Fads, Outbreaks, and Health Policy

Transcript

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz, and I’m here with Howie Forman today. Who are you, by the way?

Howard Forman: I am Howie Forman, indeed. Indeed.

Harlan Krumholz: You are Howie Forman, you are indeed.

Howard Forman: We are physicians and professors at Yale University, and we’re trying to get close to the truth about health and healthcare. And we typically have a guest most weeks, but about once a month we try to have at least one episode in the studio. We are here with Ryan McEvoy in the studio at Yale today, and we’re going to do a deeper dive into health and healthcare.

Harlan Krumholz: Amazing Ryan McEvoy, yeah.

Howard Forman: That’s right.

Harlan Krumholz: Yep. And with Miranda Shafer, our usual producer, and Gloria Beck, and Donovan Brown’s off today.

Howard Forman: They are remote, but Ryan’s actually with us.

Harlan Krumholz: Ryan’s actually—

Howard Forman: We could pull them in here if you wanted to.

Harlan Krumholz: We could. We could. All right, Howie, I want to start off with this.

Howard Forman: Yeah.

Harlan Krumholz: So, you’re so deep into healthcare, I mean, you were so excited when we had Zeke on, and talking about eat your ice cream and stuff like that. So, I wanted to just ask you, this year, has there been one health habit that you’ve embraced that you didn’t do before, based on information that’s come out?

Howard Forman: Yes.

Harlan Krumholz: And what is that?

Howard Forman: It’s funny that you’re asking me this. I’ve been very upset with how many protein bars I have a day, and I happen to have a protein—

Harlan Krumholz: How many do you have a day?

Howard Forman: Two to three, and maybe more on some days. I have two meals a day, and then protein bars are my snacks throughout the day.

Harlan Krumholz: Okay. Before you get to the habit, I want to know. There are many kinds of protein bars, and many of them have these sort of sugar alcohols—

Howard Forman: That’s the ones I think are the most unhealthy.

Harlan Krumholz: So, which ones do you choose?

Howard Forman: So, I still have some healthy ones that I retain, but the unhealthy ones are the ones that are the quickest, easiest, cheapest, and they satisfy me the fastest. So, the one I got rid of, I got rid of one that I was having every morning with breakfast and replaced it with eggs.

Harlan Krumholz: Really? So, you went from the ultra-processed to—

Howard Forman: To making my own—

Harlan Krumholz: Are these considered “ultra-processed”?

Howard Forman: Absolutely. And switched to eggs every morning.

Harlan Krumholz: You don’t want to say the one because then we’ll never get an advertisement from them.

Howard Forman: And there are several bad ones, and I don’t want to say—

Harlan Krumholz: People listening know, we don’t have advertisers.

Howard Forman: That’s right, that’s true.

Harlan Krumholz: And what was it that was in that bar that made you think, without naming the bar, what was it that was in that bar that made you say, “I think I can do better”?

Howard Forman: I think it was the erythritol, but I think it might not even be the only sugar alcohol in there. It’s a very tasty bar. I still like it, I still have it occasionally, just not with breakfast.

Harlan Krumholz: That’s interesting. I gave up gum. This isn’t the—

Howard Forman: I gave up gum also.

Harlan Krumholz: But because of the... I did find that there is one natural gum I sometimes use... I like gum. But that gum, it’s very sticky, it doesn’t have a good texture to it. And whatever the regular gums do, which I did like to chew gum from time to time, but I just thought, “Why am I using these chemicals?”

Howard Forman: Maybe it’s too late in life to be making all these changes—

Harlan Krumholz: Never too late. Never too late.

Howard Forman: ... but I’m trying.

Harlan Krumholz: So, okay, ask me.

Howard Forman: So, what about you? What have you done this year because of Zeke Emanuel or others?

Harlan Krumholz: I have over the last several years, you asked me this year, I’ve over the last several years decided to not drink alcohol. And that’s a bet on my brain, I just thought, “That’s my instrument, my brain.” And I wanted to—

Howard Forman: So, you cut it out completely?

Harlan Krumholz: Yeah, I don’t drink.

Howard Forman: Well, me neither. But I think a few years ago you were still willing to have a beer, but...

Harlan Krumholz: I mean, beer, a drink. Yeah, but I don’t know. I just, like I said, it was an investment in my brain.

Howard Forman: I’m happy to get rid of it.

Harlan Krumholz: And I just thought... And my point was that, how much did it really mean to me? It didn’t really mean that much to me, when I had one. So, you were going to say something?

