The ‘Big Beautiful Bill’ and Other News

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

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. We are doing one of our occasional no-guest episodes because you and I have a lot to catch up on, Harlan.‌

Harlan Krumholz: We have a lot to catch up on, and I’m so glad always to have the chance to talk with you, Howie.‌

Howard Forman: Me too, me too. It’s fun. There’s a lot... It really is a lot to talk about. We won’t even get to all of it, but we’ll try to cover some good stuff.‌

Harlan Krumholz: All right. Well, let me kick off here, and this is a bit of sad news. We’ll start off on a little bit of a lower note, but I wanted to take a minute and honor and remember Atul Butte, who passed away last week at the age of only 55 years. He was a good friend, someone I knew well, and it’s hard to overstate how much he meant to the field of biomedical informatics, data science, and medicine. And even more, I think it’s hard to capture really the depth of love and admiration people had for him as a colleague, a mentor, a friend.‌

I mean, this is a thing I think that’s so important for all of us to remember. In the end, it’s about the relationships, the connections, the way that we can help other people. And he was one of those individuals that people didn’t forget. He was a visionary. He believed deeply in this idea of once we let the data flow, lifelong discoveries can become possible. He was at UCSF in his most recent position where he was the inaugural director of the Bakar Computational Health Sciences Institute and the chief data scientist at the UC Health System, where he built this remarkable ecosystem for data-driven discovery and was always focused on the right things. He co-founded a bunch of companies, but really what stood out was that this guy was somebody with boundless energy.‌

He could light up a room with a smile, tell stories. He was working in a highly technical field, but was a great communicator. He adored science. He adored people, and people adored him. I just want to give you a couple of things that people said that wrote about him. This is the words of Marina Sirota, one of his long-term colleagues, said, “Atul’s loss is deeply felt, but his influence endures in the lives he touched, the data he unlocked and the future he helped shape.”‌

Euan Ashley wrote a really nice piece in LinkedIn that I’ll just read part of it, “Atul Butte died yesterday. The world lost a giant. A big bear of a man. With a huge smile. With love for everyone. With energy that could power a room....” Actually, makes me sad to read it, to think about him go being gone. And finally, Bob Wachter wrote that, “His dazzling intellect, relentless curiosity, generosity of spirit, boundless charisma, and infinite optimism left a mark on everything he touched and everyone lucky enough to know him. An enormous loss.”‌

I so agree with that. By the way, our own Lucila Ohno-Machado, who leads our bioinformatics initiative, was one of his mentors, actually. He was her student at one time. But anyway, I just wanted to take a moment to say word about Atul and for the kind of person he was. That’s why.‌

Howard Forman: I did not know him at all. But literally on either Friday or Saturday night, when I was working in the ER, one of our medical students told me about him. And so I went back and looked at many of the things that you just read, and he certainly was loved and he made a big contribution.‌

Harlan Krumholz: Yep. What’s up, on your mind?‌

Howard Forman: So yesterday... we’re taping this on Wednesday. Yesterday, Tuesday, Kaiser Family Foundation was out with a new survey of attitudes toward the Big Beautiful Bill, which we spoke about last week, and reminded to our listeners that this has passed the House by a razor-thin margin, is now being discussed in the Senate. And under our government the likeliest outcomes are that the Senate passes a considerably modified bill from the one that passed the House and that this goes into a conference committee to reconcile these bills. And then they have to pass the new reconciled bill again in both the House and the Senate.‌

The faster track, which is still possible, is that the Senate would preemptively negotiate with House leadership to pass a bill that would be acceptable to the House. And then would move swiftly to the House for a likely even more razor-thin margin. This is all to say that it is not at all guaranteed to pass the Senate before July 4th, which is what the president’s informal deadline is, nor that it will even be ready to ever pass, although the president wants this signed into law during the August recess. ‌

But public opinion really does matter, which is where the Kaiser survey comes in, and the more people learn, the less they like the bill. So some examples, generally people do like the idea of Medicaid work requirements. In fact, 68% of people believe that adults who can work should work if they’re going to get Medicaid. But when people hear the fact that most Medicaid individuals already work and that this requirement would represent an obstruction for these individuals, that support drops all the way to 35%; if they hear that the requirement would cost states money but result in relatively little savings, the support drops to 40%.‌

