Julie Rovner: On the Health Policy Beat

Transcript

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, and we’re trying to get closer to the truth about health and healthcare. Our guest today is Julie Rovner. But first, we always check in on current or hot topics in health and healthcare, and they are infinite right now, Harlan. So, what do you have for us?

Harlan Krumholz: Oh, it’s been a whirlwind two weeks in obesity medicine, and I thought I’d focus on that a little bit.

Howard Forman: Yeah.

Harlan Krumholz: So, let me start with the big question: how far can medication actually take us when it comes to weight loss? And if you’ve been following this space, the last two weeks have been extraordinary. The pace of news alone tells you that, I think, something fundamental has shifted.

Let’s start with retatrutide. Retatrutide is a triple agonist that activates GLP-1 and GIP. This is what’s in tirzepatide, but also has something for glucagon. So, the GLP-1 and the GIP reduce appetite; the glucagon increases energy expenditure. In a Phase III trial—now, these are the trials that are really regulatory based—announced by the company, participants lost nearly 30% of their body weight, on average.

Howard Forman: Wow.

Harlan Krumholz: To put that in perspective, it translates to more than 70 pounds of weight loss, starting for someone with an average of about 250 pounds. This was over almost 70 weeks, more than a year. And that level of weight loss used to be reserved for something like bariatric surgery. Seeing it with a medication? Amazing. And who was studied mattered here. They were adults with obesity or overweight, many with severe obesity. And in this trial, participants had knee osteoarthritis. And one of the things was, one of the endpoints was, what happened with the osteoarthritis? And they had improvements in pain, function. Of course, cardiometabolic markers improved. As with other drugs in the class, side effects were mostly gastrointestinal. About 1 in 8 to 1 in 5 stop treatment because of the side effects, but most people were able to tolerate it. And an important note about transparency, they were announced by the company ahead, because of the SEC regulation. So we still haven’t seen the paper about this, but it’s a pretty amazing signal.

So let me just go quickly. It’s not just this drug. In the past two weeks, we also see entirely new approaches. One is early data from a gene-silencing therapy. There are these therapies that silence some of our genes. And same: not just a weight loss, but it’s selectively reducing visceral fat and liver fat, potentially with far less frequent dosing. These are early studies, but they’re amazing.

And at the same time, the last thing that happened that was amazing this week, oral launch of the GLP semaglutide, approved specifically for weight loss. It’s been used oral for diabetes, but this is a daily Wegovy pill. And this matters because the pills are cheaper to make. It’s going to change the whole thing about access, logistics. Many people would prefer a pill to injecting themselves. And all of this is layered on top of ongoing pricing moves, direct-to-consumer strategies. You may have seen, we’ve talked about it before, Hims & Hers talking about microdosing. And early signs that some health systems are pulling back coverage. We talked about that also. So wow, lots of stuff going on, taken together. This isn’t just drug development. It’s about re-engineering how obesity is treated. And the question is going to be whether or not the health systems are really ready to handle this.

Finally, the New York Times’ Paula Span had an article about how many older people who start GLP-1 drugs, they experience benefits, but they stop them within months. And people are thinking this isn’t really about the drugs, but it’s because they can’t really ultimately afford them. So, lots to do, lots to happen. I know we’re going to have Ania Jastreboff on soon to talk with us about some things that are happening with her, and we’re going to focus on this area, but I just wanted to take a moment about it.

Howard Forman: No, this isn’t going away. This is an exciting time for us in medicine for patients, for patient care. But you’re absolutely right. I know people who have gone on and gone off, and not because of cost. And then there’s all the separate issues around the sarcopenia, the loss of muscle mass. And so there’s a lot to be learned, but there’s no question as right now, the benefits are just dramatic.

Harlan Krumholz: And the cost of these pills, they’ve taken them down to like $149 a month. This is going to be much more affordable. It’s going to be a whole different deal than we’ve had before.

Howard Forman: Absolutely. It’s an exciting time.

Harlan Krumholz: There’s more to come on this, Howie—

Howard Forman: Absolutely.

Harlan Krumholz: ... but let’s hit our interview, Julie Rovner.

