Jessica Federer: Closing Gaps in Women’s Health Research

Transcript

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

Howie Forman: And I’m Howie Forman. We’re physicians and professors at Yale University, and we’re trying to get closer to the truth about health and healthcare. Our guest today is Jessica Federer, but first we always check in on current hot topics in health and healthcare. What do you got covering for us as we come into the holiday weekend, Harlan?

Harlan Krumholz: Hey, Howie. I thought I’d just schmooze with you just a little bit about the email that we got today about Yale’s indirect rate. I don’t know if you had a chance to see that.

Howie Forman: I have not seen that. Tell me about that.

Harlan Krumholz: The research grant pays for the experiment, but where do you do the experiment and how does... There are all these rules associated with the grant that you have to comply with that lawyers and a whole range of staff need to attend to with regard to the budgets and how they’re distributed. And then by the way, then there’s the heat and lights and air conditioning and everything else. These are all the things that we call “indirect costs,” the things that aren’t the actual paying for the experiment itself or paying for the trial itself. And so these are the things that you’re supposed to tabulate and then there’s a whole bunch of accounting principles that lets you calculate exactly what does it take for you to keep the doors open so the costs can come in and pay for the experiment. And that’s what the indirect costs are.

So they’re nudging it up just a little bit. It’s going to be 68%. And I just wanted to talk about it just for a moment and just get your ideas because this was hot in the press for a long time as the Trump administration was suggesting they were really going to give a haircut to this indirect rate. And just to remind people, so when you say 68%, this is, by the way, it’s called “grant overhead” and it’s applied to what they call the modified direct cost base. So they exclude things like equipment and patient care, tuition, sub-award amounts... so if we make a contract with another institution, that whole thing doesn’t get applied. And Yale says that basically in their own estimation on a grant that’s about, I don’t know, a request about $450,000, which may be a typical NIH grant, this ends up being maybe close to $150,000 or something, like 30-some percent of the total budget. So it comes across as 68% it sounds, but it doesn’t get applied quite to everything, but it’s still a substantial amount.

And these are supposed to be administrative expenses, but they also include utilities and building maintenance, data security, compliance, a whole bunch of stuff that includes the administrative costs, but basically what it costs to run the place. And I think when people hear that like 68 number, they kind of think that this is way higher, especially when the government was talking about a flat 15% cap. They tried that. The courts upheld the ruling against it and said Congress would have to get involved if they really wanted to apply this, not the executive branch.

But one thing I think that does—and this is what I want to talk to you about, Howie—one of the things that does occur to me with this is that there was a question that was raised about the equity part about this because the wealthier, largely private institutions over time have been able to configure themselves in a way where they’ve made investments in their infrastructure and have overhead rates, have indirect rates that are at the very high end of the spectrum, and yet there are many other institutions around the country—and many of them state-run institutions—whose indirect rates are much, much lower than this.

And the question was being raised, I think nationally and by some of the people in Congress—is this fair? Is this fair? And you know, there’s a formula, we all follow the formula. It’s not like we get favored, but according to this formula, if you’ve invested over the years and this is what it costs you to do business, you get reimbursed for it at the federal level. And I don’t know what you’re thinking about indirect rates now, what you think are the right rates and how to manage this going forward. And this equity issue about, if you’re in Oklahoma, you’re not quite getting maybe the same as you would... Yeah, I don’t know these numbers, but I’m assuming that’s right, from what I’ve heard.

Howie Forman: Yeah. So here’s my take on it. I think number one, I think for our listeners to understand that for the most part, federally funded research is a money loser. No matter how much you might pile on indirect costs or anything else, the nature of the way grants are funded tends to be a money-losing operation.

Harlan Krumholz: And by the way, I just want to let people know, you’re vice chair of radiology. I mean, I just want to say, you’re actually speaking as someone who sees the P&L for the department and knows—

Howie Forman: That’s right.

Harlan Krumholz: ...how the funds flow and recognize.

Howie Forman: That’s right.

Harlan Krumholz: And I just want to say to people, you’re not just an outside observer in this case, you actually see this.

Howie Forman: And let me make sure this is clear for people. While it may be a money loser, it doesn’t mean that it doesn’t bring a greater glow to Yale University, it doesn’t attract students here, it doesn’t raise our profile. So there are reasons why you do things that lose money, even allowing for the fact that you might be purely capitalist-oriented, you can afford to lose money on something if you believe in—

Harlan Krumholz: Even though we get a 68% rate, of course, like I said, the reality is not 68%, we lose money.

