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Episode 75
Duration 36:05
Michael Alosco

Michael Alosco: The Toll of Repetitive Head Impacts


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. We’re trying to get closer to the truth about health and healthcare. This week, we’ll be speaking with Dr. Michael Alosco, but first, we like to check in on current health news. And I know there was a study that you pointed out to me, Harlan, that you wanted to talk about.

Harlan Krumholz: Yeah, there was a study came out this week in JAMA that had been presented at the American College of Cardiology meetings, that was about whether or not we should be treating to target with lipid levels. Most people are familiar with this idea that you come in, you get your cholesterol level checked, and if it’s elevated, and especially if you’ve got heart disease people, the clinicians may recommend to you to have your blood levels reduced to a certain target level. And often now people are talking about getting people under 70, for example, under 70 milligrams per deciliter of LDL, the so-called “bad cholesterol,” low-density lipoprotein cholesterol. But the thing is that really all the cholesterol trials were about giving people a cholesterol pill and seeing whether or not that reduced their risk. That is, they weren’t trials that were testing whether or not getting people to a certain number was actually better.

By the way, we have these studies in hypertension. Does getting people down to 120 to 130, is that better than 130 to 140? We have these in diabetes, where we saw whether or not pushing people’s hemoglobin A1c, an indicator of their blood glucose levels, down lower among people with type 2 diabetes would be better in that case. In hypertension’s case, it was better; in diabetes, it wasn’t. But in cholesterol, we really haven’t had these kind of trials. And so a lot of times the guidelines will tell you to try to get to a certain level, but it’s not based on a clinical trial; it’s based on extrapolation of other evidence. It’s not an unreasonable extrapolation, but it’s still an extrapolation. So investigators from Korea took it upon themselves to do a study in which they randomize people to either trying to get them to a target level between 50 and 70 or to just simply give them a high-intensity statin.

And that means, for example, atorvastatin, Lipitor, and giving it a higher dose, or rosuvastatin. These are more potent statins and especially at higher doses. And so they made this comparison, and this was in a bunch of people with coronary artery disease. So people who did have heart disease, and I won’t get into the mechanics of the trial, but basically they were trying to demonstrate whether these were not significantly different from each other, rather than trying to show one’s better than the other. The question was, were these going to be about the same? And so they looked at a three-year outcome of all-cause death, heart attack, stroke, and having bypass surgery or PCI [percutaneous coronary intervention], having a stent placed. And what they saw was really, there was no difference, no difference at all between the two groups.

So for all the commotion about we got to get you down to a certain level, honestly, just putting people on a high-intensity statin produced about the same benefit. Now interestingly, this group in their conclusion was sort of saying, this is an endorsement of the target level because it’s not inferior to just giving a high-intensity statin. I actually took it the other way, which is just like, “Set it and forget it.” It’s like—

Howard Forman: I know.

Harlan Krumholz: …somebody comes in, I don’t have to have them continue to come in repetitively to keep checking cholesterol levels, titrating them, doing—

Howard Forman: That was my question for you. So I’m on high-dose simvastatin, basically, on the 40 milligrams, which are reasonably high-dose. I’ve been on it for a long time. I went on it because I had a very high cholesterol, and my father had a heart attack below the age of 50. I felt like it was at high risk and I’ve no side effects from it that really bother me so I’ve sort of just left it alone. So my question for you is, does this change anything for me? And I think you’re telling me no.

Harlan Krumholz: Yeah, I mean I sort of like what it is, it sort of endorses this idea that, like I said ... I don’t know. What was that like? Some microwave oven or some people say “Set it and forget it” when they’re working in the kitchen. It’s like this strategy is that instead of a lot of effort to try to titrate and get to a right number, you’re just putting people on high-intensity statins, people who are at risk, it seems to help them. I’ve often thought about these statin drugs as risk-reducing drugs rather than cholesterol drugs. I mean, their mechanism is through the cholesterol, but I mean mostly think about you’ve got a high risk, here’s an opportunity for you to lower your risk. That’s what these drugs do.

