Rahul Rajkumar: Intensive Home-Based Care for High-Need Patients

Harlan Krumholz: All right. 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 today. Our guest is Dr. Rahul Rajkumar, Yale alum. But first, we always check in on current or hot topics, but Harlan, you’ve just returned from one of your many trips to China as part of your role as editor of JACC. So any updates on that? What was that experience like?‌

Harlan Krumholz: Thanks, Howie. I had a great trip. It was fantastic. It always strikes me, this sort of juxtaposition between the geopolitics, where the two countries are really at such odds with each other, there’s so much tension, and actually, what happens when you have people connecting with people. When I go over, what I see are people who are just aspiring to live their lives. The students I meet are just so diligent. They really want to learn. Of course, we’re meeting them in the context of healthcare, and they’re trying to figure out, how can they make a contribution? How can they be as good as they can be? How can they generate research? How can they find a path? And I’m always sort of elevated by the opportunity to meet people of very different walks of life over there who are just amazing people. And so I had a really great trip. I just wish the world could connect more like that than all these other sort of things that are going on around us, which are making it hard.‌

I wanted to just say that I don’t think I’ve ever talked about the Biosecure Act, but there’s just all these forces that are happening that are separating the countries, and there’s all this discussion about uncoupling the economies and uncoupling the work. And I think that when the world’s interdependent, there are such great incentives for us to get along. The more that we uncouple, the more likely we are to have little incentive to make sure that we can all work well together.‌

This Biosecure Act is interesting. It was passed by the House of Representatives in September. The U.S. bill aims to curb foreign influence, especially from China, on U.S. biotech. And on the surface, it’s about protecting national security. I understand it, but beneath that, it really raises critical questions about global health, research, patient care. So this whole thing is that China’s biotech sector is advancing rapidly, and it’s aided by policies like this military-civil fusion, which integrates civil technologies with the country’s military capabilities, which is what raises everyone’s level of concern, that these aren’t really just private enterprises, but they’re state-owned enterprises.‌

And so the bill specifically targets five Chinese biotech companies, including BGI, which was the Beijing Genomics Institute. It became called BGI and actually moved out of Beijing. I’ve been there, visited them. They have vast capabilities in the areas of genomic and genomics and proteomics and something like WuXi AppTec, which provides critical services in drug development and gene sequencing. And I say this because if you’re interested in health and healthcare, invariably that intersects with biotech and the work that’s going on there. So like I said, I’m over there. Everyone wants to coordinate and collaborate. How can we work together on studies? How can we help build capacity around how do you do clinical trials? How can we improve healthcare quality? What can we learn from each other? There’s a lot of work there around AI. I saw some amazing programs that can help extend the ability of physicians to provide great care. I visited extraordinary hospitals that have just amazing new approaches to care that we can each learn from each other.‌

And at the same time, right beside that, we have this Biosecure Act, hasn’t passed the Senate yet, but I’m guessing in this next administration, this might move forward. I think also, the Biden administration has also had all these concerns. And this bans federal contracts with these designated companies, restricts U.S. entities from using equipment or services from these firms, and introduces safeguards to protect U.S. genomic and biological data. So when I’m an open science guy, I’m really pushing for how can we all get along and how can we share? And then these forces are sort of pushing away, and it’s going to affect drug availability, by the way. WuXi AppTec provides a pivotal role manufacturing key ingredients for lots of drugs. So it’s hard to see how that’s going to work.‌

Higher research costs because firms like BGI provide affordable gene sequencing. And if that’s really considered part of the Chinese government, we’re going to cut that out. That’s going to be a problem. Collaboration breakdowns, and it could even cause access inequities around ability to provide services and drugs and so forth to underserved areas. So in essence, this is going to be about how you balance security and health: where are those areas that we can come together no matter who you are in the world, and where are those areas that are going to be problematic? I don’t know where it leaves us, but like I said, I had a trip where I got to meet a lot of people who are eager for positive collaboration that can contribute to advancing global cardiovascular health. And at the same time, we’re in the midst of a moment where the countries themselves see themselves as openly competing for similar resources and are worried about how collaboration will undermine national security. So I don’t know where it ends, but anyway, that’s the circumstance.‌

Howard Forman: Look, we’re in a time right now where isolationism and sort of America First agenda is rising up again. And while there may be benefits to some populations in the United States from that agenda, it is not without its costs as well. And so I am not looking forward to seeing what the outcomes are, but I do believe what you’re seeing is real, and we have challenges ahead.‌

Harlan Krumholz: So, we’ll see. But meanwhile, I build on the friendships I have, and we try to find out places where we should all be holding hands and trying to make progress together. So we’ll continue to try.‌

Howard Forman: Yep.‌

Harlan Krumholz: All right. Well, hey, we’ve got one of our favorite people coming for the next segment, who’s doing some very interesting things entrepreneurially. Let’s get to our guest.<start>‌

Howard Forman: Dr. Rahul Rajkumar is the CEO of Accompany Health, a new organization taking an integrated approach to bringing care to underserved patients at home. Previously, and this list could be very, very long but we’re going to keep it short, he was the senior vice president and chief medical officer at Blue Cross North Carolina and chief operating officer at Optum Care Solutions. And prior to this, he was the deputy director for the Center for Medicare and Medicaid Innovation, where he also helped to launch alternative payment and accountable healthcare community models. An internist by training, Dr. Rajkumar worked as a physician at the Brigham and Women’s Hospital before becoming a consultant at McKinsey. And he holds a bachelor’s, an MD, and a JD, all from Yale University.‌

Harlan Krumholz: And he was one of our favorite students.‌

Howard Forman: He absolutely was. I’ve known him since—‌

Harlan Krumholz: One of our favorite students of all time.‌

Howard Forman: First year of medical school, I think both of us have published with him. He is a gentleman and a scholar. So we’re really pleased to have you here. And usually I start and talk about the journey, but in this case, I sincerely want to learn about Accompany Health. I don’t know enough about it. And I’d love to ask you, what prompted you to start this company? You’re the founder and CEO of it. And what are the goals, and how does it compare to other companies in this space?‌

Rahul Rajkumar: Yeah, thank you. First of all, thank you for inviting me here today. And may I just add one thing to the introduction before I answer your question? The most important thing you left out is that I’m a failed health services researcher.‌

Howard Forman: That is not true.‌

Rahul Rajkumar: I just want to offer it to all of your other students. But if you totally wash out on the Harlan track, there’s still something for you in your life.‌

Harlan Krumholz: You found a different track that was best for you. It wasn’t about what you couldn’t have done. You’re pluripotent. You could do a wide variety of things. It’s just—‌

Howard Forman: Choices.‌

Harlan Krumholz: This is an important point, Rahul, that sometimes people come in, I see students, and they think that we want them to be us, and we just want them to be them. Where can they make the best contribution? What, for their life, is going to be best? I have just looked at your career with such pride. The degree of contribution, and the way in which you’ve been able to manage different opportunities, it’s been fabulous. You didn’t wash out on anything.‌

Howard Forman: He’s kidding. And look, some of the publications you have been involved in were fantastic. So there’s no question you could have been whatever you wanted to be.‌

Rahul Rajkumar: I really appreciate your saying that. Please allow me just to dwell on this for one second because this may be the most important thing I say on your podcast, because I feel like I’m speaking to current and future students of yours. Harlan, you probably don’t remember this conversation, but when I told you I wasn’t interested in research, 25 years ago now, I was very nervous about that conversation and, very much to your credit and to Howie’s, you have continued to be a wonderful mentor and guide—both of you have—and we’re talking today! And so what I would say to future students, current students is, don’t be afraid to do what you care about and what interests you.‌

Harlan Krumholz: That’s right.‌

Rahul Rajkumar: So Howie, to answer your question, Accompany Health provides home-based, technology-enabled primary care. We do this for low-income Americans. And so, every one of our patients gets a full-care team. They get a community health worker, a nurse practitioner, physician, psychiatrist, social worker, pharmacist. So think of this as high-intensity, home-based, tech-enabled care for people that really need it. And we are focused specifically on Medicare/Medicaid duals.‌

Howard Forman: Explain.‌

Rahul Rajkumar: So these are people that are on both the Medicare and Medicaid programs. So think of it as an overlapping Venn diagram. There’s Medicare beneficiaries, there’s Medicaid beneficiaries, and there’s 10 million Americans that are on both public programs. And being on both Medicare and Medicaid, in addition to being in these two public programs, it’s a wonderful heuristic for selecting a population that has a very high clinical need and a very high social need. You basically have to be old and poor, or disabled and poor, to be on both of these programs. These patients, in addition to having high clinical need, high social need, they all have really complex benefit structure. You would think that Medicare and Medicaid have figured these things out, but they really haven’t. They’re often on two different managed care plans, and just the benefit structure itself is extremely complex. So this is the place where we apply the care model, but we provide home-based care, and I would describe it as care that we try to treat our members as if they were members of our own family. And that is the guiding value and principle.‌

Howard Forman: Can I just do a couple of quick follow-ups to that, just to clarify? One is, who is paying you? Are you working with a Medicare Advantage plan? Are you working with a coordinated plan? And secondly, did this become more accessible with the ACA passing? Because prior to the ACA, there wasn’t even a central office for dual-eligibles. They really were very discoordinated programs.‌

Rahul Rajkumar: Yeah. I think ACA helped a little bit, and I think we expect that there will be continued tailwinds in this space. But to answer your question, we work with managed care plans. And so, we take full capitated risk from D-SNP plans. D-SNP is Dual Special Needs Plan. It is a specific type of Medicare Advantage plan that’s specifically designed for dual-eligibles. So people on both Medicare and Medicaid have a special type of Medicare Advantage plan that they can enroll in. And that’s the type of plan that we work with. And capitated risk means that we take full risk for the healthcare dollar. We are responsible for all of the medical spend for the patients that we serve. And that is the magic by which this care model works. The theory of this is that by providing intensive primary care, behavioral care, you’re keeping people out of the hospital, you’re improving their quality of care, and we harvest those savings to power the whole thing.‌

Howard Forman: So this is a good segue. I want to make sure we have time for you to talk about what your personal healthcare experiences have been like and how they have informed your decision to pursue this.‌

Rahul Rajkumar: You may know my father got sick about three years ago, and then he died last December. It was the most important learning experience in the healthcare system I’ve ever had. And the types of things that you learn are what happens in the interstitial spaces of healthcare. So we see patients as providers in the office, during a hospitalization, but what happens to them in between those times? I’ve been very blessed to have not only both of you, but many of the people I trained with that helped my father during his illness. Without those people, I just don’t know how we would’ve made it through that.‌

Part of what we have tried to reconstruct in our own care model in Accompany Health is that level of support. When I say we treat people like family in the care that we provide, I literally mean it: be available to them 24/7, help them with complex decision-making. One of the things we do, to give you a concrete example of it, we actually accompany our patients to visits, to a primary care visit or to a specialist visit for our most complex patients, as if we were a member of their own family. And we try to build a bridge to the primary care provider, to the specialist.‌

Harlan Krumholz: And who’s the “we”? What level of training is that person who’s accompanying?‌

Rahul Rajkumar: It would be a community health worker who does that. The function of that person is just take notes, to make sure complex instructions are followed, to relay information back to our care team. It’s to be a bridge. I have played that role. When I think about my father’s care, yeah, I’m a physician, but when interacting with his providers or his oncologists—he died at Yale, he received care from your colleagues—but I was taking notes, I was asking questions. I was there to support him and make sure that we were making good decisions together.‌

Harlan Krumholz: So, can you just articulate the central thesis to this? Because a lot of people would like to go after this idea, but it’s hard. It’s hard because of the perverse incentives in our system, the way in which everything’s set up. The social determinants are so overwhelming for these people. It’s really not about just medicine. It’s about the holistic approach to patients, but there’s so much that conspires against being able to execute successfully. So as you moved forward and you were trying to convince people to come on board, what was the central thesis here? What was going to be the special sauce and the differentiator for what you were going to do, and what was it that was going to be the key success factor that distanced you from others?‌

Rahul Rajkumar: Yeah. So I’d say the thesis is a blend of really three things. We hire really special providers. We hire about 1% of the providers that apply for jobs in our company. We put everybody through case-based interviews. We are looking for do-whatever-it-takes providers. We arm them with technology. So the second thing is, where do you place the tech bets? And so there are plenty of companies out there that I see placing bets on technology that I think are ill informed. We are not trying to rebuild the EMR [electronic medical record]. We’re not trying to build bots that take care of patients. We have very specific applications of technology to make our providers more efficient and effective.‌

But the third is finance. I am no longer the world’s greatest doctor. I’m not sure I ever was, but my superpower is the connection between healthcare finance and healthcare delivery. And you really have to know what population you can zero in on where you can make the math work for this type of care model. And I can tell you some of the ideas we discarded along the way. There are many subpopulations of deserving Americans that could benefit from this type of model where I think you can’t make the math work. So one of the differentiators is zeroing in on the right population where you can make the math work. It’s three things. It’s people, it’s tech, it’s finance.‌

Howard Forman: So along those lines, you yourself, I think, still live in sort of the Mid-Atlantic region or thereabouts?‌

Rahul Rajkumar: I live in Maryland, yeah.‌

Howard Forman: And your original locations where you’re deploying this, I don’t know if it includes the Mid-Atlantic, but I think it’s including places like Detroit and some other areas. Can you tell us about how you make decisions like that about where do you first deploy your resources to start contracts?‌

Rahul Rajkumar: Yeah. We look for a certain amount of density. We look for a certain amount of clinical and social need and a relatively unmanaged population. So there are some islands of excellence in the United States with well-managed populations. There are relatively few of them, but we’re looking for a relatively unmanaged population that has significant clinical opportunity, improvement opportunity. But the other part of this is that we’re going where we can find an interested payer partner. And so our first relationship was with CVS Aetna, and this was a priority market for them in Detroit. I would say Detroit is probably one of the hardest places where you could start, just for historical reasons. It’s a very challenging place to start from a perspective of the labor market and the patient population. So it is like the hardest version, but Bob has this wonderful saying, Bob Kocher, about you should start with the easiest version of the hard thing. This was like the hardest version of the hard thing, doing this in Detroit.‌

Harlan Krumholz: I’m intrigued by this idea about where the math works and where it doesn’t work for two reasons. One, it may point us to where policy needs to change, where actually people are being disadvantaged because there’s just no way for innovators to come in and try to put together new models of care because of the way it works, and then, by where it does work, by what that can teach us. Because where the math works are places also where we’ve, I think, largely around the country failed to provide the kind of care that people need, even though the math would have worked. That you’re coming into that suggests that it still represented open space for someone to be able to create something, to really take what’s possible and make it happen.‌

But let me start in the first one. So as someone who’s been in government, who are the people who are really being left behind, that there’s just no way for sustainable innovation to take hold because the math is just so bad, given the reimbursement and what happens? Who are those people?‌

Rahul Rajkumar: Yeah, I’ll give you a couple of examples. I think if you look at a straight Medicaid population, I think many people may not appreciate that Medicaid is actually multiple programs wrapped up in one. So there’s an expansion population, there’s TANF, Temporary Aid to Needy Families, there’s age, blind, or disabled, and then there’s children. And each of them has a slightly different financing structure and slightly different authority behind it. But within each of those, those populations are really problematic for building a care model, for two reasons. One is the underlying payment rates are quite low.‌

Harlan Krumholz: Again, I just want to make sure listeners understand. When you say “care model,” could you just explain what that is again, just so people know?‌

Rahul Rajkumar: Care model is what your providers do. It’s what do the doctors, nurses, community health workers, all the people on the care team, who’s on the care team, and what do they actually do? What kind of care is being delivered? We provide a lot of care. And what I’m saying is that you can’t pay for a lot of care if the financing is not high enough. And it’s both a question of the financing being high enough, or adequate, but it’s also that the population is really unstable in straight Medicaid. There’s a lot of churn in and out of the program, and it is very difficult to make it work if you make an investment in a population and patient, and then six months later, they’re out of the program. You really need to make investments and then see a return over many years.‌

Harlan Krumholz: But who? I’m just trying to pin you down a little bit. So who would be an example of a group that we really need a better policy remedy to make it attractive for people to come in and innovate how we deliver care to these people because the revenue would be sufficient to provide reward for a group that innovated and improve the care?‌

Rahul Rajkumar: Yeah, so I would say a low-income, 35-year-old adult is an example, just making up an example, who is not Medicare-eligible but is on Medicaid and has—‌

Harlan Krumholz: The reimbursement is so low, essentially, for those groups that it’s very hard to find any margin for an entrepreneurial solution to create a fix. Is that what you’re saying?‌

Rahul Rajkumar: That’s a nice way to put it. Yes. I would say there are populations of children that have multiple complex needs. Really, think of a child that has—‌

Harlan Krumholz: But I’ve seen entrepreneurs trying to build models for caring for patients, children with Medicaid. And are you just suggesting that they can try, but in the end, the margins are so low that it’s very difficult to be able to make it work?‌

Rahul Rajkumar: I haven’t seen a successful one.‌

Howard Forman: So along those same lines, Harlan and I just recently talked about, I think, CareBridge, which is one of the Carelon subsidiaries of Elevance. We know that just in the news today, UnitedHealth Group is being blocked by the Department of Justice in buying Amedisys, which also has home care elements to it. There’s Oak Street. There’s a lot of firms out there that on the margin are trying to do, I think Cityblock, another example, that are trying to do some of the things you’re doing. Do you see yourself competing with any one of them? I don’t mean competing head-to-head, but do you see yourself in that space, or are you so unique compared to those entities right now that you’re just a level above?‌

Rahul Rajkumar: Each of those is a really interesting, wonderful comparison that we could have a half-hour conversation about any one of those. I would say this. We are different from each of those, but we have learned a lot from each of them. So there are people on our team that come from some of those companies. I often describe us as a fourth-generation primary care company in the sense that we are not the first people to build a company on the rails of capitated primary care risk, but we have the benefit of learning from others that have done variants of this before.‌

So CareBridge does risk-based care management for a specific type of Medicaid beneficiary. There are some duals mixed up in there, but it’s not focused on duals. Oak Street Health is clinic-based care for seniors that are on Medicare Advantage plans. And so there are little things that we have learned about their operations, about how they provide care, what they focus on, how they contract for risk, maybe too many things to talk about in the time we have, but the higher-level point is there’s a lot to learn from others that have attempted related things.‌

Harlan Krumholz: So as someone who’s sort of in the midst of this, I don’t know if you know, but last week there was an election. There’s going to be some changes in the country in approaches towards this. Does that matter for your company? Does it matter which administration’s there, or will that affect you at all?‌

Rahul Rajkumar: I’m sure it’ll affect us. I don’t know the ways in which it’ll affect us. My own prediction is that... well, I have two things. The concept of value-based care, of making healthcare more efficient, of improving its quality, these are broadly shared by Republicans and Democrats. There’s quite a bit of support for Medicare Advantage, for ACOs [accountable care organizations], for value-based care from both Republican and Democratic administrations. I think there are some ways in which a Republican administration could create tailwinds. We contract with managed care plans. So one thing that’s happened for your viewers, over the last 20 years, is the penetration of Medicare Advantage has increased, compared to 20 years ago. Now a majority of Medicare beneficiaries are in Medicare Advantage plans, and I would expect that to continue or even accelerate in a Republican administration. Notwithstanding any of my personal views, of which you can Google and look, but—‌

Harlan Krumholz: But you’re kind of insulated from it. Let me ask you another quick question, and then I’ll pass it over to Howie. So how does an entrepreneur take care of him- or herself?‌

I’ve stumped you, I see.‌

Rahul Rajkumar: No, no, no. Well, I get up early in the morning, I run. My main form of stress relief is running. I just love to run. I try to make time for myself, but that’s the main way I use it. Maybe this is a message I’m leaving to future self or children who will watch this in the future. This has been an incredibly difficult two and a half years.‌

Harlan Krumholz: And just to finish this, one of the things that I found as I was dipping my toe in this was that I really believed in something that I was doing, but... and there’s no “but” here. One of the principal responsibilities is to sell the idea and to sell the product, to really get people on board. And it puts you in a different position than you’ve been in before because... and I found that personally hard because it just seems so obvious to me this is a good thing, but sales is a whole nother thing. Was that hard for you at all?‌

Rahul Rajkumar: The answer is yes, but I would maybe shift your frame a little bit, Harlan. I think that, my personality is, I’m a deeply introverted person, and this is probably the most that most people will ever hear me speak on this podcast. And so if in your mind you conjure the image of a sales guy, I’m never going to be that guy, and that’s an impossible bar for me. But if I were to reframe and say that the CEO’s job or the founder’s job is to tell the story, I think there I feel that I can excel. And I’m sure you do, too, because there are different things you can draw on in the art of storytelling, and it’s okay and it can be an asset to be truth-seeking, to be honest. So I would maybe resist the caricature of selling, and I think it’s more about nuanced storytelling.‌

Harlan Krumholz: Oh, that’s beautiful. Well, this has been a remarkable conversation. I know people who are listening can get a sense of your soul, what really is important to you and what you try to accomplish. This is the best of the entrepreneurism, where a need is identified, especially for a group that’s being neglected, and innovation is taking place. And I can’t tell you how much I wish you the best of luck in actually succeeding because you’re building an approach that really will benefit so many people if it can get embedded and it is successful. So thank you for all the work you’re doing. And like I said, you’ve taught me and Howie a lot. It’s best when students end up teaching teachers, and we continue to watch your career with admiration.‌

Howard Forman: 100%. Thank you, Rahul.‌

Rahul Rajkumar: Thank you so much, guys.‌

Harlan Krumholz: Well, that’s a terrific interview. I love what he’s doing. And you talk about a person who’s got their heart in the right place, that’s Rahul.‌

Howard Forman: For sure. That is for sure.‌

Harlan Krumholz: All right, look, like I said, Howie, we had an election. I know I’ve got to tell you that we did. And usually what you’ll do is summarize some of the key points that occurred for the thing. So I’m eager and I’m hoping you’ll do that for us this week, to put in perspective some of what happened.‌

Howard Forman: Yeah, and I’m not going to review Congress or the presidency because I think that’s covered well in the news, but there was a lot of healthcare explicitly on the ballot in quite a few states. It surprised me as I was trying to summarize this. So I thought it would be useful to do our annual post-election rundown of what the public voted for and what they voted against this year.‌

There were 11 statewide abortion measures on the ballot this year, two in Nebraska alone, and Nebraska bears a little bit of time to explain because it was the most emphatic, and there were two clearly described measures. And what did they do? They rejected the codification of Roe principles, that is allowing abortion until fetal viability, but they voted in favor of prohibiting abortions after the first trimester, with the exception of incest or sexual assault. So, they do have abortion available through the first trimester in Nebraska. In pre-Dobbs times, this would’ve been seen to be extreme. But in the current climate, this is not as restrictive as 15 states that now have complete or near-complete bans on abortion.‌

Voters in Arizona, Colorado, Maryland, Missouri, Montana, and Nevada all passed measures establishing rights to abortion, and not by small margins. Montana had 57% voting in favor. So, this doesn’t quite align with what people naturally think might occur in each state.‌

New York voters passed the Equal Protection under Law amendment, which prohibits discrimination based on reproductive healthcare decisions, including abortions. It’s not a big change from their current practice, just an additional protection. South Dakota had the most lopsided vote against abortion access with only 41% voting in favor. Illinois voters approved a non-binding advisory question asking whether health insurance should cover reproductive health treatments, including abortion. Florida had 57% of the population or voting population in favor of codifying Roe-like standards for access to abortion, but the constitution demands 60% in Florida. So this measure fails, and Florida therefore has one of the most restrictive bans in place, beginning at six weeks of gestation, a time when most women are not even aware they’re pregnant.‌