On the other hand, if they heard that this change would result in more money available for the elderly, disabled individuals, and children to be covered, the support climbs to 80%. This is all to say again, public opinion really matters. The bill itself, the overall bill, not just the Medicaid requirements, they start off very much unfavored. Only 35% view the bill favorably. Thirteen percent of Democrats, 27% of independents, and only 61% of GOP view it favorably. That figure, the overall figure of 35%, drops to 21% when individuals learn it will adversely impact local hospitals. It drops to 25% when people learn that roughly 10 million more people would be uninsured. And drops to 33% when they learn that this would result in substantial Medicaid cuts. There’s a lot more to discuss from the survey, but suffice it to say that the more this is personal, the more that the public understands it, the more people dislike it.‌

In the spring and summer of 2009, the GOP held town hall protests to help make Obamacare almost dead on arrival. Our listeners may not remember how difficult this was to pass despite enormous Democratic majorities in both the House and Senate, and much more than the current situation. And really Nancy Pelosi and Max Baucus and several other representatives and senators really got this across the finish line. In this case, there is a huge tax cut at stake, as well as the fear of our current president. So it’s hard to know what will happen, but I do think it should inform all of us that communicating the full breadth of effects of this piece of legislation are really important and an effective thing to do if you oppose this bill. And I’ll come back to some of these in a few minutes.‌

Harlan Krumholz: Well, you may know, Howie, that of course a lot of people who voted for the bill in the House, at least some of the people have said they didn’t even realize what was in the bill.‌

Howard Forman: I know.‌

Harlan Krumholz: And this goes to this sort of strategy where these things are being put together rapidly. People don’t get a chance to read them carefully, people who are voting on them, let alone the public to learn about them. And this isn’t the way to govern. Look, whether you’re for or against the bill, if we’re going to pass bills, we ought to be able to have a chance to see what’s in them, and they ought to be able to be debated. I think that what may ultimately deep-six this bill is that the Congressional Budget Office, as you know, released a new dynamic score of this One Big Beautiful Bill on Tuesday, yesterday. This is going to drop on Thursday, this episode, as you said, but estimate it’s going to increase the budget deficit by as much as $2.8 trillion over the next decade—‌

Howard Forman: And that doesn’t include the additional interest on the debt. So that brings it up to $3.4 trillion.‌

Harlan Krumholz: Yeah, so this way... It’s interesting, the Democrats are usually less bothered by the deficit and the debt ceiling, but in this case they seem to be now to be deficit hawks as well. And there will be Republicans who are very much bothered by this. And so it’s going to be very interesting to see how this plays out, but it does seem important to me that the aspects of this bill get to be debated and there is some understanding about how—by the public—about what actually is happening here with regard to it. So I think that’s a good topic. Thanks.‌

Howard Forman: Yep. What do you got?‌

Harlan Krumholz: Well, there’s a ton of stuff, and there’s some longer-form things I want to do, but did you see this today? That Vinay Prasad has been named now the chief medical and science officer at the FDA? So—‌

Howard Forman: Good for him. Good for him.‌

Harlan Krumholz: ... good for him. So Prasad, who is a highly controversial character, he’s an extraordinarily smart guy who I’ve known for a long time, who really started his career taking shots at industry in oncology and oncologist and was raising, I thought, really important points and demonstrating a lot of courage to stand up to a lot of vested interests. But in recent years has sort of pivoted in a different way and has been sort of very much against the FDA. In the kind of the same way that Kash Patel was using his podcast and other ways of communicating to take down the FBI and then now be in charge of the FBI.‌

Prasad has for years now been attacking the FDA for its vested interests and attacking commissioners and so forth. And now he started by being in charge of the vaccines in CBER, but now he’s being elevated to a greatly expanded role and he’s a very much of a trusted advisor to Marty Makary, who’s the commissioner. And as a hematologist and oncologist, like I said, he’s been a long-term healthcare provocateur, somebody who’s been counter to the establishment, and it’s going to be very interesting to see now as he gains more responsibility how his views evolve, what actually happens in this role.‌