Howie Forman: Right. And some of the reasons why we lose money are, as you know, we’re only allowed to charge to a cap for certain salaries and some of our most highly priced researchers are earning salaries that may be twice or even higher for that matter what the federal government will reimburse us for their times.

Harlan Krumholz: And that’s like $220,000 or something.

Howie Forman: I believe that’s about right. I think that’s where the cap is now, about $220 [thousand]. We have researchers in the medical school who are getting multiples of that, and you might say, “Well, why do you pay them so much?” Just like anything else in the marketplace, these people are looking at opportunities. That’s the market rate for bringing them into Yale.

Harlan Krumholz: And who’s responsible for what they call the “over the cap,” where the NIH will pay... A radiologist may make $800,000.

Howie Forman: Right.

Harlan Krumholz: When their 20% of their time is covered by a federal grant, it’s only covered to a maximum salary of $220,000.

Howie Forman: That’s right. That’s right. So there are many different ways in which... and by the way, it’s not just clinicians that are over the cap. We have PhD researchers that are making twice or more than that over the cap. One way or the other, the medical school figures out in the medical school—by medical school, we usually mean departments figure out how do you cover that? Some of it may come directly from the medical school because that person is a highly valued resource to the entire university. It’s worth it for them to pay part of it. Some of it may come from commercial grants, grants that are not from the federal government. Some of it may be direct subsidies from the clinical enterprise. And by the way, the clinical enterprise benefits from these researchers in the sense that there are patients that may be drawn to Yale for their care because of the reputation that these researchers bring us. So it’s not an easy P&L to construct.

Harlan Krumholz: I mean, actually, you could say the direct costs are kind of artificially depressed, like the institutional—

Howie Forman: That’s my point.

Harlan Krumholz: Even really reimbursed fully for the direct cost, this indirect can be somewhat of an offset.

Howie Forman: That’s my point. And in many cases, as you also know, some of these researchers are only expected to fund themselves to 80% or even lower than that to cover their salaries and you’re expecting the institution to cover other parts of it. There are many reasons why the research enterprise, at least on a very simple P&L basis, is generally a substantial money-losing proposition for a university. You typically also lose money on education for that matter, and you effectively have to make up the money on the clinical enterprise. And by the way, you might say, “Okay, well, that works. So what’s the problem with that?” Clinicians are in a competitive market as well. They’re not happy to necessarily see some of their earnings go to other parties. So you’re always having these competing resources between these—

Harlan Krumholz: And the margins were better a decade ago than they are now, so that when—there was more cash around, right?

Howie Forman: Right. No, look—

Harlan Krumholz: The margins are getting tighter.

Howie Forman: ... at Yale, I think the last several years between the COVID pandemic, which shut down a lot of things that had high fixed costs and then now many of the changes from the Trump administration, either the indirect cost issues, the tax now on the endowment, which was subsidizing some of the work that we’re doing, and then separate from that, the actual cancellation or slowdown of approval of new grants in certain areas forcing the institution to absorb those costs. All those things have made the research enterprise even more tenuous. And we are lucky to have a very large endowment and to have a very conservatively budgeted university to be able to back this up, but you can’t do it forever.

Harlan Krumholz: Just to be clear again, we call them indirect costs, but you’ve got the direct costs. What does it take to run the project? And you’re saying they still don’t all cover that, but like salaries and reagents and whatever you need. And then there’s a part about keeping the doors open, the rent, the utilities, and—

Howie Forman: Everything.

Harlan Krumholz: ... the administrative side, the dean’s side and the legal side and the compliance side, the IRB [institutional review board], all this kind of things.

Howie Forman: The physical building in many cases is an indirect cost. So you might be able to get the grant to pay for time on a PET scanner, but all the equipment that is in place to allow you to have a PET scanner, all the physical brick and mortar stuff that allows you to have the PET scanner, the MRI scanner, the operating rooms for animals, all those types of things, they require heavy investment and a lot of that does fall under indirect costs.

Harlan Krumholz: It does just seem in the end this is all going to be something that needs to be attended to because I’ve seen this myself. If you have too many people who are grant-funded, you have trouble—

Howie Forman: That’s absolutely right.

Harlan Krumholz: ... squaring your budget within a department.

Howie Forman: And I’ve now heard at several universities that they’re now being more aggressive about effectively penalizing clinicians who are scientists because as you said, they can no longer subsidize the over-the-cap costs for a highly paid clinician when the bottom line is so thin at this point.

Harlan Krumholz: That’s right. Interesting. Well, I’m sure we’ll hear more about this going forward. Hey, let’s get to our interview with Jess. This’ll be great.

