Anna Kaltenboeck: Untangling Drug Prices

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.

This week we’ll be speaking with Anna Kaltenboeck. But first we like to check in on current health news and, Harlan, you brought up to me today a series of articles related to exercise. And all I kept fixating on after I saw that was the tiny mice on these tiny treadmills. So tell me more, because I think I got distracted by the little mice treadmills.

Harlan Krumholz: And there’s really a very interesting mouse study, but I want to first talk about this UK Biobank study. You know I love a good UK Biobank study, I often bring these up in the podcast. And to remind folks, the UK Biobank is an amazing study of more than about 500,000 people in the United Kingdom who’ve agreed to donate information, provide biospecimens, undergo imaging, sometimes put on wearables, and then be followed over time. And it’s really kind of one of the best examples of a study where they’ve accumulated an enormous amount of data about people throughout the United Kingdom and made that data available to researchers around the world so that they can exploit it to learn things. And it’s yielding so many important insights.

So what’s up this time? Well, there’s a group of investigators who are interested in looking at physical activity. Now you may think, “Physical activity, don’t we know enough about that?” Certainly there are many studies showing that there’s a very strong relationship between the amount of physical activity you do and the ability to lower risks of mortality and morbidities, including cardiovasculars and cancer.

But one of the things they decided to look at was what about the timing of when you exercise, when you do your activity, and does that matter? Is this just about adding up how many steps you take or whether you do moderate to vigorous activity? And that was their focus, by the way, “moderate-to-vigorous activity.” Or does it matter? Because as you know, there are lots of studies are coming out now about the importance of circadian rhythms, even when you eat, the whole thing about intermittent fasting.

Let me just stop by that, by the way, Howie. I know you’re an exercise aficionado. This is something that you do every day in your life. Do you have a particular favorite time that you exercise?

Howard Forman: I do aerobic exercise typically in the morning, but I do sometimes do it in what they would consider the afternoon, after 11 o’clock in the morning. But I do do about an hour of what they describe as vigorous exercise every day. And I did read—

Harlan Krumholz: And I’m so proud of you, you’re so devoted to that. I think that’s wonderful.

Howard Forman: I think I’m addicted to it. I need it in order to function properly.

Harlan Krumholz: So the UK Biobank took some—remember I said there were about 500,000 people in it—about 100,000 of them were identified and agreed to wear a wearable, like a watch or something, that was going to collect their activity for about seven days and record all their activity over that course of that time within the day. And then, instead of asking people, “How much do you exercise?,” they’re able to take the information that was coming from the wearable and to divide people up by when they exercised, how much they exercised, and so forth. And then link that with outcomes.

And in this case they were able to study people for over about seven years. And over that course of time, only about 3% of people died, and including 1% from cardiovascular disease and 2% from cancer. And they found, like everyone else has, that this sort of moderate and vigorous physical activity is associated with a lower risk of all-cause death, of cardiovascular death, cancer mortality. And by the way, it topped off that it was pretty steep. That is, the more you exercise, the lower your risk, came until you got to about 150 minutes per week and then it kind of stopped. If you did much more than 150, maybe you would feel better, maybe you liked it, but in terms of your risk of dying, it didn’t seem to affect it. And the curves were pretty striking.

But now they got to this issue about, let’s look at three time windows. Let’s look at the morning, let’s look at the afternoon, let’s look at the evening. And they took a look at this. And what they found was, interestingly, was that if you compared the morning to this midday/afternoon and evening, that midday/afternoon was the sweet spot where actually people had a even lower risk. So the more you did up to 150 minutes was all good; you got reduced risk. And then if you look between when people exercise, this midday/afternoon, or if you mixed it up, sometimes in different times of the day, like you do, Howie, you actually also generate a benefit. Interestingly, that was for all-cause death and for cardiovascular death. For cancer mortality it didn’t seem to make a difference.

Now when you see studies like this, remember, they’re not randomizing people to different times of day. They’re looking at people’s habits. And so it’s hard to be really confident about whether there’s a signal here, but it did show that there was some suggestion of it. So then you may leave this study feeling pressure—the actual differences were relatively small between the different times. And what seemed to be the major message was, the more you exercised up to 150 minutes, the better off you are. And they still left with this message about trying to do that. And it gets published in Nature Communications, which is a really good journal.

