Nate Wood: Cooking Lessons for Better Health

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, we’re trying to get closer to the truth about health and healthcare. Our guest today is Dr. Nate Wood, but first, we like to check in on current hot topics in health and healthcare. What do you have today, Harlan?

Harlan Krumholz: Yeah, I got a couple of things, Howie, I’ll try to get through them quickly because we have such a great guest, and he’ll have a lot of good things to tell us today about food and culinary medicine. But look, this week at JACC, we have a spotlight on the hypertension guidelines. And hypertension guidelines were released in August, and these things come out and then I don’t think people really internalize them or contextualize them, and we spent a whole issue, invited 24 commentaries, Erica Spatz, who’s a faculty member with us here at Yale, played a key role in this, to try to get people to see from different angles. But just as a public service announcement, I want to be really clear about what the guidelines are saying now. They’re saying that your blood pressure should be below 130, and there’s encouragement to get it below 120.

And so, it’s unequivocal now. A lot of people grew up where people were talking about 140 over 90, and that became kind of ingrained in people’s thinking. But study after study after study has shown that we shouldn’t be content with getting people to under 140 over 90. And by the way, many people are not even at that level, but that we really need to be trying to get people to lower levels, working with them through lifestyle, working with them through medications. And then I wrote a piece in this issue that just said, I think the blood pressures of 160 and above, systolic of 160 and above, that’s the top number, should be a never event. We still have thousands of people in the Yale Health system, for example, walking around with blood pressures, we’re not talking about whether they’re 145 or 135; they’re at 165, and we’re not really making the commitment to get that under control.

And I was calling for “never event.” Now, in medicine, what we call “never events” are things that just should never happen, like you shouldn’t leave a sponge in someone in surgery, you shouldn’t do wrong side surgery. These are the kind of ways that people talk about safety never events. I was trying to get people to refocus a never event on something in prevention and population health. We should be making sure there’s no one in our system who doesn’t have the chance not to have severe hypertension; meanwhile, we have to be working at the other end to get people to a lower level. So, that was one thing, I’ve got one other, I don’t know if you want to make any comments about that first.

Howard Forman: Yeah, very quickly, I think if I remember correctly, and this is not my field, so do correct me, but I think it even is the case that for the very elderly, getting their blood pressure down still matters a lot, it’s not something that you just have to do at 60, we should be doing it at any time that we can affect it.

Harlan Krumholz: There are two very good trials, actually both out of China, they enrolled people 60 to 80 and also put them in this same regimen, half of them randomized people—unequivocal benefit. Unequivocal benefit. People tolerated it well. Yeah, people get worried about frailty, or as you get older, are people going to faint? This was well tolerated and unequivocal benefits. And so—

Howard Forman: That’s great.

Harlan Krumholz: The second thing I just quickly wanted to mention about ICER, right, this Institute for Clinical and Economic Review?

Howard Forman: Yes.

Harlan Krumholz: So, this is an independent nonprofit research institute that conducts these evidence-based evaluations of health care inventions, like drugs, diagnostics, and so forth. Just today, that’s why I wanted to mention it, just today, they came out with a report that looked at the anti-obesity drugs, and I really think this is a landmark study. And you know that there are many healthcare institutions who are dropping these anti-obesity medications... I’m not going to mention any names, but some that you know very well have dropped it from their benefits. So, people are like, these drugs are known to have discrete important health benefits, and they can’t get it through their insurance coverage anymore. Yale University, to their credit, has maintained it and kept it. They were debating it because it’s costing them money, but they kept it.

This report, which is looking at semaglutide and tirzepatide, these highly effective weight loss drugs that are unquestionably beneficial, they lead to substantial weight gain, but I would say even more importantly is the health. This isn’t about weight loss, I say; it’s about health gain. And they found that injectable semaglutide, oral semaglutide, and tirzepatide added to lifestyle modification, provided greater clinical benefit and long-term cost offsets than lifestyle alone. They’re showing that this is economically attractive, it’s a good place for us to invest with regard to the return. Even though these drugs cost money, they’re actually providing us long-term outcomes benefits that would really put us in a position of saying that they should be exactly on the formulary, they should be available to people on health insurance, and it makes clear that affordability and access are the limiting factors, and that really we should be in a position where... we’re in a broken delivery system is the reason why these can’t get made more available. But I really like this assessment, emphasize the quality-of-life gains, the productivity, stigma reduction, all these under-quantified benefits that really make a difference to people.

