America’s Healthcare Paradox and Other News

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 who are trying to get closer to the truth about health and healthcare, and this is one of the times we’re in the studio, which is always a lot more fun.‌

Harlan Krumholz: Howie, it’s so great to see you.‌

Howard Forman: I know, it really is.‌

Harlan Krumholz: Every time I see you, you get more and more handsome.‌

Howard Forman: Thank you so much. I dressed for you today.‌

Harlan Krumholz: It’s incredible. I don’t know what you’re doing.‌

Howard Forman: I dressed for you.‌

Harlan Krumholz: You look great. You look great.‌

Howard Forman: I dressed up nicely. Thank you.‌

Harlan Krumholz: Although you have a suit, tie. I mean, you have a jacket and a tie.‌

Howard Forman: Jacket and tie.‌

Harlan Krumholz: And you were wearing a hat.‌

Howard Forman: I’m wearing a hat and my—‌

Harlan Krumholz: I guess our El Presidente is showing—‌

Howard Forman: It’s influencing. I saw his red hat.‌

Harlan Krumholz: I saw him yesterday. He was wearing a suit, but he’s wearing a hat.‌

Howard Forman: It’s a red hat. But I’m wearing jeans and sneakers. He doesn’t do that. So I think I’ve got him on that.‌

Harlan Krumholz: I like your style a little bit better.‌

Howard Forman: Thanks. Thanks. Don’t tell him. Thanks very much.‌

Harlan Krumholz: All right.‌

Howard Forman: So I don’t know, I want to just quickly give an update in the news because no matter what, this will be stale by the time it comes on tomorrow. But I think it’s just worth mentioning as we record this, the Big Beautiful Bill that we have talked about, that we have discussed, is still very much alive and it is still—‌

Harlan Krumholz: Is it really?‌

Howard Forman: Yeah. And it may become law.‌

Harlan Krumholz: Do you think it’s going to pass?‌

Howard Forman: I don’t, not in this form. But it could by the time this posts tomorrow, it could be law. I mean, or it could be on the way to becoming law. The president could sign it on July 4th, as he sort of has promised.‌

Harlan Krumholz: Should make a prediction. Everyone should know. This is Wednesday, it’s right now with the House.‌

Howard Forman: I believe that the House will not pass this version and that they will end up conferencing this. But it is anybody’s guess, because there’s so much fear of the president right now that anybody who votes against it has to do so knowing that they may not serve in the next Congress.‌

Harlan Krumholz: Okay, since you want to talk politics, that Lisa Murkowski thing drives me bananas. So she’s willing to pass it for the country as long as her state gets exemptions and sweeteners. That is not a profile in courage. I just want to say, look, I’m not even going to enter the politics about whether it’s right or wrong, the bill itself. Let’s just say, if you don’t think the bill is good for Alaska, then your move is to say, “Let me exempt Alaska” rather than say, “I’m going to vote against the bill on behalf of the country”? I just think that’s unbelievable.‌

Howard Forman: She’s one of the more successful political figures of this time, more so in my opinion, than a Mitch McConnell because she really understands the state of Alaska. And the first rule of politics is that you have to get re-elected. This is how they think.‌

Harlan Krumholz: Is that the first rule of politics? How about the first rule of politics is to show leadership and who is right for the country.‌

Howard Forman: So that’s the first rule of policy and leadership. But politics is getting re-elected, and I think that’s what’s in her mind.‌

Harlan Krumholz: And for those listening, by the way, the reason it connects to this podcast, because obviously you might think like—‌

Howard Forman: Oh, it’s all health.‌

Harlan Krumholz: ... her exemptions, not counting the sweeteners, the sweeteners or something else. But the exemptions were largely around SNAP and Medicaid and—‌

Howard Forman: Children’s nutrition, family nutrition, Medicaid.‌

Harlan Krumholz: So, it was health. She said, “I want Alaska not to be damaged by this bill with regard to their health,” but the rest of the country—‌

Howard Forman: They bought her off. I mean, they literally bought her off. But it is, this is a woman who has survived the challenge from the right before and run independently as a right-wing candidate and won in Alaska. She understands her state. And what I will say is—‌

Harlan Krumholz: I guess, if you want to get reelected more than anything else.‌

Howard Forman: ... it would not shock me that in a final version she votes against this. And I still think it’ll come to a final version for her. But I agree with you.‌

