Sara Rosenbaum: Expanding Coverage, One Step at a Time

Transcript

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howard 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 Professor Sara Rosenbaum. But first, we always like to check in on current hot topics in health and healthcare, and there’s a lot we could cover, Harlan. What do you have?

Harlan Krumholz: My topic today is AI is eating healthcare.

Howard Forman: Okay.

Harlan Krumholz: It’s maybe a familiar topic.

Howard Forman: Is it eating it or is it making it better? I thought it’s making it better.

Harlan Krumholz: I want to spend a few minutes on a new January 2026 report from OpenAI called “AI as a Healthcare Ally,” because I think it captures something important that’s happening mostly out of sight. We spend a lot of time debating whether AI will replace doctors, but I think that framing misses what’s actually going on. AI is not entering through the front door of diagnosis and treatment, for many people. It’s entering through the side doors—insurance, paperwork, preparation, after-hours support. It’s interesting, and it matters in a system where roughly 70% of Americans now say healthcare is either broken or in a state of crisis. The scale of what the report shows is striking.

First of all, I was surprised to find that more than 5% of all of ChatGPT messages globally are now about healthcare. That translates into more than 40 million people every single day turning to this platform with health-related questions. But here’s the key point. They’re not primarily asking about symptoms. Many are, many are—but not primarily. Between 1.6 and 1.9 million messages every week are focused strictly on health insurance. And that’s got to be coming from the U.S. Comparing plans, understanding coverage, appealing denials, making sense of bills. We all know this is stuff that’s driving everybody crazy. So, this isn’t them asking for medical advice.

It’s for people trying to survive administratively in a system that’s become nearly impossible to navigate without help. AI in this context is acting as a infrastructure, organizing documents, drafting appeals, preparing people for conversations they know that otherwise will be confusing or even adversarial. This report also shows that AI is filling in other structural gaps. Seven in 10 health-related AI conversations, interestingly and maybe not surprisingly, happen outside of normal clinic hours: nights, weekends, moments when maybe anxiety is high and professional help is unavailable. We see the same pattern in hospital deserts, areas more than 30 minutes from a hospital.

In these regions, in these rural areas that we have had trouble forever providing care and support to, people send nearly 600,000 healthcare-related messages every week, and it’s more than in other places. This is indicated by the fact, for example, in the United States, Wyoming, the least populated state, has the highest rate of these hospital desert interactions in the country. They’re the place on a rate-based per capita basis. Then more people are using it for these sort of health questions. And for millions of people, it’s the only immediate way to interpret a lab result, decide whether someone feels something is urgent or not, or prepare for an appointment.

On the clinician side, it’s a little bit confusing that they do report something I believe to be true. Almost 70% of U.S. physicians now report using AI for at least one task, nearly double from last year. Think about that. It’s almost impossible to change physician behavior. And in just a year, we’ve doubled the number of people who are using AI for at least a task. Almost half of nurses report using it weekly, and the pattern matters. According to ChatGPT, it’s really using AI a lot for documentation, summaries, billing support.

The use for diagnosis has barely moved in their line of sight, but I think they don’t see what’s going on in OpenEvidence and other platforms where I think people are using it quite avidly for diagnosis. They’re saying that they don’t think clinicians are handing over judgment. I don’t think they’re handing over judgment either, but I do think they’re depending on these AI systems a lot to generate differential diagnoses, to help provide treatment, to understand options. I’m seeing it every day. So, I think one point is this report gives us a snapshot of what’s going on, but I think it’s where AI starts, not where it ends.

The fact that it’s being trusted today for navigation, preparation, administrative work for sure is not a limitation. I think it’s a prerequisite. It’s building trust in these systems, in low-risk, high-friction spaces. And by the way, that’s about how every major technology enters complex systems. I think you’re going to see clinicians and patients using AI more for medical reasoning, not just for general purpose but for specific reasons that they’ve got. And that’s also going to be for implications for diagnostic and therapeutic support. We’re watching this early phase of a much larger transition.