I just say one other thing, you’re bringing up this mouse thing. So there was an article in the—

Howard Forman: Yeah, I want to hear about the mice.

Harlan Krumholz: Yeah, so, article in The Washington Post that summarized this article and a couple of others. I sent you that, we’ll list it in the end. And there was this article where they took these little mice that they put them on little treadmills and they ... some of them stood on the treadmills and some of them got to exercise on the treadmills, and they also had them looking at whether they exercised at different times.

And what they found was, interestingly, was that it did matter when these mice exercised and that the mice who exercised soon after waking up seemed to be in a better position. They were releasing more of these substances that were going to help them remain healthy. All this is surrogate. They didn’t look and see how long did they live, what their lifespan was, but they were looking at their little mouse metabolism.

Now mice aren’t people, and whether this translates is hard to know, but it is raising this issue, that timing of exercise, timing of eating, all these things, the way our circadian rhythms work. I think in the coming years we’re going to gain more perspective and understanding about how to optimize all of these things. But yeah, I think it’s hard not to smile when you think about these little mice exercising on the treadmill. And I don’t know what kind of music they were playing, but….

Howard Forman: I know. I just have this image in my head of them wearing headphones and working out. But yeah, it made me smile.

Harlan Krumholz: All right. Hey, let’s get to the interview.

Howard Forman: All right, here we go.

Anna Kaltenboeck: Let’s do it.

Howard Forman: Anna Kaltenboeck is a health economist, focused on how reimbursement policy shaped the market for prescription drugs and other health technologies. She’s now a principal and head of the Prescription Drug Reimbursement Group at ATI Advisory, a D.C.-based healthcare research and advisory services firm. Before that, she was a senior health advisor on the Senate Committee on Finance, working on the Medicare Inflation Reduction Act, or IRA, and specifically the prescription drug reimbursement provisions.

Before that, she was program director for the Center for Health Policy and Outcomes and the Drug Pricing Lab at Memorial Sloan Kettering Cancer Center, where she conducted research on prescription drug payment and improving patients’ lives. Kaltenboeck received her undergraduate and master’s degree in economics from Tufts and then she came to Yale for her MBA, which is where I first had the great honor to meet her.

First I want to welcome you to the Health & Veritas podcast, and Harlan and I are both going to ask you questions about the prescription drug pricing reforms—

Harlan Krumholz: Really, really hard questions. Really hard questions.

Howard Forman: Absolutely hard, but we want to get to the meat of that. But I do want to start off by asking how you got so interested in this area, which you’ve pursued since college, effectively?

Anna Kaltenboeck: Well, first of all, Howie, thank you. Howie and Harlan, thank you so much for having me. I’m really, really excited to be here because I’m a huge fan of the show, and I listen every time there’s a new episode. So this is really great. And I’m extra excited to get to talk about basically one of my favorite topics in the world, which is how we arrive at prescription drug prices in the United States.

Yeah, how did I get here? I think in about 2006, which is when Medicare Part D came online, was when I started my career. And I joined at the time an economic consulting group called Analysis Group, where my goal in life was to do some work in health economics and outcomes research so that I would eventually identify the true question that I wanted to answer with the eventual PhD I was going to get in economics. And one thing led to another, and I ended up doing consulting for about 10 years because I got really engrossed, first in the health economics and outcomes research, but then also in this question of why do manufacturers price the drugs the way that they do, and how do payers give access to them? And that led me squarely into the world of pricing and market access strategy and diligence for investments for manufacturers.

And that was a pretty fascinating world to be in. What ended up happening, so it was at about 10 years in I really started to question what seemed to me to becoming the dominant strategy around drug development and commercialization, which was really that it seemed to me that the driving factor around what determined whether or not a drug was getting developed was really how high of a price a manufacturer could charge for it without getting blocked out of the market by payers. And it was increasingly feeling that that was becoming secondary to what the drug was achieving for patients.

And so I was having some questions around the issues of what the financial incentives in the system were and how they were starting to affect affordability but also innovation. And that’s when I met Peter Bach, who was the lead at Center for Health Policy and Outcomes at MSK at the time and was just standing up what eventually became the Drug Pricing Lab. And so he convinced me to try a career change, and so I did. I joined Memorial Sloan Kettering. I worked there for about five years, including the time I was in the MBA program with you, Howie, to really dig in on understanding what the incentives are.