Howard Forman: Julie Rovner is the chief Washington correspondent for KFF Health News, and hosts the weekly health policy news podcast What the Health? She was previously a health policy correspondent with NPR for 16 years, where she served as the lead correspondent covering the passage and implementation of the Affordable Care Act. Prior to NPR and KFF, Rovner covered health policy for Congressional Quarterly and National Journal’s Congress Daily, among others. She’s the author of the critically praised reference book Health Care Policy and Politics A to Z. And in 2005, she received the National Press Foundation’s Everett McKinley Dirksen Award for distinguished reporting of Congress. And so many other honors over the years. Rovner earned her bachelor’s degree in political science from the University of Michigan in 1980 and has been serving in the health policy journalism realm for 40 years. She truly is the dean of health policy journalism at this time.

So first, I want to welcome you. And there is so much going on right now, both in Congress as well as, locally, in healthcare and in public health. How do you even figure out what you focus on at this point? You mostly used to cover insurance and healthcare issues, but it’s expanded into public health and so much else. How do you make decisions on a weekly basis even as to what you cover?

Julie Rovner: It’s not very easy right now. It’s been really crazy busy. I should say I have covered public health since the beginning of my career. I’ve covered the changes at the FDA and the CDC. I mean, I’ve basically covered everything that’s handled by the Department of Health and Human Services. That’s been my “beat.”

So I got into bioterrorism after 9/11 and the anthrax attacks. I’ve sort of dabbled in most everything. I have a particular interest in workforce policy just because I worry that as I’m getting older, there are going to be enough doctors to take care of me in my old age that’s rapidly approaching. But it is. I say I sort of drink the news from a firehose and then try to arrange it in some understandable way for our weekly listeners.

Howard Forman: I just want to follow up that in right now, Congress is actively discussing the ACA subsidies, basically. And we may really get a bill—I, at least, think we may really get a bill. What are you hearing? You just interviewed Avik Roy at the end of the last year on your podcast, who’s a Republican. What are you hearing about the likelihood that something could come together in the next few weeks?

Julie Rovner: I still think there’s a chance. There’s sort of the political reporter intelligentsia keeps saying, “Oh yeah, this thing is going to pass the House,” which we know, because they got all the Democrats and four Republicans, which is enough to give it a majority. And it’s going to die in the Senate because the Senate voted on a three-year clean extension in December, and it failed. I don’t agree with that. I think that senators coming back from this break have gotten an earful over the break. We saw President Trump this week basically wag his finger at the Republicans, suggesting that there may be the need for some kind of a compromise. He knows that this is a big issue.

Then I saw a bunch of people saying, “Oh, well, they have three weeks to finish this.” It’s like, no, they actually don’t. They could renew these subsidies whenever they wanted. It would make a huge mess. It’s already going to make a huge mess because we’re past the December 15th deadline to sign up for January coverage. But I’ve seen Congress do messier things before they could decide in March that they want to put these subsidies back and force all of the exchanges, and the insurance companies, and consumers to go back and recalibrate everything. In fact, I wouldn’t be shocked if they don’t do it not in the next few weeks but perhaps sometime between now and the spring.

Howard Forman: So just last follow-up on that, you think the politics are leaning in its favor right now after the break? That people are becoming much more acutely aware of what this has meant?

Julie Rovner: I do. It’s funny, I expected that when they came back, this would be sort of top of mind, and obviously, other things have interfered. Cough, Venezuela, cough. So, it’s not quite as prominent in the news as it could have been. But do I think this is absolutely going to happen? No. But I still would give it sort of 60/40 odds that something does happen between now and the middle of the year on continuing these ACA subsidies.

Harlan Krumholz: I thought it was interesting. In the last few days, we’ve seen Republicans struggle to find a unified message on healthcare, which tells me this is going to be harder than maybe anybody thinks, especially after President Trump suggested flexibility on abortion funding tied to extending ACA subsidies. And I just think as you’re getting a feel on the Hill for what’s going on within the Republican Party, what do you see as the real pressure points? Because I thought this issue about abortion for them would be a red line, but maybe it’s not. And I don’t know.

I mean, are you hearing anything about what you think is going to happen? Because as you said, Trump’s showing some flexibility, but that’s not going to be true. And you’ve got the narrowest of majorities on the Republican side. Maybe it is going to be, I guess, Democrats or Republicans coming together who want to see the subsidies pass.