Howie Forman: Jessica Federer is an investor and board member adept at using technology to make advancements for business and society. She is the founder and managing director of the Women’s Health Fund and serves as a founding board member at Angelini Ventures, a fund investing in biotech and digital health companies. She’s also a senior external advisor for McKinsey & Company. As a global health leader in health technologies and women’s health, Federer was previously the chief digital officer, leading the digital transformation for Bayer AG. She was the first woman to hold this role in the global pharmaceutical industry and is recognized as one of the top 100 global CDOs. She received her bachelor’s degree in public health from the George Washington University and her master’s degree from the Yale School of Public Health, which is when Harlan and I first met her. She currently serves on the Yale Institutional Review Board and the advisory board of the Blavatnik Fund for Innovation at Yale.

So first of all, I want to just welcome you back. Today’s show—we’re taping this on July 1st; we’ll release it on July 2nd. This is the beginning of the new academic year, in a sense. The new residents have arrived. Our new MPH students in the Accelerated Program and the Advanced Professional Program have begun today. So it really is the new academic year, and I keep thinking this is 20 years now since you started at the School of Public Health. And so it’s a great time to just reflect on what—

Harlan Krumholz: Exactly—

Howie Forman: Exactly. You were a middle schooler at the time. But now reflecting back on that, what were you thinking then? How has the world changed and what do you see as the promise of the Yale School of Public Health going forward, considering that you’re actually very actively involved with them as well?

Jessica Federer: Such a great question. I think public health has become so much more relevant in our daily lives 20 years on. We’ve all now felt it so much more. Twenty years ago, we still had to explain to people what is public health, what are you studying, and now post-pandemic and a new world, we’re really aware of how the environment, our workplaces, our education, how everything comes together for that public health ecosystem. And so you mentioned my current involvement with YSPH. The new dean, Dr. Megan Ranney, I mean, the vision and the enthusiasm and the approach for how to truly make the public health professionals of the future that are integrated in business and integrated in government and integrated across society is the most proactive, meaningful approach to public health. It’s what we’ve all wanted to see. So 20 years on, I think we’re just getting started, and I’m more... I’m more, what, I’m more optimistic than ever that public health is really going to continue to grow and infiltrate and integrate into everything that we’re doing.

Howie Forman: And just as a quick follow-up, when you arrived here, what did you think you were going to do when you graduated?

Jessica Federer: You know, probably work back for the government. So I came over to YSPH from HHS. I was assigned to AHRQ, the Agency for Healthcare Research and Quality, and we were doing a big initiative in the government. And I had every intention of going back into government but at a higher GS rating after your master’s. And then of course just fell in love with drug discovery and drug development, and I went to the dark side to big pharma, and I absolutely loved it. But I do remember at the time feeling bad that, “oh no, I’m going into industry,” because there was still that tension at the time of, you know, where are you going with your public health degree?

Howie Forman: For what it’s worth, we don’t see it as the dark side at all. So I’m appreciative of what you’ve learned from that experience.

Jessica Federer: Thank you.

Harlan Krumholz: So Jess, I got so many questions for you. And for those listening, I mean, Jess Federer is the force of nature and her disposition is about optimism. She’s technology-forward. She’s always thinking about how things can be better. She brings a bright spark to every room she enters, and it’s been such a pleasure to know you all over the years and to watch your impact and to see how... various ways that you’ve been trying to make a difference.

I actually have a whole bunch of questions because your network is expansive and I want to get into a little bit about what you’re seeing out there and what you’re excited about. But since Howie started on the School of Public Health, if you were giving the School of Public Health—and you probably do—advice in this time, it’s one thing we can sing the praises of public health, but the truth is the field is under some assault right now and schools of public health are in a difficult position. They depend importantly on tuition. In many cases, full-paying people from other countries, it’s more difficult for them to get in. The enrollments are dropping. I’m not talking about Yale, let’s just talk writ large around public health schools around the country.

The idea of a career in public health is not as certain a destination for many people. Now they look at what’s going on at CDC. They wonder if the country’s going to invest in public health, if these kind of jobs are going to be available in the future. If you’re giving advice to schools of public health about how do they reinvent themselves, how do they give themselves the sort of coolness factor going forward so that people can appreciate the vital importance to our country, to our economy, to so many different aspects of our lives? You know, it’s not just about health, it’s really about the vibrancy of a country that they’re willing to invest in public health. What do you say to them and what is the business model going forward for these schools and how can they position themselves?

