if a drug company is going to be making a little bit less profit, then they are less likely to take on the riskiest projects. And some of those projects—a very small number but some—that might have led to a cure for a rare disease or some unusual project that they were pursuing, will not get discovered.

So there is a risk to innovation, but you have to balance these risks. And we’re getting to a time in history where more and more people are unable to afford even the most routine drugs. And so the risk seems like a good trade-off here.

Harlan Krumholz: Yeah, I’ve never really bought into this innovation argument. It seems like something you can push without real evidence that it actually happens. It seems like the industry is always going to tack towards potential blockbuster interventions that are going to make a difference. We already are seeing, by the way, that other groups are coming into this, by the way, making investments, private equity, others, it’s not just the drug companies. Drug companies are letting others do the early work and then they’re coming in later anyway.

I saw this as just a tremendous win, and it was crazy how high the insulin prices were going. And so the most amazing thing that you said though is the stat of 85% both parties, really bipartisan support among voters, but yet we still had this divide among...couldn’t get a Republican to vote for it. And somehow we got to bridge this gap. But anyway, it was just an amazing, amazing, amazing piece of legislation. I’m eager to see its implementation, so thanks for giving us that summary.

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 find us on Twitter.

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

Howard Forman: And I’m @thehowie. That’s @T-H-E-H-O-W-I-E. You can also email us at Aside from Twitter and our podcast, I am fortunate to be the faculty director of the healthcare track and 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, or you can check out our website at

Harlan Krumholz: By the way, how many people you have in that healthcare track for the MBA program?

Howard Forman: We average about 25 every year, and three of them are our Pozen Health Equity Leadership Fellows.

Harlan Krumholz: Well, aren’t you also leading the MBA program for medical students?

Howard Forman: We have the MD/MBA program where we have a separate seven this year, seven medical students that began the MBA program in August.

Harlan Krumholz: Yeah, it’s an interesting trend to see docs being trained this way, and it’s great that you’re leading the program.

Howard Forman: The outcomes are great, as you know. And we have our Surgeon General, who’s our alum of that program, coming to visit us over the next two days.

Harlan Krumholz: Yeah, Vivek Murthy, a terrific individual, and a person who—I know he speaks so highly of the program and you’ve made such a difference in his career, Howie. It’s something so nice.

Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Jenny Tan, and to our producer, Miranda Shafer. Talk to you soon, Howie.

Howard Forman: Thanks, Harlan, talk to you soon.

Department: Faculty Viewpoints