Julie Rovner: Well, I should point out, and I’m going to stop and try to explain this on our podcast this week that abortion funding is already banned in the Affordable Care Act. This Hyde fight is a fight over extending abortion funding bans beyond what they already are, and they are already quite severe in federal funding. So, that’s one thing. It’s not a matter of “this would somehow loosen abortion restrictions.” It would not. And the abortion restrictions on, even in the Affordable Care Act, which of course almost killed it before it passed, those abortion restrictions are there and they’re real. What the Republicans want is to make them even more stringent, about people using their own money, basically, to pay for abortion coverage. So, that’s one piece of this. Which is why when Trump says that you have to compromise, he’s not saying rolling back any restrictions. He’s just saying not adding to the restriction. Sorry, that’s one of the things that just makes me crazy in this whole debate.

But I agree with you that abortion has been a red line in this whole thing. I think Trump saying that Republicans might have to compromise on it was just Trump’s way of saying, “Hey, you guys got to do something about these subsidies expiring because it’s going to hurt us politically.” And that’s effectively what he said.

Harlan Krumholz: But the only thing that I... It’s hard for me to see how you walk this, because if they allow the subsidies to be extended after they put the nation through the shutdown because they wouldn’t do it, it does seem to me like they’re going to stretch to find a narrative that makes sense other than they should have just done it in the first place.

Julie Rovner: Well, their narrative doesn’t make sense right now. The narrative of, “Let’s give everybody $1,000 in an HSA,” instead of so they can pay their $30,000 in ACA premiums doesn’t really work very well either. I think the biggest pressure point for the Republicans is that they’ve, for 15 years, have been saying the Affordable Care Act is terrible and a failure. I think that’s a bigger hindrance to many of them voting to continue these subsidies. On the other hand, I’m reading about some of the details that this bipartisan group and the Senate is working on. And they are things that the Democrats could... I won’t say swallow. I mean, just accept. It’s like, “Okay, let’s not have zero premium plans that make it possible for fraud. Let’s have $5 a month plans.” “Let’s not say that the subsidies are unlimited, there’s no cap. Let’s make it 700% of poverty,” which will still hurt some people who live in very expensive areas. Seven hundred percent of poverty is a good chunk of money, but some of these premiums, as we’re seeing, can be $5,000 a month.

I mean, there’s already a cap. There’s already an effective cap on the subsidies because it has to be a certain percent of your income. So when you get to the point where the premiums are less than 8.5% of your income, then you don’t get a subsidy anymore already. But there are a lot of ways where they could make those, what would turn out to be fairly minimal structural changes. And the Democrats, I think, would be happy to take them. So I think there’s still a possibility for that, but I do think that a lot of the ideological opposition to the Affordable Care Act is pretty strong.

Of course, the other way that the narrative doesn’t work for Republicans is they keep saying, “Let’s not subsidize insurance companies.” It’s like, that’s what you’ve been screaming about for Medicare for the last 25 years. It’s been the Republicans who’ve been subsidizing the insurance companies for the last 50 years. It’s like, when did that change?

Howard Forman: Right. It’s the most lucrative segment, yeah. One of your colleagues... I think it’s one of your colleagues who wrote an article recently about the lack of transparency or communications coming out of Medicare. And I imagine that that is a more widespread problem right now with the administration, and it comes and goes in waves.

I’m just wondering, as a journalist and as someone who’s worked in multiple administrations, how is communication occurring between the agencies, and journalists, and others? And are there things that could be done better even under this administration?

Julie Rovner: And I’ve said this many times because I started when Ronald Reagan was president. So, I’ve been through Democrats and Republicans. And one thing I can say is that it’s been harder and harder to communicate with federal officials in each subsequent administration. The Democrats cracked down as much as the Republicans in many ways. In fact, I think I can say that the most open administration I dealt with was the George W. Bush administration in terms of being able to actually talk to people in the federal government. I think they had the best organized communications staff at the... It depends. It’s the career people versus the political people versus the White House people. And basically, the instinct is always to keep those channels as narrow as possible. So this administration isn’t that much, frankly, worse than the Biden administration, which wasn’t that much worse than the previous Trump administration, which wasn’t that much worse than the Obama administration before that.

So, it has been increasingly difficult as a journalist to get particularly substantive information from the administration. And I don’t think that’s good for the country, particularly places like CDC, which has always been a black hole since the 1980s, the CDC communication staff. For some reason, the staff whose job it is to tell the public about public health has been the least accessible to journalists. The Medicare and Medicaid officials used to be much better. Again, it’s not been so much a partisan thing. It’s just first, you see the top people at HHS cracking down, and then you see the White House people cracking down on the people at HHS, and it just gets harder and harder and harder to get information out of the government.