Jessica Federer: Well, before I answer that amazing question, I do have to say what an honor it is on the recording here to be on The Howie and Harlan Show. You two are such—

Harlan Krumholz: I think it’s the Harlan and Howie Show.

Jessica Federer: Yes, hypothetically. The Harlan and Howie Show.

Harlan Krumholz: No no no, it is Howie. Howie’s the headliner. Howie’s the headliner.

Jessica Federer: I’m sure you all listened to the Clickety-Clack Car Talk brothers religiously as I did, but you are the Car Talk brothers of healthcare and the way that you get—

Harlan Krumholz: We’re going to cut this section, by the way, so you can go as long as you...

Howie Forman: Ha ha ha ha!

Jessica Federer: No, no, no. This part’s staying in. You rarely come across two leaders with such integrity that shows through over decades and decades of not only how they live their lives and coach their students and support their students and innovate, but the integrity with which both of you lead your careers, it’s truly such an honor that I got to take your courses early on in my master’s degree and to have that influence of both of you, which really showed truly what an impact you can have. So first, thank you both so much.

Harlan Krumholz: Thank you, Jess. Thank you.

Jessica Federer: This show is phenomenal.

Harlan Krumholz: Thank you.

Jessica Federer: And I can’t tell you—

Harlan Krumholz: Thank you.

Jessica Federer: I’ve been telling everybody, I’m so excited to be on this show with you too because you mean the world to me. Now, how do we make public health sexy? I think public health suffers from a term that’s like “public health,” “public bathrooms.” It’s not the sexiest of terms, right?

And frankly, women’s health, which is an area I’m super passionate about, suffers from the same thing. People think “women’s health” and they just think of having babies. They don’t think of the fact that we’re just starting to learn what the genes on the second X chromosome, when they escape inactivation, which ones escape inactivation and what they do, they don’t think of the most profitable category or the most profitable industry of the world being led by women. It just has this boring “women’s health umbrella” and public health is very much in that same boat. It sounds like “infrastructure,” right?

If it’s done right, you don’t even know it’s there. But it’s that infrastructure approach that makes it incredibly sexy, because do you know what else is infrastructure? Internet, AI. Every big company that’s growing in the world is developing some type of infrastructure. And if we look at public health by the lens of—it is the infrastructure that enables us all to have successful businesses, to have a healthy workforce, to have an economy that’s growing. It becomes such a valued driver for everything that we want to accomplish in public and private sectors. So the fact that public health is infrastructure and is so embedded in how we’re able to work, how we’re able to operate, how we’re able to get talent in the workforce, how we’re able to continue to nurture our environments, it is the most exciting space because it’s that practical applied application of what we’re learning in science and technology to the lives around us now.

Howie Forman: I want to pivot to another Yale personality, and that is Basmah Safdar, who’s a recent guest on our show just a few months ago and someone you’ve worked with now in innovation. And the two of you converge from two very different angles. Basmah is somebody that Harlan and I both know.

Harlan Krumholz: Spectacular. She’s just spectacular.

Howie Forman: She’s spectacular, but she comes from an emergency medicine setting, which is where I first met her, but she does cardiac emergency medicine. So she knows Harlan from that angle. She’s a clinician first, a scientist second. She’s a full professor at Yale and now the director of Women’s Health Research at Yale. And you come from a public health background, a digital health background, the health tech background, and the two of you converge on a lot of areas of women’s health innovation. And I want to just hear from your point of view, what is the opportunity set there, and what does an office of women’s health research at Yale represent to you when you think about what your vision for the future is?

Jessica Federer: Great question, Howie. Dr. Basmah Safdar is a trailblazer. You mentioned her work in emergency medicine, but what she’s now doing, leading Women’s Health Research at Yale, which is the oldest academic institute focused on women’s health in our nation. The way she has brought it through to pull together the different stakeholders from research and industry to accelerate the research that’s happening has been amazing. Women’s Health Research at Yale just had their first research symposium a couple weeks ago in New Haven. And it was back-to-back-to-back research presentations from neurology, endocrinology, oncology, ophthalmology—you name it. Going down the list, every single therapeutic area you can think of was presenting innovative, meaningful research for the half of the population that had been excluded from research until 1993. I think it was the most inspiring single day of research I’ve been to in decades. It showcased what’s on the horizon and what’s the low-hanging fruit and what the true potential is for women’s health.