AI will increasingly be used not only to prepare patients and reduce burnout but to support diagnosis, guide these treatment changes, personalize care, monitor response, and flag risk earlier than humans can. I think you may have also seen this week that OpenAI is launching ChatGPT Health for consumers designed to ground questions in personal data in longitudinal context. People will be uploading their records into what is asserted to be a secure space whereby the AI platform will be able to give them insights that they wouldn’t have otherwise answer their questions, using their data as a basis.

And it’s opening APIs that already power much of healthcare ecosystem so that other applications will be able to interface with this AI platform. It’s not a single product launch. It’s a coordinated push across patients, clinicians, and systems. People used to say software is eating the world. I think what we’re watching now is AI eating the world. And healthcare, slowly at first, is clearly on the menu. The utilization numbers tell us something important. More than 230 million people globally ask health-related questions every week. People aren’t waiting for the system to be fixed. They’re building it their own way and through it. I’ve asked for access, early access to ChatGPT Health.

I’ve heard that I’m going to be granted access. I will report back to you after I do. I’m very curious to see what it’s like and how it works. But believe me, this is not a pilot phase. This is not a curiosity. This is transformation that’s already underway. Healthcare won’t be eaten overnight, but it’s clearly being consumed bite by bite, workflow by workflow, conversation by conversation. Used well, it won’t replace clinicians. It’ll extend them, guide them, and empower patients. I really believe it could lead us to a better day. It will be disruptive and transformative. It’ll be up to us to guide it in the right direction.

Howard Forman: I know this won’t be the last time we talk about it, so I’m really glad that you’re as engaged in this as you are and that we’ll continue learning about it over time.

Harlan Krumholz: Yeah, we’ll see, Howie. I don’t know. I hope you’ll get access to this too. I’m really curious what you think.

Howard Forman: I’ll let you know.

Harlan Krumholz: All right. Let’s get to our guest, Sara Rosenbaum. It’s going to be great.

Howard Forman: Professor Sara Rosenbaum is Professor Emerita of Health Law and Policy and the founding chair of the Department of Health Policy at the Milliken Institute School of Public Health at George Washington University. Professor Rosenbaum is one of the most cited health law scholars in the country and is widely recognized as a leading authority on health policy. She has devoted her career to advancing health justice and healthcare for medically underserved populations, and she’s particularly known for her work on national healthcare reform, Medicaid, and health insurance and, I would point out, for children in particular.

Over her career, she has played a major role in shaping federal health legislation and policy. She has served as a health policy advisor to six presidential administrations and 19 Congresses, served on the CDC Advisory Committee on Immunization Practice and was a founding commissioner of Congress’s Medicaid and CHIP Payment and Access Commission, or MACPAC, where she also served as chair. She grew up outside of New Haven, received her bachelor’s degree from Wesleyan University and her law degree from Boston University Law School and an elected member of the National Academy of Medicine. And let me just say, when we start looking at the honors you’ve received, they are so long.

The list is so long that to pick any one of them would somehow diminish somebody else, so we didn’t list them, but you are an incredibly honored individual. And I want to start off by just trying to get a little background of, how did you get to this point? Because until today, quite frankly, even though I think you told me about family before, I had forgotten that you’re from the area. Can you tell us about what it was like to grow up outside of New Haven in a connection to Yale?

Sara Rosenbaum: Yeah, I actually grew up in a family that was completely intertwined with Yale when my grandfather and his four or five brothers came from Russia. At the turn of the century, they were little kids, needless to say, impoverished children living in New Haven, very brilliant. And Yale gave them all a free ride at a time that Jewish students were admitted, but they couldn’t belong to anything or do anything, but they got a great education, loved Yale. My father and his brother went to Yale, and I was admitted to the first class of women at Yale, but told my family I wanted to go to Wesleyan because if you’re from New England, you know that 15 miles or 20 miles is like a huge... I needed to get away from the family.

