Sherry Glied: Getting Ready for the Next Pandemic

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

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This week, we will be speaking with Dean Sherry Glied of the Wagner School for Public Service at New York University. But first, we like to check in on current health news. For me, and I think for all of us, the biggest news is that masks are disappearing at a rapid pace, and I don’t know that we have adequately helped prepare the public for this, nor considered what our plans are if there is a new serious outbreak.

In this particular regard, the Biden administration and/or Congress needs to seriously and apolitically talk about mask regulations because we will likely face a serious respiratory virus pandemic again in the future or a new exacerbation of COVID. If the CDC does not have the authority to institute mandates in such situations, we should all want to know who does. A future virus could be considerably worse than COVID, and so this single judge in Florida who has the authority to overrule this executive order has really upended things in a huge way. I’m curious to hear your thoughts, Harlan.

Harlan Krumholz: Well, my ears must not be right because I thought you said that the Biden administration and/or Congress need to seriously and apolitically talk. I thought maybe you were hallucinating a little bit, because as you know, this is, from the beginning, been a very political issue that has made it difficult to just talk about the science and to be able to have forthright public dialogue about what the right thing to do is, and to ultimately have the government extol certain policies that we, whether we agree or not, all comply with because we want to be able to help advance the public health and recognize that there are nuances to any governmental decision that have to do with the pandemic.

In this case, I guess what bothered me the most was what’s unraveled the travel restriction has been a single judge in Florida who ruled that the CDC didn’t have authority within the context of a public health emergency to mandate masks. I find that off note. Now we can be debating whether or not we should be wearing masks and whether or not there should be mask mandates at this point in time from the government, but to suggest that our major public health agency doesn’t have the authority to protect the population in a time of a pandemic, and by the way, this wasn’t weighing COVID versus something else or the risks or the science; simply saying the government doesn’t have this authority. To me, I found that surprising and disappointing. I think it was wise for the Biden administration not to fight this outright, but I do think we need a public discussion about where do we stand with regard to public health policies and does this make sense.

For my own part, when I fly, I will indeed be wearing a mask when I go on public transportation. I will when I’m in closed spaces. I also believe that ultimately most Americans will be infected by the virus. It is highly infectious, and it’s hard to stave off. It’s just that I’m not in any rush to be infected, and if I’m one of those that can avoid it, I prefer to. The bigger issue we have in this country I think is not the mask, but the fact that we have so few people who are still not fully vaccinated and we have so many people who are at great risk should they get infected.

If future variants take a turn for the worse with regard to their pathogenicity, their danger, these people are unprotected. In a way, I feel that the mask conversation needs to be had, but I’m worried that we’ve moved off of the vaccines too fast and that this still remains a big issue. We’ve just encouraged it for people 60 and above, the fourth dose, and by and large people aren’t doing it. Anyway, this is the issue, I think.

Howard Forman: We have consistently underperformed in this pandemic. We pat ourselves on the back all too often, but if you look at the overall data on deaths, hospitalizations, the vast majority of our peer nations have outperformed us, and the masking issue is just one symptom of a larger problem.

Harlan Krumholz: Yeah. And the fact that more Republicans have died in this pandemic than Democrats, just looking at geographically where the toll has been, has not changed the stance of the Republican Party with regard to the pandemic. I think we can conclude that this is going to remain highly political, and we just need to do our best, I guess, as a country to figure out what is it that we can agree on and move forward. I do think, given that former President Trump has been vaccinated, that maybe Republicans and Democrats can agree about the importance of vaccination because the person ostensibly leading the Republican Party has endorsed them also. Perhaps it’s most important that we find those areas that we have full agreement on and try to at least implement a strategy that we can get all Americans on board on.

Howard Forman: It’s great to entry introduce Dean Sherry Glied. Dean Sherry Glied is the Dean of NYU’s Robert F. Wagner Graduate School of Public Service. Previously, she was a professor of health policy and management at Columbia University’s Mailman School of Public Health from 1998 to 2009. She’s also worked extensively on health policy, serving as the assistant secretary of planning and evaluation in the Obama administration from 2010 to 2012 and on the president’s Council of Economic Advisers in 1992 and 1993 under both Presidents Bush and Clinton. Dean Glied has been an elected member to the National Academy of Medicine and the National Academy of Social Insurance and is a research associate at the National Bureau of Economic Research. Her research interests focus on health policy reform and mental health policy. Most notably to me, she is a graduate of Yale College. Subsequently, got her master’s degree in University of Toronto and her PhD in Economics at Harvard.