But abortion wasn’t the only healthcare item up for a vote. So this year, voters in Florida, North Dakota, and South Dakota rejected measures that would have legalized recreational use of marijuana. And in the case of Florida, more than 55% voted in favor. But again, the constitution demanded 60, so this failed. Nebraska established a right to medical marijuana, and they have joined 38 other states in having some marijuana legalization.‌

And lastly, since you know this podcast, we do not shy away from talking about magic mushrooms. Our listeners will recall that Oregon and Colorado have legalized psychedelics, or magic mushrooms in some cases, use in some circumstances. Massachusetts, which had it on the ballot this year, does not join this auspicious duo because 57% of the population voted against this limited legalization.‌

So that’s sort of the rundown this year of what was on the ballot. Obviously, abortion gets most of the attention, but it’s interesting to see the trends with marijuana and psychedelics.‌

Harlan Krumholz: So let me ask you, because that’s quite a list, and thank you for summarizing that, was there anything that surprised you about what—‌

Howard Forman: Massachusetts, which had one of the earliest marijuana laws, really aggressively rejecting psychedelics surprised me a little bit. I would have thought that they would have been along with Oregon and Colorado.‌

Harlan Krumholz: Yeah. What’s interesting to me is how different the states are with regard to their approach. You would think for many of these things there would be a federal approach. And maybe we’re going more and more in this direction, but it does seem like as you decide where you want to live in the United States, you may take into account the sort of laws and approaches that are being taken in those states because your life, your rights, what you can do may be very different state to state now.‌

Howard Forman: And by the way, not just where you live, but where you go to college, where you go to graduate school, where you might live temporarily on your way to a different job. There are large numbers of states right now where a woman, not just a woman’s right to choose, but a woman’s right to receive all forms of reproductive healthcare are substantially impeded by laws that are scaring away OB-GYNs, that are causing some OB-GYNs to be much more cautious about how they manage a pregnancy. I think there are unintended consequences that we’re beginning to see over these last couple of years. And I think that if you look at the polling, I think the population has moved more in the direction of having more reproductive access, but the votes, like in Florida where you need 60%, make it very difficult.‌

Harlan Krumholz: Yeah, the laws that surprised me the most, this isn’t about the election, but just is that the ones that have said, I mean, wasn’t it true in Texas that if you went, that if you traveled to a state that you’re—‌

Howard Forman: Potentially subject to prosecution, yeah.‌

Harlan Krumholz: Potentially. So it’s not even that you’re now seeking care at a place where it’s legal, but if you’re a resident of the state, they’re restricting your ability to go out of the state to get care that they wouldn’t provide there.‌

Howard Forman: Right, and we’re going to address, over the next few years, access to mifepristone, which is abortion medication that is going to be very difficult to legally access in states like Texas and some other states, and we’re going to have to figure out how to manage that as well.‌

Harlan Krumholz: When I went to medical school, we just learned what we thought was the best way to care for people. And now we’re going to have to take into account what the local laws are that in some ways may restrict us. It’s remarkable. 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 various social media. And let me highlight, since Harlan and I talked about this morning, Bluesky is the current social media of choice, replacing X and Twitter for many healthcare and public policy-oriented individuals.‌

Harlan Krumholz: Yeah, the thing that was annoying me about X was Musk has now created the algorithm, so he inserts himself into every conversation, meaning whatever string I’m on has multiple entries from Musk. I don’t even follow him, but he’s forcing me to see his stuff. Besides all the other stuff, it just seems people are leaving it. So we want to hear your feedback, questions, anything. And if you like the podcast or anything you feel about the podcast, rate us, review us. We always look at this stuff. It helps other people find us.‌

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 produced at the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles, Sophia Stumpf, and Tobias Liu, and to our producer, Miranda Shafer. They are outstanding. We are so lucky to work with them.‌

Howard Forman: They certainly are.‌

Harlan Krumholz: Talk to you soon, Howie.‌

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