Mary-Ann Etiebet: Confronting Preventable Disease

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 Dr. Mary-Ann Etiebet. But first, we like to check in on current or hot topics in health and healthcare. Start us off, Harlan.

Harlan Krumholz: Yeah, thanks, Howie. And today I want to talk about something I think people may not have noticed, but I think it’s going to be very important. You and I have often talked about whether doctors are in a position where they could ever be replaced. And we’ve talked about this in radiology, but we’ve also talked about cardiology, or any place with the advent of AI. And you and I, we sometimes are talking about the AI as tools or better image interpretation, as adjuncts to our practice, smarter risk prediction, workflow support—all that is real. And it’s already starting to change practice. We’re at the very beginning, but something very different is also happening. And there was an announcement at J.P. Morgan in San Francisco two weeks ago, and a kickoff meeting yesterday by the U.S. government. The U.S. government. It’s through this ARPA arm is funding the development of autonomous clinical care. Not AI that helps clinicians, but systems that can observe patients over time, reason with data, make decisions, and act. And the place where this is starting is heart failure, the care of patients with heart failure.

This program’s called ADVOCATE. As I said, it’s run by ARPA-H. That’s the Advanced Research Projects Agency for Health. For a long time, the government’s had an agency called DARPA—

Howard Forman: Right.

Harlan Krumholz: ...which is very close to Department of Defense, to do targeted moon shots, to try to help it create transformative advances. And that’s been very successful. In fact, out of DARPA came the internet, honestly. And so, this is intentional. They wanted to mirror what was going on in DARPA and take on big high-risk problems that conventional funding mechanisms can’t address. This would never come from NIH. And they’re talking about throwing 50 or 100 or more millions of dollars into a big project where they expect big gains.

And this, in particular, is not a grant to build another app or decision support tool. The explicit goal is to create a pathway for autonomous cardiovascular care that’s safe, regulated, and scalable. From the beginning, it’s being developed in coordination with regulators and payers, including FDA and CMS. In other words, it’s not just asking whether something can be built, but it’s building the infrastructure, the scaffolding, so it can be evaluated, authorized, trusted, and paid for. Now, heart failure is a good place to look because—not that we lack effective treatments. We have a lot. But it’s a clearest example where there’s a disconnect between what we could do and what’s really happening. Many people don’t receive the guideline-directed therapy. Doses aren’t started, or they’re not titrated or sustained. Diagnoses are delayed or not made. And so, this is a place where AI could do a lot of good.

And the workforce is under strain. We don’t have enough heart failure specialists in the country. And in fact, there’s a certain number of spots for training, those weren’t even filled last year—

Howard Forman: That’s crazy.

Harlan Krumholz: ...maybe at only 50%. The promise of autonomous care is, at least in theory, is not that machines are smarter than clinicians, but they could be more consistent. They could apply the evidence more reliably, and they’re going to fill in this gap.

And just finally, it’s like this analogy to autonomous driving. I think if you would have asked me 10 years, I would have said “It’s impossible.” Not just because the technical engineering challenges, but culturally, who’s going to get in a car without a driver? Who’s going to trust that they can do that? And then you go to San Francisco or L.A. or any number of other cities today and you see these Waymos, and they’re mind-blowing. And you realize that what you couldn’t have envisioned before is actually already happening.

In healthcare, what they’re building, the government funding, the link with FDA and CMS, you’re seeing the beginning of a blessing of something that we might have thought was science fiction, but that people are starting to envision and build the means by which it could become real. And this was just staggering—this meeting, the presentations, the idea that this is getting started, funded, and that there’s a lot of excitement about it. It’s something we ought to keep our eyes on.

Howard Forman: What are the incentives that they’re offering? Is this startup grants? Is this tax credits? Do you know specifically how this works?

Harlan Krumholz: Well, Howie, the way it works is, there are actually three tiers to this. One is the actual autonomous system itself. One is, they’re going to fund a surveillance layer, an evaluative layer, an AI system that can determine how it performed but also how heart failure care is being performed. And then there’s another grouping of funding for health systems to develop them as laboratories for testing this product. And what they’re going to do is take essentially solution applications. You know, just give a pitch for what you’re doing, it’s about six or eight pages, and there’s a whole lot of details around it. And a whole bunch of people will put these in. They’ll pick a bunch of them. Not many—some. And then those will start on the journey. And then, ultimately, it’ll be one of them will emerge as the lead and they’ll continue to invest. And they want to move fast.