Harlan Krumholz: But she had to assume this was the fact.‌

Howard Forman: Final version when she—‌

Harlan Krumholz: Absolutely. And that was, to me, the disconnect there is that she literally, moments after voting for the bill, said, “I hope the House doesn’t pass this bill because it’s not ready.”‌

Howard Forman: Exactly.‌

Harlan Krumholz: Her public statement’s just in complete opposition. Right.‌

Howard Forman: This was not a good bill.‌

Harlan Krumholz: Absolutely.‌

Howard Forman: And it is a horrible bill. Let me just quickly remind people why it’s a horrible bill. At least 11 million more people will be uninsured, which puts us right back into pre-Obamacare times. It’s going to explode the deficit by probably around $4 trillion once you include interest expense. It cuts Medicaid, not just the loss of insurance, but it makes states more accountable to the cost of healthcare, which means that either hospitals will go bankrupt, particularly rural hospitals, which was one of the issues that Senator Murkowski and—‌

Harlan Krumholz: Josh Hawley brought up.‌

Howard Forman: Right.‌

Harlan Krumholz: Although he voted for it in the end.‌

Howard Forman: Correct. So there’s so many implications for healthcare in here. Not to mention that this is the bill that will dramatically increase the endowment tax, though not as high as for—‌

Harlan Krumholz: I mean, just to say there is stuff for Yale involved here.‌

Howard Forman: No, absolutely.‌

Harlan Krumholz: But I mean the bigger picture here is that we’re cutting a lot of benefits for a lot of people. I will say also personally, climate change to me is a major big hit in this bill. Meaning the interventions to try to move the country in a way that was going to do that. And by the way, that’s also health-related. It’s going to have big impacts on health.‌

Howard Forman: Absolutely. Environmental health.‌

Harlan Krumholz: Yeah. But even what I’m just bringing up about Murkowski is even separate, meaning whether you’re for or against the bill, to have someone who doesn’t believe in the bill to get carve-outs for her state in order to give her the vote.‌

Howard Forman: I’m more sympathetic to her only in the sense that she wields enormous power and she’s going to use that power to benefit her constituents. That’s not anathema to being a politician. That’s what they do.‌

Harlan Krumholz: Oh, I’m going to make a prediction, too. I don’t think they can get this bill through the House. But I’ve been surprised before.‌

Howard Forman: But then the real question is, if it doesn’t pass the House, which is why everybody fears this. If it doesn’t pass the House, eventually it goes to conference committee. If it goes to conference, can it actually emerge and pass both the House and the Senate completely at that point? Because I wonder if the public, as they become more aware of just how bad this is.‌

Harlan Krumholz: Yeah, that’s right. The more time the passes, the harder it will be to get this through. So we’ll see what happens. And I believe, by the way, it won’t be because of concern about the safety net cuts. There are people in the House who care deeply about the deficit and there are people in the House who care deeply about the taxes on the Northeastern states that this has changed from what the House version was before. And I think that’s why.‌

Howard Forman: Let’s not forget that one of the top three employers in almost every congressional district in the country is a hospital.‌

Harlan Krumholz: So this brings up an interesting thing. I was in Ohio this week, Howie. My mother hasn’t been well. I love my mother, and it’s hard to see her struggling. Dayton, Ohio, where I’m from, is in a much worse position than when I grew up. There are parts of it that are continuing to do well. But if you go downtown, if you go to the area where I grew up, north of Dayton, if I say “apocalyptic,” I’m not exaggerating, certain parts of it.‌

I mean, really, shuttered stores. There’s no sense of thriving at all. Let me just put it like that. But I will tell you that when you look at Dayton, where are the palaces? Where are the hospitals, the healthcare systems? I mean, you look at those buildings and when I took her to appointments, I mean they are fabulous. I mean, fabulous. And so it just made me think about the engine of the economy in many places in the country is—‌

Howard Forman: Hospitals.‌

Harlan Krumholz: I was going to say healthcare, but hospitals.‌

Howard Forman: Well, the health systems, and they’re all in consolidations and their margins are small to begin with. Medicaid, even though it may be a poor payer overall, it’s a major payer. It’s a large chunk of the population. You cut Medicaid, people are going to feel it.‌

Harlan Krumholz: And will they vote?‌

Howard Forman: Right.‌

Harlan Krumholz: That’s a big question.‌

Howard Forman: Yep.‌

Harlan Krumholz: All right, let me change this to something else. A lot of people listening have some connection to Yale or interested in Yale, or at least they’re interested in us and we’re at Yale. And I thought I’d at least report what’s going on here. So there is this uncertainty about what’s going to happen in terms of finances with regard to universities writ large and especially a private university like Yale is vulnerable, both with regard to the endowment tax regard to a whole range of other things.‌