Howard Forman: No, I was going to say on the alcohol thing, what I observed in the ER is that once you’re in your 60s or early 70s, alcohol puts you at a substantially increased risk of falls and other traumas and other problems. And so, my recommendation to people is that even if you do, as you describe, enjoy alcohol, figure out how you can taper it off enough that you only need one drink in those later years. Because I think the risk is more than we’re measuring it, I think it’s a quiet... we don’t talk about it. People come into the hospital—

Harlan Krumholz: Oh my God, our whole society promotes drinking in such overt ways.

Howard Forman: Absolutely.

Harlan Krumholz: We should do a whole episode on drinking, because it’s such a great topic, and there is more information coming out, and there’s disparate points of view about it. So, that would be good. But the thing that I think I’ve tacked to, again, as a bet, I’m starting to be persuaded about these plastics.

Howard Forman: I know, I get scared about that.

Harlan Krumholz: Well, and—

Howard Forman: I love my nonstick pan.

Harlan Krumholz: ... I don’t think you need to be scared about it. But it’s like, for example, how many times would I go to a Chinese restaurant and then they put this really scalding hot soup in a plastic container, almost to make the plastic deformed?

Howard Forman: Yeah. I know.

Harlan Krumholz: I mean, you’re looking at the plastic and it’s literally—

Howard Forman: It’s melting. I know.

Harlan Krumholz: You can feel—

Howard Forman: Or the spoon, you put the spoon in and it starts to melt. I know.

Harlan Krumholz: I mean, it’s right before your eyes. You’re seeing that the integrity of the container or, like you’re saying, fork is changing in front of you, that has to be shedding plastics. And this study that came out, that I saw, that suggested that in a very short period of time, if you make relatively modest changes, you can decrease the amount of detectable derivatives of plastic in your urine and so forth. So, it’s a bet, but it’s sort of saying, I don’t know... Now, I can’t look at takeout food now the same when it’s so hot and they’re putting it in plastic stuff, I don’t know.

Howard Forman: I worry about so many things. I mean, there was probably 20 or 30 years ago, people were going crazy about aluminum foil, and I use a Teflon-coated, or maybe it’s not officially Teflon, but it’s a nonstick pan when I make my eggs in the morning. You worry about so many of these things.

Harlan Krumholz: Yeah, there can be so many crazy things. So, you just have to decide what’s worth it to you. I’m trying to figure out how to stay sharp and healthy for as long as I can. And maybe with a shorter time horizon, it’s more important than ever. And I enjoy that commitment. So, I don’t feel like I’m giving up something, and like I said, my friend who feels that drinking is an important part of his life, I get it, that would be a sacrifice that he would make. As opposed to, for me, it’s almost like, yeah, I’m hacking my health, every little thing I can do to energize me, and things like, it’s one more thing I’m trying to get done.

Howard Forman: I’m comforted a little bit by the fact that moderation in all things is probably also just a good strategy. And I look at my father, who’s literally one of our biggest listeners to the podcast.

Harlan Krumholz: Love your parents. Love them.

Howard Forman: He’s currently reading Bob Wachter’s book. He read Eric Topol’s book. He read Zeke Emanuel’s book, gives me reviews on all those things. And everything he does is in moderation, he doesn’t do anything to excess. And he’s in pretty good shape, and is 93 and a half.

Harlan Krumholz: Well, I think that’s because he was an amazing teacher all those years, and—

Howard Forman: It helped as well.

Harlan Krumholz: ... it’s coming back to—

Howard Forman: He’s a good soul.

Harlan Krumholz: He’s a good soul. But yeah, so I think people just need to decide and know that you’re making bets.

Howard Forman: Yep.

Harlan Krumholz: All right. Hey, how about you? What’s your—

Howard Forman: So, I wanted to start off with something that we touched on last week about cyclosporiasis.

Harlan Krumholz: Howie, what is cyclospora?

Howard Forman: Cyclospora is a parasite that grows on produce, it is spread from humans to the produce, and it’s from there that it is transmitted to other individuals. Since May 1st, CDC has logged about 4,000 lab confirmed cases, with another 7,400 under investigation. So, 11,000. Same window last year, 249, that’s a 17-fold increase, and the largest cyclosporiasis outbreak ever recorded in the country. Michigan alone, 9,000. Ohio, your home state, 2,500. One piece is solved, about 2,000 cases from nine states traced to shredded iceberg lettuce from a single supplier in Central Mexico, served at Taco Bell. It was recalled July 17th, but that’s a fifth of the total.

Harlan Krumholz: Wait a minute, but I thought that was the one the FDA backed off on.

Howard Forman: Only on the actual confirmation of the DNA of that specific thing. But epidemiologically, that’s confirmed.

Harlan Krumholz: Oh. I didn’t realize that. Oh.

Howard Forman: Yeah, it’s a difference between lab testing and the epidemiology. The epidemiology is settled.

Harlan Krumholz: So, it actually was true that that lettuce at Taco Bell, I thought that had been overturned.

Howard Forman: No, that’s correct. But that’s a fifth of the total. I mean, so we still have this massive number of outbreaks that we haven’t identified.

Harlan Krumholz: So, lots of people who had it positive never went to Taco Bell.

Howard Forman: Correct. From other states, some of them are slowly being traced to cilantro, or something else, but not part of that outbreak. But let’s talk about proportion, because you’d always remind me of this, you’d say, “Why are we making such a big deal out of this?” Zero deaths, roughly a hundred hospitalizations in the outbreaks that we’ve traced. Norovirus, which you’ve talked about twice in the podcast, it always makes you sick just to talk about it.

Harlan Krumholz: It does.

Howard Forman: Sickens 19 to 21 million Americans, hospitalizes 109,000, and kills about 900 a year. That’s something like 1700 times the illness burden of the worst cyclospora year on record. So, why do we care about this small outbreak? Because cyclospora is preventable in a way that norovirus simply isn’t. Cyclospora doesn’t spread person-to-person at all. The oocysts, which are the little spores, leave the body non-infectious, they need weeks in the environment to mature. So, there are no secondary cases. Every infection traces back to contaminated food. Pull the lot, the outbreak stops. It’s a lot different than norovirus. Norovirus, 10 to 100 viral particles will infect you.

Harlan Krumholz: Yeah, that’s crazy.

Howard Forman: It spreads on surfaces, it survives hand sanitizer, you cannot recall your way out of norovirus. So, here’s the part I think people are getting wrong. And I’m not an expert on this at all, so I’m just framing it the way I understand it. Everybody keeps talking about “the Trump administration, they cut FoodNet surveillance, they got to put it back,” but FoodNet surveillance was never an outbreak detection system; it’s tracking trends in food illness. Restoring it gives us a better count of a growing problem, but it doesn’t actually solve anything. What we actually need doesn’t exist. There’s no PulseNet for parasites. We have PulseNet for salmonella, but not for parasites.

Harlan Krumholz: PulseNet?

Howard Forman: It’s the DNA typing system that is done to culture when somebody gets an infectious diarrhea, let’s say. You culture it, hospital, you send the sample to CDC, they track the DNA in that, then they track it to other outbreaks, and they can use that to track it all back to that one source. We can’t do that with cyclospora, it can’t be cultured. So, we can’t genetically link the cases the way we do with salmonella. And Congress just pushed food traceability requirements out even further to 2028. What we need is innovation, we need out-of-the-box thinking, and we need incentives to draw people to solve this problem. And that’s where I come on. And I just want people to realize, it’s easy to blame the administration or Congress. “Why is this outbreak so big?” It’s a bigger problem than that.

Harlan Krumholz: Wow. Yeah, no, that’s really interesting. I mean, still the proportionality is different. I mean, you think about maybe because the solvability is different.

Howard Forman: Right. That’s the big issue.

Harlan Krumholz: But I wonder how many people were shot on the streets in America last—

Howard Forman: No question, no question.

Harlan Krumholz: ... couple weeks.

Howard Forman: And preventable.

Harlan Krumholz: Preventable also.

Howard Forman: 100%.

Harlan Krumholz: I mean, known to be preventable.

Howard Forman: No, and this captures the public’s imagination. Obviously it scares us away from lettuce, I look at people eating lettuce now, and I’m like, “What, are you crazy?” But actually the good news is that they are pulling the lettuce batches, there’s no way you’re going to get lettuce from that source. Now, could there be another lettuce cyclospora outbreak? There always can be.

Harlan Krumholz: Yeah. No, thanks for clearing that up, that’s really good. All right, let me jump to something else. BPC-157.

Howard Forman: So, we talked about this topic in April, and I have to say, just shoot me.

Harlan Krumholz: All right, let me run them. BPC-157, KPV, TB-500.

Howard Forman: Just shoot me.

Harlan Krumholz: MOTS-c, Epithalon, Semax.... Howie, these sound less like medicines and characters from a science fiction movie. But an FDA advisory committee has just recommended that all six become eligible for pharmacy compounding, each by relatively narrow vote. The FDA itself still has to make the final decision. So, let me just level-set here because lots of people are hearing about peptides these days. What in the heck are peptides? Well, they’re short chains of amino acids, the building blocks of protein. These are something that our body produces for developing proteins and running all the things in our body. They often are active signals telling cells what to do. Insulin’s a peptide, the GLP-1 receptor agonist drugs used for diabetes and obesity are based on a peptide hormone. So, there’s nothing inherently fringe or suspicious about peptides.

Peptides are ubiquitous. These six, however, are largely synthetic copies of fragments of different biological molecules. BPC-155 [157] is a synthetic 15-amino-acid compound associated with gastric protective peptide. KPV is just three amino acids taken from the end of alpha-melanocyte-stimulating hormone. TB-500 is a seven-amino-acid fragment from thymosin beta-4, a peptide found throughout the body and associated with tissue repair.

MOTS-c is particularly science fiction–sounding, it’s modeled on a 16-amino-acid peptide encoding mitochondrial DNA, and it’s been promoted for metabolism, obesity, and muscle function. Epithalon is a synthetic four-amino-acid peptide promoted for sleep and anti-aging; Semax, synthetic seven-amino-acid... You’re getting the idea, right? Several different amino acids strung together and people making the leap to say this is something that can be used for health. These products are generally manufactured chemically in laboratories, the vial is not being extracted from someone’s thymus, stomach mitochondria. The biological molecule provides the inspiration, but the patient receives what is a manufactured product whose identity, purity, dose, stability, and contaminants all matter.

And that brings us to the problem. These compounds are being promoted for everything, from wound healing to ulcerative colitis to obesity. I’ve seen them for osteoporosis, insomnia, stroke... Look, the issue isn’t that they lack strong evidence; they lack data at all. It’s not that the evidence is weak; it’s hard to find evidence on these. The committee’s argument was essentially harm reduction. People are already buying these products online or through the black market. Allow compounding pharmacies to make them, the reasoning goes, patients may receive a more reliable product, but that’s not clear. And it could vastly expand the number of people using these peptides. That’s what the critics are saying; they’re saying this is a system turned upside down. Ordinarily, we generate evidence first and then broaden access second.

Here, we would broaden access partly because evidence does not exist. And so, where’s the opportunity for harm reduction? And money’s being spent on this, people are hearing about them and thinking they’re magical. And at a time where people don’t trust vaccines, they’re willing to trust these peptides produced by compounding that we’ve got little idea about their purity and contamination, a whole range of other things, and yet they’re ignoring the kind of things that do have evidence behind them.

Howard Forman: And once they’re out there, it becomes even harder to do the types of randomized controlled trials that we should be doing. I’m all in favor, I’d be in favor of the federal government paying for or subsidizing large clinical trials of these things to at least get the evidence that people should have. We don’t have it. And by the way, I don’t know how different this is from the supplement industry, which is I think a $75 billion industry as well.

Harlan Krumholz: Yeah. And you talk about trials, but I’m not even sure we have the foundational evidence upon which you would make the rationale to spend the money on a trial.

Howard Forman: I don’t remember which one it is—

Harlan Krumholz: You’d almost need to go back to understand what biological effects are these causing. But there are two things here, Howie. One is, even in its purest form, are there biological effects that could be beneficial? We don’t know. But then once you open up to compound, which is not overseen by the FDA, and is really mom and pop shops everywhere, able to make these products and sell them. You don’t really know actually what you’re buying. So, even though it’s labeled one thing—and it could be contaminated, it could cause problems, it could cause harm separate from what the effect of the actual peptides are.

Howard Forman: That’s right. That’s right.

Harlan Krumholz: So, this is what concerns me is, do you know what you’re buying? And even if you do know what you’re buying and you get what you think you’re getting, what does it do? And it’s imperative that we produce an evidence base. And like you said, maybe we should push to trials because even though we don’t even have the foundational evidence of the biological effect, people are using them.

Howard Forman: Using them.

Harlan Krumholz: So, we ought to know what’s going on. But we also should be monitoring the quality of the products that are being sold, so people can feel safe in what they buy.

Howard Forman: Yeah. No, I couldn’t agree more. Zeke Emanuel had a post on LinkedIn about this topic, with a fairly emphatic statement similar to yours. He was far more critical of the panel itself, which was heavily weighted toward industry people voting in favor of approval.

Harlan Krumholz: That’s a whole nother thing, who’s actually making this recommendation, and was it packed?

Howard Forman: Right. And he made this emphatic thing, and you could just see dozens of industry people coming to attack him for this. So, there’s a lot of people that want to make a lot of money in this industry.

Harlan Krumholz: I mean, there’s nothing that stops you and I from actually starting—

Howard Forman: That’s right.

Harlan Krumholz: Wait a minute.... Maybe we should...

Howard Forman: I know. I know. We could do it. We could do it. New business.

Harlan Krumholz: What’s next?

Howard Forman: So, a few weeks back, the trustees issued their annual report on the status of the Medicare and Social Security programs, and I’m only going to talk about Medicare today.

Harlan Krumholz: The trustees.

Howard Forman: The trustees. And ironically, too—

Harlan Krumholz: Whenever you say “trustees,” I’m always thinking Yale trustees.

Howard Forman: Yeah, no, it’s—

Harlan Krumholz: Who are these trustees?

Howard Forman: So, one of them is the secretary of the Treasury, one of them is the secretary of HHS, there’s two public trustees that I believe are not named, and then I forget if they—

Harlan Krumholz: Is this written into legislation, who these trustees are?

Howard Forman: Yes.

Harlan Krumholz: So, in Medicare’s...

Howard Forman: The Medicare and Social Security trustees are real people, although two of them have not been—

Harlan Krumholz: And the legislation said, “These are the people who are going to meet and they’re in charge of making decisions about the solvency”?

Howard Forman: Yeah, they’re ceremonial. So, the trustees oversee this report. The report is done by the bureaucracy, which is basically actuaries, statisticians, health services researchers. I’ve read this report.

Harlan Krumholz: And can this be mucked with, like the jobs report or anything?

Howard Forman: Not that I can see. In fact, that’s what I’m going to get to here. The Part A program, which is the Hospital Insurance Program from Medicare, runs out of money in the second quarter of 2033, according to the actuaries of the trustees. That’s when the dedicated revenue only covers 89% of costs, and then it drops to 87%. This is a big deal, by the way. The Committee for a Responsible Federal Budget frames that as an 11% cut to hospital payments, growing to 16% in 2040. And this year’s number is worse than last year’s number. The depletion date moved up by a full quarter. Some people might say, “Okay, no big deal, full quarter.” But why did it move? Not mainly demographics, it’s largely a tax loss story. Roughly 13% of Part A’s revenues come from income taxes. Seniors pay on their Social Security benefits and the reconciliation bill known as the One Big Beautiful Bill Act, the Medicaid Cut and Tax Act, permanently extended to lower 2017 income taxes, it expanded the standard deduction and added a new deduction for taxpayers over the age of 65.

Prior projections had assumed those tax cuts would expire. They didn’t. So, seniors now pay less tax in their benefits, less money flows to Part A. But here’s what I found striking in the report. The trustees also changed two big demographic assumptions this year, and both point in the same direction. They cut their fertility rate from 1.9 to 1.75 children per woman.

Harlan Krumholz: That’s a huge cut.

Howard Forman: Huge cut. And I’ve been watching this year after year.

Harlan Krumholz: When did they have the 1.9? They haven’t been adjusting it every year?

Howard Forman: No. And I’ve been watching it, it’s insane how I watch the ultimate assumptions, but I do, I teach it in class every year. And they lowered the projected annual immigration rate by 150,000 people. Fewer future births, fewer future immigrants, both mean future workers paying lower payroll taxes into a pay-as-you-go program, that’s a structural headwind stacked right on top of the tax law hit. The single biggest, fastest growing piece of Medicare Part A is actually Medicare Advantage, private plans paid through Part A.

Medicare Advantage spending is on track to exceed traditional fee-for-service Medicare spending by 2028. So, how hard is this to fix? Mechanically, it’s not that hard, the trustee’s own math, a 12% cut to scheduled benefits, which would be brutal, or raising the Medicare payroll tax from 2.9% to 3.46%, a 19% increase starting now closes the gap. The problem is—

Harlan Krumholz: No one’s going to do that.

Howard Forman: Exactly. It’s the waiting. We defer this until the last possible moment, and then it requires even more to fix this problem.

Harlan Krumholz: Wow. I think people ignore this because they feel like, “Okay, there’s all this stuff going on, Congress isn’t going to let this thing default.” But then the question is, what will they do about it when it comes up? And to me, they’re even being conservative about this. I mean, if you cut the immigration, people who are immigrating to the U.S. actually tend to have more babies that... There’s lots going on in this thing.

Howard Forman: Spot on.

Harlan Krumholz: What’s your guess about what’s going to happen?

Howard Forman: I think this will hit the wall. I think this is going to be just as people have watched periodically over the last few years, us have Congress come to a halt over the debt ceiling, or over the federal budget, the government shutdowns, things like that, I think we’ll get to that here. I think sometime, whenever we get to the actual time, whether it’s 2032 or 2033, that’s not that far off, I think Congress will look like a deer staring into the headlights, and finally be forced to act—

Harlan Krumholz: Here’s the part that I’m really concerned about with. Your piece is one part of it. Here’s the other part, Howie. The debt’s never been greater, we’re spending money like crazy on things like ICE. So, $250 billion on ICE.

Howard Forman: It’s insane.

Harlan Krumholz: We’re now embroiled in a war that’s burning cash.

Howard Forman: Tens of billions of dollars.

Harlan Krumholz: Burning even more.

Howard Forman: I’m saying per month.

Harlan Krumholz: Per month. And so, all the fiscal conservatives, what they’ll do is they’ll pivot... After we give $1.5 trillion to the military and do all of that, when it comes to social services and social goods in the country, or things even like Medicare, we’ll be saying, “Oops, now’s the time we’re out of money.”