So spent those five years really getting my feet on the ground in terms of evidence development. And then that translated pretty clearly to the task at hand on Senate Finance, where I was really trying to lead forward to a Senate framework around Medicare negotiation.

Harlan Krumholz: I’ve got just a few questions, and I just want you to really break this down for the audience. You wrote a piece in Health Affairs, and part of the piece you said that, you make the point about the drivers of high list prices. And you said that really these drivers are related to two issues. And that the Inflation Reduction Act actually tried to grapple with these underlying drivers of high list prices.

And you also make the point that it’s really high list prices on a relatively minority of the number of drugs that are available out there. 80% of the drugs are generic, so there’s 20% that are nongeneric. And in that 20% there’s a small number who are extraordinarily high and they’re driving a lot of the costs within healthcare.

I wonder if you could just explain, what do you think, what are the drivers of these high list prices that everyone hears about? And in what ways does the bill that just passed help us to get control of those high costs?

Anna Kaltenboeck: Harlan, thank you so much. That’s a really good question. And I think it gets to the heart of the continued reform efforts that we’re going to be talking about in the next Congress address. And so you’re right, there are two major drivers of prescription drug price inflation, especially for drugs that get dispensed at pharmacies. And this feels paradoxical, because really it’s a surfeit of competition in a complete act of competition.

And what that really boils down to is that for some drugs, there’s a lot of therapeutic alternatives—think for example, insulins. And so the way that they compete with each other is they compete to get covered on what’s called a plan’s formulary. Formulary is basically a list of drug that determines what beneficiaries of a plan have access to.

And so what happens is, these drugs in very competitive classes will compete with each other to be on the formulary. And the way they do that is they offer rebates to the health plans, and it’s much easier to offer a lot of rebates if your list price is higher. This has led over time to this escalation in list prices and categories where you would think that competition would actually bring prices down. And in fact, on the net price level it does, once you take the rebates out of the list price. But the problem of course is that patients, when they fill their prescriptions at the pharmacy counter, pay based on the list price.

The flip side of this, the complete absence of competition, is really what happens when there’s drugs that are de facto monopolists. And that occurs when drugs are essentially the only thing available to treat certain things and health plans have to cover them. Or in the case of Part D drugs, it’s the pharmacy benefit in Medicare. It’s drugs that are required to be covered by CMS and by law. And those are called protected class drugs. They’re drugs that treat cancer, depression, and other conditions, and so that’s...sorry, I should clarify: “CMS” is Centers for Medicare and Medicaid Services, which determines what these plans offer.

So in those instances, what happens is that health plans have to cover the drug. And the question for the manufacturer is really, why would you not price your drug high in that context when you basically have guaranteed coverage.

Harlan Krumholz: And just to clarify this. There’s one point where people have to make the drug available so that they can set the price and they can’t be excluded because they must be in, that’s the one case you just said. And the other case you said was, where there is a lot of competition, and the way in which the pharmaceutical companies manage this through these pharmacy benefit managers is through these rebates, but those rebates aren’t available to average people.

Anna Kaltenboeck: Exactly.

Harlan Krumholz: They’re only available through particular mechanisms when people are making purchases such as payers. Much like what happens in the hospital, where they may negotiate a rate for UnitedHealthcare, but if I come in without insurance, they’re slapping me with a bill that actually no other person, no other group has to see, except for the people who have to pay the list price. That’s essentially the two issues you’re talking about. Is that right?

Anna Kaltenboeck: Bingo. Yep, that’s exactly right.

Harlan Krumholz: And then so how did the law address some of these?

Anna Kaltenboeck: Basically the law was really a response to that sticker shock that you’re talking about that people were getting at the pharmacy. And this is particularly bad for Medicare beneficiaries, because they’re going to the pharmacy and getting these drugs at a very high cost, and there’s no annual out-of-pocket limit today in Medicare Part D.

And so what happened is that there’s a center point of this entire framework, which is really that Medicare cost sharing for prescription drugs is now limited to $2,000 a year, starting in 2025. And it’s great for beneficiaries, because it’s going to let them stop rationing their drugs on the basis of their financial burden. But the downside of it is, if you only do that change alone, if you only make that one change, you’ve now taken away one of the few ways in which these plans mitigate costs, which is they rely on that rationing. And so now you have to find a way to keep that insurance policy, to keep the insurance policy sustainable, financially sustainable, which means you have to start to tackle some of those underlying dynamics.