First of all, welcome to the podcast. Thank you for making the time to do this with us. I think I’ll just start off and ask you a question. I just came off a webinar with Farzad Mostashari, and Farzad and I were talking about what data do we need to inform public health emergencies and pandemic awareness, and how do we use that data better? You have consistently been both someone who analyzes data, but also someone who has worked with data in policy positions in government. I’m just curious to hear your thoughts about how do we do better in the future and what could we be doing better now?

Sherry Glied: Yeah, so that’s a great question. It’s been obsessing me for about the last two years. I am really struck by the following horrible scenario. What if the vaccines had never been invented, which was a very reasonable thing to imagine. Back when COVID was first identified, there was a lot of speculation that we would not get effective vaccines for quite some time or possibly forever, after the HIV experience, right? What were we going to do if we never got vaccines? How were we going to figure out how to live in a world where COVID was at that point already pandemic? We have an infrastructure of epidemiology and public health response that’s really focused on stopping an infectious disease in its tracks, but we don’t actually have a really good way of thinking about what to do with infectious diseases that are already in the system, already endemic.

I have an ex-colleague from Columbia, Steve Morse, who’s an influenza epidemiologist and introduced me to how horrible our understanding of influenza epidemiology is. How after a century of knowing about influenza, we actually still don’t really know very much about how to intervene there. Why don’t we know more? I think Farzad is totally right. Farzad called COVID in New York City—I don’t know if he told you that story—because of his syndromic surveillance system. I think he is totally right that we need better data so that we can stop pandemics in their tracks so we can do all of that. But I also think we need to be able to learn better, and we need a better infrastructure for thinking about what happens if it doesn’t work, if you can’t actually stop it.

Data is only the first piece of that. You actually have to analyze the data to make anything of it. Farzad’s data is the cleanest data because it almost speaks for itself. It almost shouts for itself, but most data doesn’t speak for itself. Most data needs to be analyzed in order to be able to infer something from it. One of the things about COVID is there’s been an enormous amount of analysis, an enormous amount of data. We have all this cell phone data, these notification systems, universities around the country that either did or did not close down their dorms, that either did or did not close down their classrooms, that either did or didn’t put people three feet apart or six feet apart or whatever, and yet the evidence based on which we are making policy is so pathetic. We need actually to tackle this problem as a scientific problem or a problem of evidence development and not just assume that more research and more data are going to answer it because more research and more data are not helping us at this point.

Harlan Krumholz: Well, I’ll say that’s a big disappointment for me too. For all the things that have been catalyzed throughout the pandemic, we haven’t seemed to have been able to really overcome this issue around data flows. Yet we have the technology to be able to maintain privacy, security of the data, to be able to de-identify it in ways that are suitable for public health uses. Yet we still don’t stream data regularly from the hospitals. We have no idea really. The hospitalization rates and their labeling is highly inaccurate. Even the deaths, we have issues around delays. We’ve been doing some work with the death certificate data in Massachusetts. We get it up into the week. If you really want it from CDC, it’s markedly delayed. I couldn’t agree more. Maybe this will be the push we need to be able to think about what the data infrastructure largely should be in the country. But I want to go back. I know Howie wants to go to a very pragmatic, tangible questions about the pandemic. Yeah, go ahead.

Sherry Glied: I actually want to interrupt you though, Harlan, for a second, okay? I think the problem is all of us as researchers, and this is just what we are, we’re fixated on getting access to the data so we can do our wonderful analysis of the data. But I think we can’t stop there. Our analysis of the data is not the evidence that policymakers need. The evidence that policymakers need is something that actually takes your study and Kosali Simon’s study with cell phone data and someone else’s study on the west coast with wastewater and all this information and actually brings it together. That’s actually the place that we haven’t made the methodological changes that we need. We don’t have a learning system.

It’s not just us. It’s all the countries around the world, so I think it’s not just a data access problem. It’s actually a science problem. We don’t have methods for synthesizing and learning that work efficiently in a pandemic that can absorb and ingest the varieties of data that studies use, the varieties of techniques they use, and actually draw a conclusion. Let me ask you a question. We’re having this whole fuss about face masks on airplanes. Should we have face masks on airplanes, or should we not have face masks on airplanes? I’m sure you have an opinion about it, both of you, right? But suppose I asked you without telling me, like I do with my students. Put it in the chat and don’t tell me. Don’t tell it to the rest of the class. By how much does universal masking on airplanes reduce the spread of COVID? By 10%? By 40%? By 80%? I don’t think anyone has a clue. And how is anybody supposed to make a decision based when they have no clue?

Harlan Krumholz: Well, you’re opening up so many different things. Look, I agree with the synthesis, but I can tell you that even the basic research can’t even be done if people don’t have ready access to timely data.