Howard Forman: You were involved I thought in the last... Because I remember thinking you should have talked about it on the podcast, in a study with Jason Abaluck, related, not exactly the same, but an adjacent topic about the benefits of the GLP-1s.

Harlan Krumholz: Again, putting in perspective, Yuan Lu, we published this in JAMA Network Open, again trying... Jason did a great job with this, we really took a look at Medicare data, tried to put it in perspective. And just adding to the evidence that again, I think ICER might have used, and others will look at, you can’t simply look at the cost side of the equation here; you have to be able to look at the benefits. We were looking at healthcare utilization, but when you really start looking at the whole range, people’s physical activity, the reduction in absenteeism, the increase in productivity, how people feel, the accrual of these benefits starts to show you the offsets, and I think it’s short-sighted just to say, we’re going to cut a highly effective medication because we’re trying to cut costs. And when you see it being done in institutions that are healthcare institutions, I think that’s a shame.

Howard Forman: I’m going to come back to that in the outro.

Harlan Krumholz: Okay, great. Hey, let’s get to Nate Wood, kind of an adjacent topic because lifestyle, culinary. Nate’s amazing, rock star. Let’s bring him on.

Howard Forman: Absolutely. Dr. Nate Wood is an assistant professor of medicine and the inaugural director of culinary medicine at the Yale School of Medicine, and Irving and Alice Brown Teaching Kitchen at Yale New Haven Health. Board-certified in internal medicine, lifestyle medicine, and obesity medicine, Nate practices as a primary care physician, serves as a core faculty member in the Yale Primary Care Residency Program, and co-leads the Weight Management Clinic at the New Haven Primary Care Consortium. As a chef and a doctor, Dr. Wood’s research centers around nutrition education and using food as medicine. He is passionate about educating the public with multimedia platforms, and works with patients through a comprehensive approach to health.

He received his bachelor’s degree from University of Michigan and attended the Institute of Culinary Education in New York, graduating in 2018 before completing his medical degree in 2019 at Wayne State University School of Medicine, and then doing his internship and residency in primary care at Yale New Haven Health before completing his master of health science in medical education at Yale School of Medicine and joining our faculty. So first of all, welcome to the faculty, you are doing not just amazing things, and all our guests are amazing, but you’re doing novel things, things that are just not in the mainstream of typical primary care doctors or any doctors, and I just want to start off by letting you explain a little about both lifestyle medicine and culinary medicine or the kitchen at Yale.

Nathan Wood: Yeah, absolutely. Well, first of all, thanks for having me and kudos to whatever PI dug up all that information about me, they did a great job. Excited to be here, talk about some fields that people don’t really, I feel like, know a lot about sometimes. I frequently will lecture around and say, “Who’s ever heard of culinary medicine?” And most hands do not go up. So, really appreciate the opportunity to talk about that. And I think culinary medicine is really this interdisciplinary field—some people consider it to be part of lifestyle medicine, others would say it’s quite adjacent or complementary, but culinary medicine really has this idea that if you take nutrition science, medical education, preventive and internal medicine and combine that with hands-on cooking, that you can better empower people to improve their health through food.

So, I think people are pretty familiar with the work of dieticians, where they give advice to patients about what to eat and help them break down some barriers of how to do that, but I find that one of those big barriers that is not addressed in the clinic is what if people actually don’t know how to cook, how to meal prep, how to grocery shop? And some of those skills are taught really, really well in Teaching Kitchen. So, we use the Teaching Kitchen both to teach patients culinary medicine, of course, that’s very direct, how can we positively impact your health by teaching you how to cook and prepare healthy foods—and enjoy them, I might add, and to make them more accessible—but then we also teach our trainees as well culinary medicine. So, how can we drive home these nutrition learning points with our trainees so that they’re more excited and prepared to talk to their patients about how to use food to improve their health? So, I’m passionate about both of those aspects.