So what’s happening? Well, something is happening here. Just June 30th, the Yale’s provost announced a university-wide 90-day hiring pause effective immediately. New staff hires being frozen. New faculty searches need special approval now at Yale. And capital projects are delayed and raises are getting trimmed. So this is all because of the legislation that’s going through, which would sort of radically alter how universities are taxed and how federal research is funded. And, of course, there’s this: within the bill, the university endowment tax, moving from 1.4% could be as high as 21%, right?‌

Howard Forman: Right. In the current bill we’re looking at 8%. But you’re right, it could be anywhere.‌

Harlan Krumholz: It could be anywhere. It says 8% right now, right, exactly? But that’s hundreds of millions of dollars to Yale. I also noticed that although we’ve got a big endowment that has, had posted generally good returns, a lot of it’s invested in private equity. There are now questions being raised about the valuations of that.‌

Howard Forman: That’s correct.‌

Harlan Krumholz: Part of the endowment, which is also sending a shudder through the entire private equity community because those kind of questions aren’t just about universities, but it’s leading Harvard and Yale, by the way, to sell at a discount.‌

Howard Forman: That’s right.‌

Harlan Krumholz: A lot of their assets that are in private equity so that they will have cash on hand to be able to handle this. And Nancy Brown, our dean, also came out and said that she wants to continue to make sure that we are supporting junior faculty, that we’re continuing to grow, that there’s important buffers for people who are here. But just for anyone listening to say, like, yeah, things are moving. And I would say we are making fewer changes in some other places. Other places have moved faster and have done more dramatic interventions.‌

Howard Forman: Absolutely. One of the faculty members at Harvard posted a Twitter thread that said, “Here are the major universities and the effect of the Trump administration on them.” And I went down the list thinking we were going to be there. He had 14 major universities, he didn’t even include us.‌

Harlan Krumholz: The provost said this is about being nimble and minimizing harm. The dean said this is about protecting early-career scientists and sunsetting unproductive programs and finding new sources of support. If all of this happens, it will fundamentally reshape the strength of our universities nationwide.‌

Howard Forman: I think it’s already done so. I mean, let’s just also enumerate the other things besides the endowment tax. We have issues around whether we can get visas for our students, for international students, disproportionately, many of whom pay full tuition compared with our students that come here with large financial aid packages.‌

So we lose revenue on that front. We lose revenue on the indirect costs of grants. If they push that down, there’s no question that’s going to come down. How far down it goes, nobody really knows. That’s another effect in there. And then there’s the withdrawal of grants so that you have faculty members who maybe—‌

Harlan Krumholz: Have built programs. By the way, have patients enrolled in studies.‌

Howard Forman: That’s right. Big programs, big staff, lots of things going on one day and the next day it’s not funded. And the university doesn’t just fire everybody immediately. In fact, there are many large costs that are going to be incurred for years to come on grants that are no longer existing.‌

Harlan Krumholz: And you and I both agree that, look, universities are far from perfect.‌

Howard Forman: Of course.‌

Harlan Krumholz: There’s a lot that needed to be addressed and improved and we needed to be innovative in our approach. But the net net of our large university systems and what they’ve contributed to society and how they’ve been an engine for the economy is undeniable. And this is all at risk.‌

Howard Forman: And the legislation is written so specifically to attack a very few universities. Yeah. I mean, if you go look at even universities like Washington University, it affects it much less than Yale because their endowment relative to the size of the student body is just below the threshold that would put them up at the 8% level.‌

So they literally wrote the legislation to target their enemies, so to speak, which is not the way to run any government. If you don’t like behavior, target the behavior, don’t come up with back-end means of hurting so-called enemies lists.‌

Harlan Krumholz: And the rumor is that the Harvard litigation will be resolved and the Harvard issues will be resolved. But we’ll have to hold our breath to see what happens.‌

Howard Forman: Yep, yep. So I want to talk about something really wonky if it’s okay, but really quick.‌

Harlan Krumholz: Sure. The ultimate wonk.‌

Howard Forman: Yeah, I know. But this is funny because I learned—‌

Harlan Krumholz: I say that in a good way. Respectfully.‌

Howard Forman: No, no. So when I teach my class, people bring things up and I know just enough to nod my head about them very often and I’ve never really spent enough time to understand them. And the 340B programs are one of those. So I figured our listeners might want—‌