So, I did not continue the Yale tradition but have stayed, of course, very involved with so many colleagues and friends at Yale. And as I say, I was back all the time because that’s where my family came from.

Howard Forman: And your career begins in the law and in advocacy. You start off, I think, in Vermont, but you eventually become very attached to, I think, the Children’s Health Defense Fund. I forget the name of the organization, but really deeply involved in children’s healthcare. And I was reading a profile of you. I think it’s from the Wesleyan Magazine. I’ll thank Tobias for digging it up from about eight years ago. And one of the things you said was so similar to one of the things that Ted Kennedy said when I worked in the Senate 25 years ago with him, and that is, like, you get your foot in the door and then you wedge it open more and more. You basically said incrementalism is the approach to policy.

Can you explain a little bit about how that has been the success for expanding coverage in this country over time?

Sara Rosenbaum: Yeah. And I mean, I should note that also, I’m sure Senator Kennedy felt the same way, which is that he was a man of greatly ambitious thinking and would have vastly preferred to do it all at once. But the way Congress historically has worked on social welfare policy, at least from about 1965, which was a revolutionary year, until the present time, when Congress seems to have stopped working at all. But the way historically things have worked is that you build incrementally. It took us, let’s see, we started trying, for example, to expand Medicaid eligibility for children in 1977, and it took all the way until 1989 or ’90 to enact legislation that by 2003 would assure that all low-income children would be insured.

It was only done incrementally year by year. There were some great leaps. Of course, the greatest of the leaps was the Affordable Care Act. That’s the great leap I lived through, preceded, of course, by Medicare and Medicaid, which were the great leaps, but you have to be a very patient person in America if you want to move social welfare policy forward and figure out how to make the notion of much greater health equity both feasible and appealing. I used to think of it as the unfortunate reality. It’s unfortunate, but it is the reality of the American legal system, really, and political system.

Harlan Krumholz: I wanted to focus on this piece that you wrote this month, which I think is an example of your pragmatism, which is this piece that you wrote in HealthAffairs where you’re talking about how tying Medicaid eligibility to the work reporting is really a centerpiece of this Big Beautiful Bill that’s going to cause maybe five million—and everyone just, let’s pause on that, five million. I mean, it’s a big number, five million or more people to lose Medicaid coverage, to be left uninsured. And instead of just bemoaning the bill, what you do is to think hard about what the bill actually says and what it means, and particularly about what the exclusions are for the work requirement.

So, you also talk about whether the work requirement makes sense. How many people does this actually cover? What is it going to do? But then you identify an issue within those dense, 10 dense pages you talk about in the bill, and it’s about this issue about frailty. I wonder if you could just explain to our listeners a little bit about this issue, what led you to unpack this and what you think the potential is for the use of this in the legislation to help mitigate some of the harm that might accrue to people who are going to lose their insurance?

Sara Rosenbaum: It’s a great question. There was no provision in the One Big Beautiful Bill Act that was the subject of a more intensive effort to stop it than this one. As you point out correctly, it’s a work reporting requirement because 92% of Medicaid beneficiaries either work or fall into an exemption group of some kind because they’re parents of very young children or because they’re taking care of somebody with a very serious disability or have a serious disability of their own. It was a provision that was designed to remove people from the program. For example, one of the things that a number of us argued was that they were applying this exclusion at the point of enrollment, actually the application for coverage.

And we already knew from an experiment in Georgia that if you make people have to jump through all of these hoops at the beginning, they don’t understand. And whereas Georgia expected almost 400,000 people to be eligible, they have enrolled 7,000 people. And we were informed that the name of the game here is to remove people from the expansion population. Rather than just repealing the expansion population outright, the architects understood that you could make it impossible for people to get on or stay on the...

Harlan Krumholz: And just to be really clear, put a point on this, what you’re saying is that it wasn’t really about determining who could work or not, but by creating an administrative layer, a burden, in the same way Voting Rights Acts create an administrative burden, you’re deterring people who are eligible by law from getting through all the hoops that are necessary to get there.

Howard Forman: That’s right.

Harlan Krumholz: I don’t think that’s been adequately discussed, actually.

Sara Rosenbaum: No, no. That it was quite intentional as a very clever way in their view of eliminating the very important Medicaid expansion that was part of the Affordable Care Act for low-income adults. They knew that they would have too much opposition doing it that way, but if you wave work around, people are hard-pressed to oppose what they see as work. So, the name of the game since July 4th has been trying to figure out how to try to mitigate the losses. And part of that effort is going on right now to figure out how to make sure that people who are working and do have an electronic paycheck, which of course a lot of poor workers don’t—they’re handymen, they’re babysitters, they’re people who pick up jobs, odd jobs—but for people with an electronic paycheck, how to get the payroll system aligned with Medicaid, but we knew that for especially older workers, people who fall into the 40-and-older group, that they are going to be at highest risk because I don’t need to tell either of you health experts this, but their health status is the status often of people who are 20 years older. Some of them are what we would call disabled, meaning that they meet the federal law’s very, very stringent definition of a disability, which is truly an inability to work.

But the bigger problem, far bigger, we suspected, and it turns out to be the case, as the evidence shows, is the large number of older people who are what we call “health-burdened,” who have a series of conditions—obesity, anxiety, high blood pressure, diabetes—that are hard for them to manage. Their health is very unstable. In any given months, they may be able to put in 80 hours of work, which is the requirement, but there are months or weeks where they just can’t. And above all, they’re on multiple medications and they need access to their Medicaid coverage to even have a remote chance of being able to live and not spiral into profound illness. And so, what we tried to do was construct a picture of these people. Who are they?

And it turns out that the statute, as you point out, Harlan, the statute’s terminology is such that we think there is a way because the phrasing is “serious or complex.” And we think that if health advocates can point out that you can have a complex condition, even when none of the specific diagnoses standing alone is enough to be very, very serious or disabling, you put them all together with people who are older and you have a serious profile on your hands. And importantly, we also note that in this category, you don’t have to show that you’re incapable of work, which is very important. These are people who work, but they don’t work steadily. They may have breaks in their work.

And so, we think we’ve hit upon a way to snake some group of people through. The real challenge will be how to handle the applicants. How do you take a 50-year-old woman who is applying for Medicaid for the first time? She lost her job. She no longer has employer coverage. She’s very poor. She’s in poor health. How do you get her the evaluation she’s going to need to show that she’s got a complex condition? Now, thankfully, there are places like the Cornell Scott Health Center in New Haven that are going to be very heavily implicated in doing health evaluations, we think.

And the question is how to support not only the classification system but then the front-end evaluation process to help folks like this get on the program and stay on the program. I will tell you that there is no way that once you get on, you will not be expected to repeatedly show that you are still complex. If you’re on SSI, which is of course the supplemental security income for people with profound disabilities, that’s a permanent status. But for the kinds of people we’re talking about, every six months, they’re going to be required to re-prove, re-up their complexity.

And it is going to be, we think of it as the legal equivalent of Dunkirk, when thousands of little boats had to go and rescue people because there was no great rescuer coming. I will tell you that the hope is that before the implementation happens with a change in the midterms and with the states really running aground badly and being able to do this and with a number of people who will be hurt, that Congress will push back, if not eliminate entirely the requirement. But right now, none of us has a choice here, but to try and save these... There are 20-plus million working-age adults—

Harlan Krumholz: Twenty-plus million. Mm-hmm.

Sara Rosenbaum: ... working-age adults on Medicaid as a result of the expansion. And I will tell you, they’re disproportionately not young men sitting and playing video games. They are older people who have no option but Medicaid. That’s what Medicaid is there for. So, it is a bigger job than any of us have ever had to face.

Howard Forman: Yeah. And it really is just a highlight of how Congress just changing a few votes can make such a huge difference.

Sara Rosenbaum: Exactly, exactly.

Howard Forman: I want to pivot to yet another catastrophe facing America right now. Yesterday, South Carolina announced yet another enormous tranche of measles cases, and it hearkens back to the fact that we, this past year, 2025, exceeded the number of cases in 1992. And 1992 is a year that’s important to you because you were empowered at that time, during the last big measles epidemic, with helping develop the Vaccine for Children Program in America. Can you just talk about, because we don’t solve everything with government, but just how critically important that program was to helping us get to the last couple of decades where we had measles elimination status until probably about a year ago.

Sara Rosenbaum: Yeah. I’m so glad you asked that. I should point out for listeners that on February 13th, a federal court in Boston is going to be hearing an oral argument in a profoundly important case brought by the American Academy of Pediatrics. I’m working on this case that will, if it succeeds, essentially eliminate all the changes that have happened since April of 2025. They are asking the court to simply nullify what has happened over the past year—

Howard Forman: Under Kennedy.

Sara Rosenbaum: ... under Kennedy, both the appointment of rogue advisory committee and immunization practice and the directives, the arbitrary directives simply wiping out the pediatric schedule as recently as last week. You’re absolutely right. And I find it to be one of the great ironies of all time that the outbreak that launched the Vaccines for Children program was none other than measles. I was fortunate enough to go to work for President Clinton, and the first initiative out of the box in the Clinton administration, I must say, as far as health reform, when it was that and the Children’s Health Insurance Program were the two that succeeded.

But the Vaccines for Children Program, which was enacted in 1993, so it was within the first eight months of his presidency, was designed to do really two things. One was to make sure that all states in covering immunizations for children, which all states already were required to do, but would have to cover at the level of the standard of care. In other words, that their coverage rules would be bound by the standards set by the advisory committee and immunization practices. And as such, that model, which I developed as part of the team that worked on this law, served as the basis for the great preventative benefits amendments in the Affordable Care Act.

It’s exactly what we did in the Affordable Care Act for all people across many different conditions. The second thing that the Vaccines for Children program did, which is often not well understood, is that it set up a fully federally funded, free delivery system right into healthcare practices so that the problem of missed opportunities, which was traceable to clinicians not having the vaccines on the shelves in their offices, ready to go, so that that problem would be addressed through a steady supply of free vaccine, with the administration fee then, of course, paid by the Medicaid program.

So, it is one of, to me, one of the epic examples of Medicaid as both a form of insurance but also as a public health program. It was designed to do two things, to directly address clinical preventative practice as well as coverage. And one of the terrible problems we’re having right now is that all of the pronouncements that Kennedy has issued, even as they say, “Well, this won’t affect your coverage. If you really want these vaccines, you can get these vaccines.”

That is nonsense, because what has happened is they have so confused clinical providers and families and so raised the specter for clinical providers that if they deliver vaccines that are not on the recommended routine schedule, that somehow will expose them for legal liability, which is not the case right now, but they are busy unwinding the legal liability protections as well. They have made a tremendous mess through this massive disinformation campaign, coupled with real measurable changes in how the U.S. sends vaccines into the delivery system for children. Well, there’s no other word for it. It’s a killer.

For our brief in the case, we’re busy trying to make a chart that would show a court very simply the vaccine that’s been threatened, the year it was adopted and the estimated number of lives saved, the number of hospitalizations averted, the number of serious and lifelong conditions averted, so that a court can see the consequences of the destabilization.

Harlan Krumholz: I wanted to just return to one thing you wrote about a few months ago about the effect of these Medicaid worker—I’m still stuck on this because to me, it still is such a thing. And I do want to make sure the listeners hear this clearly. This is not about getting around the law. It’s about ensuring that what is written is accurately followed. I mean as you’re talking, and I don’t think anyone would understand this one, but I just want to put a point on this, which is, this is about following the law, but making sure that there’s clarity with regard to what is written and how it’s implemented. And I think that’s what’s so great about how you’re pursuing this.

It’s not advocacy for a different law, or trying to get around the law that’s written. It’s about this law, making sure this law is properly implemented. One of the things you raised that I don’t think was recognized to the extent that it should have been was the effect of these requirements on community health centers, which play such a vital role in so many places throughout the country. And what happens to this safety net if millions of patients lose coverage? You could also say the same about hospitals, but the community health centers are in particular... and you were talking about what, like $32 billion in revenue loss over five years.

I mean, a catastrophic loss of the business model, if I can say it that way, for these really nonprofit community health centers that are trying to serve their populations, but rely on... these revenues have always been inadequate. The Medicaid has never truly compensated adequately, but they have been revenue that has been able to flow this infrastructure. So, do you want to just take a minute or two to share your insights about this? Because again, I don’t think it’s adequately appreciated.

Sara Rosenbaum: Absolutely. And I thank you for asking the question. The Affordable Care Act, first and foremost, had a remarkable impact. The Medicaid provisions had a remarkable impact on access to health insurance for low-income adults, working-age adults. A side benefit of that was that for community health providers like community health centers, the same would be true for family planning clinics or community mental health clinics. The providers that are there for low-income families, including a lot of working-age adults, the expansion was transformative for them as well.

So, at the time that the Affordable Care Act was enacted, probably somewhere between 25% and 30% of health center patients were covered by Medicaid. By the early 2020s, the number is more like 50%, particularly in a state like Connecticut, which has of course been all in on the expansion and making the expansion accessible. And with that near doubling of Medicaid penetration into the population came two things. One was a vast increase in the financial resources flowing to community health centers because they could now get paid for services that they struggled to provide out of very small grant funds they had.

The other, which is seldom really focused on, but it’s equally huge, is that suddenly because they had insured patients, they could manage them much better. They could treat them much better. They could get them specialty care that they don’t provide. Our community health center here in Northern Virginia, which is a wonderful health center. The director told me a story once about the fact that for his uninsured patients, even where there’s a suspected problem, he cannot get a free diagnostic mammogram. To say that we live in an area spilling over with medical resources, we’re one of the most affluent areas in the country, the fact that he cannot get anybody to donate a mammogram for a patient who has no insurance is pathetic. As soon as they have Medicaid, though, these are the things that they can get. They can get treatment. And so, to now take away the insurance coverage of so many of their patients or threaten the insurance coverage. First of all, of course, as I was saying, as we were talking before, health centers will be on the front line of trying to help their patients keep their coverage or qualify for coverage by doing the medical evaluation work that will be needed.

And if you have brilliant AI people at Yale, I can say that we need all the help we can get figuring out how to write the programs once we have the rules that will—

Howard Forman: That’s great, great point.

Sara Rosenbaum: ... identify people and churn out the letters and provide the data to the Medicaid agency. But it’s not just a matter of keeping the revenues going. It is a matter of their being able to manage their patients, again, at the standard of care, to not be in a box canyon, where all they can do for their patients is far less than what the patients need. And so, it is threatening the quality of care as well as, of course, the financial support for care.

Howard Forman: I’m going to ask one quick question. It may be a long answer and you can defer if you don’t want to answer it. And it’s a little more controversial. And that is, I’ve personally felt like the provider taxes has been a gaming issue by the states. I’ve not been in favor of it. I’ve always felt it’s like it’s a workaround to what really should be happening, which is to say that we don’t send enough money from the federal government to the states to pay for the healthcare for the Medicaid populations and make sure they have adequate access. What is the solution? Do we completely fund it by the federal government?

Do we elevate the funding rate? Is there a solution that you think is possible in the next few years?

Sara Rosenbaum: It’s a really good question. And look, the first round of efforts to curb the use of provider taxes, which was done, of course, in a different era in a much more responsible way, was in 1990. My friend, the great Gail Wilensky, who of course tragically died last year—

Howard Forman: Year and a half ago.

