Measles Outbreaks, Preventative Cardiology, and Other News

Transcript

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

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University, and we’re trying to get closer to the truth about health and healthcare. Once a month or so, we like to do a deeper dive on what’s going on.

Harlan Krumholz: Plus, we like to see each other.

Howard Forman: And we do, and we’re seeing each other. We’re in the School of Management studio today. Sometimes we’re in the other studio.

Harlan Krumholz: One of our sponsors is School of Management.

Howard Forman: That’s right.

Harlan Krumholz: It’s great to see you.

Howard Forman: It is good to see you also.

Harlan Krumholz: Haircut today, right?

Howard Forman: For those that might have the visual, I am shaved down to the skin today.

Harlan Krumholz: To the nub.

Howard Forman: As my daughter says when I said I went for a haircut, she said, “How many?”

Harlan Krumholz: How long does it take for them to do that?

Howard Forman: He wears a blindfold the whole time. He just shaves it down until he feels skin. Yeah.

Harlan Krumholz: You look good. You look good.

Howard Forman: We’re trying. We’re trying. But let me just say, honestly, we could fill hours today with so much news. I decided I’m going to stick to my—

Harlan Krumholz: Don’t scare people away. We’re still going to have the same length—

Howard Forman: Same length. And I’m going to do public health topics today, just because there is so much to cover, but we could go on and on. And I’m curious to hear what you’re going to talk about as well. Let me start, if you’ll allow me, with measles. Can I do that?

Harlan Krumholz: Let’s start with measles, Howie.

Howard Forman: Okay. Because the reason why I want to start with it, first of all, I have two different segments on measles, but there was this excellent report in MMWR. That’s Morbidity and Mortality Weekly Report. We’ve talked about this before on the podcast. It’s from the CDC, and to the great—

Harlan Krumholz: It’s still coming out.

Howard Forman: Correct. I was just going to say, to the great credit of the CDC, it’s still coming out. It does not seem to be politicized, at least in my opinion. And it’s a very, very useful report. And I got to tell you, if you’re a young person thinking about going into public health or healthcare, read that report, and it will inspire you to think about what public health really means, because this report details an outbreak of measles from May and June of last year—it took them eight months to get this together, but they did a great job—due to an unvaccinated international traveler who acquired measles in the U.S.—not in Colorado, by the way—travels to Colorado to fly out of the country, flies back into Colorado. By the time they arrive back into Colorado, are showing signs and symptoms of measles. And so the CDC goes to work trying to track who they may have exposed during that time.

And it turns out they discovered 17 related cases, secondary and tertiary cases, starting with this traveler from another state. It gets confusing. So let me just make sure you understand each point about it. By the time they get back, they are symptomatic. They were unvaccinated. CDC and the Colorado Department of Public Health meticulously tracked as many people as feasible, including the international flight and the domestic flight of this individual.

Proximity to the index case was an important risk factor. If you were seated nearby, you were more likely to get infected, but there were some other interesting findings. This was an airplane and an airport. Among the 10 people infected, only one was a child. Airplanes, more adults, and so on, which is different than our other measles outbreaks. Three more adults were known to be unvaccinated. Two of them were hospitalized. One child, unvaccinated, was exposed, got infected, and got hospitalized, and one more adult had an unknown vaccination status and was hospitalized. Five more patients were vaccinated and none of those were hospitalized.

So again, you brought this up before. We’re seeing more cases among vaccinated people. Why is that? And I think this is a great example of just how infectious this disease is and how vaccination is imperfect. Undoubtedly, dozens if not hundreds of individuals were exposed and protected by their vaccination status. And in a setting where vaccination status would be expected to be very high, there are still travelers that are unvaccinated. And I cannot say whether the vaccine is showing waning effects and not living up to its 97% effectiveness if you got both doses. But the data from this example would not refute such high effectiveness. Four of the infected individuals were exposed on the international flight, all in close proximity to the index case. Three of them were vaccinated. As the outbreak continues to grow in this country, it may be the case that we change our current stance about getting an extra vaccination, but right now we’re not recommending that.