Harlan Krumholz: I wanted to ask you just a little bit about Medicaid. To me, this is a really big story, but it doesn’t feel like it hits the headlines. And I think in part, I’m talking about the changes that were included in the Big Beautiful Bill. And I get it. It’s down the line. It’s not today. It’s coming. But it seems to me like it doesn’t get the coverage and attention that it really deserves, considering what they did to Medicaid. But I don’t know, do you have a view on this?

Julie Rovner: I’m kind of smiling because I think over the summer, when it was getting all the attention, we had a lot of people saying, “Hey, how come the expiring ACA subsidies aren’t getting more attention? We’re paying all this attention to Medicaid.” So, I think it’s like, short attention span.

Harlan Krumholz: Yeah. I guess, with too many stories out there. But...

Julie Rovner: There are. But I do think—

Harlan Krumholz: This is a huge deal. I mean, it’s going to be huge deal to the states.

Julie Rovner: It is a huge deal, and it is not. The Republicans wrote that bill so that most of the things would hit after the midterms, but we’re seeing a lot of things that are already hitting. We at KFF Health News have a lot of people in a lot of states, which is great because we get early warning systems from “the great out there,” if you will. And we’re seeing cutbacks in the great out there already, particularly in rural areas, with clinics closing, and practices closing, and hospitals cutting back, and state.... States are cutting back in advance because they have to make budgets balanced this year, and they know that the money is going to stop. So, they’re already making cuts.

I think this is, particularly combined with the ACA subsidies, I think there’s going to be a big blow-up in the not-too-distant future. And by “not-too-distant future,” I mean before the midterms.

Harlan Krumholz: I mean, it does seem like a precarious time with regard to coverage. I mean, you’ve seen a lot over the years. But this retrenchment in coverage is real, and the stories are really connected. I mean, the ACC subsidies are putting people in a position where there’s going to be more uninsured because they’re not going to be able to afford it. And then Medicaid cuts are going to take a lot of people off the rolls that are being supported now. The states are going to suffer from... because somebody’s going to have to pay for the care, and so there’s going to be a lot of bills unpaid. The hospitals are going to suffer. The states are going to not be able to care for the people that they’re responsible for. I don’t know.

I mean, as you’ve seen this historically, do you see this as a major moment?

Julie Rovner: I do. And I think it’s not only is it going to be a major moment, I think it’s going to bring us back to a real serious debate about the future of our healthcare system. The last time we had this serious debate was in the run-up to the Affordable Care Act in 2007 and 2008, when we had mostly the problem of the uninsured and, secondarily, the problem of cost. But now, I think it’s not just the problem of what’s going to be a new problem of the uninsured and a continuing problem of cost, but also a dysfunction in the entire healthcare system that makes everybody angry.

I broke my wrist this year. I’ve...

Howard Forman: No.

Julie Rovner: How you were just asking, “How’s your wrist?” My wrist is all better, but I still have a stack of bills on my desk that I’m trying to work my way through. And I do this for a living, and I can’t figure out what I owe to who. It’s really infuriating. And I think people can’t get care, you can’t get an appointment. People who are well-insured are having trouble navigating the system. I think everybody is unhappy with the system as it is, and don’t think that’s a good thing. I think that’s a terrible thing. But I think the only bright spot is that, I think, it’s going to force this to the top of the policy agenda.

Howard Forman: So I want to follow up with that. You have an amazing podcast. I don’t think we’re promoting it enough right now. And when you listen to it, it’s nonjudgmental. You’re great at listening to people. You feature different speakers. And most recently, you had Avik Roy, who is a policy figure from the Republican side, and he’s had very strong opinions about the direction of healthcare. There are areas where Republicans and Democrats do probably get to compromise.

Are there some ideas that you’ve heard? I’m not asking whether you personally support them, but are there ideas that you’ve heard where you’re like, “Oh my God, they’re so close,” that you think should be talked about more?

Julie Rovner: There are a lot of thing—you know, what we’ve seen, I think, the last 5 or 6 years and we have seen a lot of bipartisan agreement on a lot of things in healthcare, particularly on things like drug costs and surprise bills, which is important and good and helpful for consumers, but it’s nibbling around the edges. And I think we might be getting to a point where the entire healthcare infrastructure is starting to crumble. And while it would be great to have a bill that gives more transparency to pharmacy benefit managers, that is not going to fix our system at this point. Our system has much deeper problems than that, even though many of these bipartisan things would be beneficial for all concerned. Beneficial politically, beneficial for the system, beneficial for providers, and in some cases, beneficial for consumers.