Harlan Krumholz: Yeah, that’s good. So no one will know what the 340B program is…‌

Howard Forman: No, I imagine not. 340B programs have existed for three decades now. And like I said, I talk about them with people periodically, but I mostly nod, I’ve never understood it enough.‌

Harlan Krumholz: What is the 340B program?‌

Howard Forman: Right. So I’m going to get to that. But it came up in a federal court ruling last week, so I figured this is a good time to talk about it. The program was implemented in ’92 as part of the Public Health Services Act. It was intended to provide lower-cost medications.‌

Harlan Krumholz: It’s called 340B because that’s what the legislation was called.‌

Howard Forman: That’s just the code, right, exactly. It was intended to provide lower-cost medications to covered entities, which are hospitals or community health centers that care for indigent patients, Medicare and so on. They have specific rules for this. The best estimate for last year is that—‌

Harlan Krumholz: But just say it again. What does it do?‌

Howard Forman: I’m going to tell, I’m going to tell. But I got to give you—‌

Harlan Krumholz: You know how impatient I am.‌

Howard Forman: The magnitude is just incredible to me. I can’t believe this. Last year, $148 billion in list-priced drugs were transacted under this program. That’s like 20, almost—‌

Harlan Krumholz: So are you saying this is a federally supported program that—‌

Howard Forman: It’s federally mandated, but it’s really paid for by the drug companies.‌

Harlan Krumholz: I see.‌

Howard Forman: Right? And it continues to grow at double-digit rates, okay. And so initially the program’s intent was to get manufacturers to sell their drugs to these entities at a discounted price. And then by selling the drugs at a discounted price, it would help impoverished people. And it does do that.‌

But if a hospital then gets paid by Medicare, Medicaid, or a private insurer above that price, the hospital or the community health center gets to keep the overage, gets to keep the profit, so to speak, the margin. And you can look far and wide and you will see that many hospitals, many community health centers have literally balanced their budget on the backs of this program. If you don’t participate in this—‌

Harlan Krumholz: They’re making profit off of selling drugs that they’re getting at a discount that’s mandated by this law.‌

Howard Forman: Best way to summarize it. And it really, for a lot of these places, it’s the difference between them sustaining their other operations and going out of business. That includes a lot of community health centers. I won’t go into—‌

Harlan Krumholz: And can they only sell those drugs to certain patients?‌

Howard Forman: Certain groups are covered by this, but it’s a wider array than you might otherwise imagine. As long as they’re cared for by the center under specific programs, they are eligible for that. The program is now heading towards $200 billion a year. And if you are a drug company and the federal government is forcing you to sell the drugs at a steep discount from what you could sell it for, you’re getting nervous about this because it’s eating into your profits each year as well.‌

This is a federal mandate that affects the drug companies primarily. So the drug companies started to recognize that there’s a lot of inefficiencies in there that are not built into the code. Meaning that a patient might qualify for two different types of discounts and they get double-counted at the same time. There’s enough of that to matter to the drug companies.‌

And the drug companies came up with a workaround for that where they said, “We’re going to provide you with software to track these patients better and know which ones deserve to get the money and which ones don’t.” And the federal court said, “Drug companies can’t put this in place. Only HRSA, only the federal government can put this in place.” And so we’re left at this moment in time right now where it’s back to them to figure this out. I do think they will fix it. I do think it’s a problem. But I also think it’s just important to understand that while this may not be a grift or a graft, it is absolutely impacting hospital finance and drug company finance.‌

Harlan Krumholz: Is this why, every time I see something in the news that says they’re about to change this program, that the hospitals just freak out?‌

Howard Forman: Oh yeah. I mean, I don’t know how much our hospital makes off it. It would not surprise me if it’s in the eight or nine digits. I mean, probably not nine digits, but probably in the tens of millions by running a program like this. And I should say that, reservedly, I don’t even know what our hospital does with it, but I’m pretty sure we have a 340B program.‌

Harlan Krumholz: Is it related to the specialty pharmacy aspect of what we do?‌

Howard Forman: I think specialty pharma would be covered under it, but I don’t know exactly how they interact.‌

Harlan Krumholz: Because I’ve noticed a lot of the hospitals have built these specialty pharmacy programs, infusion centers, and other things that—‌

Howard Forman: Those are profitable on their own basis because of the way Medicare reimburses for it. But it may interact with this as well.‌

Harlan Krumholz: Wow. Wow. That’s amazing.‌

Howard Forman: Yeah.‌

Harlan Krumholz: All right, let me get to some science here, Howie. I thought you might like it. So can you say, Zimislecel?‌