Howard Forman: I sure hope so. I sure hope so.

Harlan Krumholz: Well, I’m sure, Howie, you’re doing the right thing. But anyway, I thought it was an interesting study for folks to hear about who may be seeing people who are chasing numbers, but actually this looks like just the drug itself was good enough. Hey, let’s pivot and get to our guest. I’m really eager today because this is just a terrific topic about the issue of this repetitive head injury and also relevance to professional sports, amateur sports, and other ways that people bump their heads. So yeah, let’s get moving.

Howard Forman: Dr. Michael Alosco is a clinical neuropsychologist and a co-director of the Boston University Alzheimer’s Disease Research Center Clinical Core and lead investigator of the Boston University Chronic Traumatic Encephalopathy Center. He’s an associate professor of neurology at Boston University School of Medicine and the principal investigator of multiple NIH-funded grants. His research focuses on the relationship between repetitive head impact and traumatic brain injury with later-life cognitive decline and neurodegenerative diseases. He studies chronic traumatic encephalopathy, which we call “CTE” and Alzheimer’s disease as well as Alzheimer’s disease–related dementias. He’s the author of more than 150 peer-reviewed publications and is the co-editor of The Oxford Handbook of Adult Cognitive Disorders. He received his undergraduate degree at Providence College and his doctoral degree in clinical psychology from Kent State University. He completed a clinical internship in neuropsychology at VA Boston Healthcare System.

So we’ve eagerly awaited you as a guest on the Health & Veritas podcast. So first, I just want to say welcome. You have been part of a community of scientists who have helped us understand the mechanisms and epidemiology of repetitive head impacts and long-term adverse cognitive and behavioral outcomes, primarily in American footballers. Can you just walk us through what the key findings of your own center’s work are?

Michael Alosco: Of course. First, thanks for having me. It’s real honor to be here and talk about this important topic. So repetitive head impacts. First, what is it? It’s just like it sounds repeated hits to the head. It can be from any source. In American football, we’re talking about those hits to the head that happen on every down, every game, every play. What we find in our studies is that these repeated head impacts are the primary risk factor for the neurodegenerative disease chronic traumatic encephalopathy. And in particular, the more years of exposure to these head impacts or the more years of American football play is associated with an increased risk for this disease. There’s a dose-response relationship.

Harlan Krumholz: It’s so great to have you on, and let me just get to some basic things. So I think people have heard a lot about these extreme cases, both when horrific acts occur, perhaps someone like Junior Seau taking his life or prominent football players, people we know, names we’re familiar with and some horrific thing happens that seems out of character and then ultimately gets attributed to these repetitive head injuries as evidenced on the autopsy study. But do you have any sense of what percent of, for example, people who’ve played in the NFL actually have experienced some form of this? Because like I said, we hear about the extreme cases, but what about in the mainstream? I mean, what percent of people are actually suffering some of these effects, maybe even not quite at the far end of the spectrum?

Michael Alosco: I think that’s a really good question. And to be completely honest, I don’t think we know the answer. What we see in our center are people who come to us and are more likely to have symptoms, they’re more likely to have problems. And so while we see it quite frequently, that number is not necessarily representative of what’s out there in the general population.

Harlan Krumholz: So are you seeing some people come to see you who don’t have extreme symptoms, but then when they ultimately pass and you do autopsies, you’re seeing evidence of it? So even people who may think that they aren’t being affected actually have pathologic evidence of it?

Michael Alosco: I mean, most of the people who come here have symptoms. I mean, there is a continuum and we do see it in people who have mild symptoms. But I would say for the most part, people who are coming here have some level of concern.

Howard Forman: And you have an actual brain bank, right? You have a collection of pathological specimens and you’ve documented that some footballers, some people who’ve even played for many years don’t at least have pathology associated with CTE. Is that correct or could you tell us what that has shown?