I’m not saying they wouldn’t be good. What we don’t see is a big bipartisan agreement on what the system should look like. There’s still this enormous division of how much... well, it used to be how much should be government, how much should be private. Now I think it should be, how much should be government and how much should be individual. I mean, where we’ve moved even beyond... Republicans are moving beyond private because private used to be, “We’ll let the insurance industry and the health industry hammer it out.” And now they’re into, “We’ll let consumers negotiate on their own.” Good luck with that.

Howard Forman: Right.

Harlan Krumholz: I do love this idea, and this is the only optimism I can bring forth, is that we actually need this big crisis in order to hit a point where we’re going to have to have transformative change. And it may be that that’s what’s necessary. You get to hear a lot of ideas from a lot of people. You’re on your podcast, you’re hitting around. One of the biggest issues in the U.S. remains cost. I mean, let alone coverage, everything else. We’re a far outlier, and yet we don’t get the return on that spend when you look at all the other countries.

What are some of the best ideas you’ve heard that we should be doing to control costs? What are the best ideas you’ve heard?

Julie Rovner: That’s what I’m waiting for, are some of the new ideas. Although one of the things I keep yelling as I drive around and listen to Republicans talking about how we should have more transparency, it’s like, transparency and price is good, but that’s not going to bring down the prices. And why do these other countries have more affordable healthcare? Because every other country regulates the price of healthcare, and we don’t. I have no idea what the best way to do that is, but I know that we don’t. And that’s why we pay so much more and that’s why they pay so much less. I know that much.

Howard Forman: I want to ask. This has bothered me for decades. We talk about subsidizing Medicare and Medicaid, and we talk about the ACA subsidies, and yet the biggest subsidy is the insurance that Harlan and I get from our employer—

Julie Rovner: And me.

Howard Forman: And you. It is in a larger magnitude than we’re talking about for the ACA subsidies, but we never... It doesn’t get the coverage. I know you know it, I know you’ve written about it, others have written about it, but the public doesn’t get it. The public is like, “Why should we be giving them a subsidy?” I’m like, “I don’t know, why do we give you a subsidy?” They don’t get it.

Is there something we can do to get the public to understand this better? It’s hundreds of billions of dollars a year.

Julie Rovner: It’s not bigger than Medicare, I should say that.

Howard Forman: No, that’s right.

Julie Rovner: It’s the biggest tax subsidy.

Howard Forman: That’s right.

Julie Rovner: But actually, I think Jeanne Lambrew, who helped implement the Affordable Care Act under President Obama, has been putting it very well, and I’ve been just sort of parroting her. The ACA subsidies were, basically, subsidizing the last group of Americans who were not already getting subsidized healthcare.

Howard Forman: That’s what I say, right.

Julie Rovner: We subsidized the seniors with Medicare; we subsidized the poor with Medicaid. We subsidize people who have job-based insurance in two ways: by making it tax-deductible for the employer and by making the value of the insurance not taxable for the individual who’s getting that insurance. Only the people who were buying their own insurance, because they don’t have employer insurance, they’re not on Medicare, they’re not on Medicaid, those were the only people who weren’t getting a subsidy, and now they are. See? I just did that in 60 seconds!

Howard Forman: Right. But the public does not get that.

Harlan Krumholz: I love that. That was so good.

That was so good.

Julie Rovner: It’s okay. We could just keep saying it in 60 seconds.

Howard Forman: Oh, we got to. We got to make TikToks out of that.

Harlan Krumholz: So as we get to the end, I’ll just—

Julie Rovner: I’ll explain it to my dog. I make TikToks where I explain health policy to my dog. That will be the next one.

Harlan Krumholz: I want to hear, as we’re getting to the end, your prediction. What do you think is going to happen in the next several months here with regard to healthcare? Because there’s going to be something, there’s going to be some action. But what’s your prediction?

Julie Rovner: I think we’re going to have a really big fight.

Harlan Krumholz: Okay, that’s a good... that’s an easy prediction.

Julie Rovner: Yeah, that’s easy. I know it’s not always an easy prediction because sometimes, you think that things are going to rise to the top of the agenda that don’t. So depending on whatever else goes on, I do think that this is going to be fairly top of mind for lawmakers and for the administration in the coming months. As I said earlier, I think there’s a better chance than not that something happens, but I don’t think it’s like 90/10. As I said, I think it’s like 60/40. I think that makes me more optimistic about something happening than most other political reporters. I may be wrong. I’m not...

My predictions don’t always come true. But I do think that we are, and I’m planning my year as if we are headed towards a more major debate over healthcare writ large than we’ve had in some years. That’s as far out on the limb as I care to go.

Howard Forman: And we could have some big action maybe in a lame-duck Congress, also, if we—

Harlan Krumholz: I will say a split Congress where Johnson has almost no margin could be the conditions for something coming together that’s quite novel because of the groups that it brings together. I mean, I think it could be not straight along party lines. They’ve been voting along party lines for so long, but they’re so close now that there could be things that are picked up.

Julie Rovner: If this were 20 years ago, I think I would think that, but I feel like the Democrats have moved fairly far to the left, and the Republicans have moved fairly far to the right. During the Clinton health reform debate, there was a bipartisan group of 20 senators who sat in John Chafee’s office, his little hideaway off the rotunda of the Capitol, every day for a month. And everybody was standing in that un-air-conditioned hallway in July, being miserable. And I kept stomping around and saying, “It doesn’t matter if these 20 people get a deal or not, there’s no 21st vote.” And I was absolutely right. The 20 people got a deal and there was no 21st vote. I’m not sure there are even 20 people now. I know there’s a group of 7 or 8 who are working on what could be a compromise, but I do worry about the people at the far ends of both polls. I do feel that Congress is much more polarized than it’s been at any time in the 40 years that I’ve been covering it.

Harlan Krumholz: Yeah.

Howard Forman: Before we go, I just wanted to say that I’m a pretty unidimensional person. Health and healthcare is just all I do. You, on the other hand, have a life outside of healthcare and I love following it, because you’ve got your corgis and you compete with them; you’ve got a horse as far as I know.

Julie Rovner: I do.

Howard Forman: And you are an avid University of Michigan fan, and never ashamed of that.

Julie Rovner: Nope.

Howard Forman: How do you do all of those things? And how does the horse work with the dogs?

Harlan Krumholz: Well, I want to hear what she thinks about what’s going on at the University of Michigan.

Julie Rovner: Oh, it’s a mess. Although, hey, our quarterback and our number one wide receiver are coming back, so it’ll all be good. And our basketball team is the best in the nation! (Even though we’re still right at number two.) It’s fun. As I say, I do videos with the dog because I spend a lot of time in the car because of the horse and the dogs. So, I listen to a lot of health policy. I listen to podcasts. I listen to the news. And I yell at people who I think are wrong, which was the origin of the videos with the dog. I said, my dogs know more about health policy than most graduate students because I teach them as I drive. So, I started doing the videos where I explain health policy to my younger corgi, though the older one doesn’t need to have it explained to him. He knows it all.

Howard Forman: Well, we are really lucky to have you here. And by the way, you’ve come to Yale before. You helped us during the pandemic as well. You’re a great friend to so many people. And it’s just such an honor to have you on the podcast today.

Julie Rovner: Always a pleasure. Thank you so much.

Harlan Krumholz: Nice to see you.

Howard Forman: Oh, she’s so good. I love listening to her.

Harlan Krumholz: Yeah, she’s great. And gives really the long view, but so much energy and so articulate about what’s going on in healthcare. It’s great.

Howard Forman: She’s wonderful.

Harlan Krumholz: All right. So, what’s on your mind this week?

Howard Forman: So I want to get back to flu, because as we mentioned a few weeks ago, we are experiencing an extraordinary influenza A outbreak with faster spread, higher numbers, and unclear virulence at the moment. And particularly bad in Connecticut. The CDC reported this week the highest percent of outpatient visits presenting for flu-like illnesses. Highest on record. It’s not a long record, but the highest they’ve ever measured. And every chart I have seen shows us that we are in this unusual space. And I just finished three weeks working in the emergency room, emergency department at Yale, and the number of flu presentations in both adults and pediatric patients is a bit alarming. It may be that the season is just early and compressed, but I want to point out that there are a lot of pediatric deaths being reported right now, even with the CDC lagging in the numbers. The numbers are growing, and we’re seeing them in unusual places.

Also worth noting that Connecticut is already at a higher level of case presentations than last year’s peak, and we’re five years earlier than last year’s peak. We also have 50% more hospitalizations now than at the same time last year. Now, if flu season is following the usual time curve, we are still not at the midway point, and I would still urge everyone to go get vaccinated if you haven’t been already.