Howard Forman: In the interest of full disclosure, I do think it’s worth saying that you’re being very generous. He has publicly on social media attacked me. He has publicly on social media attacked you, and not for things that are substantive, in my opinion. I mean, he is a provocateur who is sort of relentless.‌

Harlan Krumholz: Yeah. And I would say in the case of my stuff, I would have felt that he took things out of context, exaggerated. He sort of was... and they were mean-spirited. The thing I didn’t like was that not only were they being sort of exaggerated and taken out of context, but that he wasn’t respectful in any way about this. And that’s to say it lightly. But there are a bunch of people out there who make their name... You’re not going to get eyeballs on social media by being kind in general, and you’re not going to get... I mean, mega eyeballs, right? You get mega eyeballs by inflaming, and this is the role that he had.‌

Now he’s got substantial responsibilities within the FDA. So you know, I’m hopeful he’s the guy who is capable of doing well. He’s bright. It’s interesting, people can get away with being mean-spirited and acting out that way. Patel’s another example, at the FBI. And still in this administration being elevated and in a way forgiven for saying stuff that may have been on the fringes. But here’s a guy who’s, like I said, I’m hopeful, hopeful still that somehow—‌

Howard Forman: Like I said, I’ll repeat what I said. You’re being very generous. I do think... I agree with you 100%, he is very bright. It is frustrating to watch someone who has... he’s not just violated norms, he has sort of ignored decency in his quest for attention, and that’s—‌

Harlan Krumholz: Well, I would say the thing that bothers me in these things is that they ascribe mal intent as if... if they even identify a mistake or an issue. It can be exaggerated, taken out of context, and they suggest they’re bad people on the other side. And that’s the part that I guess bothers me. But now in this position of responsibility, maybe he will no longer be doing that. And he has power, he has a ton of power here. And there are things we’ve often thought at the FDA that could be improved, but we have to watch carefully.‌

We have to be vigilant in our oversight of what’s actually happening there to ensure that there’s not harm... There already has been harm inflicted by many good people being driven out of the agency. And even though that change is necessary, the way it has been proceeding so far has raised concerns. I’m concerned. I think the industry is concerned; the healthcare environment largely is being concerned. We’re going to talk about the vaccine policy in this podcast too. So we’re going to have to watch carefully. He needs to be accountable now because he’s got responsibility, just as Marty Makary does. But I’m not going to... Let’s see what happens.‌

Howard Forman: I’m with you, I’m with you. So I’m going to pivot back to the Senate bill just because it is in play now and I do think it’s worth making sure people understand what’s going on. The two bills don’t differ in huge ways, but they do differ. And we’re likely to see, as we mentioned just before, the debt increased by $3.4 trillion over 10 years, including the $2.8 billion in direct expenses. And then the added interest on the debt. In both cases, the House and the Senate bill we’re going to see Medicaid enrollment decrease and the number of individuals uninsured increase by about 10 million. And then provider taxes, which we’ve talked about in the past, would be curtailed. And I want to emphasize this in this segment, Medicaid-related provider taxes are a game. We’ve talked about it before. It’s a way in which the states are able to artificially or I guess elevate federal funding for Medicaid beyond what was built into the actual law.‌

Congress passed Medicaid almost exactly 60 years ago. This August will be 60 years. And they set cost-sharing levels for each state that varied between roughly 50 and 84 cents on the dollar of Medicaid costs. And it varied based on how wealthy a state was. If you were wealthy, you were only going to get 50 cents on the dollar. If you are a poor state, you might get as much as 83, 84 cents on the dollar. The provider taxes are a means of artificially inflating the federal support. And we’ll link in the notes the prior episode where we explain this. I’m opposed to these provider taxes. I think it’s bad. It doesn’t mean I’m opposed to the need for greater funding for Medicaid populations and services. I just think it should be done in a more explicit way. So for instance, the expansion of Medicaid under the ACA for populations that were newly covered, were covered at 90%.‌