Harlan Krumholz: You’ve been such a champion for women’s health. You have such an extraordinary network. This is where I wanted to get back to. And there’s so much happening in digital health. Of course, as you ran that office at Bayer, you’re advisor to so many different kind of companies and you are an investor. What are you seeing that’s exciting you most? What’s really going to change what’s going on for women? And I think that, I don’t want to say people have discovered this area, but in some ways on the business side, they’ve recognized the total addressable market. It takes that to wake people up. It’s not about saying it’s the right thing to do or we’ve neglected a group, but when the market finally appreciates, first of all, who’s got the purchasing power in healthcare, and second of all, what’s the unmet need? Then there’s really an explosion of innovation that occurs. But what is it that you’re seeing that’s exciting you most?

Jessica Federer: So about four years ago, we started bringing investors together for women’s health. And at the time, there was no data to reference on women’s health. They were all coming from special interest groups. I didn’t trust the data. So I called up McKinsey, and I was begging, “Please, let’s get a report out with numbers that I can reference and that I can trust and that have been pressure-tested.” And so McKinsey has been steadily putting out reports about the women’s health market and the market’s size. And as you said, Harlan, that’s been such a critical driver to recognizing the opportunity because for a long time in pharma, when I was over at Bayer, for a long time we really strove to treat men and women the same. Our goal was to treat men and women the same. We truly didn’t know that was the wrong goal.

And so now as we’re really aware that women have twice the rate of side effects of men, we’re really aware of the data gaps from not having women in research till 1993. We’re really aware of trying to understand why women are 80% of autoimmune disease—eight-zero—and two-thirds of Alzheimer’s cases. We’re really aware that there’s something different that we missed. And so bringing the McKinsey market data together with the new scientific innovation, that’s where the strategics are getting very interested. That’s where investors are getting very interested because now you know the true opportunity and it’s significant.

Harlan Krumholz: So give me an example of where do you think the direction is that’s going to make the most change in the near term?

Jessica Federer: I think the basic science will be the biggest driver in the near term. So we all know that second X chromosome that women have is inactivated, but that we’re starting to understand which genes escape inactivation and when they escape inactivation, what are they doing. And this is all very new science, but it looks like the majority of your immune genes are on the X chromosome, not on the Y. And so if women really are getting that double whammy of immune response, that will help us to understand so much about the inflammatory process, everything from autoimmune conditions, GI, neuro, osteoarthritis, you name it. It’s a pretty systemic driver, and that’s what a lot of investors and scientists are quite excited about.

Howie Forman: There are a lot of areas where I sort of understand underinvestment because it may be less profitable to be treating diseases of under-resourced parts of the world. It may be less profitable to be treating diseases that afflict poor individuals even in the United States. I can get that at least from a logic point of view, even if it doesn’t make an equity or justice sense. When it comes to women, though, there’s pretty strong marketability of women’s health problems and it strikes me—and part of it is because I worked with you and one of our medical students on a paper on this topic—it strikes me that this is a problem of the investor community, that they’re just not shining a light on this area. They’re just unaware of it. And so it does make people like you and people like Halle Tecco and so many of our students that are in the entrepreneurial space. We had Jaya Dadwal on the podcast recently.

It means that those opportunities just need more light on them and need someone to be explaining them more. I mean, obviously you’re doing that, but how do we get more people to recognize the enormous opportunity set?

Jessica Federer: Yeah. Investors are starting to become more, what, more active in this space. The size of the investors that have been participating in women’s health have gone from really little funds to now your a16z’s and Mubadalas and the giants in this space. And the strategics have been really instrumental in that. So when I talk about “strategics,” I mean, like Eli Lilly or Merck or some of the other big pharma companies that have set aside a special investment focus for this category, knowing the opportunity it has. But I think what your question is getting at is something that’s truly systemic. I mean, the VC industry, which funds much of the early innovation, has been run by men and a rather homogenous population of men. And so because those have been the drivers of capital, we have seen less enthusiasm and understanding for the women’s health conditions and market opportunity.

So that has been something that we’re still continuing to struggle with is the amount of GPs, the amount of general partners at venture capital funds, that are able to do deals or on investment committees, it’s a lot less than men. And so we’re still looking for the continued diversification in that space. And frankly, we’re trying to get more men excited about women’s health and help men feel more comfortable investing in women’s health. You don’t need to send an interesting deal to the one woman partner. This is something that really... the more we learn about, let’s say, women’s brains or the women’s immune response, the more we also understand about men’s brains and the male immune response because there’s always, we’re learning from both sides of that new science. So it’s also trying to get everyone excited about it in a mainstreaming way so that women’s health goes from being the fertility menopause space to truly mainstream.