Sara Rosenbaum: ... year and a half ago, was the person who helped design that. And I can remember many discussions with Gail about how to align state revenue-raising practices in a more reasonable way, because of course it’s certainly the case that we use many, many kinds of revenue-generating mechanisms, right? Including user fees. I mean, that’s basically how the FDA runs. So, the notion that hospitals or doctors or pharmacies would pay to help support the system is not outlandish. This is not uncommon. What would happen, what happened, of course, was that states figured out how they could generate massive return on local investments, provider investments. And the curbs were put into place in 1990.

And of course, states then developed more mechanisms, new age mechanisms, particularly in the use of managed care, came online where you would essentially use managed care to generate, again, a lot of revenue. And I don’t think anybody felt it was wrong. And in fact, the Biden administration tried, tried to put some limits into place and they were challenged legally by Texas and Florida and everybody else to stop them from some commonsense limits. And so, states were sitting ducks for what happened last year, which is not just curbs, but of course, again, draconian when it comes to the Medicaid expansion states.

Howard Forman: And no substitution for it.

Sara Rosenbaum: No. I mean, what they did was to use a crackdown on provider taxes or curbing provider taxes and what is called state-directed payments to literally go after the expansion states. So, Texas and Florida and Georgia got rewarded basically for not insuring anybody with a more generous set of reforms and Connecticut and New York and Vermont and the New England will be killed by what they’ve done.

Howard Forman: Right. Well, look...

Sara Rosenbaum: It’s always the issue with Medicaid, how to make some commonsense reforms and how the program runs. And you’re totally correct. I mean, the way to run Medicaid would be to do what we did with the expansion, which is a very, very generous federal financing coupled with some rules about where the state funding comes from.

Harlan Krumholz: Or how about Healthcare for All? That might...

Sara Rosenbaum: Well, that would be the best.

Harlan Krumholz: That would take care of it.

Sara Rosenbaum: I’m afraid I’m almost 75 and I don’t think I’m going to make it to Medicare for All, but one can only go.

Howard Forman: We’re still—

Harlan Krumholz: Things sometimes—as you know, windows of opportunity open. You never know.

Sara Rosenbaum: They do. And when you got to be prepared to run right through. Absolutely.

Howard Forman: We appreciate it.

Harlan Krumholz: What a pleasure to have you on.

Sara Rosenbaum: What a pleasure to be here.

Howard Forman: You are awesome.

Sara Rosenbaum: It was so nice to see you all. And I’m very sorry that I no longer come to New Haven all the time for family. Otherwise, I’d collect you and we could all go have coffee.

Howard Forman: That would be lovely. Well, we should still try to do it.

Harlan Krumholz: Please do. Please do.

Howard Forman: Thank you so much.

Harlan Krumholz: Well, that was a terrific, terrific interview.

Howard Forman: She’s so bright. She knows everything. Yeah, it’s great.

Harlan Krumholz: And actually, I love our podcast because I learned so much. I learned a lot from her.

Howard Forman: Yeah, me too.

Harlan Krumholz: But I also learned a lot from you. And Howie Forman, what’s on your mind this week?

Howard Forman: Yeah. So, more than 100,000 children below the age of 14 are newly infected by HIV each year, many through maternal fetal transmission. Forty years ago, this would have been a death sentence and seemingly an intractable problem to even tackle, but today we have the means to completely eradicate vertical transmission or what we mean by transmission from mother to child. And I’m glad to say that the World Health Organization certified just last month that Brazil has now meaningfully eliminated maternal fetal HIV transmission.

This is a multi-decade, multi-national achievement and occurs because Brazil, as with so many other nations, has made enormous strides at testing for and treating HIV and also destigmatizing the infection sufficiently to make this even possible. It is the most populous nation in the Americas to make this achievement. To achieve this designation, they needed to reduce vertical transmission to 2%—I’ll come back to what 2% means—and also to achieve 95% coverage for prenatal care, HIV testing, and timely treatment for pregnant women living with HIV.

