Sachin Jain: Has Managed Care Lost Its Way?

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. Sachin Jain, but first we always check in on current hot topics in health and healthcare. And Harlan, you’re all the way on the West Coast. So what weighty topics you have to share with us today?‌

Harlan Krumholz: Well, look, I have two things I want to hit on today. First of all, as you know, and as everyone listening knows, Los Angeles is on fire, and over the past week, the Palisades and Eaton fires have burned more than 38,000 acres and destroyed all these structures. We’re seeing it all the time on the news, and loss of life as well. I know at least two people who lost their homes, and most people know someone connected who’s—‌

Howard Forman: I know some people, yep.‌

Harlan Krumholz: ...been affected and so many people displaced. Firefighters risking their lives. I saw National Guard sleeping in these neighborhoods, making sure that looters and so forth don’t get in and communities just struggling to wrap their head around it. So I just at least wanted to start with that.‌

Howard Forman: Yeah, that’s right. A hundred thousand people are out of their homes right now.‌

Harlan Krumholz: And I thought I might just mention, since we’re Health & Veritas, that there’s this immediate danger of the flames, but then there’s this invisible threat looming around wildfire smoke. It’s more than just this haze, and it’s more than when we think about poor air quality. As I got to work with Kai Chen in the School of Public Health, who’s really an expert and there’s a big initiative at the School of Public Health around climate that he’s leading. And of course we have people all over campus, forestry, medical school, everywhere, who are increasingly interested in this topic. But wildfire smoke—and Kai’s published about this—is a particular hazard because it’s this cocktail of toxic particles that there’s the PM2.5 or this fine particulate matter which can penetrate deep into the lungs and enter the bloodstream and cause all sorts of problems, but fires destroy homes and infrastructure and they release this toxic mix of chemicals.‌

Think about lead, asbestos, arsenic. So when I first thought about this, I thought, “Yeah, this is just like bad air pollution,” but it’s not, it’s much worse than that, and it’s going to affect people’s health for a long time, and people really need to stay inside. There’s these recommendations, “use an air purifier if possible.” Most people lost their homes in these areas, so it’s not like you can do that. Masks, some people have masks, but people are dealing with such destruction.‌

So anyway, I just wanted to mention that, hearts go out to folks and this is also a big health issue and we’re likely to see, unfortunately, more of these kinds of threats as we deal with climate change. Well look, let me leave that. I just want to mention one other thing that came out, you just asked me what I was thinking about. So the Lancet Commission, a group of people that were convened by the medical journal the Lancet has come out to talk about obesity and our definition of it. So, what if I told you that something that affects a billion people worldwide may all be wrong because we’ve been doing all these calculations using BMI, or body mass index.‌

Howard Forman: Sure, sure.‌

Harlan Krumholz: And you know, body mass index is your weight divided by your height squared. I mean, somebody came up with that and thought this is a good representation of overweight or obesity.‌

Howard Forman: But very imperfect.‌

Harlan Krumholz: Right. So this international commission of experts is saying it is not just outdated, but it’s misleading. And so they’ve got this new proposal and saying the problem with BMI is it’s too simple, doesn’t account for differences in muscle and fat, body composition, where the fat is located and everyone always talks about muscular athlete who might have a large BMI but is largely made up of muscle. So one person on the commission, Robert Kushner, said BMI doesn’t provide adequate information about a person’s health, and that probably is true, but they dug in and they said, well, we’re going to start defining this as preclinical obesity, someone who has excess body fat but no signs of organ damage or other health problems yet. In clinical obesity, when excess fat starts causing harm, instead of solely relying on the BMI, you should be getting other measures.‌

Well, of course, waist circumference, waist-hip has always been something, but you can get advanced scans like DEXA scans, which are imaging studies, which can give a clear picture of fat and health. So this is going... just to wrap this up, just to say that we’ve been using BMI for a long time. The trials that we’ve had of the new drugs have had qualifications based on BMI. Now to start saying we need a more complex and nuanced approach makes sense, but how it actually is going to be done, whether it’s going to lead people who, for example, are on these meds to be taken off the meds to not have the meds paid for, how will it get people thinking?‌

Is it going to make us in a position on prevention where we don’t act until actually something’s happened, so we don’t really move on preclinical, but only when there are clinical manifestations? Is this the right thing to do? It can have far-reaching consequences from how doctors diagnose obesity to who gets access to the drugs. And the question is, is this going to catch on is right. There’s a big controversy in obesity medicine field about what the right thing to do is. So I’m just signaling this because people will have read maybe this in the news.‌

Howard Forman: Sure.‌

Harlan Krumholz: It’s not a done deal. It’s a proposal that we reconsider it. The idea that we get more precise aligns with our efforts to have precision medicine, have each person get what they uniquely need given their circumstances, all the information we know about them. But these broad-based categorizations also can be helpful, like BMI in a directional sense of what’s going on with society, and it’s very simple. So whatever new system we come to, we have to be careful about not overcomplicating this in terms of trying to figure out who might benefit from what.‌

And like I said, our literature is based on the BMI, including intervention trials. So, to start saying we need to start using different definitions, we’re going to have to start developing an evidence base based on this before we can even begin to implement it properly. So anyway, it’s quite interesting and another thing that’s been in the news this week.‌

Howard Forman: We will stay tuned.‌

Harlan Krumholz: Great. So let’s get to our guest. Sachin Jain, the terrific, terrific person, and I’m so glad we have on today.‌

Howard Forman: Dr. Sachin Jain is the current president and chief executive officer of Scan Health Plan and the Scan Group, a nonprofit offering Medicare Advantage plans. He is responsible for more than 300,000 enrolled members, which is growing rapidly and he will give me an update on that in a minute, and manages over $5.5 billion in revenue, also a stale number that I’m sure has already increased. Since he joined the company, Scan has doubled their revenues, expanded into four new states, developed new health plans for women and for Asian-Americans as well as people in the LGBTQ+ community. Prior to taking over the leadership at Scan, Dr. Jain held myriad leadership positions at healthcare organizations including CareMore, which is the division of what is now Elevance, Aspire Health, Merck and Company, and working in the U.S. Department of Health and Human Services at both the inauguration of the Center for Medicare and Medicaid Innovation, as well as in the office of the national coordinator.‌

He continues to teach currently as an adjunct professor at Stanford. He obtained his bachelor’s degree from Harvard, where he graduated magna cum laude and then his MD and MBA from Harvard Medical School and Harvard Business School, respectively. So first of all, it’s a great joy to have you on the podcast. I’ve been fortunate to know you now for probably about 15 years, and I’ve followed your career really closely and you’re just an enormously influential person, not just in the work that you do at Scan, and I want to get to that, but also in your ability to communicate to audiences of all types.‌

You have hundreds of thousands of followers on multiple different social media platforms, and you communicate in a very thoughtful way. And I thought maybe the first thing we could start off with is your most recent piece or one of your recent pieces in Forbes, where you really were one of the few courageous executives to come out and speak about the aftermath of the assassination of the UnitedHealth Group executive. And you are in that industry, and I thought you offered a really good viewpoint on what we can do better going on from here. So I thought if you could just start off what got you to write that piece and what would you like our listeners to know about that situation?‌

Sachin Jain: I think all of us are here trying to make things better, which brings us to the piece that I wrote in Forbes, which essentially was titled “We Are Sorry,” which really reflects I think how much we’ve lost our way in the U.S. managed care industry. Every one of us who started to work in managed care did so because we wanted to make healthcare better. But along the way, we have implemented things that I think are not necessarily pro-patient. The way in which we administer utilization management, it sometimes feels inhumane to people. The idea that going to have high-deductible health plans to get people’s skin in the game now seems so foolish. I mean, it was kind of foolish at the time because we said, “Hey, people don’t shop for healthcare the same way they shop for everything else.” But the truth is that what we now have is a system where people actively avoid seeking medical care because it’s just too expensive for them.‌

And so, forget an entry point into the healthcare system. I mean, people are literally just trying to avoid the healthcare system. When you think about just how complicated all of us insurers have made it, and all the regulators who regulate the insurance industry have made things, it requires an alphabet soup, it requires a master’s in public health from Yale, literally to just understand how the healthcare system is organized. I would say most doctors and most patients have no idea how the funds flow, how they actually work, and so, again, I think we lost control of the system at some point. I think the idea of professionalism and doing the right thing, even when it’s against your financial interest, has been completely stripped away from this industry, and it’s time to take a hard look at it and hit a big reset from my perspective.‌

Harlan Krumholz: It’s a great pleasure to have you on. I admire the kind of things that you’ve been involved in from the very beginning. I think as I’ve tracked your career and as you and I have talked, that you’re always trying to do the right thing. And now you’ve been in these positions increasingly of influence to try to do that. As Howie said, your writings are also very compelling. So I just wanted to take a few things that you’ve written and explore a little bit further with you. So one of the things that you wrote in a blog piece that you did was, “One of the healthcare industry’s biggest problems is our ability to call our baby ugly. Make no mistake—it’s an ugly baby. Maybe the ugliest. But when we fail to see things clearly, when we normalize the abnormal, we rob ourselves the opportunities to improve. We hold ourselves to lower standards.”‌

And in the course of this piece that you wrote, you said that we have to stop celebrating things that are fundamentally anti-patient, to quit representing incremental as innovative. And of course you were saying from whatever corner of the industry that you work in, but I had the feeling that you were strongly reflecting on this area of managed care and on this side trying to organize. I wonder if you could just expand a little bit on the “ugly baby” idea, the notion that we are celebrating things that are anti-patient and then, what can we do about it? Because so many of these things are embedded in the way that we’re organized right now.‌

Sachin Jain: So Harlan, years ago, I was being recruited to a very senior position at one of the top insurers in the country. I met with the head of HR and I said, “Tell me what makes X company really special.” And they said, “It’s really our culture and our focus on the patient.” And I’ve lived in environments, I’ve worked in environments, I’ve trained in environments where they really focus on the patient. And most managed care companies, contract networks pay claims and answer the phone. And usually they don’t even do that very well. But there’s a gaslighting that happens inside of these companies, a propaganda development that actually happens, which is, presents what we do in more heroic terms than we’re worthy of. And ordinarily, I’m not that offended by that, to be candid with you. I think every organization needs to create some of its own mythologies to perpetuate the right kind of culture.‌

But what happens when you say things to yourself like “we’re all about the patient” and you’re not, then you stop trying to actually be more about the patient. And I think that there’s a tension between who most healthcare organizations say they are and then who they actually are. And great organizations, virtuous organizations struggle with that tension. But then I would say that the struggle in U.S. managed care has largely died. And the struggle in healthcare entrepreneurship has really died. We glorify the latest funding round, and we glorify the IPO far more than the impact of the companies. And I think that culture—that’s cultural—and I have a longstanding debate with a handful of people in our industry.‌

They say, “It’s all about the incentives, it’s all about the incentives.” I mean, they’re slaves to the incentives. But those of us who have spent time in clinical training and in clinical settings know that there is a brand of humanity that is not totally a slave to incentives, that is about doing the right thing even when it isn’t in your best financial interest. And you can’t plan for or regulate every single situation. And so there is a need for a higher calling. There is a need for a higher professionalism in situations where human life is really concerned. And you see—‌

Harlan Krumholz: This is such an interesting point, I just want to hit on it a little bit more because as—and this is true in academic centers too. I mean this is every organization healthcare has got this issue, which is things are becoming more transactional. The things that we would see in the hallways and in the rooms historically in medicine was people spending an extra hour, people investing more for nothing in return. I mean, meaning, for everything in return about what it meant in terms of our fulfillment or what we felt our job was or what we felt that we were here for, everything about that, but not in terms of that I was going to be able to bill more, get paid more, or that anyone would even see me, sit down, hold that person’s hand, and spend an extra 15 minutes looking into their eyes and understanding their circumstance when I had other work to do.‌

That was what was special about the profession, was that people were consistently, that social capital were investing in ways that there was no external incentive except for your own internal compass about what it meant to be a doctor or what it meant to be a healthcare professional. And this is what I see being lost in the work towards saying, how did you spend every minute? Where are you in every hour? How much productivity measured by these ways? I’m just going to push you back, too, is how do you recapture that? I mean genie’s out of the bottle now. We’ve made this turn, and this is what’s being lost.‌

Sachin Jain: Well, it starts with saying out loud what we all know to be true, that the genie is out of the bottle. And I would tell you, I think you invited me to this podcast because I’m a bit outspoken and I sometimes feel very alone in our space because among people who have positions like mine, there aren’t a lot of them standing up and saying, “You know what? My baby is ugly. My organization could be doing a better job at all of these things.” Instead, we do this toxic positivity thing where we’re like, “Oh, we’re promoting the affordability of healthcare” or this nonsense line that so many companies use. “Oh, we promote whole health.” What the heck does “whole health” actually mean? And so the point I’m trying to make is that, this was something I learned early in my public policy studies in undergrad is how you define a problem influences how you solve a problem.‌

And there is some sense making around that has to happen around the problem definition before society can engage in a productive process around actually solving the problem. And I actually think the work of people like the three of us is to actually provide more sense making. And when you’re in the classroom and teaching undergraduates how, it’s got to be like, “Hey, this whole thing is FUBAR right now,” and your job is to keep calling it FUBAR until it’s better. Not become part of the tribe. Years ago, as part of my undergraduate thesis, we studied this idea of embedded criticism. This notion that the most powerful critics in society are the ones who are actually in the system speaking credibly about the opportunities to actually fix them. The guys who stand on the outside and throw bombs, we know who they are too. Those guys don’t have the credibility because they’re not living with it, and they don’t necessarily see it through all the dimensions and the angles.‌

Those of us who actually are in positions of responsibility have a much higher calling, from my perspective, to actually say out loud what isn’t being said. And we talk a lot about leadership in healthcare. I mean, we teach classes on leadership in healthcare, we give lectures on leadership in healthcare, but what do we do? We trot out the usual set of suspects, the CEOs of the big systems, the CEO of the big health plans, and we call them leaders. I remember when I was 12, 13 years old when we talked about leadership, we talked about Gandhi, Martin Luther King, Malcolm X, people who spoke out against great atrocities in our society at great personal cost to themselves.‌

So again, if we’re going to change this thing, it’s not just about advocating for different incentives, it’s not just about pointing at the other sector of healthcare that’s driving costs and problems. It’s about looking inwards, which is why I wrote the piece, Howie. Some people have asked me, “Have you heard from other managed care CEOs?” I have not. And I’m not waiting for the phone call. I’m not sitting by the phone waiting for the call. Because the truth is that the industry reaction after everything that happened with BT and then everything that followed after, it was like, let’s just play it safe and not say anything.‌

Howard Forman: So let me take a step back, then. Let’s talk a little about Scan Health, because it’s at the intersection of two more unique areas in the health plan industry. One is being a not-for-profit. Most of the health plans are now for-profit, and it’s Medicare Advantage, which is a dominant force in Medicare, but it’s still, it’s private Medicare plans and mostly been the Humanas and the UnitedHealth Groups and the Elevances of the world. What makes Scan Health unique? What are the things that you are trying to do to distinguish them and to avoid the mistakes that others have made?‌

Sachin Jain: Look, if you work for a public for-profit managed care company, your equity research analysts say that we’re going to peg your margin at 5%. That’s what we want to see quarter after quarter from your MA book of business. And if cost of care goes up, we still want to see 5%. If the government cuts rates, we still want to see 5%. And so what you see in for-profit Medicare Advantage plans is you see a lot of benefit instability, you see exits and entrants into markets. You see a lot of behavior that is meant to feed the quarter and not necessarily meant to meet the overall health needs of the people that you serve. One of the great things about working for Scan is that we actually think long-term about our patients, about the communities that we serve. And when there are changes on the margins, we’re able to make decisions that are, I think, more pro-patient than they are necessarily for shareholders—because we don’t have shareholders.‌

That said, I think there’s a lot of pressure to conform in this industry. There’s a lot of pressure to look like everybody else and to operate and perform like everybody else. But I would say that’s a lot of what our board pushes us on is, how do you be different? Which is why we did introduce the LGBTQ+ product, that’s why we did introduce the women’s product, that’s why we go into markets where we’re not necessarily going to be profitable if there is a real need in that community. And that’s how we’re trying to show up differently. That’s why we maintain our benefit stability even when there are wild fluctuations in rates based on changes in the coding model or base rates that are introduced by CMS.‌

Howard Forman: Just one quick follow-up. We had a guest on who is chief medical officer of Included Health—‌

Sachin Jain: Ami Parekh, probably.‌

Howard Forman: Oh, right, of course. Thank you.‌

Sachin Jain: Yeah, of course.‌

Howard Forman: Thank you.‌

Sachin Jain: Yeah, of course. Great person.‌

Howard Forman: And that got me thinking about how do you create products for the LGBTQ+ community and then reading about skin and seeing that you had products for women, and I thought for Asians, or at least a new product—‌

Sachin Jain: We do, we do. We have a new product for Asians, yeah.‌

Howard Forman: So can you speak?‌

Sachin Jain: It candidly didn’t sell as well as we’d hoped this past year. We believe, look, this is a very competitive marketplace, Howie, and one of the great advantages of Medicare Advantage, despite some of the flaws that I think its critics point out, is that there is an opportunity to tailor your offerings, to tailor your networks, to tailor your benefits, to actually specifically meet the needs of specific communities. And in a competitive marketplace where we’re trying to win share, we have to do things to attract members. I think one of our great successes over the last three years really was our LGBTQ+ product. We have over a thousand members enrolled in that product, which is more than we have in the whole state of Texas, actually, remarkably. A thousand doesn’t sound like a lot, but in this business, it’s actually pretty hard to introduce a new product in a very mature market and actually attract that kind of share. So I think we’re speaking to a group of people who, frankly, the rest of the healthcare system doesn’t speak to.‌

Harlan Krumholz: I want to bounce back to something else that, I love so much of what you’ve written, and there’s a quote though that stands on you on the web. I can’t actually figure out where it comes from, but it said that “Healthcare is at the beginning of a dialogue with the world.... As healthcare providers, we have to ask ourselves the question, what stories are we not hearing?” Was that something you wrote?‌

Sachin Jain: It is something I wrote. It is something I wrote.‌

Harlan Krumholz: Wonder if you could just expand on what did you mean by that? What stories we’re not hearing?‌

Sachin Jain: Well, I think when I’ve now sat in pharma, I’ve sat in managed care, I’ve sat in the federal government, and so much of how we think about solving problems is based on the stories that we hear, but there’s so many people who are not in the room. This really speaks to healthcare disparities and this question of how we design solutions. And I think there’s a lot of people who are designing healthcare solutions for San Francisco and not necessarily thinking about Xenia, Ohio, right? I mean, those are the kinds of things that we need to really think about. And when you are sitting at the top level of top corporations, you’re often not hearing from the people you really need to be hearing from. And I think you need to do some active work to actually make sure that you are getting the input that you need to get to begin to design the kinds of solutions that you need to solve for.‌

And again, I think we start out, everybody starts out with the best of intentions. They attend Howie’s course or the equivalent course at different undergraduate schools or medical schools around the country. And then you hit the real world, and then you start living your life. And it’s very easy to get very disconnected from the people that you’re trying to serve, that you start out in your career trying to serve. And so again, when I think about who it is that we’re solving for, and I’ll tell you a good story actually, when I was at CareMore, we were the first Medicare Advantage plan in the country to partner with Lyft or Uber on member transportation. And this was in 2016 and 2017 that we did this.‌

Harlan Krumholz: I remember that. I remember you did that.‌

Sachin Jain: Yeah. So that was 2017. So I went to a group of 250 of our members at a town hall, and I said, “How many of you have heard of Lyft or Uber?” How many hands went up? Five hands went up. Five hands went up. And I said, “Oh, so how have you heard of Lyft or Uber?” “Oh, well, I got a ride from you guys from them, but I had never heard of them before that.” And so I’d been at that point using Lyft and Uber for probably six, seven years. And it was normal, it was part of our everyday life. Now we’re talking about Waymo. And the truth is, is that there’s a whole group of people who, for socioeconomic reasons, age-related reasons, technology literacy–related reasons had never heard of a really dominant company in the world at that point. So again, that’s the point is that I think we got to bring different kinds of voices into the room and remember who we’re not hearing from.‌

Howard Forman: Can you speak just briefly to the strategy that Aetna, UnitedHealth Group, Humana, and pretty much all of the big health plans have taken, which is owning physician groups and using physicians particularly for their most complicated patients, but often for even more than that. You’re a smaller health plan, I’m wondering if that’s part of your strategy and how it’s different, if it is?‌

Sachin Jain: We do have four medical groups. So we have Welcome Health, which is our primary care medical group; Homebase Medical, which provides clinical wrap around services for other physician groups for their high-need patients. We’ve got Healthcare in Action, which is our medical group for patients experiencing homelessness all over California. And then we have myPlace Health, which is our PACE entity. And so again, I do think that there is lots to say about creating more connectedness with the delivery system and, in fact, owning part of the delivery system to create a more integrated, comprehensive experience for patients. I would say when the national companies that are doing it, I think some of what they see is the opportunity to do more risk adjustment. Let’s just say it out loud.‌

They’re seeing as an opportunity to make sure sick members are coded appropriately and that they’re being paid appropriately for taking care of those patients. And then I think that some of the greatest opportunity in health insurance is to better manage the most complex patients, the people who cost you the most, the ones who are getting admitted and readmitted, the heart failure patients that Harlan takes care of when he’s done clinical service, who frankly probably would benefit more from an intensive ambulatory care model than they would from anything that they would get at Yale New Haven Hospital. And so that’s the kind of stuff I think that these companies are investing in. That said, the work of managing care delivery organizations is so different from the work of managing health plans. And I used to say this when I used to run CareMore, that the business of CareMore is actually providing more care.‌

And the business of health plans is often denying care and denying coverage. And people who grow up in this world of “Hey, I’m restricting utilization” don’t often get that the best way to actually manage costs for a subset of the population is to really intensively provide care. And so I think that there’s a clash of cultures that’s going on as these companies are going on these journeys, and it’s going to take really enlightened clinical executives who can bridge both worlds. Someone like a Sree Chaguturu at CVS, who can actually understand that and translate that for his colleague in the boardroom.‌

Howard Forman: Well, we really appreciate you coming on. I will point out for our listeners that you are also an incredible mentor. There are just dozens and dozens of people that are part of your diaspora by now, and I imagine that you’re continuing to develop talent. So I just want to point it out for people that you can be in your position and still be part of generativity of our profession and our field. So thank you for everything that you do.‌

Sachin Jain: Thanks so much, Howie, you’re a true mensch. Thank you, Harlan. It’s great to be with both of you, and look forward to next time.‌

Harlan Krumholz: Well, that was a great interview. You can see he’s so thoughtful and articulate.‌

Howard Forman: Yes.‌

Harlan Krumholz: It’s just wonderful to interview.‌

Howard Forman: He’s a great communicator.‌

Harlan Krumholz: But speaking of great communicators, Howie, I love getting to this part of the podcast. What’s on your mind this week?‌

Howard Forman: Yeah, so two things came out this week. First, a new Gallup poll offers some sobering news about how the public rates trust and honesty among a relatively long list of professions. And the good news is that nurses are at the top of the list, and physicians not only make it into the top five, but they’re among the select group with a majority “high or very high” ratings. But it was still sobering to me that physicians also had the fifth-highest decrease in ratings over the 15-year window. And by the way, they had the highest decrease since 2021. But one could plausibly assume that physicians had achieved an unnaturally high ranking in the wake of the pandemic.‌

Just as an aside, lobbyists, TV reporters, members of Congress, all had strongly negative net rankings, unsurprising given the divisive times we live in. Also this week, The New York Times did a nice profile of trends in childhood vaccination rates, noting that there has been a steep decline from the start of the pandemic onward. And while one could easily explain some drop-off due to the shutting down of physician offices in schools during the pandemic, it only got worse from there. Vaccination rates for measles, polio, whooping cough are down by several percentage points. And many experts feel that we are now at that tipping point where outbreaks are more likely to happen. And the trend remains downward, worth noting that while the biggest drops and the lowest levels are seen in red states, those Republican-led states, this is by no means perfectly correlated.‌

This is a problem with most states to one degree or another. Maine, Connecticut, Alabama, and Kansas had increases over this interval. And the absolute highest rate in the country is West Virginia, and the absolute lowest rate is Idaho. So it’s clearly not just about politics. I’m linking these two stories because trust in individuals and institutions can be a lever of higher vaccination rates. And lack of trust may well be driving our vaccination problem. In an age of dominant social media where mega-influencers can also be conspiracy theorists, we have yet more challenges to health.‌

We need evidence-based mega-influencers to push back against those that have other interests at heart. Later this year, we’re going to feature one such individual, but we need a lot more than that to right this ship, or we’re going to suffer the consequences. And a reminder to our listeners, we are talking about decades-old, tried-and-true, extremely safe childhood vaccinations. It is a true shame if we lose so much of the progress we’ve made over the last seven decades.‌

Harlan Krumholz: Well, I agree it would be a shame, but I don’t quite know what the solution is right now. That there’s such a sort of tide of, I don’t know what it is, anti-expertise?‌

Howard Forman: No, no. I do think—‌

Harlan Krumholz: Let me give you an example, Howie. There is a whole group of people who are saying that it was the Eastern elites who led to all of the kind of interventions that occurred during the pandemic, as if all of those interventions were harmful in and of themselves as opposed to acknowledging that, for example, the states that were more likely to institute the shutdowns and have the most restrictive policies had the lowest mortality from the pandemic—and again, I’ve been working on this with Jeremy Faust—compared to what their predicted mortality was.‌

So it’s not saying we know that, for example, states that didn’t impose these policies have higher mortality rates at baseline, but you could predict, based on their historic averages, what would they have had in the pandemic and what were the excesses, and the excesses were always so much greater in those areas that weren’t implementing these policies. But now it almost seems like a done deal that this was stupidity. People are calling still for the jailing of Fauci and blah, blah, blah. There is strong sentiment in the nation that everything was wrong about our response to the pandemic, and it was all because of this expertise. And that bleeds into trust in the system, bleeds into the issue of vaccination.‌

Howard Forman: But again—‌

Harlan Krumholz: I don’t know how you combat it.‌

Howard Forman: But that’s the point. We’re not going to censor, we’re not going to stop people from speaking, but we could push back by having similar mega-influencers on the side of science as there are on the side of conspiracy.‌

Harlan Krumholz: Yeah, and we had Peter Hotez on, and I think Peter was talking eloquently about this, but many people vilify Peter, as he knows.‌

Howard Forman: Absolutely.‌

Harlan Krumholz: Here’s the issue, I think. If you’re on that other side—same craziness—I don’t think you’re getting death threats. I mean, I think you’re just out there howling in the wind, and there are many people picking up on it. If you’re on the side of combating that mob on that side, that’s saying things that... and it’s not things I disagree with, I’m saying things that are blatantly not true or conspiracy laden. So we’re not talking about where there are places that we can have honest disagreements, we’re saying that there are people saying things for which there is not even no evidence, but it’s counter to...‌

Howard Forman: But that’s my point. So those are conspiracy theorists, and one way or the other, we’ve got to invest in having influencers on the side of evidence. It doesn’t have to be the scientists. Joe Rogan is not a scientist.‌

Harlan Krumholz: I’m just saying people put themselves at risk when they do that because they become then targets. Anyway, it’s tough, and I also think it is tough. I mean, what do you think, Zuckerberg this week said, we’re dropping the...‌

Howard Forman: Right, so we’re not going to have censorship. We’re not going to have anything censorious. What we have to have is a pushback by people that actually believe that science should lead.‌

Harlan Krumholz: Then you agreed with that decision by Meta?‌

Howard Forman: Oh, no, no. Look, I’ve always felt that they have editorial responsibilities and that they actually should be doing something to be able to control information flow. But I also understand that in today’s society right now, anything that comes across as censorious is going to be litigated to death.‌

Harlan Krumholz: But you know that if you’re a television station, you can’t do that. I mean, there are guard...‌

Howard Forman: That’s right because they have... That’s right.‌

Harlan Krumholz: It’s interesting, like they’re outside of those norms that are created for...‌

Howard Forman: Because they consider themselves a platform and not an editor and that’s the distinction.‌

Harlan Krumholz: That’s a big deal. Yep. Well, I know you’ve been out there pushing facts.‌

Howard Forman: I’m not a mega-influencer. I wish I was.‌

Harlan Krumholz: Oh my goodness. You’re a—‌

Howard Forman: I’m a micro.‌

Harlan Krumholz: You’re not a—‌

Howard Forman: I’m a micro influencer.‌

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? Email us at health.veritas@yale.edu or follow us on any of the many social media, most notably Bluesky lately.‌

Harlan Krumholz: And we want to hear your feedback questions, your own experiences. I was talking to one of our listeners today, I didn’t even realize he was one of our listeners, and I was blown away, Howie. I mean, he started quoting to me one of our episodes and was giving me feedback. I so appreciated that.‌

Howard Forman: That’s great.‌

Harlan Krumholz: It was wonderful to hear. Thank you, Freddie. If you’re listening, that was very much appreciated. But yeah, all of you please, we—‌

Howard Forman: Give us feedback.‌

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

Harlan Krumholz: Health & Veritas is produced by the Yale School of Management, Yale School of Public Health. Thanks to our student researchers, Inès Gilles, Sophia Stumpf, Tobias Liu, and to our producer, Miranda Shafer. Terrific people, we’re so privileged to work with them, and they help make the show great.‌

Howard Forman: We are very fortunate.‌

Harlan Krumholz: Talk to you soon, Howie.‌

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