That was an explicit way in which Congress allowed for more funding to go to the states for expanding Medicaid coverage. But when you allow gaming, it distorts all the incentives and behaviors, and it’s inefficient. So while I’d like to see this fixed, I would not be in favor of seeing all the dollars taken out, and I think it’s the dollars being taken out that is a bigger issue. And similarly, I’ll just give one last point. Work requirements for Medicaid. Again, they do sound good. Why shouldn’t we expect able-bodied persons to work to support themselves with or without Medicaid? The fact is that it is a very small percent of Medicaid-eligible adults who are not working. And even those numbers are probably poorly documented, meaning that it’s an even smaller number than we think. We’re just not getting the data the way we’d like it to be.‌

Just because we don’t know, doesn’t mean they’re not actually working or incapable of working, in some cases. So last example, Georgia put in place a Medicaid work requirement called Pathways to Coverage. And it proved a good number of things. Number one, fewer people got coverage. Far fewer than they expected. Costs were higher than expected, and much of the money that was being spent extra was being spent to pay consultants to get people to enroll because it was so difficult to get them to enroll with these new work requirements. And many eligible folks who did eventually enroll found it difficult, slow, and they were ultimately really delayed. And so the Georgia program is a good reminder that these well-meaning people who think work requirements make good sense may be causing way more harm than they’re fixing anything.‌

Harlan Krumholz: I’ve got a great idea, Howie. It’s not just healthcare. Why don’t we do this? And I saw this idea proposed by someone. You don’t get police attention unless you’re working. And if you’ve got a fire at your home, if you’re not working, actually the fire department doesn’t protect you either. Why don’t we just say all services, we’re going to put a work requirement on people. Now I’m just—‌

Howard Forman: I know. I know.‌

Harlan Krumholz: ... obviously making ridiculous suggestions to say this doesn’t make any sense at all. And it gets to this root of this problem. Howie, imagine a country where you actually didn’t have to worry about healthcare costs. You could see a doctor whenever you needed to. You could get care when you needed to, and you weren’t charged. You can get the meds you need, and you weren’t charged. Oh my gosh, yeah. That’s like most other developed countries in the world—‌

Howard Forman: That’s correct.‌

Harlan Krumholz: ... actually provide this kind of healthcare. Canada provides this kind... and don’t talk to me about wait lists. I mean, the burden on people, the bankruptcies, the stress, the missed appointments, because people are worried about what they have to pay—‌

Howard Forman: That’s 100%— ‌

Harlan Krumholz: ... far outstrips any of the other issues. Plus, if you’re still in any of these countries, if you can afford it, you can still get private insurance if you want. No one stops you. So this is a national disgrace, that we’re sitting here debating about at the fringes who gets medical coverage and I’m mad as hell—‌

Howard Forman: And to pay for a tax cut.‌

Harlan Krumholz: ... and I can’t take it anymore. We—‌

Howard Forman: Right.‌

Harlan Krumholz: ... got to fix this.‌

Howard Forman: And it’s to pay for the tax cut, which is just so frustrating at this point. We are missing our entire moral compass here. I mean, we’ve just lost it.‌

Harlan Krumholz: And when people talk about, they want more babies in the country, well let’s give family leave. Let’s support paternity leave and maternity.... We need to provide that kind of support to families. We need to take off the table people’s concerns about paying for healthcare. By the way, businesses would be liberated. Businesses are being... their profit margins, their ability to invest in their businesses and grow new businesses are being deterred by these healthcare costs. This should be something we should be managing in a very different way.‌

Howard Forman: But we’re, at the moment, the thing that’s on the table is really harming poor people—‌

Harlan Krumholz: No, no, we’re going backwards, people.‌

Howard Forman: Right. Exactly.‌

Harlan Krumholz: We’re going backwards. And it’s regressive.‌

Howard Forman: That’s right.‌

Harlan Krumholz: That is the people most vulnerable are suffering the most and—‌

Howard Forman: And the richest will benefit the most.‌

Harlan Krumholz: I think it’s time for us to really dig down into this, and maybe in the podcast we should be talking about this more.‌