Howard Forman: We have to have “fiscal austerity.”

Harlan Krumholz: Now we have to have fiscal austerity, after we’ve spent all this money. And I don’t know where that’s going to leave us as a country, because we’re not making the investments, let alone infrastructure. What happened to infrastructure week? I don’t know. That was over.

Howard Forman: Well, we got the Inflation Reduction Act, which was partly infrastructure.

Harlan Krumholz: But not implemented very quickly.

Howard Forman: No. Right.

Harlan Krumholz: And as these things have been very slow to roll out. And then there’s so much we need to do, I mean, we need universal healthcare. We need to do lots of things in this country. And I worry that we’re about to enter a pivot point where everyone will say, now’s the time we need to be responsible.

Howard Forman: I couldn’t agree more. I worry about this, and I worry about the nation because I don’t think that anyone... or I shouldn’t say “anyone,” but the majority of Congress does not have their eye on the ball.

Harlan Krumholz: If I had to sum it up in one way, we have no long-term thinking in this country.

Howard Forman: That’s right.

Harlan Krumholz: So, everything becomes short-term. It’s almost like the quarterly calls with investors.

Howard Forman: Mid-term elections.

Harlan Krumholz: And somewhere along the line, someone’s got to say, “What do we want this nation to look like in a decade? What are we building for?” Because this kind of idea of, okay, we’ve got a crisis every week, or we’re dealing with this, or getting distracted by voter registration when there’s never been really a major fraud, it’s not you can’t deal with these, but is it the top priority in the country? Is it the most important thing that’s threatening our country? And by the way, also just these natural disasters with climate, we’re in a point of climate denial. And every week I see we need the way to deal with these, help people...

Howard Forman: No, I look back, and I think there are some major pieces of legislation that have helped people over the decades, they have come out, at times bipartisan, the Balanced Budget Act of 1997 I think did some good things, the ACA, which was not bipartisan, did some really good things. I think the Inflation Reduction Act did some good things. But net-net right now, we’re not tending to our own economics well.

Harlan Krumholz: And then, we got all this stuff with AI. I mean, no one’s really dealing with this.

Howard Forman: Regulation.

Harlan Krumholz: All of this is a problem.

Howard Forman: Yep.

Harlan Krumholz: All right. Since I’m going to AI, let me take that as a segue.

Howard Forman: Yep.

Harlan Krumholz: So, here’s something I think we’ve been tracking on the podcast for some time, but it’s starting to really take off in a big way. ChatGPT now is really rolling out this health feature that allows people to connect supportive medical records and Apple Health data. My wife just did this today. In part because we were curious. What actually does it look like? How do they interact with you? What happens as a result? It also means that they can look across your medications, lab results, recent visits. They—

Howard Forman: Can know you.

Harlan Krumholz: They get to know you in very intimate ways. And OpenAI says that more than 300 million people already use ChatGPT for health-related questions every week. And they’re thinking a large number of these people are going to come into this. Now, let me just say, this is potentially a step forward, there’s another side. Is this going to replace the clinician? This is just the week, by the way, where someone has sued OpenAI for bad medical advice. And this litigation is going to, I think, be the catalyst for people to start paying attention to this and to move on. I was talking to David Rhew last week, the chief medical officer at Microsoft, and we were saying, for a long time, people have been ignoring this safety issue, but once it becomes a litigation issue, there’s actually money behind it, and it may actually change what happens, how much, seriously, people can talk about that.

So, OpenAI says connected health data is protected and added safeguards have been put in place, and it’s not used to be training their foundation models or target advertising. But we’ve heard this before, and what kind of assurances can we get? How can we be sure? How can we know that there’s not going to be a leak? I also read this week there was another leak of some conversations that were occurring on the Claude chatbot. We’ve had this before on OpenAI. So, to what degree can we trust that this will be this way? There are also leaks out of healthcare systems too. So, we have to be fair in thinking about this. They’re not the only ones. So, let me ask you this. Have you connected your records, and are you going to do it? And anyone who’s thinking about it just needs to be doing it eyes wide open.

Howard Forman: So, I did.

Harlan Krumholz: You did?

Howard Forman: I did.

Harlan Krumholz: You did.

Howard Forman: I have not gone—

Harlan Krumholz: We’re breaking news on the podcast.

Howard Forman: I know. I did, but I’m ridiculous with these things, I just am like, “Eh, who cares?” But when you’re doing it and they’re asking you the series of questions, “Do you want us to take this? Do you want us to do this? You have the right to...,” you realize just how much you’re conceding to them. And I do worry about it. And I worry about it not so much for me, but I worry about it how it could be used against people who are in more vulnerable situations. Someone who may have had an abortion but doesn’t want a partner to know that. Someone who’s had a sexually transmitted disease but doesn’t want someone to know that. Other vulnerabilities—

Harlan Krumholz: Sexual orientation.