And we see it as a consideration across autoimmune, neuro, musculoskeletal, you know, all the way down the line of... it’s an important consideration of all of those categories.

Harlan Krumholz: I think there’s another facet here that’s really important that you’re making me think about, which is that this whole world of investment is a lot about pattern recognition and that has to do with who gets hired, who gets promoted, but also who gets invested in. Does a company with a woman’s CEO get the same kind of attention? Do people have this sort of pattern recognition of these tech bros who, you know, if they’re going to go, they’re kind of crazy, they’ll walk through walls, they’re a little outlandish, a little juvenile and that’s the successful... maybe a lot, right?

Even as they’re successful and become trillionaires, they maintain that same sort of persona that then gets pattern-recognitioned on down. Maybe the secret is to go to the wealthy women of the country, the Alice Waltons and others and to say that money’s going to break this. And we got to say from the beginning, and this isn’t up, men against women, but it’s about saying that there does need to be sort of at least a complementary approach where we’re mentoring, growing, and breaking the idea about what the pattern recognition has been in the past.

Because I do think that there’s, I’ll just say it like this, a high likelihood that women have been disadvantaged in these industries. It’s not that women don’t want to become investors. It’s not that women don’t want to rise within these firms. It’s not that women don’t want to be—lead innovative companies. And by the way, there are many great examples of women who are leading companies. So I’m not diminishing that, but April Koh, I mean, Spring Health. I mean, there’s lots of people who have been a Yale grad and someone we should be really proud of, but there are lots of good examples, but proportionately it’s not matching what you might expect, given that women have just as much talent as men. So what are your thoughts about that? How do we seed the industry? How do we create that better balance within the industry, give everyone a fair shot?

Jessica Federer: How do we give everyone a fair shot is such a... we need a whole other podcast just on that one. There’s nothing inherently fair about business, and we do operate under so many different political constraints regardless of what country your company is in. Some countries have done a really good job of pushing for more diversity, better representation of all parties.

Harlan Krumholz: By the way, just to go in that, I think as you know, you’ve taught me this too. The goal isn’t representation. The goal is to give everyone a chance to achieve their promise, right? It’s not for the purpose of balance, it’s for the purpose of, are we holding people back given the current way that we do things? Right? I mean, I’m just saying it out loud.

Jessica Federer: Absolutely.

Harlan Krumholz: Because people might hear this is about... that’s where we get into trouble, where people are saying like, “Well, these people don’t deserve it.” But you’re just saying if this is the balance, can you really make the argument that the talent’s not equally distributed? I don’t think you can.

Jessica Federer: I agree with you. I agree with you. If we could fund... What’s a good example? Eli Lilly has a separate fund and I got to call it out because it’s brilliant. They have a separate fund that just invests in African American fund managers for their first two funds because there are so few African American fund managers in America, they have set aside a specific focus on we’re going to back them for their first couple funds because that’s what you need to change the tide. And you started with this huge generational wealth shift, and all the banks are talking about this. This is the biggest transfer of wealth from men to women that we’ve ever noted in the world, and it’s happening right now. And so more women than ever are—

Harlan Krumholz: You mean that the baby boomers, as the men die, the women—

Jessica Federer: Pretty much.

Harlan Krumholz: ... or the survivor, not they have been—

Howie Forman: No, but I think it’s also a shift in just employment over time also.

Harlan Krumholz: What did you mean by “men to women”? That’s why I just wasn’t clear what you meant by “men to women.”

Jessica Federer: Yeah. Harlan, you’re right. So there is a generational wealth transfer that’s happening from the men as they’re passing away to the wives and daughters. And so for a lot of big banks that work globally, they are seeing this change. And so they’re being given new direction in what opportunities they can invest in and what considerations they need to have for investments. So it is this big generational sex-wealth transfer, and it’s causing the whole banking industry to also take a look inside and change the way they’re operating because they haven’t been used to working with so many female customers.

Harlan Krumholz: And it must be combined with the fact that the generation’s coming up, women are often making more than the men. So actually women have, I mean, more control of wealth than ever before.

Jessica Federer: And that’s a very new trend. And what’s interesting here is women are, again, generally speaking in the U.S., they’re not as active investors as their male counterparts yet. And so to the extent that we can activate more women and feeling comfortable and investing in companies that resonate with them, investing in companies that are trying to solve for women’s health. You know, there’s ones today, you can go on your Robinhood app and show your support by buying some stock, but women just haven’t been as accustomed to that approach, and we’re starting to see that shift as well. So with the science moving, with the investment moving, when I say I think women’s health is the most exciting area for meaningful advancement during our lifetimes, it’s all of those factors coming together because right now we don’t even know what we’ve missed because we didn’t have our lens on women. We didn’t even have to power our studies to show sex-based differences. That guidance from the FDA just came out in December. It’s all new.