Michael Alosco: So we have a brain bank at the BU CTE Center, where we essentially are ... it’s all people who are exposed to these repetitive head injuries. It’s actually the largest in the world of its kind. We have over 1,300 brain donors, and yes, so we do have people who’ve had years of exposure to these repetitive head injuries but don’t have CTE at autopsy. And I think that’s a really important point.

Howard Forman: And among those, do we know if some of them had symptoms that still might have been associated with this or are there other things that are sort of subpathological that may represent long-term damage?

Michael Alosco: So it becomes really complicated at this point. So you can have the path where you go on to develop that neurodegenerative disease known as CTE. But we’re also seeing that these repetitive head impacts can lead to other types of injuries to the brain. So if you think about our brain, we have gray and white matter. We’ve shown studies where the white matter of the brain can be particularly hurt by the repetitive head injuries, that can lead to symptoms. Then there’s a third potential path. People who go and play football tend to be more aggressive to begin with. This is kind of who these people are. So maybe as they get older, with age, some of these already traits that are there come out even more.

Harlan Krumholz: So here’s a question. Do you watch football? Are you a fan?

Michael Alosco: So I have watched football, and I would say I was a fan, and I would say that I’ve lost joy in watching the game in part because I’m thinking about the science a lot.

Harlan Krumholz: I remember when I was in high school, we had a drill on the football team and something that was sort of celebrated, which was people were identified to stand and hold the ball and then people would run at them from 60, 70 yards away and hit them as hard as they could. And the culture, by the way, with no guidance about how you would hit, by the way, let alone the neck vulnerability but I mean for the repetitive head injuries, and the culture was that you needed to learn to take a hit, and by the way, you needed to learn to give a hit. And so I think back to that and I sort of shudder a little bit to think about how we were training people to be, but when you have the experience of meeting these individuals and then being able to see ultimately the pathology in a lot of individuals who suffered as a result of being part of something like the NFL, I mean, do you have thoughts about what we should be doing as a society?

I mean, is this the gladiators, where these people are in and some people are ... I mean, they aren’t losing their lives in the moment but ultimately are putting themselves in a position where they’re doing harm, and we’re just sitting on the sidelines cheering and still ringing their bell. We talk about ringing the bell as if that was a really good hit, and we celebrate that in slow motion. We watch it over and over again. What do you think we should be doing as a society as we think about this? And there’s nothing bigger than the NFL. I mean, this is big business, baby. I mean, this is the biggest sports enterprise in the world.

Michael Alosco: No, I agree with everything you said, and I think society, there’s kind of two components. One is the players or the people who engage in the sport and people are going to do risky behaviors, whether it’s football, whether it’s smoking cigarettes, whatever it is, people who are going to do it, but it’s how do you mitigate that risk, right? And so that’s what really the advocacy efforts are focused on with CTE, delaying tackle football. Don’t play in the youth level but wait until your high school level. Wait until you as an individual can understand the risk that come along with it and make that informed choice. So that’s one component. And then the other component you raised is us as fans cheering for these head impacts or these players. I think it’s not going anywhere, and you’ll have fans. I don’t really know the answer to that. Me personally as a scientist, someone who’s involved in this, that’s where I lose the joy and I can’t have those cheers.

Howard Forman: In some ways the NFL is ahead of colleges in terms of paying attention to concussions. Individuals have agents who are hopefully looking out for them. And I believe that the NFL more so than colleges, there are some leagues I think that do have, have either banned or limited the amount of impact practices that they have. Are there other specific mitigating measures that can be taken that either the NFL or colleges or even less than colleges should be taken but aren’t doing at the moment to reduce the harm that comes from this?

Michael Alosco: So I will say there have been steps you just described that the NFL has made and we should applaud those steps. But even with detection of concussion, we saw all those policies failed this past year. Right? And we’re not even talking about concussions here. We’re talking about those repetitive head injuries. Those aren’t going anywhere in the game of tackle football. A helmet’s not going to stop them from happening, and it’s part of the game. So unless you go flag football, like they did for the Pro Bowl, route, unless you go flag football, that’s what’s going to happen.