It should also be comforting to know that vaccinated individuals are less likely to have severe disease. None of them had severe disease, whereas the unvaccinated people did have severe disease. And finally, there were seven other cases not tracked by the Colorado Department of Public Health that were managed outside of Colorado. We don’t have follow-up on them. The CDC does. We do not.

Harlan Krumholz: That’s very interesting. I mean, I think we have to be careful the degree to which you make inferences from small samples. Presumably, there were hundreds of people on that plane.

Howard Forman: Correct.

Harlan Krumholz: I think what’s really interesting is I think about how infectious measles is—

Howard Forman: Oh, my God.

Harlan Krumholz: ... that more people didn’t come down with it.

Howard Forman: There’s one case from the plane, I believe, either five or 10 rows back from this individual who presumably was infected.

Harlan Krumholz: And to me, it makes sense that... I mean, again, we’re just speculating, but I would guess that the vast majority of people on that plane had been vaccinated.

Howard Forman: That’s the point.

Harlan Krumholz: And given what we know about that virus, you would think that that is playing a role. I’m just saying, you’re on a plane for hours and hours with someone, and that person invariably is going to the bathroom, is walking through.

Howard Forman: That’s right.

Harlan Krumholz: Plus you’ve got the air circulation systems. I know they have HEPA filters, but still...

Howard Forman: All you need is for two people to be in close proximity for probably two minutes and you probably have a high risk, yeah.

Harlan Krumholz: Measles is such…like that. So actually, I find it quite reassuring in some ways. Again, and I do find it strong evidence again that you should be vaccinated.

Howard Forman: Agree. No question. And I did the math on LinkedIn for anyone who wants to look at it and to think about how is it possible that such a high percent could be vaccinated in this sample? And if you do the math, you start to realize the vast, vast majority of people on that plane were probably vaccinated. They’re higher-income individuals, generally higher-educated individuals, and they’re from states that are generally high-vaccine status in general. If you add that together, the people on the plane were highly likely to be vaccinated.

Harlan Krumholz: And of an age where there was not even a question about measles vaccination.

Howard Forman: That’s right.

Harlan Krumholz: This wasn’t about—

Howard Forman: That’s right.

Harlan Krumholz: …when everybody was getting it.

Howard Forman: It’s not the new group. Right. Exactly. So this is very comforting to me, but it also just shows the power of public health to track these cases down, to learn things. There are other things in the report for people that are more wonky about using urine testing to see from measles. There was at least one case that tested positive in urine, but not on a nasopharyngeal swab, other things. But anyway, I just loved it, partly because I was never a public health person until I became a public health person. In my early—

Harlan Krumholz: You’re a heck of a public health person.

Howard Forman: I love this stuff now. I do.

Harlan Krumholz: But I also think it’s interesting, the high percentage of people who were hospitalized among those who are unvaccinated.

Howard Forman: Unvaccinated.

Harlan Krumholz: That’s a very high rate.

Howard Forman: And they pointed out the symptoms. These were people that needed to be hospitalized: severe disease, dehydration, diarrhea.

Harlan Krumholz: Yeah, that’s concerning.

Howard Forman: Yeah.

Harlan Krumholz: Yeah. Are you going to talk about South Carolina too?

Howard Forman: I’m going to come to that later on. I’m going to listen to you first. I want to hear what you got to say.

Harlan Krumholz: Well, I’ve been thinking about how well you communicate about health on this podcast. And so I’m going to try to replicate you. I’m sort of like “my take, my take” on this.

Howard Forman: Okay, okay.

Harlan Krumholz: So I’m going to at least, especially since we have today, I’m going to give you a take.

Howard Forman: Yes.

Harlan Krumholz: So here’s my take on something. This is about innovation incentives in the missing center. And I’ve been thinking a lot about, this week, about where innovation in medicine is actually headed and where it isn’t. And we talk consistently about innovation, new drugs, new devices, new AI tools, and there’s no question that extraordinary things are happening. But when I step back, what strikes me is how little of this innovation is really aimed at improving everyday quality of care, making care more reliable, elevating outcomes, preventing people from needing care in the first place. What seems to be missing in innovation is that piece that’s simply trying to help people do better.

And part of the reason, I think, is the uncomfortable reflex that we’ve developed. When someone proposes an idea, they can come to one of the hackathons, they can come to anything. The next thing people immediately ask isn’t “Will this improve outcomes?” It’s “What’s the business model?”

Howard Forman: Yes.

Harlan Krumholz: And so everything can gain a momentum. People can get excited. Everyone’s talking about why this is going to be great until someone asks what the business model is. And in today’s healthcare environment, there’s no strong business model for a product or system whose primary effect is that patients are made healthier. Complications are avoided. Hospitalizations don’t happen.<start>

We talk a lot about value-based care, but in practice, the dominant question remains: Will this drive revenue? Will it help the bottom line? For most healthcare organizations, quality is still treated as an externality. It doesn’t reliably show up on the books. It doesn’t consistently affect demand. All too often, it doesn’t command the same sustained attention as financial performance. You can see this clearly where so much of the AI innovation is going right now. A lot of it’s focused on revenue cycle management. That means tools designed to capture more codes, document more complexity, and ultimately generate more reimbursement. It’s not about elevating the care.

I understand why this happens. I understand the mantra “No margin, no mission.” I’ve heard it a million times. And healthcare organizations need to be financially sound. But when the path to financial stability doesn’t align with continual investment and better outcomes, we have a problem. And that problem isn’t about bad actors or ill intent. It’s about the system we’ve built, especially when we’re talking about nonprofit institutions. What are they here for if not to serve the health of the communities around them? This isn’t about blame. It’s an indictment of the circumstances we’ve created, and it’s a call for urgency. Because until we build real accountability for outcomes, not just inside hospitals but in the communities they serve, innovation will continue to flow toward revenue optimization rather than human benefit. The solution isn’t less innovation, it’s better alignment, and policy solutions that make patient outcomes central to the business model are critical, not incidental to it. That’s the gap I keep coming back to. We’re innovating fast, but we’re not always innovating where it matters most.

Howard Forman: Yeah. I love that you brought that up. First of all, I think about this a lot with regard to even radiology. All of the biggest innovations are all about productivity. It’s all about a business model, making the case to a hospital, a physician group, and so on. It also comes up into my mind. I don’t know if you saw this, it was just last week, but Sunny Kishore and Bob Kocher had a perspective piece in The New England Journal of Medicine about hypertension and why we’re not making more progress on that. And even though it’s not purely about this, it’s a lot about this. And it just reminds me, here you have a problem that you as a cardiologist know is such an important risk factor for so many diseases. It is a cause of so much morbidity and mortality and so on. But the business model for treating hypertension, it doesn’t fit into our little buckets the way we usually think of.

It’s a big investment short run, long-term payoff, hard to explain to companies why they should be doing this in a big way. As a side note, Aetna just sent me a blood pressure cuff to my home. I have no idea why they picked on me—I have the lowest blood pressure—but they did. And so I take my blood pressure every day, and it tells me how great I am because I’m normotensive. But I love that you brought this up. I wish that our health system was more focused on public health and a national healthcare directive because then we could invest public dollars in some of these things rather than just count on the private sector.

Harlan Krumholz: Yeah. And by the way, Sunny just emailed me today about his piece, and I’m going to get back to him, but I did think that was a nice piece raising this. I don’t know if I ever told you about the time I went to the hospital board meeting. I was invited by Marna Borgstrom to give a presentation. And I said, “It’s nice to be here.” And before I give my presentation, I said, “We really should set a stretch goal because we’re talking so much about how we’re one of the biggest hospitals in the nation. I think our stretch goal should be that we’re able to get rid of half of our beds in 10 years, that we’ve decreased the demand in our community for hospitalization such that we can actually close off a bunch of these beds and we’re no longer one of the top five hospitals in the country.” It was met by silence—I think stunned silence. It was because half of their discussions were about how can we keep the beds full?