This is a thing, Howie, where one group, which by the way, it could be companies, could be universities, anybody can apply. These will be contracts that the government will have. And I think what I think is the most transformative, revolutionary thing about is not that there will be one that will get funding, because it could be a company that.... It could be Google or Microsoft. It could be a company who’s already got tons of money, but they’re providing a glide path. And other people who may not be selected or may not have even applied will be able to use this pathway. They’re plowing the field. You’re going to be able to follow on whatever they’re doing so that FDA will have a mechanism for people to apply for approval if they’ve got such a product. CMS will have a mechanism. There will be precedent set.

And I think all of this makes this very interesting, very important to watch. And very different than anything we’ve seen before.

Howard Forman: Well, next week we have our very special episode with Dr. Robert Wachter dropping. And after reading his book, I am incredibly optimistic about this.

Harlan Krumholz: His book on AI and healthcare. His book on AI and healthcare.

Howard Forman: That’s right. Everybody should look for that episode as well, because that’s coming out just in six days.

Harlan Krumholz: Great. Let’s get onto our guest, Howie. This should be very interesting.

Howard Forman: Yep. Looking forward to it. Dr. Mary-Ann Etiebet is the president and CEO of Vital Strategies, a global public health organization. She previously served as the lead and executive director of Merck for Mothers, as well as Merck’s Associate Vice President for Health Equity. She began her career leading the University of Maryland School of Medicine’s HIV/AIDS programs in Nigeria. She later served as a director of ambulatory care strategies at New York City Health and Hospitals, driving efforts to improve health outcomes for underserved communities. She remains a strong advocate for women’s health and health equity domestically and globally. She received her bachelor’s degree, medical degree, and MBA from Yale University, and she completed her medical training at New York Presbyterian Hospital System and is board-certified in internal medicine and infectious diseases. And I want to point out that you... Not only are you—

Harlan Krumholz: Howie, she’s a superstar, I just wanted to let you know.

Howard Forman: She’s a superstar. But I want to point out—

Harlan Krumholz: Not clear.

Howard Forman: Not only a superstar, but she was our seventh guest on the podcast. Our seventh episode of the podcast.

Harlan Krumholz: She basically launched us. She basically did.

Mary-Ann Etiebet: Well, you launched me, I have to say. And I’m so excited to be back talking with you, in communion with you. I think a lot of what I learned about being a physician, being a public health leader, I learned at Yale with mentors such as yourself. I’m just so excited to be back.

Howard Forman: Thank you. Thank you. And look, when we talked to you last time four years ago, more than four years ago, you were at Merck for Mothers and doing a lot of work to reduce maternal mortality. You’re still working broadly on those topics, but now you work for Vital Strategies. And up until last week and in preparation for this podcast, I’ll be honest, I did not know nearly enough about Vital Strategies other than that you work there. Can you start off by just telling us about the mission of Vital Strategies and how it’s different from so many other public health organizations, global public health organizations?

Mary-Ann Etiebet: Thank you so much for the question, Howie. I was so excited to get the opportunity to lead Vital Strategies. It’s been a year and a bit now. We focus on protecting the public through strong foundational public health systems, working in close partnership with governments around the world. And we do that because we want to tackle the world’s leading causes of death, disease, and disability. And as many of your audience will know, doing this work is not necessarily easy. It’s about playing the long game. We focus on prevention. We focus on policy change, because we believe that is the vehicle to having sustainable impact at scale as well as impact that is inclusive of everyone in the population. And we do that by really keeping our heads down and working hand in hand with our government and community partners. That may explain why you haven’t heard so much about us.

I think now when our field is under threat, we feel a responsibility to share more about our work and to demonstrate the impact it’s having on what I call the everyday lived experiences of people around the world.

Harlan Krumholz: And I’m so excited for the trajectory of your career. Because, first of all, you’re such a capable individual. You’ve taken on big problems. The issue of maternal mortality: big problem. This issue now, you’ve even gotten into a larger issue of noncommunicable diseases, and with a worldwide global view.