Sherry Glied: For sure.

Harlan Krumholz: I’m just saying we can do as much synthesis as we want, but unless the data’s available. I want as many smart people as possible—

Sherry Glied: Yeah. But the British have the data, right? The British have the data and the French have the data and the Dutch have the data, and they haven’t done it either. They don’t know what the answer is on airplanes anymore than we do.

Harlan Krumholz: The answer about masks I think is a little more nuanced, which is that from the point of view of the entire country, it’s a minuscule impact. It has to be a minuscule impact. Maybe in the beginning of the pandemic when it was being spread from China to the U.S., that initial case, which then spawned millions of cases, that initial case might have been critical, but at this point in the pandemic, because you have to just look at... what’s that, amount of spread versus supermarkets versus offices versus a whole range of other places, but it’s more I think about each individual’s risk and what that social contract is for being on the planes. But yeah, I don’t even think we have a good estimate of masking itself or many of the public health interventions. But that information itself, yeah, is remarkably difficult to generate given all the various influences on it. Look, I couldn’t agree more. We were flying blind.

Sherry Glied: I just think the project can’t stop with data. The project can’t stop with collecting the data and letting it be out there for all of us to write our papers about it. The project has to keep going beyond that, and it has to think about how you put together data from many different sources.

Harlan Krumholz: Well, let me say this. I think it’s also about who’s asking the questions. The way research often works is a researcher sits in a room and comes up with a question and then hopes they find an audience. I’ve argued for a long time, we had to flip the script. Really the question is, people who are in positions of policy, what are their 10 most important questions that they wish they knew the answers to and maybe we should be doing XPRIZE for that, right? We get data out and we say, “So who can answer this the best because this question has immediate policy relevance?”

The reason our group likes to work with CMS [Centers for Medicare & Medicaid Services] is because they tell us their questions. We can help provide answers, and in a nanosecond, all of a sudden that influences policy. As opposed to the usual thing where academics are throwing rocks over the wall, criticizing the status quo, hoping somebody on the other side listens. Instead, they get bonked in the head and say, “Who in the hell is that person over there? They don’t even understand my constraints, my problems, or what my need for information is.” Then, in essence, the academics get sidelined because they’re not working in alignment with people who are actually in positions of responsibility.

Sherry Glied: Totally, couldn’t agree more. I had this idea that early in the pandemic, the CDC should have put out 10 questions that they care about. How effective are face masks? Which is I think a question. It should be “How effective?,” not “Are face masks effective?,” which is a totally useless question. They should have said, “Okay, our current estimate on a scale of 0 to 100 is that face masks are 50% effective and the confidence interval on that thing stretches from 10 to 90.” I made that up, right? Anything you can give us that tightens the confidence interval is worth researching. How much can we get that number down? Of course, you’ll tell me it’s not face masks generally. We have to think about all the sub-questions. That’s fine.

Harlan Krumholz: No, but let’s solve it. The issue I think is that we have to think differently about how we motivate the research and the synthesis. Actually, I had written an editorial at one point that said, don’t give people grants for grant applications. Show me what the product of the grant is going to be. Write a mock article that says, “Here’s what I think I’m going to... If, best case scenario, here’s kind of what I can find.” Or when you’re done, don’t pay them at all, but tell them we’ll put it up on eBay minus the results, and we’ll see how much people want to bid on what the results of the study are.

Sherry Glied: That’s awesome! I love that. I love that.

Harlan Krumholz: Because as you know, as an economist, value of information, so much of what gets produced in these academic articles—

Sherry Glied: Useless.

Harlan Krumholz: No one would bid a dime on it.

Sherry Glied: Right, useless.

Harlan Krumholz: If they didn’t have the results. And so, where are they taking risk and where are they trying to produce information that has value? We should flip this. But imagine we go to CDC and say, “Let’s go to XPRIZE.” Let’s say, “Here are your 10 questions. For the person, within the next 90 days, whoever answers this the best is going to get a dollar prize for that. And everyone else, thanks very much.”

Sherry Glied: I think the general point is, we have to... If we want to do better in the next pandemic, it’s not just an investment of money into public health infrastructure and surveillance. It is changing the incentives for all of the researchers and all of the work that gets out there to actually answer the questions we need to know the answers to, because otherwise we’re not going to... we’ll just have a lot of more articles. Then who cares?

Harlan Krumholz: I had another question, but I’m going to yield to Howie because I’m taking up all the time. But Howie, go ahead. I’m getting mine ready for when you’re done.