Howard Forman: I think now with our beds being over-full, they would have welcomed any ideas like this. But I also think it’s exactly what you said. It’s a stretch goal, but it’s a long-term goal. We’ve got to make investments today that may pay off in 10 years, and that doesn’t look great on a nonprofit’s balance, you know, AP statement.

Harlan Krumholz: And that’s the problem. And that’s why you can’t blame the hospital. Look, people go into healthcare, healthcare administration for all the right reasons. They’re in a circumstance where if they—

Howard Forman: Do the right thing.

Harlan Krumholz: If they do the right thing, and if we decrease demand, then there’s going to be a problem. By the way, that’s jobs, that’s a whole range of things. It’s a medical-industrial complex.

Howard Forman: But even put that aside, even if they invest, let’s say a hundred million dollars this year to do something that downstream is going to have a perfectly neutral effect on their bottom line, it’s still $100 million in cash they have to come up with, right?

Harlan Krumholz: They don’t have it right now. The margins are so thin.

Howard Forman: Right. Right.

Harlan Krumholz: They’re so thin.

Howard Forman: So let me go back to measles if I can. We’re taping this on a Monday. Just to remind our listeners, we’re going to post this on Thursday, as we usually do, and there’s going to be more data coming out tomorrow, but I don’t think it’s going to be stale. As of this past Friday, the outbreak in the United States is continuing to take off. We are seeing roughly 250 new cases each week right now, the majority coming from South Carolina. Compare that to last year’s peak when Texas was all in the news and that’s all we talked about. That was 115 a week. So we’re vastly higher than that. It’s well within the realm of possibility. I think it’ll be easy that we will surpass last year’s 33-year record total of 2,267 before we even get to summer. Probably in five months, we’ll get to that.

Florida, South Carolina, North Carolina, and Oregon all already have more cases this month than all of last year. And that list is going to continue to grow. And just today, as we’re taping this, we learned that an ICE detention facility in Texas where the young boy and his father from Minnesota were being held and are thankfully back in their home in Minnesota, they have an outbreak among detainees there, two different people in that center. And it’s now in a lockdown situation, which is just the convergence of two bad policies, in my opinion.

The good news so far is that hospitalizations among measles-infected patients are down to only 3% of cases, from 11% last year, but important to point out that the figure of 4% vaccinated that we talked about just earlier continues to hold. Four percent of all cases are among individuals with full vaccination status. Again, that number may be surprising, but not when you consider the fact that the vast majority of people are vaccinated. Only a small percent of people have no vaccination status and therefore it skews the numbers quite a bit.

Lastly, almost every outbreak is occurring in communities with lower or low vaccination rates. The key word is “communities.” Even if a state has a great vaccination level, if a pocket of the state is under-vaccinated and even one patient with measles visits, an outbreak can and will likely occur. Just look at what happened when an unvaccinated family from South Carolina ventured over to Snohomish County in Washington State where they visited another unvaccinated family and infected that family separately and you have a small outbreak now building in Snohomish County, Washington State. Our listeners, if our listeners have any questions about your vaccination status, go see your physician or provider and consider assessing your immune status.

Harlan Krumholz: What are the trends right now on the vaccination for measles? I mean, is it turning around or...

Howard Forman: We get lagged numbers on this. So in—the nice thing that I’ll say, to the great credit of the people of Texas and the community around where the original outbreak happened, they really surged vaccination. In those areas, they got to really good vaccination levels quickly. And I think that’s why they stopped the outbreak in Texas. That’s a great credit to them. We should not forget that. I think nationally the trend is still down, but that may be not a good indicator because we’re getting data from like nine months ago or a year ago. I’m hoping it’ll turn around. I’m hoping that with us messaging, with other people messaging, and with people realizing just how far afield we are.... We have people on social media that continue to talk about this like it’s chickenpox.