Howard Forman: The cognitive impairment is just one of the things that you’ve been able to measure. Can you also talk about the other downstream effects? It’s not just cognitive decline, right?

Michael Alosco: So we’re still learning the specific signs and symptoms of this neurodegenerative disease. We know what this disease looks like in the brain quite well. We don’t really know the specific signs and symptoms, but we’re getting closer. So cognitive impairment, particularly memory problems, problems with multitasking, problem solving, we see those quite frequently and those are quite frequently tied to what we see in the brain with CTE. There’s this other component that we refer to as, the technical term is neurobehavioral dysregulation. And you can think of that as being impulsive, trouble managing your emotions. We see this a lot, but we don’t have a good understanding of what that exactly is tied to. Is that related to what we see in the brain or other factors?

Harlan Krumholz: I wanted to just ask you quickly. You’ve correlated these injuries. Now, I know we’ve talked a lot about the NFL, and I want to pivot off it in a second, but one final thing on it. You have related it to the number of years that you’ve been in the NFL. It does seem like different positions, though, put you at different risks. I didn’t see in your articles your reference to whether or not there are some positions or some people who are at particularly greater risk based on the work… I know you’ve got a selected same people coming to you, but do you have any sense of that, whether or not there’s a gradient of risk depending on whether you’re on the offensive line or whether or not you’re a receiver, running back?

Michael Alosco: At least through the generation of people we’re studying, so remember, these tend to be older individuals, so they played a while ago. We don’t see actually positional differences in our effects. Our strongest relationship so far has been with the number of years played.

Howard Forman: And you do capture that information?

Michael Alosco: The position, we do capture position. Yeah.

Howard Forman: That’s awesome.

Harlan Krumholz: And we’ve talked a lot here about the NFL, but it does seem to me like there’s so many different activities that may put people in a position of risk. I mean, gee, we teach people how to do headers in soccer and that seems to me to be something that over a period of time can also cause trouble. Is there any evidence that soccer players are also experiencing this?

Michael Alosco: Yeah, so I have two points there. So one, yes, we’ve seen it in soccer players and we’ve seen these large, more epidemiological studies that also show soccer players are at higher risk for death from neurodegenerative disease, these mortality-based studies. So we have seen it in other sports besides football. The other comment I want to make too is that we talk about professional football as people who play in the NFL, but we see it at the amateur levels, and there’s only a very small portion of the population who goes on to these elite levels. We really need to focus on college and high school, because that’s majority of the population.

Howard Forman: That’s what worries me the most. And we have kids that are having multiple, multiple impacts for three, four, or five years or longer. And we’re not treating them the same way. They don’t have agents, they don’t have somebody pulling them out every time they have a concussion as much. I know you’ve done at least one large paper that’s been extremely well cited, but what is the evidence that we have on the high school and younger population right now?

Michael Alosco: So I would say that the risk for CTE so far based on our data seems to really increase once you play five or more years. So people who are playing just high school or below, their risk is probably low. But that said, in that large study you’re referring to, a high percentage of people who play that college level had evidence of this progressive brain disease and millions play at the college level. So that’s concerning.

Harlan Krumholz: Let me just finish up with my soccer thing. But is there any movement to try to eliminate headers in soccer as a result of these concerns? I mean, because you could continue to play soccer but just not penalize people who do headers.

Michael Alosco: So there’s been a ban of age, right? There’s a ban of when you can start heading. You can’t head the ball ... I’d have to double-check, but I think below 14 you can’t head the ball. I’m pretty sure. I made that comment before I had at a conference. It was in Germany, actually. And I said you can—

Howard Forman: Not well received.

Michael Alosco: Not well received! I think my quote was, I think you can remove heading from soccer and not fundamentally change the game. And that did not go over well.