I hear you about playing the long game, but I’m also impatient. And I see us in many areas of noncommunicable disease, and particularly, I’ll just raise cardiovascular disease, losing ground. There were decades where we just expected year after year we would be making progress. And we’ve entered a phase, maybe the last 10 or 15 years, where that progress has not only slowed but has shown signs of reversal. Despite the fact that our science continues to march forward, we continue to celebrate large-scale trials and advances on the ground. On the ground, the lived experience of people around the world is actually not getting better.

What are you thinking about in terms of brash strategies? You guys are focused on execution; you’re also a catalyst. And what are you thinking we need to do to shake this up? Because so much of this suffering is preventable. So much of this can be actually turned back. It’s not like waiting for the next discovery, but it’s on the implementation side. What excites you the most about the possibilities?

Mary-Ann Etiebet: And Harlan, I’d like to answer your question in at least two parts, and distinguish what we’re experiencing here in high-income countries and what the global majority is experiencing in low- and middle-income countries. I think you are aware that noncommunicable diseases, the diabetes, the hypertension, cardiovascular disease, lung disease, cancer, these are taking up to 75% of lives around the world. Over 78% of those premature and preventable deaths from NCDs are happening in low- and middle-income countries, and only two to three percent of global health financing is going towards NCDs.

Howie, you asked the question, why Vital Strategies? I felt that it was about time, Harlan, as you said, that we need to put more attention on NCBs. How can the greatest killer of people around the world be receiving less than 5% of resources and efforts and commitment?

I actually feel more optimistic when we look at this issue globally. One of the things that’s happening now, as you know, is a tectonic plate shift in global health. And I think that has created an opportunity for national governments to help set the agenda and prioritize how they want to think about national health strategies. And because of that, NCDs are coming to the fore. Because they’re hearing from their constituents that this is what is killing their mothers and fathers and relatives prematurely in their 50s, in their 40s. And up until now, they haven’t really had the ability, or as much of the ability as they would want, to be able to target funding towards these efforts.

I do think that they’re opening now to really bring NCDs at the forefront of national health strategies and to direct funding towards that. And to do that in a way where we’ve learned from perhaps the, I don’t want to say mistakes but nearsightedness of the past. Where we have focused on vertical programming and implementation, it’s been rather top-down. And we haven’t focused enough on health system strengthening at the government and foundational level. Whether that’s investment in your primary healthcare system, in healthcare workers, in basic information and education and awareness about these diseases.

I think we forget how many people actually don’t know about these diseases, and that’s where we have to start. And that’s one of the places that Vital Strategies focuses a lot of work on, raising public awareness. Not just for individual behavior change and making sure that you are getting screened but also for policy change. What are the things that we can do to prevent risk factors for these diseases? Health taxes is one of the things that we’ve been working on this past year. We’re seizing the opportunity that the reduction in global health financing is creating, where we know that we need more domestic resources for health. We know that health taxes not only saves lives, and the estimates are 50 million lives over five years, but also creates huge amounts of resources, $3.4 trillion, again, over five years.

And we know that through secondary prevention we’re going to be reducing healthcare costs and burden to the health system, which I know is something that you’ve worked long and hard on. All in all, I think there’s an opportunity to be seized now, to put NCDs at the forefront, to do this in a way that is focused on prevention but is also helping to build a stronger health system.

Howard Forman: First of all, I want to make sure our listeners know that NCDs, noncommunicable diseases, and that we’re talking about many of the things you just mentioned: diabetes, hypertension, cardiovascular, and so on. You mentioned, you brought up the health taxes, and that’s where I wanted to go next. In the United States, if anything, it’s probably more difficult to impose health taxes because so much industry is based in the United States, and you’re basically threatening the sugar soda industry, the processed food industry, and so on. I’m wondering what it’s like in other countries when you go in there, because there is evidence, as you point out, even in America, in small cities in America about sugary soda taxes. And I tend to agree with you that the data is strong, that you can reduce the burden of disease and raise money at the same time, which seems pretty astonishing.

But I think in America it’s really difficult. I’m wondering how much success you’re having. And what are the strategies other than raising funds that you’ve used to convince governments to impose or consider imposing such taxes?

Mary-Ann Etiebet: Yeah, a great question. I would say, for example tobacco, one of the top three harmful commodities that we work on. There’s been such progress in the United States, and that’s something we look to and we point towards. It is difficult, and these are multinational companies and conglomerates. And the playbook that the tobacco industry used we are now seeing being used by the beverage industry and the food industry. But again, if you are engaging with the public, raising awareness with the public, sharing with them why this makes sense for their lives, we do get public support, over 60%, up to 75% in national polls that we’ve done in different countries around the world. The antidote to industry pushback is public support. And that’s one of the things that our strategic communications team works very strongly on, and we’re seeing it have impact.

Last year, exactly this time last year, Brazil passed groundbreaking legislation for all three harmful commodities: tobacco, alcohol, sugary beverages. We’ve also seen recent wins in Vietnam, as well as more recently in Bangladesh. And so, progress is possible. What we’re trying to do is link countries that are thinking about health taxes with countries that have advanced health taxes. Peer networks can learn from each other. We’re not duplicating or replicating work. But we can also drive more public support and civil society momentum around these issues.

Harlan Krumholz: For people listening, I want... sometimes people may be thinking... and this is kind of jargony, I think, for many people, this “NCDs,” but we really are talking about heart disease, diabetes, chronic lung disease. All of the things that are the result of industrialized society. The sedentary behavior, the habits and exposures we’ve developed over time that have led to preventable diseases becoming very much common. And listening to this, you might have the sense that there’s some competition between funds for fighting infectious causes versus not.

But one of the things that came up in the pandemic that was really interesting was that addressing these other issues, getting people in greater, for example, cardiometabolic health, actually helps them resist infectious disease. And so, these things all come together. And I think that a group like Mary-Ann’s leading is not just leading the charge like these are important, but these are intrinsic to health in general. Right? And just as people listen to it.

Mary-Ann Etiebet: Yeah. And at the end of the day, we not only want to improve health and save lives but also reduce the disparities and advance health equity. And as you mentioned, during COVID we just saw how important burden of disease for cardiometabolic health, as you mentioned, drove disparities that we were seeing in COVID deaths. I think the other thing that I continue to think about is how in the solutioning we are able to walk and chew gum at the same time. We’re building programs, we’re training teams, we’re building delivery systems that can address both the infectious disease and the noncommunicable disease, as well as mental health and all of the things that affect people’s lives.

I like to say, you don’t come to the clinic one day with your diabetes and the next day needing your vaccination, you come as a whole person with potentially a number of issues. Not just that one moment in time but over the course of a lifetime. And our health systems need to be able to engage with you as a whole person with holistic and comprehensive needs.

Harlan Krumholz: One quick question. As you are implementing these strategies, or as you have looked back on strategies, for example, strategies that were implemented in New York City with regard to taxes. And the work on trans fats and things like that, that Mayor Bloomberg, at that time Mayor Bloomberg was leading and implementing. What are you investing in the evaluation and the science to determine what exactly has been accomplished? And so that we can say “This makes sense, we think we should do it,” but whether you’re looking back on policies or as you go forward prospectively, are you also investing in the kind of science that can help advance us as we learn what works and what doesn’t?

Mary-Ann Etiebet: Yeah, great question. And we’re lucky to be part of a network of organizations and partners that are supported by Bloomberg Philanthropies and are advancing these transformational policies that we saw started in New York City by Mayor Bloomberg. And just so proud of that work and of the partnership. I think because we are part of a coalition and a network, we have partners like [Johns] Hopkins University School of Public Health, who are focused on the evaluation and research part of things. I think it allows us to lean into what we do best and really focus our efforts in that space. Which I would say is, again, supporting governments to be able to collect, analyze, and communicate the data that they see in their populations, translate that data into policy. And not just policy on a paper, but actual legislative regulatory change that makes a difference and then do the strat comms to make sure civil society and people are onboard.

However, that is not to say that we don’t hold the mirror up to ourselves to make sure that what we’re doing is actually making a difference and having impact. I think one of the things I’m excited to work with the team on is, how do we look at our impact as an organization as a whole? I think we’re very good at being able to talk about the impact for individual programs that we have and look back to see whether it’s not just about reach numbers, but as you know it’s, are we actually changing health outcomes? One of the ways that we’re doing that, and I go back to, how do we make sure whatever it is that we’re doing, we’re not just measuring to make ourselves feel good, we’re not just doing the monitoring and evaluation to prove to our funders that they have made the right investments, but we are measuring in a way that strengthens the ability of national governments to continue to monitor and assess progress and to hold global partners that are working in their country accountable?

One of the ways that we’re doing that, and I like to use the analogy of a plumber, the plumbing of data systems for public health, things as basic as making sure every birth is registered. Howie, you talked about maternal mortality, we can come back to that. But also, every death is registered, and we have a cause of death. And we’re not looking at population health data from a sampling or estimate—

Harlan Krumholz: My gosh, this is such an important point you’re making. I was shocked when I discovered on some of my... when I was in Vietnam, I was talking with officials there, they actually don’t know exactly how many people are born. It’s all estimates. And the deaths, similarly.

Mary-Ann Etiebet: Less than 10% of the deaths are registered. And also—

Harlan Krumholz: It amazed me. I had no idea.

Mary-Ann Etiebet: We have no idea. And that’s also partly, I believe, drives the fact that we have less financing here because the data isn’t there. On the African continent, less than four out of 10 children are registered. It’s all estimates and models. And you know, depending on which survey you’re looking at or which organization is doing the modeling, they may not add up. I think sometimes in our community we spend more time discussing whose numbers are the right numbers. But as I said, we need to go back to basics and make sure that every life is counted.

Harlan Krumholz: Is accounted for.

Mary-Ann Etiebet: Yeah. Is accounted for. Every life is accounted for, and we’re connecting each and every one of those lives to a lifetime of rights, benefits, and services. Because if you are not registering somebody, they’re not in the system, how do you know when they’re missing out on vaccinations? How do you know when they’re not registered for school? How do you know when, as you said, they may be sick or die? And how do we know what they’re dying of? That’s the basic stuff our teams are doing every day in over 25 countries around the world. And there’s also exciting things at play. How can we use artificial intelligence to help us better determine cause of death? Verbal autopsies, as you may know, are pretty extensive processes. Most of these deaths are happening in communities, not in facilities, and so we need to be able to also capture that information.

Howard Forman: One of the challenges... we think about politics in our country, but politics throughout the world can be very challenging and difficult. You’re working in parts of the world that are dangerous. You’re working in parts of the world that are undergoing upheaval. Number one, how do you pick the countries that you work within? And number two, how do you protect yourselves and make sure that both your people and the people on the ground who you’re working with are kept safe during things that sometimes can become provocative for individuals?

Mary-Ann Etiebet: Yeah. We have a duty of care as an organization, which I and the rest of the leadership team take very seriously, to make sure that everybody that works for us, with us, is safe and protected. We are constantly assessing risk. But at the end of the day, we’re not deciding where we work. Because part of it is we want to be invited, we want to co-create this work, we want to be able to best match what we can bring to the table with what the prioritized needs are. But part of what we look at is, where can we have most impact? Where will our potential solutions actually have the ability to make a difference? There is a calculation around impact that’s important, but I think equally important is making sure that there’s a match around what governments are seeing as prior priorities and where we may be able to support.

I think the other thing folks should know about us is, and sometimes we use this term “policies to practices to people,” making sure that whatever it is we’re doing, we are supporting the building of institutional capacity and capabilities. Because at the end of the day, and I think, Howie, you’ve heard me say this, when we leave—and we have to leave, we must leave, we should leave—the work that we started or helped start, the impact that we helped affect has to continue. And the only way that is possible is making sure that you are building capacity as you go along.

Harlan Krumholz: This is such a great conversation, and I’ve grown in my admiration of what you’re trying to accomplish because it’s such a big issue and it’s so important. I wanted to just, as we get to the end... a lot of people have been hearing about how the United States is withdrawing from WHO, and certainly a lot of funding. And rather than debate it, which I’m not sure there’s much to debate, but what do you think will be the consequence of it? Where do you see WHO? And as I see it, it could be that depending on the administration, depending on... we’re now in an era where they can’t reliably depend on that funding, that may come and go. And there may be another administration that leans in. But because of what we’ve seen, what’s happening now, there could be another administration after that that pulls out.

How does an organization like WHO, which does such important work, manage in a worldwide environment where there’s uncoupling and there’s fragmentation? And what do you see for that with regard to the path forward for the kind of work that they’re doing?

Mary-Ann Etiebet: The first thing is, it’s devastating, and we need to acknowledge that. And we need to acknowledge the impact it has downstream on people’s health and people’s lives. I will say that WHO and other international bodies, whether UN bodies or whether some of the multilateral organizations that also have relied on U.S. government funding, are also reeling. It’s not just the WHO, this is having domino effect across the global health landscape—

Harlan Krumholz: In addition to USAID, in addition to that.

Mary-Ann Etiebet: In addition to USAID. In addition to CDC. We often forget how active CDC is globally, and that continues to be a huge loss. The other ripple effect is, we are seeing reductions in foreign aid development assistance from the European countries because they are having to backfill or backstop humanitarian and security funding. What we are seeing rising to help fill this gap is more financing from the multilateral regional banks, as well as some more private investment and philanthropy. But philanthropy cannot close this gap. And we are seeing, as I said, a restructuring, reimagining of how global financing architecture should look. I think the longer answer to that is, people are really thinking through what didn’t work about the previous architecture that has created these catastrophic gaps and how other countries also need to step up, including lower-middle-income countries and thinking about what domestic resources that they can apply to health.

I am worried that with the focus on private sector investment we may lose some of the guardrails and principles around, how do we make sure that these investments are driving the public’s health? And when we think about the public, we’re thinking about that in a very inclusive and equitable way. That is something I worry about. I also worry about the focus of investments on what I would say, solutions that may require the underlying strength of health delivery systems that just can’t support them. So we may be actually wasting resources by investing in... I don’t use the word “fancy gadgets,” but are not fit for purpose, and without the underlying systems, will not be able to be maintained over time. Organizations like WHO, like Vital Strategies are so important to continue to put the spotlight on why it is so important to invest in public health. Whether you’re coming with private money or multilateral financing, without investments and foundational systems, everything else will likely fail over the long term, as well as likely exacerbate in equities as opposed to closing those gaps.

Howard Forman: We are so lucky to have you fighting the good fight and really leading the organization. You’re a three-time Yale grad. Yale is proud of you. We are proud of you. And thank you for doing this. We hope we get you back here in less than four years.

Mary-Ann Etiebet: Anytime. Anytime. Anytime.

Harlan Krumholz: Good to see you. Good to talk to you.

Mary-Ann Etiebet: Thank you. Thank you.

Howard Forman: Thank you.

Mary-Ann Etiebet: Thank you for the questions, and we will continue to fight the good fight.

Harlan Krumholz: All right. Well, that was a terrific interview. Somebody who I think we can feel very good about. Has been at Yale, you had an important influence on.

Howard Forman: She’s been great.

Harlan Krumholz: Anyway, she was terrific. But hey, let’s get to your section this week, Howie. What’s on your mind?

Howard Forman: There is a lot of news out there, and we could talk about anything, almost. But next week we don’t have a guest, and so you and I are going to catch up on a lot. Today I thought I would talk about something really timely and topical, and that is the administration’s Medicare payment update for Medicare Advantage plans in 2027. Now, that’s 11 months away, for those keeping track at home. But such is the cycle of planning that Medicare makes this announcement now, finalizes it in three months, and then we begin the next cycle again.

And as I’ve mentioned on numerous occasions, Medicare Advantage has been an enormously profitable space for health plans, at least since 2003 when the Medicare Modernization Act established Medicare Advantage as a replacement to Medicare Plus choice. These plans are chosen by Medicare beneficiaries as an alternative to what we call fee-for-service Medicare, old Medicare, standard Medicare, government-run Medicare. And these often provide lower cost sharing, lower premiums, and/or more benefits than fee-for-service offerings. The intuition is that beneficiaries will accept tighter control over the choice of physicians, choice of hospitals, and choice of approved services in exchange for the extra benefits that they get.

There are many, many happy Medicare beneficiaries in these plans. There are also many who are deeply frustrated. But over the years, the one group that really could not complain were the plans themselves. The two companies most exposed to Medicare Advantage are Humana and United Healthcare Group. Humana shareholders had a more than 2500% return on investment if they invested in 2003 and sold at the peak in 2022. And United Health Group may not have done nearly as well, but 2300% over a slightly longer window is not too shabby. Obviously, not all of the gains on these stocks were from Medicare Advantage, but they were a key part of the strategy and a key moneymaker for them, and most other plans that we haven’t mentioned.

The last few years have seen much more scrutiny of these companies and their business model. And to the credit of both the Biden and Trump administrations, many changes have been made to make certain that the government is not grossly overpaying for these plans. Fast-forward to this week and with the notice that 2027 rates are substantially lower than were expected by either the companies or Wall Street. These stocks slumped by as much as 20% or more, losing nearly $100 billion in market value in one day. Time will tell whether the new rates will hold after the calming period. And if they do, will this result in plans leaving certain markets?