Howard Forman: Zimislecel?‌

Harlan Krumholz: I think I’m saying this right, Zimislecel.‌

Howard Forman: I don’t even know.‌

Harlan Krumholz: Yeah, anyway. So this is a story that came out of the ADA, the Diabetes Association meeting, just last week. So imagine the patients out there who are living in fear that their blood sugar might suddenly change, drop, let’s say give hypoglycemia or have unawareness of it. They’re trying to manage it. They’ve got all these drugs. they’re sort of at wit’s end about this.‌

And then all of a sudden people are coming up with something out of the... I’ll call it the rubric of regenerative medicine stem cells, human stem cells. So we’ve talked about human stem cells before in the program and there are a lot of charlatans out there who are pushing this. By the way, our new Secretary of Health and Human Services is a proponent of human stem cells. And most of the time I’m very skeptical that these are really going to help.‌

Well, there is now a treatment that, for people listening, what are human stem cells? These are stem cells that are undifferentiate. What that means is that there are cells that can grow into being anything. They’re—another word—pluripotent, meaning they can differentiate into becoming, in this case, pancreatic islet cells. So the pancreatic beta cells produce insulin, and it turns out that you can take these cells that can turn into anything and coax them into becoming pancreatic cells.‌

And then they infuse these lab-grown pancreatic cells directly into the portal vein, which is part of the liver and the blood vessel in liver. And this may sound strange, but the liver turns out to be a good place for these cells. It’s not into the pancreas, but it’s into the liver itself. And they started working. They started working.‌

So these infused cells sort of set up shop in the liver. They don’t naturally live there. These cells, these pancreatic beta islet cells, they’re pancreatic, but they could actually set a palace in the liver and started working in this trial that was then presented at the ADA, published in The New England Journal of Medicine. Twelve people with severe type 1 diabetes received the therapy, and a year later, 10 of them no longer needed insulin.‌

Howard Forman: That’s crazy.‌

Harlan Krumholz: And type 1 diabetes, for people listening, these are people who’s, probably post-infection, the body ends up attacking the pancreas and they become unable to produce insulin and they’re highly insulin-dependent. And often what we would say is brittle. That means that it’s very hard to manage the right amount of insulin at the right time. That’s why they’re susceptible to these large drops in blood sugar if they get it at the wrong time or they’re being treated wrong.‌

And so, they’ve got high glucose because they’re not producing the insulin, but they’re treating themselves with insulin and that can just put them in a very difficult position. It’s hard for many of these patients. These are ones with severe type 1s. So very difficult situation. But Howie, this is a miracle.‌

Howard Forman: It is a miracle. So The Wall Street Journal followed up on a story from last year, basically, but it had been covered earlier. Turns out that if you are a VA patient enrolled in Medicare Advantage and you go to the VA for your care—‌

Harlan Krumholz: Oh, I saw this. Yeah.‌

Howard Forman: Oh, my God, is this not horrible? So the VA cannot charge your private health plan for the care they provide. So who is your favorite patient, if you’re a Medicare Advantage [provider]? It’s a veteran who is going to seek all their care at the VA and charge you nothing and you get paid $15,000 from the federal government.‌

Harlan Krumholz: Yeah, you should find all those veterans.‌

Howard Forman: Oh, my God.‌

Harlan Krumholz: Your profits must be out the roof when that happens.‌

Howard Forman: So literally they discovered that there are certain plans that target veterans.‌

Harlan Krumholz: Well, why wouldn’t you?‌

Howard Forman: Right. And they even go back and—‌

Harlan Krumholz: It’s not illegal.‌

Howard Forman: A study is done in health affairs.‌

Harlan Krumholz: It’s a loophole.‌

Howard Forman: Right. That’s exactly how I described it. Then they go back and discover that, in these plans that have a high number of veterans, a higher percentage of them obviously have no care outside of the veteran system at least.‌

Harlan Krumholz: That’s amazing. Why did they even sign up for Medicare Advantage?‌

Howard Forman: Presumably because somebody pitches it to them as free and they can get something—‌

Harlan Krumholz: Yeah, it’s sort of backup.‌

Howard Forman: Oh, it must be. So the bottom line is that there is a piece of legislation now being proposed bipartisanly, I think, including our Senator Blumenthal here, to try to get this fixed. I got to say, as Congress debates various proposals, this seems like the lowest of low-hanging fruit. And I’ve yet to have anyone explain to me how reversing this would be a bad thing.‌