Harlan Krumholz: No, that’s terrible. Well, thanks for bringing that to us. I mean, I think people are getting such discordant messages still, that it’s why just like everything else, it’s just being politicized and depends on what side of the spectrum you’re on. And you have seen that this is being put in the course of shared decision-making, people should be able to make their own decisions, which I agree with strongly. But the question is, do people have the right facts to be able to make the decisions?

Howard Forman: So the thing with measles as opposed to certain other vaccines is measles has such strong externalities. If enough of us are vaccinated, we truly do protect an awful lot of people. If enough of us choose not to be vaccinated, we’re putting immunocompromised people at risk. We’re putting children under the age of six months of age at risk. We’re putting very elderly people at risk. These are things that we as a community have to be able to consider, not just about ourselves.

Harlan Krumholz: Yeah, that’s a good point. But we always allow for religious exemptions and things like that.

Howard Forman: That’s not true. I mean, so this is fascinating to me also, and I’ve been trying to cover it, and it’s not easy. Connecticut had religious exemptions until about 2021, and the governor recognized our vaccination set, it was just drifting lower and lower because it was the easiest thing to claim that your religion prevents you from getting vaccinated. And so the legislature passed a law and the governor signed into law—

Harlan Krumholz: No religious exemptions.

Howard Forman: ... no religious exemptions. There are very few states that have no religious exemptions. They are among the highest-vaccination states, and they are among the states that have not had outbreaks. Whereas if you look at states... And we talked recently, Mississippi used to have no religious exemptions. Now I believe they do have religious exemptions. You can almost guarantee Mississippi’s going to be at risk in five years.

Harlan Krumholz: Do you know what our rates are in Connecticut?

Howard Forman: I think it’s around 98% now. It’s incredible, and well above herd levels. And while it would not shock me that there could be an outbreak... There are small little enclaves of people that are unvaccinated, mostly among homeschooled, things like that. It would not completely shock me, but it’s very hard to get a sustained outbreak in Connecticut for that reason.

Harlan Krumholz: Thank you so much. You’re a font of knowledge about this.

Howard Forman: I’m continuing to learn, always.

Harlan Krumholz: Continuing to teach me. All right. So in this next segment, I thought I’d try something new: to talk about somebody I admire at Yale.

Howard Forman: Okay.

Harlan Krumholz: Yeah. So I want to talk about Erica Spatz.

Howard Forman: Who has been our guest.

Harlan Krumholz: Has been one of our guests, and is just extraordinary and is sort of one of these unsung heroes. She never makes it about herself. She’s a cardiologist and a researcher, but more than that, she’s someone who consistently asks the question in medicine, “How can we do better?” This maybe is a complement to my first part. “And what would we do that could make a difference?” And she’s also focused intently on people who don’t have resources. And she’s a preventive cardiologist and has spent a lot of time pioneering new ways. She’s, by the way, working with barbershops in New Haven and is forging new ground about using that kind of partnership to help control blood pressure.

But she’s got something else going that I think is worthy of attention. It’s a thing called Pressure Check. It’s this project that she’s got that was funded by the Patient Centered Outcomes Research Institute to the tune about $20 million that was going to ask the question about whether we, if we enlist community health workers and people in the community, can we do the blood pressure control a different way? Can we take it out, decentralize it, and actually empower people in ways that we haven’t done before?

So it’s built on what they call a community-based participatory model. Instead of waiting for people to come to the healthcare system, they partner with trusted community organizations, churches, and—given her experience with barbershops—barbershops, beauty salons, and other local spaces to meet people where they are, engage them as partners in their own care. Participants receive home blood pressure monitors, like you did, and are connected to different models of care that combine several things we already know work but rarely put into motion to help people. That includes digital tools that makes care easier, non-physician care teams made up of nurses, pharmacists, community health workers who focus on the whole person, not just the number, and ongoing involvement from stakeholders. So the results actually matter to health systems, payers, and policymakers.