Howard Forman: Oh my god, yeah. Americans are not supposed to tell anybody anything about soccer. Yeah.

Harlan Krumholz: Well, let me ask, follow up one question, because I’m curious what you say about this. So how does this ... so this is repetitive head injuries, sometimes—by the way, it doesn’t have to be severe, it can be minor. How does this relate to traumatic brain injury? So for people who are listening, sometimes people can even get mild head trauma. That is, it doesn’t knock them out. They don’t necessarily perceive it as a concussion, but there can be long-term sequelae in that moment. So this isn’t repetitive and then downstream 20 years later manifesting as a problem, which is more what I perceive what’s happening with the CTE, people have a period of time where they’re getting light head injury and then later on it’s manifesting. But this is a situation where even sometimes can be harsh trauma, but sometimes it can be light trauma and then people have cognitive dysfunction after. Are these related in any way?

Michael Alosco: Yeah, that is a great question. And there’s workshops going on to tease apart what is repetitive head impacts, what is TBI, right? Traumatic brain injury. So think about repetitive head impacts as an environmental exposure. They are hits to the head and that can be from any type of source. That hit to the head can cause a traumatic brain injury, like a mild traumatic brain issue or a concussion. But they can also, we think, cause injury to the brain that don’t result in symptoms. So there’s still injury, but maybe not enough to cause symptoms. But if you think about those thousands of hits that someone can have over the course of their football career or lifetime, that’s a lot. And that’s what we’re concerned about.

Howard Forman: Or were you able to document in those cases any MRI or any type of biomarkers or PET imaging? I know you’re doing lots of different ways to try to measure this. Yeah. Are you seeing measures for those things, any correlates?

Michael Alosco: Yeah. So one of our goals here is, how can we accurately make a diagnosis of this disease during life? Something we can’t do yet. And the biomarkers, right? We all know what biomarkers are. Something’s wrong with your heart, you get an EKG. Same concept, but we’re looking at the brain. So we look at MRIs to look at the structure of the brain. And one thing we’ve noticed is that the front and side parts of the brain seem to be smaller or shrink more so in CTE. And we’re looking at other advanced imaging techniques that can pick up on the specific things associated with CTE too.

Howard Forman: I wanted just one more question from actually reading about you and the other work you’ve done. You’ve highlighted that there are large populations that we are not looking at yet outside of sports, including battered women and other battered individuals. Obviously, boxers, but I mean, other individuals in different areas. Where are we with that? Are we getting good information? Are we starting to study this?

Michael Alosco: Yeah, I mean our focus has been on male football players because they offer a good way to model these repetitive head injuries. But we need to go beyond and we are starting to get in ... trying to have a real focus on females. We’re studying female soccer players, female ice hockey players. We’re trying to also get into studying intimate partner violence like you mentioned. So these are all areas that we’re actively pursuing and some of which we’ve already started studying.

Harlan Krumholz: When we talk about this CTE, a lot of people have in their minds from this repetitive head injury, the situation that occurred with Muhammad Ali. In that situation, he didn’t seem to experience specific cognitive dysfunction as much as Parkinson’s-like syndrome. Is that also part of this CTE or is that a whole nother thing?

Michael Alosco: Great question. The concept of CTE actually goes back to the 1920s, and it all started in boxers. Really, CTE didn’t come onto the scene until 2005 when it was found in a former NFL player. In boxers, we do tend to see more of a motor or movement presentation. And in football players, we see this, but it’s not often the initial symptom that we see. And some of this is speculation, but we do think that maybe the differences in the head trauma or the mechanical forces across the sports has something to do with it. Maybe they’re applying different types of injuries to different parts of the brain that are responsible for movement, for example, in boxing.

Howard Forman: I think using that term, even punch-drunk syndrome or something, which referred to boxers. We have only a few minutes left, and I just wanted to first say, this is the first time I think Harlan and I have competed for questions, because we’ve been so anxiously awaiting—

Harlan Krumholz: We’re so interested in this.