Harlan Krumholz: Yeah. I mean, it’s amazing that it was set up that way, right?‌

Howard Forman: It’s crazy. I mean, I presume that the fear was that we didn’t know how to account for costs in the VA and how they charged and not usage. But they are allowed to charge other private insurers. So it was just crazy to me.‌

Harlan Krumholz: All right. So here’s one I want to just hit with you really quickly. So you know, we’re about 40 years into the HIV epidemic?‌

Howard Forman: Yes.‌

Harlan Krumholz: Do you know how many new cases occur each year in the world globally?‌

Howard Forman: I don’t. I’ve said this on the podcast, and I don’t even remember.‌

Harlan Krumholz: More than a million.‌

Howard Forman: Yeah.‌

Harlan Krumholz: More than a million occur every year. And while we’ve made remarkable progress turning it into a chronic condition.... Certainly when I was a resident at San Francisco General Hospital and at UCSF, I mean, we were sort of right in the middle of it, and it was just so tragic. You know there has been a move towards this prophylactic treatment that, can we get people on meds so that if they get exposed, they won’t get infected. And so there is a med that you know ... and I just wanted to say, again, amazing. The FDA approved a med that is a twice-a-year injection that can prevent HIV highly effectively, it seems.‌

Howard Forman: When we reported on this the first time when they had just come out with the first trial affecting—‌

Harlan Krumholz: We have talked about it.‌

Howard Forman: ... women in Africa, I mean, it was 100% effective. Now, granted—‌

Harlan Krumholz: Yeah, and they had to stop the trial early so that they could let everybody get access to the medication.‌

Howard Forman: That’s right. Right.‌

Harlan Krumholz: I think it’s interesting because the virus doesn’t target the virus’s enzymes like most HIV drugs. Instead, it locks onto a structural protein, the capsid, the cover, essentially the shell that surrounds the virus’s genetic material. And for decades, people thought this was undruggable, that they couldn’t actually create something for the envelope around the viral DNA.‌

But really it was the team at Gilead kept tweaking the molecule to try to see whether or not ... and they kept saying they’re one atom away from figuring out— ‌

Howard Forman: It’s crazy. ‌

Harlan Krumholz: ...how they can attack this. And they finally cracked it. And, again, I mean, it’s just nice to be able to say like the era we live in. So 40 years in, I mean, they want us ... and I don’t want to say this should give people a license to unprotected sex. With high-risk sex, there’s lots of other reasons to be careful. So it’s not a license to say, but for HIV, this can be protective.‌

Howard Forman: It’s unbelievably successful. This is lenacapavir, right? I think that’s what we do.‌

Harlan Krumholz: Lenacapavir, yeah.‌

Howard Forman: It is a groundbreaking or earth-shattering innovation. And when I think back to the mid-1980’s, when people talked about the fact that we would be at least 10 years away from a vaccine, and here we are 40 years later and there is no vaccine. And maybe a vaccine will eventually occur, this is at least as good as a vaccine from an efficacy point of view, even though it doesn’t work via vaccine mechanism.‌

So it’s a great improvement. The sad side of the story, of course, is that with USAID pulling back their funding from Africa, tens of thousands, hundreds of thousands of people will likely die of AIDS for lack of being able to afford drugs like this and others that USAID was facilitating.‌

Harlan Krumholz: Yeah. I think we should dig more in a future episode into the USAID thing.‌

Howard Forman: That’d be a good idea. We’ll bring on some guests.‌

Harlan Krumholz: And there are now these large-scale estimates of just exactly how many millions of people will likely die.‌

Howard Forman: It’s tragic.‌

Harlan Krumholz: But let’s dig into that science. Like how are those estimates being made and how ... but I will just say that they’re from credible sources that suggest that ... and it makes sense, that has a lot of face validity.‌

Howard Forman: That’s the point, right. No, no. It’s very obvious that if a program, clearly before it starts, people are dying. You start a program, you’re able to treat effectively certain diseases, not just HIV, but tuberculosis, malaria, other infectious diseases and non-infectious diseases. And you stop that funding, you have a problem. And while the private sector may step into the void, to some degree, USAID was a convener and a very, very effective facilitator of these programs.‌

Harlan Krumholz: Oh, it was one of the most amazing things that we’ve done as a country.‌

Howard Forman: Yeah. I want to do another follow-up, and it’s hard for me to believe, but it was two years ago when Abbe Gluck was on the podcast.‌