Howard Forman: Yeah, anything. There’s so much in there that I—

Harlan Krumholz: Something they want to keep private, they consider stigmatizing.

Howard Forman: Yeah.

Harlan Krumholz: But I’m curious, what was your experience with it? Did you like the way that it handled your information and the answers that it gave you to your questions?

Howard Forman: I didn’t go in and do the questions yet.

Harlan Krumholz: Oh, you haven’t done it yet? You just loaded it?

Howard Forman: I just, I gave all the access.

Harlan Krumholz: Oh, my God.

Howard Forman: I know. That’s the part that I failed at.

Harlan Krumholz: Okay. Well, people are going to have to stay tuned to next season’s episodes when we drop—

Howard Forman: Yes, we’ll talk about it.

Harlan Krumholz: ...because I’m going to give you a month on our break time here to dig into this, and I’m going to be very curious what your experience is. I’ll report back what my wife’s experience is with it. I haven’t done it yet.

Howard Forman: It’s very easy to do.

Harlan Krumholz: Yeah.

Howard Forman: I mean, it’s too easy.

Harlan Krumholz: I don’t have anything to hide, but I also am just a little skittish about—

Howard Forman: They do force you to give them access to your Yale New Haven MyChart. I mean, you’re going through a whole process to give them access, it’s not like you’re just saying, whatever’s on my phone.

Harlan Krumholz: And this is something I was fighting for a long time, to let people have the ability to share their data with people, or organizations, or products—

Howard Forman: And to take it back.

Harlan Krumholz: ...what they want to do... or to take it back. So, this is the thing. I think it’s good for patients to have this option, but again, people need to go eyes wide open. What are you doing with your data once you have it? It’s kind of like you’re walking around with a folder, a virtual conceptual folder, and who you give it to is who you trust and you got to know that you trust. All right, we’re getting short on time, so hey, take us home with one more.

Howard Forman: Yeah. So, back on February 5th, I told our listeners we were seeing roughly 250 new cases a week of measles, compared with 115 a week the prior year’s outbreak in Texas. And I said it would be easy for us to blow past last year’s total perhaps by summer. Well, it may have taken us a few more weeks, but we got there. On Friday, CDC confirmed 2,318 cases for 2026. Last year’s full figure, which was revised upward from when I reported it in February, is now 2,289. That’s now in the rearview mirror. We passed a full year of measles cases in less than seven months. That is the most measles cases this country has recorded in 35 years, since 1991. And I will add, as final cases get sorted out, I wouldn’t be surprised if the crossover date actually does get revised back to June. So, where are the outbreaks now?

Seven states account for 84% of the national level. South Carolina leads with 670. The state declared that its outbreak was over in April, but it still adds some more cases. Utah does have an active outbreak at second, at 522, those two alone are more than half the country. Texas, 188. Virginia, 176. Florida, 141. Pennsylvania, 134. Arizona, 108. Look at the churn. Texas led the nation last year with 803 and is way down, Virginia had six cases in 2025, it now has 176, Florida had eight last year, now 141. Here’s the part I want people to sit with. Utah’s outbreak began on June 20th, 2025. It is now run more than 12 continuous months, and genomic sequencing ties it back to West Texas outbreak in January ’25. Same lineage now identified as moving back and forth. That’s not importation anymore, that is endemic transmission. Utah has measles the way measles used to be.

By technical definition, the United States no longer meets the criteria for elimination. And the PAHO Regional Verification Commission, which was supposed to take this up in April and—

Harlan Krumholz: What is that?

Howard Forman: I think it’s the Pan American Health Associati... Organization.

Harlan Krumholz: Oh.

Howard Forman: But they postponed this, at our government’s request, will almost certainly say that we have lost our elimination status in November. Canada lost its elimination status last November. We’re next. CDC’s principal deputy director has called that the “cost of doing business.” One genuinely good piece of news, no measles deaths recorded in 2026; there were three last year. Ninety-three percent of cases are in people unvaccinated or of unknown status.

Harlan Krumholz: What percent?

Howard Forman: Ninety-three percent. Kindergarten MMR coverage is 92.5% nationally, below what we consider the herd rate of 95%.

Harlan Krumholz: And of the people vaccinated, I’m assuming maybe those are people who were vaccinated 20 years ago.

Howard Forman: And I think, to the best that I can tell, and this is going to be more anecdotal, but there is reports, most of them are milder cases, most of them are picked up from testing. So, there is benefits from having been vaccinated, even if you actually do show up with infection.

Harlan Krumholz: And what’s the current recommendation for people who were vaccinated when they were kids, and now are in their 60s? Are people getting vaccinated again?