It’s happening in four cities, New Haven, Boston, Norfolk, and Houston. And really, by the way, this is a hard thing to get people to enroll in. And in Boston with these ICE raids, it’s made it very hard because some of the participants in the study—

Howard Forman: Are afraid.

Harlan Krumholz: ... are afraid. And by the way, even if you’re a U.S. citizen, people are afraid.

Howard Forman: Absolutely.

Harlan Krumholz: So this is just—

Howard Forman: I’m afraid.

Harlan Krumholz: People are afraid. So it’s actually affected the study, but she’s at over 80% enrollment. They’re soon to finish. And when I think about what we were talking about earlier, the misalignment between incentives and patient benefit, Pressure Check basically tests like a glimpse into what’s possible if we choose a different starting point, if we start to think about this in a different way. And it’s a new approach that’s using very basic ways of doing it. It’s so very Erica Spatz. Thinking about, How can I work with teams? How can we think about things differently? How can we help people? How can we make it so that net-net we can advance together? So I wanted to call out Erica because she’s amazing. And this project, which is at 80% enrollment, and I’m very eager to see what’s going to happen with this patient-centered work, and can it really make blood pressure control better?

Howard Forman: And back to your point in the first segment, I would love to see a system where we’re somehow able to mine information in a way that protects privacy, that targets people that are higher-risk. I’m confused by why Aetna came to me. I have this Hello Heart app on my phone now. I’m participating in it because I just thought it would be worth trying it and seeing what this is like.

Harlan Krumholz: I think it’s Yale employees, this became a benefit. Yeah.

Howard Forman: I guess, but it’s like—

Harlan Krumholz: Everyone was welcome.

Howard Forman: Everybody was welcome. And I’m a 110/65 blood pressure person. I’m the least likely person that they—

Harlan Krumholz: But it’s because you enrolled in that program.

Howard Forman: Oh, I definitely actively did, but it’s still... I just wish they’d put more resources to people that have higher... Can I ask you one question about that segment, a little unrelated to what you brought it up? I’m fascinated by this field of preventive cardiology, and maybe we should get Erica on to talk about her new work as well as the field. But just from you, among our listeners, who should see a preventive cardiologist?

Harlan Krumholz: I think anyone who’s interested in wellness. The truth is that the preventative cardiologists have in general taken a holistic approach in looking at cardiometabolic health. And what we’re increasingly appreciating is that cardiometabolic health affects the heart but also the brain, the liver, the vascular system. It’s not really sequestered. And there’s a lot of new information out these days. A lot of it starts with the basics, diet and exercise and the kind of things that Zeke Emanuel was talking to us about. But there’s also a range of strategies for people who are having trouble getting their lipids under control or getting their blood pressure under control. And then some people have what we’re calling residual risk, that is, the traditional risk factors are under control, but either because of their family history or other factors that are related to that, genetically determined that they may be in a higher risk band. And so this doctor can work with you to do everything you can to put yourself in a good position for overall cardiometabolic health.

Howard Forman: If you’re an otherwise healthy person without a strong family history, at what age might you consider seeing a preventive cardiologist? And then separately, if you’re from a high-risk history, when would you suggest someone go see someone?

Harlan Krumholz: I think one of the jobs of the preventive cardiologists is to make sure that all the cardiologists and primary care docs are tuned into the very most recent evidence about what we can do to help people stay healthy. And so I think people end up getting referred to a preventive cardiologist when it’s a little more complicated. But people like Erica are really trying to enlist everyone. So not just saying, “You need me,” but how can she make sure that the entire system is strong? As you know, she’s actually in charge of remote monitoring for the health system. She’s working with Lee Schwamm. And I think she’s trying to think, “How do I get a force multiplier effect by getting everyone?” So I would think it’s not just a matter of patients thinking, “I definitely need to see a preventive cardiologist.”

Howard Forman: That’s what I was wondering.