Harlan Krumholz: Abbe Gluck. We love her.‌

Howard Forman: We love Abbe Gluck. And she talked about the Braidwood case, if you remember correctly. And the Braidwood case was, if I can summarize it really quickly—‌

Harlan Krumholz: Abbe, one of our stars at the Yale Law School, just to say.‌

Howard Forman: That’s right. She’s our health law person. The Braidwood case presented in front of the Supreme Court was this idea that members of the U.S. Preventative Services Task Force, because those members were not appointed and confirmed by the president and the Senate, that it violated the Appointments Clause of the Constitution and therefore their decisions could be voided.‌

Harlan Krumholz: And the U.S. Preventive Task Force. You want to just explain to people what that is?‌

Howard Forman: They approve ... They rate—‌

Harlan Krumholz: It’s a bunch of experts that get together—‌

Howard Forman: It’s a collection of different types of experts, different types of fields that rate the effectiveness of preventive and screening measures, primarily.‌

Harlan Krumholz: People are promoting all the time screening measures, and they’re the ones coming out and saying, “Gee, if you look at all the evidence, what do we think about mammography, colonoscopy?”‌

Howard Forman: Exactly.‌

Harlan Krumholz: The whole range of things.‌

Howard Forman: Exactly but also prep. Also what you talked about just before, whether it works or not, and whether it should be on their level A or level B evidence to support that it’s effective.‌

Harlan Krumholz: And that affects other guidelines. It affects payments.‌

Howard Forman: Exactly. Because of the ACA, in particular, says that anything that they put as level A or level B has to be paid for and it can’t have a copay, right?‌

Harlan Krumholz: So highly consequential.‌

Howard Forman: Highly consequential, and I won’t go into who Braidwood is, in particular, but they contested this ruling and it could have undone a lot of rulings from U.S. Preventative Services Task Force. And the Supreme Court ruled in favor of the government in this case against Braidwood and said that they do not violate the Appointments Clause.‌

And the reason why they don’t violate the Appointments Clause is because the secretary can, at will, hire or fire people onto that committee. That ultimately the secretary gets to make that decision. Now the secretary is Robert F. Kennedy, Jr. So on the one hand, this is a big, big win for this specific case, but in the long run it does raise more issues because it means that he can remake this task force. He has all the power to do so, and it also means that he can change this coverage just through his signature.‌

Harlan Krumholz: And he’s already shown a propensity to do that for expert panels like he did for the vaccine panel.‌

Howard Forman: Exactly, yeah.‌

Harlan Krumholz: All right. Let me hit one more last thing. This has been a great conversation with you today, but I want to end with this. Gosh, Howie, when I look at health and healthcare and research and science, it’s almost like it’s disorienting because on one hand there’s this vision about engineering the future with AI, programmable therapies, new payment approaches, the kind of breakthroughs we’ve talked about today.‌

I mean, it couldn’t be more exciting. On the other hand, we’ve got a system on the brink, politicized under strain, growing inequality, corporate consolidation—‌

Howard Forman: Burnout.‌

Harlan Krumholz: ... more expensive every day without evidence of a return on that. How can both of these things be true? On one hand, I have the most optimism I’ve ever had about what’s possible. On the other hand, when I look at what’s going on day to day, the actual experience of healthcare. And, again, I just had this experience with my mom. But you and I have it on the other side, on the provider side, every day in healthcare. It’s disorienting and it’s trying to see how are we going to get out of this.‌

Meanwhile, Paul Keckley came out recently and was just sort of putting a lot of these numbers together. Paul is a former consultant at Deloitte and is someone who’s looking at these numbers. And the idea is that between 2024 ... this from the CMS report, I believe, that you’ve talked about when you were talking about how much longer it’s going to go. National spending will grow 63%, while the population only grows 5% over this next decade. Out-of-pocket burdens and private insurance prices are rising quite dramatically. I’ve talked to people who are running businesses and who talk about—‌

Howard Forman: Health costs.‌

Harlan Krumholz: ... because of the GLP-1 receptor agonist, the treatment of obesity, just as an example. You know that it’s having a dramatic effect on their ability to just provide overall insurance now. It’s fundamentally shifting the business model for them because profits are now being directed towards—‌

Howard Forman: Benefits.‌

Harlan Krumholz: ... towards healthcare. People are talking about precision evidence infrastructures and AI-driven care. I’m so excited about that, but I’m failing to see how that’s going to connect in a system that seems to be very rocky. And so, anyway, I just sort of want to close with this because we talk about a lot of things on here.‌