Lifestyle medicine is kind of this broader field that says there’s six pillars of, really, health beyond just medication, surgeries, procedures and that if we really employ those pillars of health that we’re able to prevent a lot of diseases and certainly treat a lot of them as well. So, one big one is diet, and that’s where culinary medicine fits in, but also things like restorative sleep, positive social connections, regular physical activity, stress management, and the sixth one is avoiding risky substances. So, really just kind of commonsense approaches to improving our health with what we choose to do and put in our bodies every single day.

Howard Forman: Do you have some basic simple advice for people, including people like me, let’s say? I find preparing food from raw ingredients does seem like the healthiest approach, simple ingredients that you can actually measure out yourself and figure out what they are, but it takes so much more time than prepared foods, and there are some prepared foods that are at least a little healthier, and then there are other prepared foods that Harlan and I have talked about, that Dawn Sherling who’s been on the show talked about, that Jerry Mande talked about when he was on the show, that are just awful for you, or at least seem awful for you right now. And Eric Topol has spoke about it as well. What advice can you give our listeners today that might help them on the path towards a healthier diet, to a healthier life?

Nathan Wood: Yeah, I think a lot of people are just confused in general about what is healthy. So, I start a lot of my lectures by putting up all these headlines like, “Is Coffee Healthy or Not?” What about eggs? Where are we at with wine? Why is nutrition so confusing? It seems like there’s conflicting headlines coming out all the time, and then add in misinformation on social media and it’s not hard to imagine why our patients are so confused about what to eat. We all feel that way. So, then I try to boil down all of nutrition science into a couple of basic tenets, and to your point, Howie, we know that eating whole and minimally processed plants are good for us, fruits, vegetables, whole grains, nuts, seeds, legumes, time and time again the research shows that. And then, so I think where people sometimes go a bit awry is to say, “Okay, we know that these plants are healthy, so what’s the opposite of that? And that must be unhealthy.”

So, what’s opposite of plants: animals. But I think really what the research shows is that if we’re thinking of two opposite ends of the spectrum, with plants being on one end, the other end are probably hyperpalatable, ultra-processed foods. And I think that’s really the nexus of interest. Is this food ultra-processed, and is it also hyperpalatable? Hyperpalatable, meaning the food is high in at least two of the three following, salt, sugar and fat. So, if a food is ultra-processed and high in two or three of those things, probably not going to be health-promoting, as delicious as it may be, or as good as it may be for our soul or for comfort. So, I kind of break down some basic nutrition science for folks using that kind of spectrum with the goal of just having people add in more whole or minimally processed plants.

But we really focus on time saving in the Teaching Kitchen, and so we really like to empower patients to buy frozen fruits and vegetables because they are just as healthy if not healthier than fresh because they’re picked at the peak of ripeness and then flash frozen. And oftentimes they’re already cut up, I should say, you can pop them in the microwave or in the skillet with whatever else you’re making, they save a lot of time, they keep forever in the freezer, right? Super easy addition. Same thing with canned legumes, you can buy all sorts of beans, and chickpeas, and lentils, and things of that nature in cans, shelf stable for years, you can buy the low- or the no-sodium version, or you can rinse off some of that excess sodium in a colander if you can’t find the low- or the no-sodium version. So, canned legumes is a big one. And then lots of pantry staples can save you time and still be healthy.

So, I think people are scared of, for instance, like minute rice, but really that is just rice that has had some holes poked in it, it’s been parboiled and then dried, and it’s just rice. It’s just rice. And it just cooks faster. So, thinking about minute brown rice or things like that to really help people save time. No problem with buying some pre-chopped veggies in the produce section, and so really focusing on things like that, or how to make things in bulk, how to batch cook and freeze things that can be heated up later, how to use things like an air fryer, which I think is becoming a modern necessity, and saves people a lot of time, and allows you to use less saturated fat when you’re cooking. So, really those easy tips and tricks combined with a basic but evidence-based understanding of nutrition I think can help a lot of folks.