And that’s where three of these policies come in. It’s really the Part D redesign, which basically shifts liability in the later stages of a patient’s spending away from government, where it is right now. Government pays 80% of a patient’s prescription drug costs, and Medicare, once they hit a certain threshold. That now shifts over majority to health plans and manufacturers. So that shifts over.

And then the other one, another major provision here, is the negotiation provision. And that really takes on this issue of lacking negotiating power for these drugs where there is a monopoly position. And then another, the last component on the payment side, is really that Medicare is now going to be able to protect the savings from the other two by clawing back price increases in excess of inflation. Their spending is attributable to that.

And then it comes full circle back to this other tiny little policy in there that says that beneficiaries’ premiums aren’t going to grow by more than 6% over the next couple of years. And that’s really designed to ensure that all of these policies have a chance to go into effect and to actually start incurring these savings and keep things stable for beneficiaries. They’re now protected both on the cost sharing side and on the premium side, while the system really starts to re-equilibrate hopefully towards a more rational way of reimbursing for these products.

Howard Forman: And when you put that all together and you’re forced by law that the Congressional Budget Office has to score this, they have to actually tell you, “Is it going to save money? Is it going to cost money?” Because there’s all sorts of examples where we think we’re doing something great and it just costs government a lot of money. When you put the entire prescription drug together and pass it through the Congressional Budget Office, what does the Congressional Budget Office say for this?

Anna Kaltenboeck: I think it’s $100 billion for negotiation alone. I think it’s another $60-something billion for the inflation rebates. In total, this is a big saver. And the reality of it was that this bill was absolutely conditioned on incurring savings. That was a critical component. It would not have been possible without showing that. And it’s one of the few places, Howie, I think where we save money not only for the consumer but also for government. So this is a very unique arrangement in that aspect.

Howard Forman: Unusual.

Anna Kaltenboeck: Yeah.

Howard Forman: Absolutely. There are many people who worry that this bill will stifle innovation. Is that a concern for you, or what do you think about that?

Anna Kaltenboeck: We took a lot of that into account when we were really working on the provision. And I will say one thing. There’s evidence, and there wasn’t so much in the last couple of years, but recently there’s been a couple of pretty convincing studies that suggest that when manufacturers are forced to give up revenues on older products, they’ll switch their investment into newer ones, developing new drugs. A lot of the industry is arguing around the specifics right now. I will say that, broadly speaking, a big part of the strategy of focusing this thing around older drugs was also that the hope was that the investment would go towards developing new blockbuster products. I mean, that’s the idea. That’s how we fund this beast of medical innovation, pharmaceutical innovation anyways.

And so my hope is absolutely that we will see a repeat of what we saw after the FTC Actavis decision, which basically said that drug companies can’t pay generic makers to stay off the market. But what we saw in that instance was that they actually poured money into R&D.

Howard Forman: There are some really expensive drugs that are in the biologic category. Mostly they’re protein-based drugs, very large molecules. And for some reason, the way the bill is written, those drugs do not face this type of negotiation until 11 years. Whereas these smaller-molecule drugs, which can be very expensive, but are at least a little less likely to face that competition in, or negotiation I should say, in six years. Can you explain why that decision gets made and how it’s made?

Anna Kaltenboeck: Sure. Yeah, so seven years for the small molecules and 11 for the biologics. And I mean, it’s the first thing...and yes, the industry has argued that this creates problems in terms of investment decisions. We can talk about why that may or may not be true. But the genesis of all of this is that we already treat small molecules very differently from large molecules in current law. And one of the major differences is that we grant far fewer years of market exclusivity to small molecules than we do to biologics.

And you could certainly make the argument that maybe we should revisit the way in which we prefer biologics over small molecules. But the fundamental reality is that the IRA is consistent with that treatment, with the slight difference that it actually reduces the amount of time between the two facing that negotiation. So it’s actually less of a gap. There’s less daylight in the IRA than in there is in some of these other legal constructs.

Harlan Krumholz: I think one of the interesting things that you’ve illuminated through your work on this law is that the way that the Part D, the drug benefit, of Medicare was configured, it allowed the sponsors and the manufacturers to benefit from these high list prices, creating this sort of impetus for them to be, if anything, cheerleading for the high prices. I mean, they shifted that financial liability to the Medicare program, so then they weren’t in that.