Howard Forman: We got to keep coming back to it. Yep.‌

Harlan Krumholz: All right, let me go onto something else I want to talk about. Another friend of mine, Sekar Kathiresan, who is a, just an extraordinary person, a nice person, brilliant person, great scientist, who went off to start a company, has done well. So this is a story in cardiovascular medicine, one that involves cutting-edge gene editing, a bold scientific vision by Sek and colleagues and a major bet from one of the world’s largest pharmaceutical companies, Lilly. So this is about Verve Therapeutics. It was founded just seven years ago. And a simple but radical thesis, that heart disease, a condition that most people get treated chronically, that is, you’re on pills for the rest of your life, statins or other things, lifestyle changes, could be treated with a single dose of a medicine. One and done. That is... we could manipulate your genome and actually move you from someone who is in a high-cholesterol band to a low-cholesterol band and you’re done.‌

You’re just as good as people who are fortunate enough to be born with the kind of genes that led them to have low cholesterol in the first place. And this comes from, over the last decades, we’ve been able to identify certain genes that when disrupted by nature lead to dramatically lower levels of LDL cholesterol and other atherogenic lipid proteins and have significantly lower rates of a heart attack. And now what essentially the idea was, could we be using this new science and clipping and snipping and editing the genome and actually taking people who are not naturally in that position and putting them in that position, where they were low-risk because of what’s called base editing. The next generation of CRISPR gene editing. And so they set off to do this, and their early data was pretty impressive. But very early, very early. A single infusion of a product that they called VERVE-102 that produced low cholesterol in people, it worked in about 50% and... I mean, it lowered it by about 50%.‌

That was comparable to actually taking a PCSK9 inhibitor, one of these newfangled drugs to lower lipids. And it was really amazing. It wasn’t just a better statin, it was an entirely new model of cardiovascular prevention. And here’s the kicker: now that it got the attention of Eli Lilly and they have announced that they’re going to acquire Verve for $1.3 billion, paying $10 and 50 cents a share and another $3 per share in milestones. And there’s still a long way to go, but now that you’ve got one of the world’s leading pharmaceutical companies behind it, it’s going to be pretty amazing. And I want to tell you a few interesting facts about this and just so you can kind of do this. One, this thing Verve’s doing, its editing mimics nature. They don’t invent new biology. It mimics naturally occurring protective mutations. So people born with certain mutations have lifelong low LDL and low rates of cardiovascular disease.‌

They’re essentially turning that into medicine so that they’re making you like other people who are like that. Another thing is that there’s no DNA insertion, no viral vectors. So what do I mean by that? Many of these new gene therapies deliver DNA by viruses, which integrate into the genome, but they can cause immune responses and the viruses can persist. Verve is using an mRNA delivery, just like the vaccines that Pfizer and Moderna were making. This is expressed transiently and then disappears. You may have heard this week that there was an unfortunate death by a kid who had Duchenne muscular dystrophy, who had gotten gene therapy. Well, the thing about Verve is that’s using an editor in an envelope. It’s being delivered through a proprietary system. A nanoparticle, GalNAc is sort of its name. It’s a sort of newfangled approach to doing this. This is different than the gene therapy that’s being used like in the case of Sarepta Therapeutics, which was behind the gene therapy for the Duchenne muscular dystrophy patient.‌

And this was their second patient death, and both of them were adolescents who had lost the ability to walk. So they had disease that had been long extended. And what happened was, they used this adeno-associated virus vector to deliver this gene into the patient’s muscle cells that was going to correct their inborn mutation. It was a one-time high-dose systemic gene therapy, but it triggered the immune response and the liver, which helps clear these viral... particles can take a big hit. That’s where they get a lot of immunosuppression, where now they can be susceptible to infection and then these catastrophic things can occur that cause a problem. But Verve is just an entirely different approach. I’m just making this point that the listeners may hear “gene therapy,” isn’t that dangerous or didn’t something bad just happen? And I’m just saying the Verve thing is a very novel approach that circumvents it.‌

Now, Verve targets the liver, they’re targeting the muscle cells. Muscle is much more difficult, so much more challenging problem. So when you’re hearing this, you don’t think of one size fits all in gene therapy. There’s different types of gene therapy, and there are different things that are evolving. But congrats to Sek. This is really a big deal.‌

I’ll tell you one thing about these milestones, by the way, since you’re... we both have appointments at the business school. So for those who are listening, what was really interesting that $3 a share sweetener for milestones that was part of this deal, it means that their milestones reaching a Phase 3 trial within 10 years. Boy, that’s a long fuse for a major pharma bet, and it just shows that they see this as a potential generational technology, but they know that they’re investing for the long run. And I think that’s very interesting.‌

And so anyway, I wanted to say that. The one last thing about Sek, I just want to say too, is here’s a guy that left academia. He really made a big bet on himself and he’s a cardiologist. And also I just wanted to say kudos to him for that because he had a great position, very secure, lots of grants, but this was a big bet to leave and try to start your own company and he deserves it. He’s that kind of guy. He really did an amazing job.‌

Howard Forman: That’s very cool. It’s nice to hear. We’re rooting for him. So I want to go back to a topic from years ago really when we first started this. We’re continuing to have a vast misinformation campaign ongoing, but now it’s more and more focused on vaccines and I’m worried about what that means for our next topic after this. In the last week alone, RFK Jr., our Secretary of Health, has heightened worries about the polio vaccine, though he clearly was talking about an earlier version, claiming that it might have caused more deaths than it prevented. It’s an implausible claim, at least at the moment based on what we know. But it didn’t stop him from making it and getting attention for it. He was speaking about the fact that an earlier version of the polio vaccine was contaminated with simian virus 40 or SV40, a virus that is known to cause cancers in laboratory animals, but for which there is no evidence despite numerous studies of increased cancer risk in humans.‌

Nonetheless, important to emphasize that this was an issue only for the vaccines given in 1955 to ’63. Separately, Stephen Kirsch, who you’re familiar with, Harlan, he’s a notorious but wealthy anti-vaccine social media celebrity, has posted many, many posts wrongly stating that number one, poliovirus doesn’t actually cause a polio myelitis and therefore the vaccination is unnecessary and harmful. He’s also claimed or rather misrepresented that... he says 79.4% of sudden infant death syndrome deaths occurred on the day of vaccination. This is completely false. And yet he used his mammoth account to promote this.‌

And then he claimed falsely that the COVID vaccine caused over half a million American deaths. That the vaccines themselves caused over half a million American deaths. This is a man with over 600,000 followers on Twitter alone, or what we call X now. Each of these claims received hundreds of thousands of views. This is a danger out there right now. There is a concerted effort by him and many others to get people convinced that vaccines are in fact dangerous when the evidence really is contrary to that.‌

Harlan Krumholz: So we’re not going to talk about him firing everyone on the vaccine advisory group?‌

Howard Forman: Well, I want you to do that as the next segment.‌

Harlan Krumholz: Well, I mean, look, I just think this all comes together, which is—‌

Howard Forman: It does.‌

Harlan Krumholz: ... what’s actually going to happen with vaccines. You’re also going into a moment where there’s a lot of anxiety about vaccines, a lot of conflicting information. And then in this case, a lot of wrong information that’s being broadcast out as if it’s fact. This is the other thing is the story that RFK Jr. took the group of people who—‌

Howard Forman: Seventeen.‌

Harlan Krumholz: ... were acknowledged experts in the area of vaccines. Not political, not with a valence on one side or the other, but people who are highly respected scientists, often took years to get vetted and nominated and competing for these positions so that they could opine on what might be the best vaccine policy for the country and summarily dismissed them all. But anyway, that wiped it clean. And then said, we finally have gotten integrity in the system because I’m appointing new people and appointed new people are clearly coming on with particular points of view and several people who are acknowledged anti-vax people.‌

Howard Forman: Absolutely.‌

Harlan Krumholz: And it just raises substantial concerns about how this is all going to play out.‌

Howard Forman: I agree, and I was very concerned about it. He named eight people, four of them seem like somewhat reasonable, although they all tangentially seem connected to this movement. