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Episode 113
Duration 35:14
Reshma Ramachandran

Reshma Ramachandran: Will the Supreme Court Upend Healthcare Regulation?

Howie and Harlan are joined by Reshma Ramachandran, a Yale family physician and co-director of Yale Collaboration for Regulatory Rigor, Integrity, and Transparency. They discuss the potential ramifications for healthcare regulation if the Supreme Court overturns the Chevron decision requiring judges to defer to federal agencies. Harlan looks at surveys suggesting an erosion of trust in medicine; Howie reports on the growing measles outbreak.


Trust in Healthcare

“Nurses First, Doctors Distant Second in Healthcare Provider Ratings”

“KFF Health Tracking Poll: Health Care Issues Emerge as Important Topics on 2024 Campaign Trail, Plus Concerns Loom Large Around Medicaid Unwinding”

Reshma Ramachandran

“What is Ayurveda?”

“On Writ of Certiorari to the United States Court of Appeals for the First Circuit: BRIEF OF DR. RESHMA RAMACHANDRAN AND DR. JOSEPH S. ROSS AS AMICI CURIAE IN SUPPORT OF RESPONDENTS”

“Agencies’ Power Under Scrutiny in Supreme Court Arguments”

“Supreme Court could reel in power of federal agencies with dual fights over fishing rule”

“Case brought to Supreme Court by herring fishermen may gut federal rulemaking power”

Reshma Ramachandran: “Medical Product Industry Ties to Patient Advocacy Organizations’ Executive Leadership”

Reshma Ramachandran: “Do Advocacy Groups Always Put Patient Interests First?”

“Citizens United Explained”

The Measles Outbreak

“Another person infected with measles at a Northeast daycare as Philadelphia outbreaks grows to nine cases”

“DC Cautions Residents of a Potential Measles Exposure”

CDC: Measles Cases and Outbreaks

Learn more about the MBA for Executives program at Yale SOM.

Email Howie and Harlan comments or questions.


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. We’re excited to welcome Dr. Reshma Ramachandran today. But first, we always like to check in on current or hot topics in health and healthcare. What do you have for us today, Harlan?

Harlan Krumholz: Well, Howie, I wanted to bounce a couple of polls that came out recently and sort of get your thoughts on them. First one I wanted to talk to you about was a Gallup poll that was recently released and talked about ratings of people within healthcare, like who’s got a positive approval ratings and who doesn’t. Of course, nurses come out on the top, that’s no surprise, 82% saying they provide excellent or good medical care. I like that. But doctors are lagging. It’s like less than 70%: 69% of people say that. And if anything, it seems like it’s going down. And then of course after doctors, you can see that hospital emergency rooms 47%, pharmaceutical companies are now down to 33%, health insurance companies 31%, and nursing homes come in, at the end, of 25%.

But what really bothered me was that doctors are at a much lower level than they had been historically. And I don’t know, this is part I think of about how people are thinking about medicine in general these days and the misinformation that’s out there. But even on the honesty and ethics profession’s ratings, nurses are high at 79%. This came out a little more than a year ago from Gallup, but that doctors are pretty distant second at about 62%. So we’re really seeing nurses maintaining a high rating. Of course, nurses are fantastic, but other provider scores are shrinking, and doctors are part of that.

And I think it’s a concern for me that, what are we doing in medicine that’s not instilling trust? Is it about this medical industrial complex? Is it that doctors really are just becoming pawns in this system now and so that people are perceiving that and aren’t really looking at doctors the way they used to? What do you think about this? Then I’m going to talk to you about one other poll before we’re done, but what do you think about this?

Howard Forman: So my biggest concern about this is that it probably aligns, you might know the answer, but it probably aligns with politics a little bit. Not the doctor’s politics, but the fact that individuals who have become identified with anti-vaccine, who are anti-COVID, so to speak, individuals have become very anti-medicine. I mean, they’re very much afraid of organized medicine and that a large part of the population is not. But any loss of faith in the institution of medicine is a bad thing ’cause it makes everything much harder from preventive medicine to our public health programs to everything becomes much more difficult if the public has lost faith in medicine.

Harlan Krumholz: Yeah. And the physicians have dropped 15 points over this period. And yeah, I mean I think that it’s up to us in the profession to be thinking about how are we standing up for folks? How are we instilling trust? What is it that’s going on as medicine’s undergoing such dramatic change, both with technology and policy and just simply the organization of healthcare in this country with telemedicine or big companies getting involved. What are we doctors doing to stand up to help people understand that we’re there for them, we’re representing their best interests, and how are we deflecting concerns that this is being degraded?

I wanted to bounce one more off you to see what you thought. So Kaiser Family Foundation came out with a poll. I think you may have seen this. This is really about what’s going on in the politics of America. And I thought what was interesting about it was to me that, when we’re talking about this 2024 presidential election, of course we’re just out of the Iowa caucuses this week, that the affordability of healthcare comes in a close second to the most important issue that people are thinking about.

The number one was the rising cost of household expense. Of course, that’s always something that’s on people’s mind, but the affordability of healthcare comes in a close second with 8 in 10 voters saying it’s very important to candidates to discuss on the campaign trail. And that was interesting to me. But also what was interesting to me is like everyone’s talking about this issue with abortion, but only 4% say that abortion is the most important issue for the 2024 presidential candidates.

And you’ve brought this up, this question of whether or not the election’s ultimately going to turn on single issues and whether a lot of people getting animated about an issue like abortion. And of course it is very important and there are a lot of people on both sides who are highly engaged with it, but it pales in comparison to the number of people who think that affordability is really the key thing in the election. And again, you, so involved in policy, you’re thinking a lot about affordability. How do you place these things and does that surprise you at all?

Howard Forman: So the affordability issue goes way, way back. I remember Ezekiel Emanuel, right after the ACA passed, said that if you look at what the most important feature of a health plan is for individuals, it’s about affordability. It’s not whether they can see their doctor. It’s not whether they can have the highest-quality plan. It comes down to dollars. Dollars matter to people. And healthcare is a very real expense for individuals because whether you’re on one drug or 10 drugs, every month you’re doling out money for prescriptions, every month you’re doling out copays for doctors and you’re on the hook in many cases for a high-deductible health plan, or about a third of commercially insured individuals are on high-deductible health plans. Which means thousands of dollars right now this time of year, January, February, March. Even the high-spending individuals have effectively no health insurance coverage until they spend a few thousand dollars to pay off the deductible.

And that I think really resonates with people. I think that scares them that every January they have to think about, can they afford any medical bill that comes down their way? And as you know, we continue to spend enormously on healthcare. We spend what, $4.4 trillion in healthcare at this point as of the most recent data point that we use, probably more for 2024. And that is everybody. That’s more than $11,000 for every man, woman, and child in this country.

Harlan Krumholz: I’ll give you one other piece out of this Kaiser Family Foundation poll that I thought you might find interesting. On this show, we’ve talked a lot about the Medicaid enrollment provisions and how people are falling off of Medicaid. And we’ve talked a lot about, and you’re one of I think national experts on this, prescription drug provisions that were in the Inflation Reduction Act. We’re going to be good to ask Reshma at some point what she thinks about this, our upcoming guest.

But when they ask people about their awareness of this, the majority still say they’ve heard nothing or only a little about the unwinding of Medicaid. And still, people are largely I think not really tuned into the Inflation Reduction Act either. So when these consequential things are going on, somehow the messages still aren’t getting through to average Americans as they’re thinking about candidates or they’re looking at these issues in the future. Does this surprise you? And if not, or either way, what do you think we should be doing about it?

Howard Forman: If you are among the 15 million people who have been disenrolled from Medicaid, it affects you a lot. If you’re not, it doesn’t. And unfortunately that’s how we live, a large number... I don’t think it’s majority, but a large number of those individuals are children, and they don’t vote. And so we’ve got to do so much more to get those messages out there. And it does affect all of us, but it is a single-issue issue for people that are particularly low-income and being kicked off Medicaid nonetheless.

Harlan Krumholz: Yeah. And the benefit of the Inflation Reduction Act also, people somehow aren’t still...

Howard Forman: Not yet. They’re going to start to feel it by the end of this year and the following year, but not yet.

Harlan Krumholz: But I’m just saying people want to get credit for...

Howard Forman: It’s hard.