And then the other thing you said, I’m just emphasizing for people listening, was that this open-ended financial liability for people in Medicare who were spending lots of money could really bankrupt people. I mean, despite the fact that they were being covered by a drug plan, they were put in a position, especially with these high-cost drugs, where, as you were saying, there was no limit. Whereas you sought to address these through the ways that you said, the cap, the $2,000. I mean, I still don’t know whether when people heard that from President Biden that they really understood the kind of protection that that was providing seniors, to ensure that they weren’t going to be vulnerable to this open-ended financial liability.

What was it like to negotiate this, because you didn’t really get bipartisan support in the end for this kind of strategy, and did you...I mean, what kind of discussions were going on that you can share on the Hill, as you were trying to navigate through this improvement in the current program?

Anna Kaltenboeck: That’s a great question. Yeah, it was not a bipartisan process. And that definitely created some limiters because both the House and the Senate were in very, very slim margins. It did mean that there were some elements of this bill that got scaled back relative to where it might have been, if it had been the Build Back Better construct that we saw a year before that, which was really much broader negotiating authority. At least initially as it was envisioned through the House, which then got scaled back to most of the older drugs and a lot fewer drugs.

I think what carried the day, especially for the negotiation provision, which is I think where the greatest amount of daylight was between Republicans and Democrats here, was that it was incontrovertible that a small number of drugs were disproportionately responsible for spending in Medicare Part D, that it was the same number of drugs or it was the same drugs that had been on the market for a really long time. They weren’t changing the therapeutic standard of care or anything like that; they’d been there for a long time.

The manufacturers who were making it aren’t necessarily putting that money that they’re making from these products into developing great new products that might address additional problems. And meanwhile, you see these patients, who are vulnerable and have bought into a program that honestly was meant to protect them from this, now really getting damaged. And that I think was really what carried the day. It was a very cleanly definable target, and people were able to identify with the folks who were getting harmed by it. And I think that’s how that evolved.

Harlan Krumholz: And just one quick follow-up, which is, so what would you have wished that you could have gotten into this bill that you couldn’t, given the political realities of the day?

Anna Kaltenboeck: I’ll say this. I don’t really want to handicap it that way. You can always quibble with one provision, like, “I would’ve changed this one line to do this one thing differently.” What I will say is this, which is that the Inflation Reduction Act is a pretty dramatically scaled-back version of the vision that the Biden administration and Democrats had in the previous year, which was Build Back Better, this much larger package, that would’ve also extended benefits like dental, vision, and hearing and other things.

I’m beyond pleased that we managed to pass a bill that both addresses climate change policy and drug pricing policy. It would’ve been wonderful to see some of those savings also go towards things that would benefit people in other ways. Addressing food insecurity or helping folks afford their dental, vision, and hearing. It would’ve been wonderful. So I certainly do, and I think definitely at the time, that we learned we’re going to be moving forward without those provisions more on those. And I do hope that there’s an opportunity in the future to take these savings and put them towards people living a better life that way.

Howard Forman: Given the experience that you had working with this very slim margin, what are your expectations in the current Congress now with a GOP-led house for passing anything? For instance, like insulin pricing reform, which constantly comes up and does seem to at times have bipartisan support.

Anna Kaltenboeck: There are areas where there’s bipartisan focus. I don’t know about bipartisan support, necessarily, because sometimes there is a partisan position in terms of what the actual underlying problem is and what the ideal solution to that problem would be. But I will say that things I’m watching closely include the insulin question, as you were arguing.

I also am watching very closely changes on the legislation governing pharmacy benefits managers. That’s these companies that provide pharmacy benefits, not only for Part D, but other plans as well, which both sides of the aisle have signaled interest in.

Harlan Krumholz: Well, this has really been terrific. We so appreciate you coming in, sharing the wisdom and your experience around this. And like I said, I mean we all owe you a debt of gratitude for...I can’t even imagine how many hours you have invested in this over those years. And like I said, there are just unsung heroes on the Hill who actually are doing the day-to-day work that put a bill together like this and make it possible.

And like you said, I hope it’ll just be still the beginning of an evolution and iteration. But our healthcare system needs iteration, if not whole-scale reform, and it’s going to take people who really understand the details to help get us through this.

Anna Kaltenboeck: Thank you so much for this.