But it’s almost as if this podcast today is emblematic of that. On one hand, we’re talking about people losing healthcare insurance, our inability to provide the inefficiencies, and problems in the system. And on the other hand, these remarkable breakthroughs that we don’t even know whether they’re going to get to people because whether people can have access and afford them.‌

Howard Forman: I know. These cuts to Medicaid are just like that and make you worry about the fact that the people who need it the most may get it the least.‌

Harlan Krumholz: This is all on our watch, Howie.‌

Howard Forman: I know.‌

Harlan Krumholz: I mean, what are you telling students as they come up and say, “I want to contribute.”‌

Howard Forman: I’m always an optimist about the fact that we can do better and that the good news is we’re spending so much already and there really is so much waste. We know there is so much waste, that the opportunity is vast. But I will say over the three decades of my teaching career now, I have not seen very many innovations that save money. Almost all the innovations add to the cost of the system.‌

Harlan Krumholz: Because the incentive system in drug development and everything is, you want to return money to investors largely. So if saving money, it’s easier to add to the pile than it is to—‌

Howard Forman: So let me give you one optimistic thing.‌

Harlan Krumholz: Okay, that’s good because we’re about at the end.‌

Howard Forman: This is real quick.‌

Harlan Krumholz: I need something to uplift me.‌

Howard Forman: This is real quick. And The New England Journal of Medicine article is in print tomorrow, the day that we release this Thursday. But it was published online a month ago. And it really is exciting and optimistic even though maybe it’s not that novel. But in a randomized trial of 889 patients, all of whom had colorectal cancer and were receiving adjuvant chemotherapy, associated chemotherapy, and they were followed for 7.9 years, the group that was randomized to get exercise, to get more exercise, had substantially better survival.‌

Harlan Krumholz: You know, that is the miracle drug, exercise.‌

Howard Forman: It is. It is.‌

Harlan Krumholz: It’s a miracle drug.‌

Howard Forman: And not surprisingly, the only downside, more musculoskeletal adverse events in the exercise group. Big deal, right? No pain, no gain, right?‌

Harlan Krumholz: Yeah.‌

Howard Forman: And this is not only not the first time we’ve seen trials like this. We’ve seen it a long time in the coming. And I went back and I looked, we had Dean Melinda Irwin of the School of Public Health on the podcast more than three years ago, talking about her work in this area. But this is just one more methodologically strong study that confirms this finding. And if anyone asks me whether they should engage in exercise, whether they’re sick or not, this is one more reason.‌

Harlan Krumholz: What’s exercise, Howard, by the way? I mean, how hard do you have to work?‌

Howard Forman: Their number was something like ... I forget if it was 14 or 21 METs. They had a specific measure for it, but it turns out to be like two and a half hours—‌

Harlan Krumholz: Do we have to use high-intensity workouts?‌

Howard Forman: Two and a half hours of brisk walking a week would put you in the exercise group. It’s not a lot.‌

Harlan Krumholz: Well, that’s the whole thing. People writing books and devoting entire enterprises to this wellness and longevity. Just move.‌

Howard Forman: Just move.‌

Harlan Krumholz: Just move.‌

Howard Forman: Get out there and walk.‌

Harlan Krumholz: Just move.‌

Howard Forman: Don’t take a bus, walk.‌

Harlan Krumholz: I 100% endorse it. 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 keep the conversation going, email us at health.veritas@yale.edu or follow us on any of social media, including LinkedIn and Bluesky.‌

Harlan Krumholz: We love your feedback. Rate us. People can find us easier when you do and reach out to us. We always love hearing from folks.‌

Howard Forman: And if you have questions about the MBA for Executives program at the Yale School of Management, please reach out via email for more information to som.yale.edu/eMBA or email us.‌

Harlan Krumholz: And we’re sponsored by the Yale School of Management, where we are today. This beautiful building is a great school. We’re so appreciative. And by the Yale School of Public Health, which is also just extraordinary and never more needed than it is now. And today we have two fabulous undergraduates, Gloria Beck, Tobias Liu, and a wonderful producer. Thank you Miranda. Miranda Shafer, who makes us good. And I’ve got the best partner in the world, Howie Forman.‌

Howard Forman: And right back at you. And these are really the most fun. Honestly, I think everybody must wonder how we schedule these things. We do this as much as we can do it. We love being in the studio together. So thanks very much, Harlan.‌

Harlan Krumholz: Yeah. Talk to you soon, Howie. Great to see you.‌

Howard Forman: Thanks Harlan. You, too.‌