As taxpayers alone, we should all applaud efforts to reach a competitive rate of pay for these plans and not create enormous profits without comparable risk or benefit. But we also must continue to ask ourselves whether Medicare Advantage plans are doing well for beneficiaries or just for the plans. Fifty-five percent of Medicare beneficiaries are in these plans, and that number has been growing. This is highly, highly impactful.

Harlan Krumholz: Howie, I don’t think anyone knows more about this than you do. Do you think these companies have snookered the United States and been able to take advantage of the laws and make these profits without returning value? Or do you think they’re being mischaracterized as having done that when in fact they’ve done a service by advancing value-based care?

Howard Forman: Yeah, and both things can be true. I think they’re always going to fight to get the most money they can get and hopefully spend the least that they can spend. And I think that’s true. I think it’s also true that the hardworking people at these firms genuinely believe in the ability to deliver value-based care that’s higher-quality, that may take longer to prove that it works than others. But there is so much evidence at this point that we are overpaying them relative to the old fee-for-service Medicare that you have to look at ways to cut back on this spending. And so, while I don’t think the full cut is going to hold, the full reduction from what was expected will hold, I think a lot of it’s going to hold. And I think it’s going to take us a year or two to see what shakes out.

Harlan Krumholz: And do you think net-net, Medicare Advantage, has it saved any money for anyone?

Howard Forman: I don’t. Yeah. I tend to think that it’s mostly been an investment experiment of hundreds of billions of dollars that may pay off in the long run if it allows us to change the way we deliver care. And maybe at some point in the future we’re going to look back and say, “You know what, we invested a trillion dollars over 20 years and it was worth it because we’re doing things differently than we could have ever done in under fee for service Medicare.” But I think that in general, in the short run, we’ve definitely overpaid for it.

Harlan Krumholz: And finally, can I get you to say something good about the administration? Do you think that maybe other administrations might have cowered at the idea of coming up against this powerful lobby, but this administration just said, “Enough’s enough, no más, we’re going to make the cuts”?

Howard Forman: It’s interesting. A couple of big hits against Medicare Advantage happened with Biden right at the end in the last two years. Trump came in and softened the blow briefly, like wanted to make nice. And now he’s throwing down the gauntlet, as they say. I think he’s doing exactly what Biden was doing. And quite frankly, both parties have done things that have improved the program. But in general, until Trump, there has not been a Republican who’s been as aggressive at going after this industry. Democrats have, but they get their hand slapped.

Harlan Krumholz: That’s as close as you’re going to get to saying maybe the administration’s doing something—

Howard Forman: Oh, I’m in favor of what they’re doing right now. I’m 100% in favor. I just don’t—

Harlan Krumholz: No, I’m just saying it’s good. And I can say what’s going on at CMS. I look at what’s going on at CMMI. There’s some things that—

Howard Forman: No, absolutely.

Harlan Krumholz: Good.

Howard Forman: And by the way, we’ve said that around MAHA as well. There’s a lot of good things; it’s just the bad things…

Harlan Krumholz: No, no, no. I was just trying to squeeze that out of you.

Howard Forman: Yeah, no, that’s true. That’s true.

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

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

Harlan Krumholz: Yeah. We love your feedback. Please reach out to us, we’ll get back to you. We learn from you and we enjoy engaging with our listeners.

Howard Forman: Well, Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. To learn more 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: I do want to say, by the way, I always find you to be very fair. You are not a reflexive individual. I know you are animated on social media—

Howard Forman: Yes. Yes.

Harlan Krumholz: ...but I do find you to be very reflective. There are things you like, you don’t like on all sides, and you do say. I just wanted to say that out loud.

Howard Forman: No, I appreciate that.

Harlan Krumholz: Yeah. I want to give a hat tip to our superstar undergraduates. We’re so lucky to be working with amazing people, Gloria Beck, Tobias Liu. With a fabulous producer who somehow makes us sound good, or at least as good as we do sound, Miranda Shafer. And I get to work with the best in the business, Howard Forman. It’s great work with you all.

Howard Forman: Back at you, Harlan. Thank you very much.

Harlan Krumholz: Talk to you soon.

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