Harlan Krumholz: Well, Howie, that was a really, really great interview. So glad that you were able to bring Anna here, and we benefit so much when you bring back your students. So many of your students have just done such outstanding work, and she’s a really great example of that.

Hey, so what’s been on your mind this week? Let’s pivot to that section of the podcast.

Howard Forman: Yeah, so I don’t know. I told you about this. It frustrated me, and maybe I’m just overreacting to it. But there’s been a four-year investment of effort by a large group sponsored by Health Affairs, which is a journal that I particularly respect a lot. It does a lot of good in the policy space, both domestically and globally. And they looked at healthcare spending and what could we do, what can help us control healthcare spending in the days, months, years ahead? Title of it is “A Road Map For Action.”

There are two things that bothered me about it, and I’d love to hear your feedback on both of them. The first is that it just seemed extremely non-ambitious. They excluded some topics, which I understood, they explicitly said they didn’t want to tackle it. But they didn’t want to talk about some of the factors in which government actually causes our healthcare system to not operate at its best. Many, many issues that we could be tackling and how we could be spending our money better. That was one.

And then the other thing is that the study of four years, with some of the greatest names in health policy, people that you and I both know or know of, people who have done really good work, and bipartisan, but the study itself gets sponsored by a industry coalition of the pharmaceutical industry and by one of the largest health insurers in the country. And I can’t imagine what they were thinking to decide to let two of the most profitable parts of our healthcare industry sponsors a study like this.

Harlan Krumholz: Yeah. I mean, certainly the optics aren’t great on that, but my guess is, my hunch about this is that, you get together a bunch of experts who are pretty much still part-time. I mean, they’re coming in maybe for some meetings; they’re having some calls. And they also are coming from maybe different directions in terms of prior statements or political affiliations.

It’s hard to broker a revolutionary document that’s going to fundamentally reshape the way we think about healthcare. I think maybe you and I think that we’ve just got such a fundamentally flawed system where we see that there are so many people who experience financial toxicity, have issues still with access, the underinsurance. Just the structural piece of this healthcare system, which continues to reward more and more without respect to actually the quality of the outcomes that are achieved. We’ve just got immense problems that we need to fix. And when you get to the pricing part of it, somebody’s going to win and someone’s going to lose in a reshuffling of the way in which healthcare dollars are spent.

And it’s probably hard to broker when you get together such a large, accomplished group. And sometimes I think a small group needs to be able to put up a straw man for people to react to and really put forth some really clear principles. But mostly, when you get these consensus panels, it’s rare that there will be something comes out. There have been exceptions. I think, “To Err Is Human,” that came out of the Institute of Medicine, National Academy of Medicine, was quite a document that changed things. There have been some documents that have been issued that change people’s perspective on what should be done, but I think they’re the exception more than the rule.

Howard Forman: I’m going to go on record and say that this is not going to be one of those, but I will say, Upton Sinclair has a quote that, paraphrased, is something like, “Never expect someone to accept change when his salary depends on not understanding it,” or to understand something when a salary depends on not understanding it.

And I think in this particular case, they were charged with doing something. They did something, but I don’t think they did anything that was going to upset the applecart at all.

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

Howard Forman: 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 at @hmkyale, that’s HMK Yale.

Howard Forman: And I’m @TheHowie, that’s @T-H-E-H-O-W-I-E. You can also email us at health.veritas@yale.edu. Aside from Twitter and our podcast, I’m 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 som.yale.edu/emba.

Harlan Krumholz: And Howie, we should say to listeners, it’s not that we don’t think there are miraculous things that occur in healthcare every day or that there aren’t dedicated people making contributions, it’s just we think we can do better than we currently do.

Howard Forman: 100%.

Harlan Krumholz: It’s not for lack of admiration, right? I mean, we do admire—

Howard Forman: No, we have the greatest healthcare in the world for a large number of people. We do not have an equitable system. And we have a system that weighs so much that we probably could have both equity as well as a robust system. And we’re making trade-offs that I don’t think we would accept if we were starting from scratch.

Harlan Krumholz: Yeah. So it’s not that we’re not appreciative or admiring of what’s being accomplished, it’s just, we don’t think we’re anywhere close to what we should be able to do.

Howard Forman: Correct.

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

Howard Forman: Thanks very much, Harlan. Talk to you soon.