Howie Forman: As we get to the end, I want to just give you an opportunity. You’ve been to our Yale Innovation Summit just about a month ago. Your eyes are always open, you’re involved in the innovation community. Are there one or two things that you’ve heard about recently that get you particularly excited? And if not, that’s fine also, but just curious to know what catches your attention.

Jessica Federer: So there’s something really special happening in the Yale Ventures group that is not happening across the rest of the country. So the Yale Ventures group a couple years ago started asking researchers applying for funding, particularly to the Blavatnik Fund as well, started asking them for sex-based differences. “What are the sex-based differences? How are you looking at this? Are you using just male mice or male and female mice, male cells or male and female cells?” And just by asking that question, it has shifted the focus of the research and the type of projects we’re getting, to the extent that at this last Yale Innovation Summit that just happened, we were able to have a pitch specifically for women’s health companies. And this is everything from innovations in knee surgeries to women die 50% more in the year after a heart attack than men. So in the cardiology space, in the hormone monitoring space, brilliant innovations.

And so at the end of the day, seven out of the 10 awards we gave went to companies with a focus on women’s health. And this is transformative because no other university has started doing this yet. And it’s such a small thing. Ask the question, how are you looking at sex-based differences? And then open up the door, say, “We’re going to have something specifically for women’s health” and watch the innovation come. But the Yale Ventures team—Josh, Morag, the team that has been driving this—the approach they’ve taken, I think within a couple years, every university is going to be following the lead of the Yale Ventures team here. This is the way science needs to be done.

Harlan Krumholz: Yeah, they’re a brilliant group. Let me ask you something as we come to the end, because this is something you can help me with. When I watch you, I think, “God, she is such an excellent communicator. She is clear, thoughtful, her ideas get across and stick.” Tell me, how did you develop that or what are your secrets for communication? Because I think even as people who listen to you here, they recognize you’ve just got this immense gift. But it’s not really a gift, right? You’ve cultivated it, I’m sure. How have you gotten to this point where you can communicate so well?

Jessica Federer: Oh, well, coming from you, Harlan, I mean, you and Howie are such clear communicators on such complex topics. Well, let’s say this. Very few people are born with a gift. Most of us just have a lot of practice, a lot of practice. And growing up as a child, I was in every debate team, every speech competition, every pageant, you name it. If there was a chance for parents to force their kids to memorize something and speak or debate or model UN or mock court, mock trial, you had to do it. And the practice and still today being intentional about what are you trying to communicate for people who want to be successful, you have to really listen, record yourself, listen to how you’re speaking, listen to if you understand the messages you’re sharing and if you’re saying it in the simplest possible terms in a way that people are going to understand and remember, because if they don’t remember what you said, why are you even opening your mouth?

So the communication piece, and this is also what I love about the Yale School of Public Health. Dean Megan Ranney has been... I was actually going to shut down all of my social media and it takes a lot of time and energy and there’s a lot of crazy people out there and not everybody’s as amazing on X as Howie over here. But Megan actually challenged me and she said, “If we don’t have public health leaders out speaking and sharing and combating the voices that are sharing misinformation, then it’s on us.” That’s our responsibility to communicate in a way, in a place to the people that need to hear it. And we can’t just keep communicating in our bubbles and in our universities. We have to get out and communicate to the folks who need to hear it and who are hungry to hear it, and we can’t keep talking to ourselves. So the communication piece, the more that we can integrate that into medical training, into public health training, into all of our specialty sciences, it’s going to make the difference.

Howie Forman: Well, we are grateful for your voice, your intellect, and, as Harlan said, your force of nature and ability to help make us better in what we do. So thank you so much.

Harlan Krumholz: Yeah, thanks for joining us.

Jessica Federer: I had the best professors. What can I say?

Harlan Krumholz: Okay. We’re going to cut that too.

Jessica Federer: I mean it.

Howie Forman: Thank you.

Jessica Federer: Seriously. Thank you, thank you.

Harlan Krumholz: No, thank you so much. Thank you.

Jessica Federer: Thank you.

Howie Forman: She’s wonderful. We’re so lucky to have known her.

Harlan Krumholz: As advertised, she is such a good communicator.

Howie Forman: Yeah. She’s a wonderful person.