Howard Forman: So, I think the CDC’s current recommendation is that if you are in a high outbreak zone, that getting an extra booster shot makes sense. Other than that, your protection is strong. If you’re immunocompromised, I think there are also considerations for treatment. The biggest important thing that we can tell all of our listeners, if you have any question, talk to your doctor about it.

Harlan Krumholz: Yeah. And this is really aligned with your prior segment, which is maybe the numbers aren’t as big as many other things that are going on, but it’s entirely preventable.

Howard Forman: Preventable. Entirely—

Harlan Krumholz: Entirely preventable.

Howard Forman: A hundred percent.

Harlan Krumholz: Yeah. No, it’s mind-blowing that we’re in this position. And again, we should just be taking care of it. This is the kind of thing that even the people who are skeptics of vaccines, if they’ve taken the time to look at the evidence, generally come around, the conservative Republicans.

Howard Forman: It’s a disappointing time in history right now.

Harlan Krumholz: I believe Cassidy from Louisiana is—

Howard Forman: He’s been very reasonable, even if he’s made some mistakes.

Harlan Krumholz: ... a physician, and also some recent… I mean, again, people may have different opinions about vaccines. To say vaccines, by the way, there are many types of vaccines, but this is one of the best buys, that you can really get rid of this.

Howard Forman: A hundred percent.

Harlan Krumholz: And this can be awful for people who are—

Howard Forman: Agreed. And it can cause, even if you don’t die from it, there’s lots of permanent damage that can happen to you.

Harlan Krumholz: So, Howie, what’s next on the podcast next year? So, we’re ending... This is Season Five?

Howard Forman: This is Season Five. We are—

Harlan Krumholz: What a joy. What joy to work with you for five years.

Howard Forman: Incredible. And you and I both know, we started this a little bit on a whim.

Harlan Krumholz: We’re just doing this for you and me.

Howard Forman: It’s been fun, and we love our listeners.

Harlan Krumholz: Listeners, we’re glad you’re along for the ride, but I do it so I get to talk to Howi, and that’s why I do it.

Howard Forman: No, we get time together, we’re going to take five weeks off right now, and come back after Labor Day.

Harlan Krumholz: Better than ever. Better than ever.

Howard Forman: Better than ever. We have a great lineup for next year.

Harlan Krumholz: We’re going after the Kelces, we really want to get in the big time here on the listener side.

Howard Forman: We want to get to a million soon. But we’re working on it now.

Harlan Krumholz: No no, we only aspire to provide a little entertainment and a lot of education and to do so in a way that is helpful to people. And for whoever it is that finds that useful, we’re glad. We’re glad.

Howard Forman: Very grateful. I’m grateful to work with you, I’m grateful to work with Miranda and Gloria and Donovan and Ryan today in the booth. I mean, it has been a fun experience.

Harlan Krumholz: Yeah, this has been great. And we love getting feedback. I know we’re kind of doing the outro informally today, but we love getting feedback. A lot of people write us and we appreciate it. Again, we’re always looking for suggestions. If you think we can do this better, we try to get good guests on, we enjoy this time where we are together in the studio. There’s always a lot of news going on in healthcare, and we’re trying to just make it accessible. We have a very diverse audience, so we try not to get too highly technical, but at the same time, we want it to be substantive. So, we’re trying to hit that right mark.

Howard Forman: And a new thing we’re trying to do is put these episodes up on YouTube, the ones we do in the studio, we’re going to try to put them up on YouTube.

Harlan Krumholz: Yeah. Yeah. That’s so you can see our wonderful smiling faces.

Howard Forman: Yeah. That’s who we’re here for.

Harlan Krumholz: All right.

Howard Forman: All right. Well, Health & Veritas is produced with the Yale School of Management, the Yale School of Public Health. To learn more about the Yale SOM’s MBA for Executives program, visit som.yale.edu/emba to learn about Yale School of Public Health’s Executive Master of Public Health program visit sbh.yale.edu/emph.

Harlan Krumholz: And we always like to give a hat tip, of course, we got Ryan McEvoy, as Howie said, who works with us in the studio, we have two superstar undergraduates, and I guess I’m really thanking them for all the time that they spent with us, and including Tobias Liu, who spent with us this year, as we’re ending this season.

Howard Forman: That’s right.

Harlan Krumholz: But Gloria Beck and Donovan Brown, a great producer who puts up with us, supports us, encourages us, and helps us put together great episode each week, Miranda Shafer. And what a privilege to work with the best in the business. Howie Forman.

Howard Forman: And what a privilege to be able to have time with Harlan every week for 50, 45 weeks of the year. It’s really a lot of fun. It’s great.

Harlan Krumholz: It’s amazing. All right Howie, talk to you soon.

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

Harlan Krumholz: Have a good break.