Harlan Krumholz: But are they with someone who seems interested in helping them avoid problems as opposed to reacting to problems? And that’s where you really want to find a doctor who’s not just helping you to deal with what’s in front of you, but thinking 10 years down the line, “How are we going to get you in a position where you’re going to be happy with whatever you did today so you can be healthier in 10 years?”

Howard Forman: That helps me. Yeah. That’s what I was wondering. I want to give a quick update on the respiratory illness season that we’re just in the middle of right now. We had quite the flu season. We’ve talked about it. But in fact, in some ways we’ve had a full season crammed into just two months. And I want to just give you a couple of data points. We peaked at historic levels during the Christmas break, and then just before the new year. Since that time, just five weeks ago, we are down a whopping 70% in terms of cases and positivity. In fact, we had not even peaked at this time last year, and we did not get down to our current levels until March or April last year. So with the benefit of hindsight, this has not been a historically bad season, though the intensity was among the worst, however briefly.

And by the way, it’s not to say it’s over for everyone. There are still some states with very high levels, including Mississippi and Arkansas. But we also see low and minimal levels, which is shocking, in areas that were at peak outbreak just five weeks ago, Connecticut, New York City, D.C. among those minimal-level flu levels. Could we have a second peak? Absolutely. It has happened many times over the years, and there are faint signs that this could happen, but nothing worth worrying about just yet. Most importantly, we are not seeing flu B taking off, remembering that this outbreak was mostly flu A. Lastly, worth noting that while COVID has been relatively low levels this year, RSV infections continue to grow in large parts of the country, though certainly not at the levels of flu.

Harlan Krumholz: Hey, so I wanted to tap into something where you can help me. So we’ve been talking a lot about these ACA subsidies and that people’s health insurance is already—

Howard Forman: Way up.

Harlan Krumholz: ... way up. Way up as a result of the government not continuing the subsidies. But this week, the federal government released the final snapshot of the 2026 ACA marketplace open enrollment period. And on the surface, it’s kind of a simple message and very positive. About 23 million people selected these plans this year, the highest number ever. And it includes about 3.4 million who are new to the marketplace and 20 million who are returning, showing a lot of persistence. So I thought that this was interesting. The enrollment, by the way, is concentrated in Texas and Florida, places that you might think would not be there. And these are the states without Medicaid expansion and with large populations priced out of employer coverage. So I guess that’s why they’re looking to the marketplace.

Howard Forman: And they’re also growing markets. I mean, they’re just...

Harlan Krumholz: So how do you piece this together? I mean, we’ve got the subsidies going away, but just on the heels... now people should know, this was the quarter before the price increase.

Howard Forman: That’s right. They’re not exposed.

Harlan Krumholz: So we’re going to need to watch and see what’s going to happen. But it’s interesting that just on the cusp of that, that’s happening. And just politically, just politically, this is 20 million people who are going to be experiencing sticker shock now, already are experiencing sticker shock. And Florida and Texas are the places that had the most growth. So you would think politically that people from those states would be very sensitive to this, but that’s not what we saw.

Howard Forman: So there’s also growth in numbers in, I believe, like seven states, all of which are states for which the governors and the legislature have decided to subsidize from the state level some of the equivalent subsidies. So in some states, and I know Connecticut is among them, I think New York is among them. You’re going to have some mitigation of the sticker shock. I don’t think that’s the case in Texas or Florida. And I agree with you 100% that once people actually have to start paying it and it starts hitting their pockets—

Harlan Krumholz: They’re going to be unhappy.

Howard Forman: And many of them are going to drop coverage because there’s nothing that keeps them in.

Harlan Krumholz: They’ll drop coverage. They’ll be unhappy. I don’t know. Maybe add some political pressure. I think what people should also know that while this can be configured as a success story for the ACA marketplace, the Affordable Care Act marketplace, it is in some way a failure because what it represents is that the system is under strain, that people aren’t getting adequate coverage through their employers. Medicaid has gaps. These people are left with this as being an only option, and that group is growing.