Now, for our listeners to understand this, vertical transmission would otherwise occur in 15% to 45% of pregnancies in women who had HIV if you did nothing else; 15% to 45% of births from women who are HIV-positive would be HIV-positive if you had no intervention. So, getting it down to 2% is enormous. The World Health Organization stated that over the last decade, just 2015 to 2024, more than 50,000 pediatric HIV infections have been averted in the region of the Americas as a result of the implementation of the initiative to eliminate mother-to-child transmission of HIV. The key strategy here is this.

You need to screen and provide prenatal care as well as then provide directive care for those who are infected if you want to spare children these horrible diseases. And I’ll point that in the United States right now, the opposite seems to be happening recently with regard to congenital syphilis. And we’ve talked about this in previous episodes. We all hope that we don’t have similar backsliding with regard to our enormous success against pediatric hepatitis B infections, but Brazil at least should give us all hope that even in underresourced parts of the world, coordinated efforts can make an enormous difference.

Harlan Krumholz: Howie, public health gets beat up now all the time.

Howard Forman: Yeah.

Harlan Krumholz: This is a real success story. I think what does their success tell us about what actually makes public health victories possible, especially when stigma and inequality are involved, as they were in this case?

Howard Forman: It’s coordination. I mean, it means that everybody has to oar in the same direction and you can’t be fighting against the tide all the time. We’ve watched this. We’ve talked about it on the podcast with the elimination of malaria, with the elimination of river blindness, or at least diminishment in that. There’s so many big achievements. Tuberculosis, another example, so many examples where we’ve had success. To watch our nation backsliding with measles, backsliding with congenital syphilis is disconcerting, but at least we know how to fix it. We just have to have the will to do so.

Harlan Krumholz: I’m so glad you brought up this example, because this wasn’t a new drug breakthrough.

Howard Forman: No. And it’s cheap.

Harlan Krumholz: It was implementation at scale.

Howard Forman: That’s right.

Harlan Krumholz: Did you get a sense of what mattered most? What was the real success factor here? I mean, you talk about coordination. Is it just that simple, coordination?

Howard Forman: I honestly think it has to do with universal coverage of pregnancies so that every woman is screened, every woman is treated if they’re positive, and the destigmatization is critical. If you go and look at a lot of countries right now, people are afraid to be diagnosed with HIV because it’s seen as a scourge and it’s a stain and so many other things. So, all these things have to happen, and it means public officials have to be willing to be honest with people about what they’re doing.

Harlan Krumholz: So, final question for you is if we know that vertical transmission can be essentially eliminated, what should be our tolerance for seeing these infections persist anywhere? Because we now know in a country like Brazil, you can do it.

Howard Forman: Yeah. No, I think, look, the congenital syphilis example in America is what I think we should focus on at the moment because that’s something that when you and I were in medical school, we knew how to tackle. That’s not new. We know how to test for syphilis, we know how to treat, we know when it’s transmitted, and yet there’s been a huge number of cases of congenital syphilis in the United States right now because we don’t have universal healthcare. We’re not attentive to all the issues going on. We’re forgetting all the lessons we’ve learned in the past. This is an opportunity for us to be so much better, and we should learn from Brazil.

Harlan Krumholz: Yeah. Well, that’s terrific. Thank you, Howie. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So, how did we do? To give us your feedback or to keep the conversation going, email us at health.veritas@yale.edu or follow us on any of social media. And again, we have that great Instagram account.

Harlan Krumholz: Yeah. Well, we’d love to hear from you. It’s great for us to give feedback. And we want to give great thanks to our superstar undergrads, Tobias Liu and Gloria Beck, to our fantastic producer, Miranda Shafer. And I want to thank Howie for letting me work with the best in the business.

Howard Forman: I appreciate you too, Harlan. It’s a great team that makes this work. Let me just remind us, Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. To learn about the Yale SOM’s MBA for Executives program, visit som.yale.edu/emba. To learn about the School of Public Health’s Executive Master of Public Health program, visit sph.yale.edu/emph.

Harlan Krumholz: Yeah, great programs, and we appreciate the support, and it’s always great talking to you, Howie. Talk to you soon.

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