Harlan Krumholz: Just hearing you talk about that stuff, I think I’m getting healthier. Howie, this was a good podcast to have because we need more people from lifestyle medicine. Nate, of course, I’ve been hearing about you for a long time because my daughter’s a big fan, you got a whole big fan club and she’s—

Nathan Wood: She leads it, actually, yeah.

Harlan Krumholz: Yeah. She did start a curriculum at University of Vermont on culinary medicine and taught—she’s a registered dietician, as Howie knows, and a medical student—but has been looking with admiration with what you’ve been accomplishing and what you’ve done. I just want to repeat what Howie said for the audience, just so that they hear, triple-boarded, internal medicine, obesity and lifestyle medicine, and a trained chef. We’re really lucky to have you here, and you’re really focusing at this intersection of food equity and evidence. I want to emphasize that, because sometimes people hear “lifestyle and culinary medicine” and they don’t think that there’s also rigorous science that’s being applied to it, but you’re really pioneering approaches that are rigorously testing these things, and I just want to say that it’s needed, it’s important, and these things you’re talking about, if we’re really going to try to get people to get healthy, we have to invest in these areas.

This isn’t just a matter of being reactive and writing prescriptions or sending people for tests, procedures, this is about being proactively trying to get people to be healthy. Wanted to ask you, so what clicked first for you, the chef’s knife or the stethoscope? When was the moment you realized you could bring these two things that you were interested in together? Because there isn’t... You talk about this little bit of precedent, but I don’t know, my residency, and in my time at Yale before you came here, there wasn’t a lot of talk about this. And so, you really are, it’s something for you to see, I can actually bring these interests together. When did that happen for you?

Nathan Wood: Yeah, it’s a good point, racking up all of these board certifications, blah, blah, blah, going to culinary school, it wasn’t just like... It was very purposeful, understanding that what I wanted to do is at this intersection of a lot of different areas, and I wanted to pull, I think, from a lot of those different areas to kind of do this type of work. But how did I get into it? Basically the story is I’ve always loved food, and actually my whole family does. So, I didn’t realize we were super unique in that way, but we have to be at least two standard deviations above the mean in how much we love food. And so, that’s how I grew up. And my first hobby was eating—it’s still my favorite hobby. The love of eating grew into a love of cooking, and then the love of cooking grew into, just even thinking about food was satisfying for me.

So, really, that’s how it all started. And then I got to medical school, and suddenly there was no time for cooking, there was no time for thinking about food, there was barely time to eat. And so, I really started to dream about this getaway to culinary school, and really how could I combine food and medicine together in order to be fully satisfied in my career, and to fill these gaps that I saw of how it was not being addressed in tandem. And so, that led me from food, to medicine, to culinary school and then ultimately to combine them in residency and beyond.

Harlan Krumholz: Help me think about this paradox between the recognition that food is so important to health, and also not just in maintaining your health but in helping people who are going through disease, their nutritional status, what they’re taking in, and the lack of respect that the medical profession has historically shown towards food, and this aspect of nutrition of health. And I just say it’s paradoxical because you think that we would double down, we double down in research, we double down in how we try to learn and think about this. And now, there’s this thing that’s come out, “food as medicine,” which feels a little different than the lifestyle medicine, the culinary medicine, how do you situate these trends that are happening? How are you helping to mainstream this? And how are you helping to help people recognize what needs to happen, given the historic neglect of this area of our lives?

Nathan Wood: A lot of good questions in there. So, to touch on this field of food is medicine. Food is medicine, yes, but it’s also community, it’s culture, it’s creativity, it’s how you stay connected to the people you love, it’s how you express love to other people... Food has all of these different roles, and of course many of those are not under the purview of medicine. But I think we’ve historically done a very bad job of convincing people that food is medicine by disregarding all of those other roles that food plays in our lives. And understanding that, I think the average patient probably thinks that their doctor eats super, super healthfully. And I have to say, on the whole, I think doctors do probably eat better than the average—

Harlan Krumholz: Or at least they also think that the doctors know a lot about nutrition.