Harlan Krumholz: We got a great spark to her. Okay, Howie, this is, as you know, one of my favorite parts of the program. What’s on your mind this week?

Howie Forman: Okay. This is, I think, the first time I’m covering the exact same topic two weeks in a row, but I’m returning to it because a major lawsuit has been filed around the issue of Medicaid medical frailty. So a quick disclosure first, one of the sworn declarations in this lawsuit was filed by Ryan Schwarz, who now runs MassHealth, the Massachusetts Medicaid program. Ryan was our MD/MBA student at Yale, and he’s been a guest on the show. This week, 25 states and the District of Columbia sued CMS over its interim final rule implementing last year’s Medicaid work requirements from the One Big Beautiful Bill Act or H.R. 1. Congress wrote a categorical exclusion into the statute for people who are medically frail, cancer patients, people with serious mental illness, people with disabling conditions, categorical.

If you’re in one of those categories, the work requirement doesn’t apply. The rule, however, as a second hurdle Congress never wrote, you also have to prove your condition significantly impairs your ability to work. And by CMS’s own account in a June webinar to the states, there was no statutory basis for that addition. The timing of this rule makes this even worse. Normally a rule that’s consequential goes through a year or more of public comment before it binds anyone. This one did not. It’s an interim final rule, final on arrival, the force of law, no comment first. Its key provisions take effect July 31st. To meet the statute’s own deadlines, MassHealth says it has to lock its eligibility systems within weeks and start mailing notices to members in early August with full rollout by January 1st. That’s why the states didn’t wait. They went to court this week asking the judge to freeze the rule before the end of this month. And the hurdle isn’t abstract, it’s paperwork, and paperwork is where eligible people fall through.

CMS concedes it. About 7% of people who are working or who qualify for an exclusion will lose coverage anyway for “administrative or procedural reasons.” Not ineligible, just unable to navigate the proof. Schwarz’s declaration makes it concrete. A MassHealth member attests some medical frailty after a cancer diagnosis gets through treatment, then develops major depression. Starting in 2028, the rule won’t let her attest a second time in the same enrollment, even for a new condition. She finds documentation she may not be able to get or she loses coverage. Massachusetts has the highest insured rate in the country, 97.9%. MassHealth covers about 1.8 million people, and the state’s own analysts under oath expect this rule to push real numbers of eligible residents off the rules, which brings me back to Ryan. I’m not neutral. I said so at the top, but what stayed with me in his declaration wasn’t the loyalty, it was the care.

He reconstructs the government shifting guidance week by week, cites the rule down to the subsection, and never loses the person inside the paperwork. It reads like someone who feels the weight of 1.8 million people on the other end of a MassHealth card and the millions more nationally a rule like this reaches. That’s the kind of public servants you want holding the pen.

Harlan Krumholz: Well, that’s a great segment. Howie, we should just put together an agentic AI that anyone can sign into and walks people through it and does the work for them and sends it in for them. In this era of agents working for you, I mean, actually we could probably get a bunch of students together on a weekend and put something together people could use.

Howie Forman: So it would work if this were something where self-attestation were the central principle, but by 2028, self-attestation will not be the central principle, and you’re literally asking somebody like, “How do I get re-approved?” And it requires billing and codes. It requires a doctor’s note in many cases. It requires going out into a lot of different systems.

Harlan Krumholz: The irony is that you can’t even find a doctor now.

Howie Forman: Exactly. This is exactly what we’re concerned about, and that’s why MassHealth is already building a big infrastructure to do this right now.

Harlan Krumholz: Yeah, that’s amazing. Thank you, Howie. That’s incredible.

Howie Forman: Kudos to Ryan. I mean, Ryan is someone that we’re both very proud of, but to see this 24-page document, and we’re going to put it in the show notes, I really hope people actually take some time to look at it.

Harlan Krumholz: Yeah, yeah. No, that’s great. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howie Forman: So how did we do? To give us your feedback or to keep the conversation going, email us at health.veritas@yale.edu or follow us on any of social media.

Harlan Krumholz: And give us feedback. We love it. We are challenging you to let us know how we’re doing and what we can do better.

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

Harlan Krumholz: And hat tip to our superstar undergraduates. Today we’ve got Gloria Beck. She is so amazing. Donovan Brown, our great producer Miranda Shafer, and I get to work with the best in the business, Howie Forman.

Howie Forman: Thanks very much, Harlan. Right back at you.

Harlan Krumholz: Thanks, Howie. Talk to you soon.

Howie Forman: Thanks, Harlan. Talk to you soon.