Howard Forman: No, we really are. It has come up obviously for the last six months and we’ve been talking about it. And I think my biggest question is, what would you do for your own child and what is the advice for other people? Because as you said, you can’t stop people from participating in sports, but you can stop your own child. And what advice would you give somebody about what types of sports you can or should not engage in?

Michael Alosco: It’s a really kind of personal decision. And I think me, myself, of course, being in the field and being close to this, I would not allow my child to play American football or tackle football as a youth. I think it’s really important that parents are educated and that they’re aware of what’s out there. They’re aware of the risks. I don’t think it’s fair for parents to knowing these risks to send children who can’t understand or grasp these risks to play these types of sports, especially football. So I do really advocate for waiting until the individuals are older and before engaging them in this types of sports.

Howard Forman: I was going to end up just asking one thing, which is of all the people you’ve seen and the families you’ve talked to, who broke your heart the most?

Michael Alosco: So actually, it’s not a specific story, but what breaks my heart, and we have a clinic here too at Boston Medical Center, where we see a lot of these individuals, and what breaks my heart is the number of people come in whose lives are completely turned upside down by their symptoms and how many people they’ve gone through where they’ve don’t take their symptoms seriously, say this isn’t real or critique the field of CTE or invalidate what they’re actually experiencing. And these people are searching for help, and these people don’t have many people to turn to. And in part because there’s not a lot of people with the expertise in the field, admittedly, but in part because not all people take this seriously as well. And that really breaks my heart. And when they come to us, we provide education, we tell them what we know, what we don’t know, and just being there to listen to them and take them seriously has been a really powerful intervention that I think everyone could learn from.

Harlan Krumholz: If somebody wants to contact your center, we’ll put it in the notes for the podcast, but do you want to just say how someone would reach out to you?

Michael Alosco: Sure. So if you would like, just visit our BU CTE Center website, and there’s contact information there for both research wise as well as our clinic, our memory and aging clinic as well.

Howard Forman: Thanks so much, Michael. I mean, I’m not kidding, you’re probably the most eagerly anticipated guest we’ve had all year, and we’ve had some amazing guests and you did a great job.

Harlan Krumholz: Now, you just insulted all of our other guests—

Howard Forman: I know, a little bit, but in fairness—

Michael Alosco: I’m going to disagree with you. I anticipate everyone’s—

Howard Forman: I will tell you for the honesty of our listeners, when this topic first came up, I had to hunt you down.

Harlan Krumholz: Yeah, thanks so much.

Howard Forman: Thank you.

Harlan Krumholz: Appreciate it.

Michael Alosco: No, this was awesome. Thanks for having me. It’s been a pleasure.

Harlan Krumholz: Howie, that was a terrific interview. Really enjoyed having Mike here.

Howard Forman: Unbelievable.

Harlan Krumholz: It was so much fun we could have gone on and on, but hey, let’s get to your part of the podcast. What’s on your mind this week?

Howard Forman: So this past week, a judge in the US District Court in the northern district of Texas, so put aside politics, but issued a final ruling in a case—

Harlan Krumholz: Is that a rural area, Howie, or does that also include Dallas? I mean, I was wondering about that.

Howard Forman: I think it includes a lot of communities, but I think it is known to have a more conservative-leaning justices. So there is a sort of political element to it. But let’s put that aside. They issued a final ruling in a case known as Braidwood Management vs. Becerra. And Becerra, for our listeners, is the secretary of our Department of Health and Human Services. And this ruling removes the requirement for full coverage of many preventive services. So the ACA Obamacare required that recommendations from our US Preventive Services Task Force, which we abbreviate “USPSTF,” must be covered by insurance without copays or deductibles. We have a lot of evidence that shows that copays and deductibles reduce the use of services. So our logic is that if something is truly beneficial, if it’s rated highly by this group, a group of scientists, that the population should have no cost sharing. So they are used more, not less.

This new ruling removes that requirement, that insurance companies do not charge for these specified services. And more specifically, any recommendation made by that group after the ACA was signed, and this is a critical point, March 23rd, 2010, would lose this protection. Some of the services that may no longer have this coverage requirement are lung cancer screening, certain drug use like Tamoxifen for breast cancer prevention in certain high-risk individuals. And what we just talked about, statins for the use for prevention of heart disease and pre-exposure prophylaxis for HIV, which we call PrEP. So more worrisome is that future recommendations or even a modification to a prior recommendation will no longer be covered. And let me just say as a caveat for slightly different reasons, PrEP is also no longer subject to any coverage at all based on religious grounds. So the first point was about copays and deductibles for PrEP. It actually applies to whether they have to cover it at all.

So let me just give a quick summary of this. I’m not a lawyer, but I think it’s useful to understand the legal case and putting aside that religious objection part is that our USPSTF members are not Senate-confirmed officers despite having positions of authority that might otherwise require it according to the Appointments Clause of the Constitution. So our listeners might wonder why we don’t just have confirmations for these individuals. And the answer is that confirmations are intensive, intrusive, and almost certainly would dissuade many if not most of these incredible volunteers from choosing to serve the United States in this way. The ruling’s going to get appealed to the Supreme Court. It’s unclear whether it’ll be upheld, but it is another direct threat to a key part of the ACA. And I don’t believe it’ll be the last by any stretch.

And for some context, 151 million people are covered by private insurance subject to these rules. And of those about a hundred million use one or more preventive services in a given year. So this is highly popular and it’s also widely used. So I think this is going to be a continued interest to me, to I think our listeners and I expect that we’re going to continue to see a tax on valuable healthcare services, and I think that people should wake up and even realize even though it’s not going to affect them today, this is of great concern.

Harlan Krumholz: Yeah, I’m glad you brought this up. I mean, just for people listening, they should know that this US Preventive Task Force, this group that carefully analyzes the literature and makes recommendations about what are the kind of things that we should be doing to keep us healthy, is in general fairly, I’m going to use the word conservative, I don’t mean this politically, but in the sense that they tend not to recommend things unless there’s actually really strong evidence. They don’t jump the gun on the evidence at all.

Howard Forman: It’s why statins were not recommended until the last decade, and it’s a good example of it.

Harlan Krumholz: Well, for primary prevention or that they’ve been ... for a lot of things. Lots of people, if anything, they’re criticizing them because they’re slow. They insist on having strong evidence before making an endorsement. And so this is why this seemed like a really good group to be the one that you would base this kind of payment policy and federal law on because you might argue you want even more covered, but it’s at least the minimum that would be covered from this. So to use this as the lever to undo some of these benefits that people get and the kind of things that might ... we’re already facing a decrease in our life expectancy. The health of the people in this nation is already turning back, and now we’re going to do more in that direction by making it more difficult for people to get preventive care. It just seems so ill advised just for the country, and I do hope that this will be ... common sense will prevail and this can be taken out of politics and looked in terms of what’s best for Americans and how best to navigate this for.

Howard Forman: Totally agree.

Harlan Krumholz: But I’m really so glad that you brought it up. It’s such an important topic. 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 or to keep the conversation going, you can find us on Twitter.

Harlan Krumholz: I’m @hmkyale, that’s H-M-K-Yale.

Howard Forman: And I’m @thehowie, that’s @T-H-E-H-O-W-I-E. You can also email us at Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs or you can check out on our website at

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management and now with the Yale School of Public Health. We’re very glad to have them join us. Yeah, this is terrific.

Howard Forman: Yep.

Harlan Krumholz: Thanks to our researcher, Jenny Tan, and to our producer, Miranda Shafer. They are amazing and we wouldn’t be nearly as good if we’re any good at all without them. Talk to you soon, Howie.

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