Howard Forman: The economy is transforming also. I talked about this in class. This is not a surprise to anybody, but we are in a gig economy. More and more people are doing Grubhub and Airbnb and Uber driving.

Harlan Krumholz: And not getting employer insurance.

Howard Forman: And so they have to make a decision. How do they get insurance? Some may go to Medicaid, some may go to the exchanges, some are going to be uninsured.

Harlan Krumholz: All right. Hey, do you want to bring us home with one final one?

Howard Forman: I do. This is a quickie, but it’s interesting. When a student asks me an earnest question, and I don’t know the answer, I do try to dig and learn more. And in this case, it’s about something called Nipah virus. There’s an outbreak of this rare but very dangerous virus in West Bengal, India.

Harlan Krumholz: Yeah, I heard about that.

Howard Forman: With two healthcare workers—

Harlan Krumholz: A very high mortality rate.

Howard Forman: Forty to seventy percent. Two healthcare workers from the same hospital are very seriously affected now. They are alive, but they’re very affected. The virus has only been known for 27 years, first identified in Malaysia where a hundred people died in an outbreak spread by pigs. There’s a seasonal pattern in Bangladesh tied to the drinking of what’s called raw date palm sap, which is a seasonal drink.

Harlan Krumholz: I’m going to write that down and not drink that.

Howard Forman: I know, exactly. Apparently infected by fruit bats. Stay away from the fruit bats, stay away from the palm sap. Symptoms start as a systemic viral syndrome and quickly manifest with neurologic symptoms, somewhat explaining why this was first thought to be a Japanese encephalitis before it was confirmed to be a new virus at the time. I don’t bring this up because I think it represents an imminent threat to U.S. citizens. The disease is primarily spread from bats or pigs to humans, and close contact is required. But it does persist in foodstuff for days, and cases have been isolated at the present time and kept to South and Southeast Asia, but they could travel. They theoretically could travel. And once a human gets it, a human can spread it, but again, only by close and intense contact, not airplane travel, but perhaps if you’re taking care of somebody who’s sick with this.

As you said, case fatality rates very high, no known effective treatments or preventive vaccines or drugs, and there’s just management of the acute symptoms. So at a time when the World Health Organization is under fire from current U.S. administration and our connection to the global health community is more tenuous than ever, it is a reminder that distant threats can become local threats and that we need to always be watchful and careful.

Harlan Krumholz: Yeah. I was hoping you were going to sort of close that loop on that, that this does just really emphasize the importance of one world, and we’re all in this together.

Howard Forman: We’re all in this together.

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

Howard Forman: So how did we do? To keep the conversation going, you can email us at health.veritas@yale.edu or follow us on any of social media, particularly Instagram.

Harlan Krumholz: Yeah, we love your feedback. Send us notes, post comments on the platforms. It’s all good.

Howard Forman: And by the way, I want to mention, I was just leaving an office today and Kate Halpern said to me that she loved your perspective piece in JACC on becoming a doctor, like out of the blue just told me that.

Harlan Krumholz: That’s lovely.

Howard Forman: And then somebody else in the office who’s been a guest on the podcast told me how much they love our podcast as well. It made me very happy. It’s great to get that type of feedback.

Harlan Krumholz: And we’re also open to any sort of critical feedback.

Howard Forman: Negative feedback.

Harlan Krumholz: Yeah, sure. Help us.

Howard Forman: Yeah. You give it to us early—

Harlan Krumholz: By the way, we get that from time to time too.

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

Harlan Krumholz: And importantly, we want to give a hat tip to our superstar undergraduate students, Tobias Liu and Gloria Beck, who just do amazing work. To our great producer, Miranda Shafer, and Howie, I get to work with the best in the business. Thank you.

Howard Forman: I appreciate you, Harlan. This is so much fun when we get to do this in the studio, and I’m just glad that we do it together.

Harlan Krumholz: It’s good to see you. Talk to you soon.

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