Nathan Wood: Both. Yes, exactly right, that they’ve been super well-trained in nutrition, they know about food, and that they eat super well. And really neither is the case. But what I think I’ve really noticed about physicians who do eat well is that they’re not overly stressed about it. They know that food’s important for their health, they’re still eating birthday cake at a party, they’re still eating pizza on a Friday night once in a while, they’re still having nachos at the game. And I think sometimes we go to the extreme as clinicians and tell our patients, “Okay, well, you have to give all of that up. If you have diabetes, you can’t ever eat sugar again. You have heart disease, say goodbye to fat the rest of your life.” And these extreme approaches I think have really done a disservice to the message that patients are hearing.

And I think what we need to do, we need to recognize that food has all these roles and one of them is as medicine. The other thing I wanted to mention is this “food is medicine,” how does that fit in with lifestyle medicine and culinary medicine? So, food as medicine is an amazing field and I think largely seeks to address actually food insecurity at the base levels, which is something that medicine hasn’t really forayed into before, but increasingly, as our social safety net in this country erodes, I think anywhere where we can find financial incentives to get people access to healthy food, that’s going to improve outcomes, and it’s the nice and the moral thing to do. So, at its base, I think food as medicine really seeks to do that, and then as you go up into the more intensive interventions, like medically tailored meals, it’s saying that basically we can keep people out of the hospital and give them, in some instances, fewer medications for lower costs if we give them access to healthy food, which just makes sense in 20,000 different ways.

So, really great field, and then if folks out there listening are familiar with the food is medicine pyramid, which shows all of those different layers of interventions along the side of the pyramid, which is to say, at each of these levels, nutrition education and culinary instruction is recommended, and that’s how we think culinary medicine and lifestyle medicine fits in. So, it’s just fun to see all of these different fields cropping up at the same time, trying to achieve slightly different things, but they work so well together, and at its core is this understanding that people should have access to and enjoy healthy and delicious foods, which I find really inspiring.

Howard Forman: So, one of the things that you just touched on are the incentives for being able to educate people to be able to bring this into your practice, you’re a primary care physician. I presume that if I were to compare you to other primary care doctors, you probably do bring this into your practice more, but there’s nominal to zero compensation for that added value that you can bring. Are there examples that you can point to right now where either systems or payers are starting to pay for this in a meaningful way that can help change behavior among the populations that need it most?

Nathan Wood: Yeah, that’s such an insightful question. So, I do provide some dietary counseling for sure in my practice—to your point, not really getting compensated for it. I think the biggest thing that I changed, the more I’ve learned about nutrition is I refer to dieticians more and more and more. And as I got my medical education scholarship training, I really bought into this idea of the flipped classroom, and I’ve started to employ that with my patients, where I’ll give them this handout, and I’ll say, “I want you to read this at home. Bring it back to me next time all marked up with the questions that you have, and let’s go through it.”

Howard Forman: Great.

Nathan Wood: Yeah. Because then that gives you some opportunities to do teaching in a more efficient way and to make it longitudinal, so I have found that to work really well with patients, and I’ll send them things via MyChart message or put it in their after-visit summary. But again, to the point of compensation, if we really want this to happen, we have to compensate physicians for it so that they can make time for it because time is so limited. I think the model that currently is working are shared medical appointments, SMAs, and so those work for lifestyle medicine, certainly, and I’ve seen them much more working for culinary medicine as well. But that’s where you get a whole bunch of patients together, maybe ideally 10 to 20, somewhere in that range, I think the 12 to 16 is probably ideal, and then folks join either in person, or you can do this all on Zoom actually, which is amazing. And then you provide some counseling, and then you do little breakout rooms where you measure their blood pressure, do some brief counseling, or help the patient make a smart goal, as they’re called.

And then, you can bill all of these patients at once for that one-hour group visit. And so, I’ve seen that actually working really well for providing this kind of commonsense, otherwise not-well-reimbursed education in the fields of lifestyle medicine and culinary medicine. Of course, as we move towards value-based care, hopefully there’ll be other opportunities to get this reimbursed in more meaningful ways, but in the interim, that’s really what I see working.

Harlan Krumholz: One thing I wanted to ask you is, of course, the anti-obesity medications are one of the hottest things going on in medicine, and how does this fit alongside lifestyle medicine, culinary medicine, a lot of your emphasis has been on how people live their lives, and what they do now, and I think this will be unfortunate messaging, but some of the messaging might be “All you got to do is take the med.” And you know of course, the best practice, and Ania Jastreboff, I know we’ve talked to her about this, is to come together on both sides. How do you improve lifestyle? And for many people, medication is needed, necessary, useful, helpful, but not to just default to medicine as if it’s the only thing, and you want to try to bring this together. But how are you seeing this and how are you integrating this into your practice? So, are you using these meds? How are you using them? And how are you bringing it together with your historic approach?

Nathan Wood: Yeah, certainly, I love these meds. You’d be hard-pressed to find someone who likes them more. So, I’m using them all the time, and I think of them as just like an extremely powerful tool in our growing toolbox. So, specifically for the treatment of obesity, what we have really learned over time, I think, is that the prevention of obesity and the treatment of obesity are different. And that is the case I think for other diseases as well. Once you have plaque in your arteries, you can’t just eat a little bit healthier and expect that plaque to regress, the treatment becomes different. And so, I like to explain that to people. But like many diet-related diseases, whether it’s fatty liver disease, or type 2 diabetes, peripheral artery disease, MIs [myocardial infarctions], strokes, and the list goes on, the combination of pharmacology and lifestyle together, pretty hard to beat. Either one alone, good, very good, but when you combine the two together, it’s just hard to beat.

And so, I feel the same about these GLP-I medications for really all of their indications, not just for weight loss and the treatment of obesity. But really, if you can give someone one of these medications, which works on the appetite control centers, as you well know, what we find is that this eliminates or reduces food noise such that patients are motivated by the number they see on the scale dropping, or they have more time or emotional energy to think about these other lifestyle interventions that they’ve undoubtedly tried in the past and know that are good for them, but now they have a greater ability to do them. So, really, I think it’s kind of a crucial time of increased motivation to really capitalize on, “Okay, now that we’re thinking less all the time about food and our food preferences are changing....” Which, a lot of people on these medications note, really gravitating less towards these hyperpalatable ultra-processed foods and craving things like fruits and vegetables.

Time to really capitalize on that, and to get them into the gym to maintain that muscle mass, getting adequate sleep because some people definitely notice some fatigue on these medications, to emphasize the increased consumption of micronutrients through fruits, vegetables, and other plants, which is necessary as they’re eating less, and to think about protein intake, and maintaining those positive social connections as they’re going through changes with their body and may need a support network. So, I think again, this story of, “I have a chronic condition, should I take a med or should I employ lifestyle?” The answer is probably “both” for a lot of people, if someone’s only really willing to do one, then I will definitely work with them on that. And I think one tool is better than no tools, but really the combination is just hard to beat, and they really support each other.

Howard Forman: Last question from me. There’s an awful lot of things that are described as “superfoods” right now, acai, and kale, and whatever... there’s so many of these. Can you just tell us, are there any of these that you truly think are superfoods? Should we be having certain foods in our diet that maybe we don’t currently have?

Harlan Krumholz: I thought your favorite superfood is ice cream? Remember when I used to see you walk around, Howie, with an ice cream cone that went up about two feet in the air, because—

Howard Forman: It’s still my superfood, Harlan. The biggest treat I have is going to Arethusa and getting ice cream. Yeah, I don’t think that’s a qualified superfood, though.

Nathan Wood: I was going to say, we’ll have to talk about your favorite flavors after the recording’s off here. I love some ice cream. My grandparents—90 years old—are a daily ice cream consumer, so runs in the family.

Howard Forman: I’ll hang out with them.

Nathan Wood: Yeah, exactly. Superfoods, I think it’s just a tricky word basically, because it emphasizes that some foods are just like, you should eat as many of them as possible, and they’re so much better than other foods, and so the media certainly loves that message. I would say it’s not my favorite word to use, but if you pushed me against a wall and said, what are superfoods? I would say berries. Berries are really superfoods.

Harlan Krumholz: Ah, berries, yeah.

Nathan Wood: Yes, packed with fiber. Packed with fiber, packed with antioxidants, really a low amount of sugar for the amount of fiber that they have, and I don’t think we can eat enough berries, really. So, berries of all kinds. And I think they’re kind of head and shoulders above the rest. So, you mentioned acai being one of them, but really any berries are good, I think we could all stand to get some more of those in our diet, especially with something like a nonfat Greek yogurt or a skyr or something like that. It’s a great way to start the day.

Harlan Krumholz: I knew this show was going to make me hungry, Howie.

Howard Forman: And we’ll put your Instagram account in the show notes, but DrChefNate on Instagram, and you do have a lot of good content there, and it’s fun to watch.

Nathan Wood: Oh, thank you, appreciate it.

Harlan Krumholz: Thanks so much, Nate, it’s wonderful to have you.

Nathan Wood: Thanks for having me.

Howard Forman: It’s awesome. We’re so lucky to have you working with us, and the patients and the community benefit so much—

Harlan Krumholz: Next time we do the show, Howie, when we invite him back, we’ll do it in the kitchen.

Hey, that was a terrific interview, that was really a terrific interview.

Howard Forman: He’s a really good guy. Did not know him before.

Harlan Krumholz: Yeah, lots of charisma, tons of smarts, and he’s really paving the way for this at Yale. We’re really lucky. Hey, but let’s get to your section. What’s on your mind this week?

Howard Forman: Yeah, so I think I’ve talked about this every year of the podcast, so I’m not going to change it up this year. Every year, Kaiser Family Foundation works with a consultancy to issue a survey of employer health benefits. It gets released each year and published in Health Affairs, and it’s a consistent methods survey. So, it’s pretty useful for looking at what employer-based or the health benefits that we get at our jobs look like nationally. And it’s unsurprising, honestly, but really still useful to highlight for our listeners. So, I’m going to just go through some of the findings here. And by the way, Yale’s health benefits, whether it’s for faculty or staff, are so similar to the findings in this survey. So, just to put it in perspective, this is not a survey where you look at the numbers and you’re like, “How can this be?” This is almost exactly Yale.

So, first of all, average annual premium for family coverage has now reached $27,000 a year, $27,000 a year. So, I want to put that in perspective, because if you are working 1,800 hours a year, which is a typical full-time job, that means your employer is assigning $15 an hour to your healthcare costs. That might not seem like a lot to some people, but that is more than twice the federal minimum wage, and it’s higher than the state minimum wages of all but a handful of states. So, when people talk about policy around minimum wages, they should think about just providing healthcare as being a core promise to employers to make certain they have something that is more valuable than just a minimum wage. And while the cost is high, the healthcare costs are high, it’s worth pointing out that the employers do subsidize most of it.

Eighty-four percent of the cost for an individual policy is paid for by the employer, 74% for family plans for when an employee is covering their entire family. That still means that employers enrolling in a family plan are using their pre-tax compensation to pay for more than a quarter of the cost of their plan, or $7,000 a year. So, again, not inconsequential; these dollars matter. So, a few other key points, and then I’ll let you tell me what you think of this. Forty-three percent of large firms now cover GLP-1s for obesity, with limits, but still that’s up from 28% the year earlier. So, that’s to the point you were making earlier in this segment, even though there are definitely places that are pulling back from coverage, broadly more places are covering obesity medications. There are some surprising findings, there’s... relatively small percentages of employers are reporting that their employees were reporting challenges with preauthorization or with denials.