Harlan Krumholz: So Howie, there’s so much to talk about flu, but there are many people out there hearing about these surges. You’ve been in the emergency department, you just said. For people listening, what does this flu surge do to their ability to care for everyone else? Because I’ve been hearing people saying, “I don’t want to go to the emergency room because there’s so much flu there,” but there are people who actually need to go. Is this sort of a replay from the pandemic? When people who really have conditions that need attention are afraid to go to the emergency department because they’re afraid they’re going to catch flu?

Howard Forman: Yeah. And we have a massive boarding problem right now. The hospital is overcrowded to a degree that is unusual for us, even though we’re always crowded, but even more so right now. And it’s hard to know. Look, I’m so sympathetic to patients when I look in the chart. And we have such exposure to the medical record now, it’s unusual. I saw one woman come in this week diagnosed with influenza A on either Christmas Eve or Christmas Day, and then COVID on New Year’s Eve or New Year’s Day. I’m thinking like, “That’s brutal.” And when you live in small quarters over the holidays, people are just spreading disease. So, I think we’re going to continue seeing this. And I do think patients should remember that there are antivirals. If you’re a high-risk patient, there are antivirals. So if you do have an illness with a fever and you’re at risk, you should get tested. You should go seek some type of care, outpatient or inpatient care. And you should also still, again, get vaccinated, because even if the vaccine is not highly, highly effective, it’s still effective.

Harlan Krumholz: But what are you telling people who don’t have flu? I’m just saying, someone’s got worsening heart failure.

Howard Forman: Oh, I see what you mean. Oh.

Harlan Krumholz: But what’s going on in the emergency department? Are you saying, “Well, you need to steer clear of this place.”

Howard Forman: No, I know what you’re saying. I think the emergency room is not where the spread is going to occur. I mean, my own little controlled experiment that I see is I’m not seeing spread among the doctors. I’m not seeing the massive spread you would expect since they’re taking care of these patients. Not like early COVID, for instance. And I think people do not need to be afraid of hospitals. I think they need to take precautions.

Harlan Krumholz: All right. So, what else? How about measles?

Howard Forman: Yeah. So, the measles outbreak in the United States remains fairly high. And for 2025, we did surpass 1992 levels, which surprised me. Because early in the year, I said I thought it would be hard to get there. We have 2144 cases, and still counting. We’re seeing roughly 60 new cases per week right now versus about a hundred at the peak during the Texas outbreak earlier last year. Two states continue to have substantial outbreaks, South Carolina and Arizona. And South Carolina has recently passed Arizona to be the second-largest outbreak state of this cycle. Texas remains number one. And while we often think red versus blue when it comes to vaccination rates, two of the highest vaccinated states are Mississippi and West Virginia, and they have zero cases right now. What might explain their vaccination and measles avoidance successes? Until very recently, both had some of the strictest vaccine mandates to attend public schools.

Mississippi just recently changed their mandate to allow for religious exemptions with some caveats, and their overall vaccination rate has fallen from best in the country to number three, but it’s still quite good. The percent of folks with exemptions is 0.7% in Mississippi, and it’s less than 0.1% in West Virginia. Now, contrast that to our outbreak states: Texas with 3.9%, Arizona with 8.5%, South Carolina with 4.4%, and Utah with a whopping 9.3% exemption rate. If I had to guess about which states are most vulnerable to an imminent outbreak, it would be North Carolina, Georgia, and Florida due to the proximity to the South Carolina outbreak. North Carolina has 2.9% exemptions and 93.8% vaccination rate. They’re probably better protected. Georgia with 3.6% exemptions and 88.4% vaccinated, and Florida with 4.8% exemptions and 88.1% vaccinations are ripe for spread if cases get into populated areas.

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

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

Harlan Krumholz: And we love your feedback. Email us, post comments. It helps people find us. We always enjoy that.

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

Harlan Krumholz: And we’re excited to come into 2026 with a spectacular team. So we’re really blessed to have superstar undergraduates, Gloria Beck, Tobias Liu, a marvelous producer, Miranda Shafer. And I still get to work with the best in the business.

Howard Forman: I appreciate you all. And I want to wish you, Harlan, and everybody, a happy new year.

Harlan Krumholz: Happy New Year. Happy New Year. See you next week. Talk to you soon, Howie.

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