Howard Forman: We have invested trillions of dollars in the recovery from this pandemic, and some of that money has gone to supporting our Medicaid programs, expansions of insurance, being able to provide care to individuals. When the public health emergency is ended, some of that additional funding is going to go away in a substantial way. Our Medicaid program, in particular, benefits right now from an elevated FMAP—Federal Medical Assistance Percentage—which is a vast way of getting money to the states. I’m curious to know your thoughts on what the unintended consequences are going to be to healthcare delivery in this country when the announcement to the pandemic being over occurs and leads to this funding challenge.

Sherry Glied: I think there is a big problem. Although I don’t think it’s really the FMAP. The FMAP was just a really efficient way for the federal government to bail out states. States are flush now, so I don’t think that the financial hit on states is really the issue. But there are other things that we did that actually seem to me to have more of a bite. One is, we extended Medicaid eligibility. We didn’t make people re-enroll. A whole bunch of people are going to fall off Medicaid because they’re going to fail to re-enroll. That happens all the time, but it’s going to happen in a wave and there’s going to be a lot of people who thought they had health insurance.

Then they’re going to be... Medicaid has some retroactive eligibility, but people are going to be scrambling, and in the meantime, they’re not going to fill their prescriptions, and bad stuff is going to happen, and we have this little mini-tsunami of dis-enrollment I think coming there. Then even more so the enhanced subsidies in the marketplaces are going to go away. There’s going to be a bunch of people who are stuck with much, much higher health insurance bills come November and December, and we know that some of them are going to drop coverage for that reason. We know actually from a beautifully done study that that’s actually going to lead to mortality. I think money is really helpful in the system in this way if we direct it to the people who most need it. Not all of that money was I think directed in those ways, but some of it really was.

Howard Forman: Yeah. I’ll say about the FMAP, the reason why I worry about it so much is that states have balanced budget acts on the books. They don’t love tapping rainy day funds. There are an awful lot of states that are very aggressive about balancing their books. If you have two things to cut, you cut education or you cut healthcare. I’m concerned that the fallback is going to be cutting Medicaid, cutting other healthcare that we can do. But I agree. There’s a lot of things that are going to happen all at once.

Sherry Glied: Yeah. I just would say, state money is fungible. Whether they cut Medicaid or not may not really depend entirely... the FMAP keeps them from cutting Medicaid because they get the match, but if there are real budget crunches, all kinds of things will happen.

Harlan Krumholz: Well, so I wanted to go back to what I wanted to ask you before. I’m a real fan of yours. You are really just such a great example of someone who approaches all their work with deep rigor but seeks pragmatic solutions. You’ve done this in so many different ways. I wanted to ask you just because the path you’ve been on in your career has been so interesting. As a PhD economist, a Canadian-born PhD economist who’s made such great contributions to the American healthcare system. If you were to go back and give your younger self when you were graduating from Yale advice, you know people sometimes ask this, but I’m always interested. What would you have advised yourself? Just to do the same thing, or is there anything different?

Sherry Glied: It’s really hard to think of the counterfactual. I actually spent a year in law school when I graduated from Yale, and I wouldn’t have done that.

Harlan Krumholz: Oh, I didn’t know that.

Sherry Glied: I think I probably went to law school because I was scared and I was afraid that if I did the things that I really wanted to do, it wouldn’t work out and I couldn’t even imagine what that was. But I’ve been very fortunate in really having the luxury of being able to take those chances at different times. Being an academic is very good in that way, to pursue things that I thought were interesting and where I really did feel like I could be helpful. I will also say I think one of the lessons I learned, and I know that we’re not supposed to say this to people, is you’re not really a great judge of what the best career path for yourself is when you’re 22 years old.

If you try to map it out too much and if you try to be too strategic, you could wind up being really bored. There were a bunch of decisions that I made where I did them for very idiosyncratic reasons. I always wanted to live in New York City, and when I got offered a job at Columbia, I took it even though it was a terrible job compared to the other jobs I had on the table at the time. But it was the right thing for me to do, and it was exciting and great. If I had been really strategic about it, I would’ve taken a different job, but I would’ve had a much less interesting life.

Harlan Krumholz: But it all depended on your own utilities, right? You were maximizing utilities.

Sherry Glied: I was always maximizing my utility subject to budget constraint, yes.

Howard Forman: I want to just close it with a question about the leadership roles that you’ve played at academic institutions. A lot of academics scurry away from these types of administrative roles, and you ran the healthcare management program at the Mailman School of Columbia now. You’ve been I think nine years or almost nine years of dean at the Wagner School, and the Wagner School has a unique mission toward public service. There’s not that many peer institutions in the country. We in fact did our podcast a week or two ago of Lauren Taylor, who has an affiliation with the Wagner School as well. I’m just curious to hear your views for young academics and young professionals about why you’ve taken up administrative roles when you have such a productive academic and scholarly output as well.

Sherry Glied: I guess I would give you two answers. One is I think management is actually a really interesting thing. Helping other people get their own work going, helping young people, hiring people, finding ways for people to be productive can actually be really fun. Actually maybe I’ll give you three answers. The second answer I think my friend Judy Fedder told me when I was thinking about taking the job at Wagner is that being a chair or dean actually gives you some credibility in the public eye. If you have things that you want to say, it actually helps you get your message across, and that’s true. I think that’s also true. But the third thing is I was really, really fortunate when I started off in academia. The dean at the School of Public Health at Columbia at the time was Allan Rosenfield, who was just a huge hero of mine, a wonderful man, but also a man who was really dedicated to his own research and service work. He was a pioneer in reducing maternal mortality in low-income countries, in contraceptive access. Although he was the dean of a huge and growing school of public health, I think he averaged three days a week in Africa. Basically, his view of management was you put really good people in place and you let them run. If that’s your view of management and you really think about it as you’re not a micromanager, your job is to create the infrastructure for people to do their work, I think it’s actually not that incompatible with doing your own work as well. It does expand your horizon.

Harlan Krumholz: I just want to thank you for taking the time. It’s always a pleasure to talk to you and this has been a great opportunity. Anyway, thank you.

Sherry Glied: Thank you both. Next time in New Haven!

Howard Forman: Harlan, yesterday you had a viral tweet thread announcing who was going to be the graduation speaker for the Medical School . It was public knowledge. You weren’t the first to announce it, but you got a lot of attention for that. I’d love to hear more of about that because it’s an interesting story about the thread, but it’s also an interesting story about the speaker.

Harlan Krumholz: Well, the Yale medical students are the ones who choose who the graduation speaker is, and this year they chose a remarkable TikTok star, actually social media star. You can find them on Twitter @DGlaucomflecken. He’s an ophthalmologist, but who has really found his place in pointed satire of the medical care system, the experiences that we have as doctors and nurses and patients within the system and has garnered quite a lot of followers. On TikTok, I believe he’s over a million.

I posted a tweet that he was a choice for commencement speaker. I said, “Academia, your time has passed.” I said it a little tongue in cheek, but I said usually at these occurrences, they’ll pick somebody from academia or someone from government to come up and make pronouncements about students and the future and try to say a few inspiring words. The students here took a different approach. They said, “Here’s someone that we admire, someone who’s doing great work, private practice ophthalmologist from Portland, but someone who’s got a message that we resonate with, and we’d really love to have him.” He said yes, and I ended with saying “Sign of the times.”

I followed that tweet right away by saying, “Just to be clear, I think it’s an inspired choice.” And I wondered whether we need new faces, new perspectives, and new approaches to our graduation speeches. We need to recognize that wisdom. It doesn’t reside only in those who have specialized titles in academia but in many different places. I was amazed. I’ve never gotten a tweet with over 800,000 impressions. I think it speaks more to his popularity, certainly. It does speak more to his popularity than mine, but he also speaks to his powers as an influencer. People are interested in what he’s got to say . Anyway, we’re really glad to have him at Yale.

Howard Forman: He is an incredibly humble guy on Twitter. He’s twice a survivor of cancer. He has survived cardiac arrest, which made for a lengthy story about him at one point, and I’m looking forward to hearing the talk. I think what you want as a Medical School speaker, somebody, as you said, who inspires the students and makes them want to do bigger and better things. He has. Even from a perch of private practice ophthalmology, he’s used these other platforms as a way to educate the rest of us about so much. I’m excited about it. I was happy about it, and it’s nice to see the Medical School being willing to not just have people who are the surgeon general, who we’re very thankful to have had, or the head of the NIH speak.

Harlan Krumholz: I’ll say clearly that many people, some people misunderstood my tweet as a criticism of this selection. In fact, even in that first thread on Twitter, I made clear that actually I’m a fan and I think it’s a great choice, and I’m really glad that he’s coming. Anyway, want to at least take this opportunity to make clear. Some people said, “Well, I walked it back later.” No, I said it from the very beginning. It’s great. By the way, I think this will be the best well-attended graduation at Yale probably in a long time. He has a lot of fans. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: How did we do? To give us your feedback or to keep the conversation going, you can find us on Twitter.

Harlan Krumholz: I’m @HMKYALE. That’s HMKYALE.

Howard Forman: And I’m @THEHOWIE.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Sherrie Wang, and to our producer, Miranda Shafer. Talk to you soon, Howie.

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