And I say that that’s surprising because my experience is that most people are actually very concerned about preauthorization or denials, and I’m wondering whether this actually represents a major disconnect between what the employers are reporting and what their employees are actually experiencing. And it may just be the fact that very few employees face such a challenge in a given year. When employers were asked what contributed to higher prices, they blamed, almost equally, prescription drugs, hospital prices, higher utilization, and chronic diseases. And then lastly, and this is a little unrelated to this survey, but it’s something we talk about a lot, the ACA exchanges, the Obamacare exchanges, will officially open nationally on Saturday, and we’ll have a preview of what is to come. So, premiums on the exchanges are set to rise a whopping 26% this year, and while the news made that sound like it is comparable to employer-based policies, it’s not comparable because 26% is not the same as 6%.

Now, lest our listeners be confused, that 26% is what insurers will charge for the policies, but then the subsidies reduce the cost to the employees for those who have a compensation at 400% of the federal poverty level or below, and 400% of the federal poverty level—we’ll just call it around $65,000 for 2026. And as we’ve discussed many times, there are enhanced subsidies that are going to expire at the end of December, if those are not renewed, and that is very much up in the air, the net cost increase to the end consumer will be more than 100%, according to the Kaiser Family Foundation. And that, in my opinion, is very burdensome.

Harlan Krumholz: There’s a lot in there, Howie.

Howard Forman: Yeah.

Harlan Krumholz: The one thing that I wonder about, though, when I look at what Americans think about what are the most important issues facing America, on one hand we talk every week about these increasing costs, the burden, poor care, bad outcomes, and only 11% of Americans are saying it’s the most important issue facing America. Still people are focused on the economy, inflation prices, jobs in the economy, and Democrats a little more than Republicans, but it’s pretty close. A lot of issues there’s a divergence, but here, Democrats, 14% say it’s the most important issue, Republicans 8%. And I just wonder if there’s going to be movement until this becomes higher. Maybe it never will become higher than inflation prices because that’s just everyday table stakes for everybody. But we talk about this, but I don’t see movement on the Hill, even I don’t see outcry about the increasing rates that are going to happen just in a few weeks, and so, of course we’re gridlocked still. So, I don’t know, I am trying to figure out what’s going to start moving the dot here because—

Howard Forman: I think it’s a good example of where social media and media in general drive things, and if you think back to ’93 and ’94, you think back to 2009 and 2010, the outrage machine around healthcare was so high, healthcare costs were so high an issue, and now they’re triple and double those levels of just a short while ago, it has to make you think that people are upset about it, but they just haven’t been stoked around outrage.

Harlan Krumholz: And just the final thing here is, you’re talking about individuals, but when you look at towns, these are roads not being fixed, these are teachers not being hired—

Howard Forman: That’s right, totally right.

Harlan Krumholz: ... because all that money’s going to the healthcare system.

Howard Forman: I agree.

Harlan Krumholz: And the healthcare system becomes big, it’s number one employer in many places, but it’s pulling money away from other things.

Howard Forman: Yes. It crowds out other spending, and that spending may be more valuable, education, roads, things like that can be very valuable.

Harlan Krumholz: Unlikely to be the last time we talk about this. 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, email us at health.veritas@yale.edu or follow us on any of social media, we’re going to have an Instagram account soon too.

Harlan Krumholz: We love your feedback, we like to hear from you, helps people find us, and we do our best to get back to you.

Howard Forman: And if you have questions about the MBA for Executives program at the Yale School of Management, reach out via email for more information or check on our website at som.yale.edu/EMBA.

Harlan Krumholz: Health & Veritas is sponsored by the Yale School of Management, the Yale School of Public Health, both of whom we’re very grateful. We have superstar students, Gloria Beck, Tobias Liu, an amazing producer, Miranda Shafer, and I’ve got the best co-host in the business—

Howard Forman: I appreciate you Harlan, really very much.

Harlan Krumholz: Talk to you soon, Howie.

Howard Forman: Thanks Harlan, talk to you soon.