Harlan Krumholz: ...controlling costs. Affordability’s on people’s minds, but they’re still not connecting with policies that are being implemented to address it. Yep. Hey, let’s get onto our guests. I’m really excited to hear Reshma’s views.

Howard Forman: Yes.

Harlan Krumholz: Especially with the Chevron case.

Howard Forman: Dr. Reshma Ramachandran is a family medicine physician, assistant professor of medicine and co-director and founder of the Yale Collaboration for Regulatory Rigor, Integrity, and Transparency. Before coming to Yale, she worked at the Johns Hopkins Bloomberg School of Public Health as research faculty for the Innovation and Design Enabling Access or IDEA, IDEA Initiative. Dr. Ramachandran is passionate about health equity and patient safety and has looked at how best to incentivize the use of new technologies in healthcare settings. Her work ranges from issues such as drug pricing and the political economy all the way to prescription drug access in industrial health policy.

Aside from her academic and research interests, she also serves as chair of the Doctors for America FDA Task Force and has worked previously on reducing pharmaceutical industry influence on health education as an American College of Medical Students PharmFree Fellow. She’s testified in the U.S. Congress several times. Dr. Ramachandran completed her bachelor’s degree and her medical degree at Brown University before completing a master’s of public policy at the Harvard Kennedy School. She joined Yale’s faculty after completing the National Clinical Scholar Fellowship here and obtaining her MHS degree from Yale.

And today is an auspicious day. There is a very important Supreme Court case that is being heard as we tape this. And I’m going to let Harlan kick off with those questions. But before we get to that, I want to start off by just asking you what your journey was like to get to where you are now? Because you went into college as a, or at least became a physics major in college, what were you thinking of as you graduated high school? Where did you grow up? What led to this?

Reshma Ramachandran: Yeah, thanks much, Howie and Harlan, for having me on here. I grew up in Miami, Florida, so I emigrated to the U.S. from India. My dad was a postdoc actually at Ohio State University. He was looking for jobs. University of Miami was offering a green card. So naturally we went there, a lot of stability and was able to stay in the country as a result. So in Miami, I did a lot of science fair. My dad was a research scientist in a lab. I spent hours after school, usually in the lab with him. And he did work around looking at Ayurvedic treatments and their promise to be new adjuvant therapies for cancer treatment. So some preclinical studies, basic science research, but then also clinical trial work.

Howard Forman: Can I just pause for one quick second? So our audience may not know what Ayurvedic treatment is, and the only reason I know about Ayurvedic treatment is because 25 years ago, our current surgeon general told me he wanted to figure out how to incorporate Ayurvedic treatment. So Miami physicians and scientists had a particular interest in this. Can you just tell us about that?

Reshma Ramachandran: Yeah, for sure. Ayurveda is an ancient form of medicine that comes from India. It’s pretty, it’s like thousands of years ago, but essentially looks at natural compounds, usually found in plants, and their health-protective properties. So my dad was trying to apply science to this. So doing rigorous basic science and clinical trial research to actually see, are the claims that are oftentimes found on supplement bottles actually founded? Could these actually be used in tandem with existing treatments including FDA-approved drugs to actually improve outcomes for patients?

Howard Forman: Excellent. And so you graduate there and you go directly to Brown and you immediately become a physics major from that?

Reshma Ramachandran: Yeah. Well, I became a physics major because I liked physics when I was in high school and I was trying to figure out how to actually get back into the lab. And my goal at that time was to actually develop health technologies. I wanted to be the person that was going to bring products to market that would save lives. And I happened to take a physics introductory class and it was taught by Professor Maris, who was 80-plus years old. And on the first day of class, he shot himself off of a rocket that he had made out of a wagon and an engine. And the fact that an 80-year-old man was doing that and talking about physics was just—that was enough for me.

So after that, being able to take classes with a cast of characters like this became the underlying reason for me to think about how to merge my interest in biology and biochemistry with physics to create health technologies.

Howard Forman: And just to finish that arc, then, when did you become premed, and then I’ll turn it over to Harlan, but I just want to understand how the transition occurs.

Reshma Ramachandran: Yeah, so I actually applied to Brown in the program for liberal medical education. So it was a straight from high school, eight-year bachelor’s and medical school admission. It was nice. I didn’t have to take the MCAT. I could kind of explore other areas including physics and also classes in international development, history, other things like that. What kind of made the transition, though, I’ll say, from physics to thinking about developing health technologies to thinking about the enabling environment for access to health technologies was during college for me.

So between my junior and senior year, I had finished my thesis requirements, had been in the lab, done all that work, and I got an opportunity to go South Africa to do quantitative data entry work with some clinics with the Medical Research Council. So this was a government-funded laboratory network and also health services research network that was actually looking at how to improve access to HIV medications. And it was there that I saw clinicians looking beyond the exam room and in the streets with their patients to protest the government, to protest policies, to protest laws, and then I was following them work alongside groups like Doctors Without Borders to actually talk about things like intellectual property and patents and drug pricing, which were concepts I had never really thought about before, that even though I might be thinking about developing health technologies, how to actually enable access to them down the road to patients was going to be a whole other thing entirely. And this was a group of clinicians that was doing that. And so that was the inspiration for me to kind of make the pivot from bench research to thinking about how to actually create that enabling environment.

Harlan Krumholz: You know, Howie, there’s so many things that are remarkable about Reshma. I think the one thing that’s always impressed me, she’s so whip-smart but actually knows how to get things done. And so she both takes a very rigorous approach to understanding practice and policy and trying to figure out how we can sort of bend this arc towards better healthcare with an ability to communicate it to those people who might be in a position to actually make change. So she’s able, whether she’s on the Hill talking about federal policy or in statehouses or seeing where the leverage points are, and Reshma, this is what I’ve really admired about your approach, which is, its very action-oriented. So it’s both scholarly, but it’s intended to try to affect practice and policy in ways that are consequential. So it’s a pleasure to have you on today.

So in this spirit, I mean, your work crosses so many different areas, and I sort of feel like you’re entrepreneurial in your approach. I mean, you’re sort of seeing where might there be an opportunity to leverage change in the system that would better serve the interests of people. And one area that you focused attention on is on this case that’s before the Supreme Court where you and Joe Ross actually submitted a brief where you were trying to influence the justices as they think about this case.

So this is so-called Chevron v. Natural Resources Defense Council based on a 1984 ruling. That was actually a ruling that was to give the EPA more authority to go against environmentalists and to institute policies that would maybe on the people in the Democratic side were pushing but that the administration was pushing back against, and in the Reagan administration, right? In the Reagan administration. So I think what’s interesting now is that Democrats and people on the left are largely pushing now for more authority of federal agencies so that they can make choices and decisions and institute rules based on congressional laws that may have some ambiguity to them.

And on the right and the Republican side, people are saying that, “No, you should have to go back to Congress,” that “Actually there shouldn’t be that much power invested within the federal agency.” So this thing is being brought up now because of fishermen, that they were sort of asked to do monitoring of their fishing, and they’re pushing back, and it’s going in front of the Supreme Court.

So what in the heck does this have to do with healthcare? Why does someone who’s pushing healthcare policy get interested in something that, for many listeners, might seem a little esoteric and sort of inside baseball around what the federal agencies are doing? What is it that provoked you to write about it and why do you think it’s important?

Reshma Ramachandran: Yeah, these two cases that are being heard before the Supreme Court today, on their face, as you mentioned, are not healthcare-related, but the implications on federal agencies and public health agencies like the FDA is pretty profound. So when we had first heard about these cases and understanding what “Chevron deference” is, this idea that if the law is unclear or if it’s silent on an issue, there’d be deference given to federal agencies because they have expertise that Congress has authorized that has in their creation these agencies have hired a bunch of, sometimes clinicians in the case of the FDA, scientists, others, who can actually interpret the law to actually apply it for regulation and develop regulations as a result.

And so historically, there’s been several court cases around this, where agencies have been determined to have this sort of deference to create regulations based on their scientific expertise. This case challenges that. Basically it would get rid of Chevron deference and the idea that if the law is silent or ambiguous on a matter that federal agencies cannot interpret the law to in creating regulations. And the FDA is chock-full of regulations related to drugs and devices, which is what our brief was focused on, but also a slew of other products including food and tobacco.

Harlan Krumholz: So let me—just a quick follow-up on this, and there was a nice piece in The New York Times today that sort of laid out some of this at a high level. But one quote that came from this article that Adam Liptak reported on in The New York Times was from the Solicitor General Elizabeth Prelogar, I think, I hope I’m pronouncing it correctly, where she said overruling Chevron—which you’re arguing against, don’t overrule Chevron, right?, allow deference to the agencies, allow the agencies to interpret the laws—so overruling Chevron, she said, would be a convulsive “shock to the legal system.” Would it be a convulsive shock to healthcare? And can you be specific about even an example of what do you fear might occur if they overrule Chevron?

Reshma Ramachandran: Yeah, definitely this would have huge ramifications, and I’ll be specific to the FDA and actually an example that Justice Jackson actually mentioned in her questioning on the plaintiff side. It was actually a similar argument to what we brought up in our amicus brief specifically. So it was around this idea of in the law, the standard for drug approval or new drug approvals is “adequate and well controlled” investigations. And the FDA has interpreted this, they’ve actually outlined what this might mean through regulation. They had a public notice and comment period, and then they refine this and they put out regulations around this.

If you get rid of Chevron deference, there could be a challenge that is raised by a sponsor, for instance, that has a new drug that they want to be approved, saying that FDA’s interpretation of the evidence or what is adequate and well-controlled investigations is actually incorrect, under, without Chevron deference. And in fact, Congress needs to actually specify this more clearly to actually entail or actually detail what that actually means. And so this could have huge ramifications and also slow down FDA’s ability to actually approve drugs in a timely manner. So...

Harlan Krumholz: What would that mean if, for example, a pharmaceutical company said, “You guys are interpreting what Congress said, it’s ambiguous what they said,” and then Congress of course is going to take years to clarify or act on it, if they ever do. So what happens in that period where there’s no clear guidance?

Reshma Ramachandran: So this could call to a judge, so a judge can, actually, will use his expertise, which may not be the same as the scientific expertise you expect at the FDA, which oftentimes includes clinicians, biostatisticians, a whole team of different folks that looks at the evidence to determine if the drug is safe and effective to be approved. And so the idea that that sort of scientific expertise would now be in the hands of a judge and because of various other forces, political motivations, because of kind of the evidence and their understanding of it, could make a decision that might be contrary to public health.

And so that’s the concern that we had, that moving away from Chevron deference would put this in the hands of judges and there could be confusion, especially if there’s interpretation across different judges about what the standard actually is. And that could slow down innovation in many ways. The FDA’s ability to actually justify and use their scientific expertise to actually make an approval decision would be slowed down because they’d have to have additional resources to actually justify why they’re doing this. And on top of that, it might be tied up in litigation in courts, and that sort of timing would slow down any sort of approvals in the future.

Howard Forman: I want to take a slightly contrarian view on this and just have you come back a little bit because Harlan’s correct of course that this is sort of a Republican/Democrat issue in general and that the administrative state as the Republicans, typically conservatives, typically talk about it, which is to say that the executive branch is very powerful and perhaps too powerful is something that Republicans have wanted to undo. And the appointment of, I think Neil Gorsuch in particular is felt to be a step in that direction.

However, there are times when the Republicans are in control of the executive branch and Democrats become quite concerned that executive branch has overreach, whether it has to do with immigration policy or health policy. And I’m just wondering, not to say that you should change your opinion in aggregate, but do you see the value at all in favoring legislation rather than regulation in these situations? And I wonder, is it possible that eliminating Chevron deference could force us to have to legislate more, which might be at least a step in that direction?

Reshma Ramachandran: Yeah, that’s definitely the argument that I heard from the plaintiffs during the oral arguments today, that Chevron has given excuse to Congress to not legislate on certain matters. And it’s interesting because we engage in both spaces. We oftentimes are critical of the FDA in terms of their regulatory decisionmaking, and we do go to Congress to talk about reforms at the FDA. In the past couple of years around accelerated approval, we’ve been quite active with our group here at Yale around this.

And I think what it ultimately comes down to is, what is the larger concern here? Should scientific expertise be in the hands of the FDA? Especially if we think of the FDA as an institution that’s supposed to represent independent regulatory decision-making that is taking into account all the data at the participant level making decisions around that. That’s the FDA that we want.

We might not have the FDA that we have right now. It might not be the perfect FDA, but the idea of putting that in the hands of Congress to make those sort of detailed, kind of scientific nuance or decisions about individual approvals about, in drugs that they haven’t even imagined coming down the pipeline in 10, 20, or 30 years seems to be a misstep in our opinion, and especially in looking at what the FDA is intended to do, to actually put together a scientific expertise to meet the challenges of not just today but also the challenges of tomorrow because they’re so involved in the drug development process with sponsors along the way.

Howard Forman: One last quick question. Any thoughts on whether—

Harlan Krumholz: We’re just not going to let you go.

Howard Forman: No, no. Any thoughts on whether the Inflation Reduction Act is stymied at all in the courts? Because that’s one of my concerns for this year.

Reshma Ramachandran: Yeah, I mean, I think in terms of where the courts seem to be going on the Inflation Reduction Act, there’s been like 10 cases right now that are challenging the drug pricing and negotiation provisions of the Inflation Reduction Act. And we have folks here at Yale Law School, including many of our colleagues, that have written amicus briefs around this to challenge what the pharmaceutical companies are saying in terms of the negotiations infringing upon their ability to recoup profits and whatnot.

I think the cases obviously are taking up time in terms of slowing down, potentially, the process, but we are seeing some good signs, some glimpses of hope that judges are rebutting and pushing off the arguments made by the pharmaceutical industry saying that they’re not sound, that they don’t have a constitutional right to actually participate in Medicare and Medicaid under negotiation provisions.

So those sorts of decisions that are coming out from the courts give me hope that hopefully this won’t be a prolonged process and this won’t slow Medicare and Medicaid down in terms of implementing the provisions. We’re seeing implementation happening now. It’s been started last year. They’ve been hiring folks to be able to make sure this goes into place. And I’m hopeful that this is going to go full steam ahead.

Howard Forman: Well, you give me hope. So thank you so much for just being the advocate and the scholar, the clinician and all that you are in helping advance healthcare in this country.

Harlan Krumholz: Yeah, what a pleasure to work with you. We’re so lucky to have you here.

Reshma Ramachandran: Thanks so much for having me.

Harlan Krumholz: So what’s on your mind this week? Let’s pivot to your side.

Howard Forman: Yes, I’ve been waiting to talk about this for a few weeks, but I think right now it’s a good moment to do it. There’s good news and bad news on the measles front, domestically in particular. On the one hand, we have not actually had a major measles outbreak in at least four years, but on the other hand, we have the beginnings of one in Philadelphia right now. And that becomes a little bit surprising for us because Philadelphia actually is relatively well vaccinated. The state of Pennsylvania is relatively well vaccinated. So this outbreak, and it’s among the unvaccinated, is seemingly going to be contained, or at least I hope it will. But if even one person from that area leaves that area and goes to an area that is under-vaccinated, we could quickly have a problem on our hands. Because measles is especially infectious. It requires about 95% of a community to be immune in order to protect the herd, as we call it. And that means an outbreak cannot occur in that community but can occur in one that’s less vaccinated.

Measles is also unfamiliar to most of us right now. One in a thousand cases results in death. Two in a thousand results in brain swelling or encephalitis. One in 10 is hospitalized, often with pneumonia. There’s long-term consequences including neurologic consequences, and the vaccine, it’s part of the measles, mumps, and rubella vaccine, MMR, is actually highly effective and extremely low-risk. Right? There should be no controversy about this. The vaccine is given at the ages of about 12 to 15 months and then four to six years. And rarely have we ever suggested boosters for certain populations.

So where are we now? You got the nine cases in Philadelphia. And then as of a few days ago, we learned that an international traveler who passed through Dulles Airport on the third [of January] and then showed up again at Reagan Airport on the fourth, was infectious, did have measles, and presumably was infectious. Now if he or she interacted with all vaccinated people, we’re fine. But if even one or two travelers was unvaccinated, becomes exposed, right around today, the day that we’re taping this right now, we should start to see some infections starting in whatever community those people were traveling to. And that starts to become a much more serious risk.

So I think we have to really, back to what you talked about on the intro, that faith in science and medicine in institutions is falling. We have data that suggests it’s falling faster among people who identify as Republicans. This is not really a political issue except for the fact that people who identify as GOP are much more likely to believe that children should not be forced to be vaccinated. This was not true in the past. Democrats, if anything, were more often to be in this group. Now it’s far, far more a politicized GOP issue.

And I think just as you talked about it on the intro, we need to figure out not just how to make public health interventions work, but we need to build up confidence among individuals in those institutions. We need to redouble our efforts to rely on science, to communicate science well, to change our opinions about things when the data changes, and to be able to get the public’s trust back to where it was.

Harlan Krumholz: I told you I was going to ask you a very pragmatic question. I think many listeners might be wondering about this, if they were vaccinated in childhood and now have heard about maybe potential exposures, should they be worried that they’re no longer protected against measles?

Howard Forman: Everything I’ve read.... So I did a little bit of reading because you and I talk about these things. I did a little bit of reading, every bit of evidence is that this is a very, very durable vaccine. Having said that, if there was a large outbreak, the CDC likely would come out.... They haven’t done this yet, but they would likely would come out with a recommendation that certain populations may consider getting a booster shot at this point. But there’s no evidence, we’re not finding cases in people who’ve been previously vaccinated. We’re seeing cases only in the unvaccinated at this moment.

I will say for our listeners, we always talk about measles, and people don’t hear as much about mumps or rubella. And the reason is that there’s a greater level of herd immunity at lower levels of vaccination for those. So this is always going to be the canary in the coal mine. You’re always going to see measles first. If we do get a massive outbreak of measles, I have no doubt that we’ll start to see outbreaks of mumps and we will see outbreaks of rubella and the congenital rubella syndrome that follows from that.

Harlan Krumholz: Oh my God, I remember having mumps when I was a kid. The thing about measles, just again, people listening, it’s probably the most infectious virus that there is. It’s the benchmark of the most infectious virus.

Howard Forman: Exactly.

Harlan Krumholz: The reason I believe that this is a durable vaccine is because we haven’t seen outbreaks among vaccinated people before. Even when we’ve seen outbreaks in certain communities in the country, they’re always being manifest in people who aren’t vaccinated. So among that group, there are older individuals who never seemed to come down even though they were only vaccinated in childhood.

Howard Forman: Exactly right. And by the way, just to give us our listeners a little optimism here, 2022, we had 121 measles cases; 2021, 49; 2020, because of the pandemic, probably, we only had 13. But the year before that we had 1,274 measles cases in this country. So we have had bigger outbreaks. We’re hoping to avoid that now, and I hope that in six months we’ll come back, and we’ll say this was a tiny blip.

Harlan Krumholz: Yeah, I think my big concern is that the pandemic has given fuel to this anti-vax movement. So it’s not just about, “Don’t take the COVID vaccine,” but it’s now introduced all this doubt about all the vaccines. It was always simmering. But this really, I think, is flared. You got a presidential candidate who’s on the stump talking about these issues, not just about COVID vaccine but about all vaccines. Enrolling us back to a sort of pre-vaccine era for many people.

Howard Forman: It’s worrisome.

Harlan Krumholz: So we have to keep our eye on this, but again, it does get to our credibility in public health as physicians and really helping people understand the balance. And then the question will be, will society weigh in with saying that we expect people to be vaccinated, or is it going to continue to be a criterion for schools or will it change? People homeschool more ’cause they don’t want to do it. It’s complicated.

Howard Forman: I agree.

Harlan Krumholz: 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, please email us at or respond to our links on LinkedIn or email us individually. Or we’re still on Twitter, which was also called X.

Harlan Krumholz: And we are using LinkedIn and others more, but...

Howard Forman: A lot.

Harlan Krumholz: I have trouble breaking up with Twitter.

Howard Forman: I know.

Harlan Krumholz: Still call it that. So I’m at H-M-K-Y-A-L-E. Though I’m posting a lot less than I used to. That’s @HMKYale.

Howard Forman: And I’m @TheHowie. That’s at T-H-E-H-O-W-I-E. Again, you can email us, but you can also reach out to us at the School of Management. You can look into our more innovative programs, including the Executive MBA program at the School of Management. And our link there is

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and our producer, Miranda Shafer. They are amazing, and we’re deeply appreciative of everything that they do. Thank you and talk to you soon, Howie.

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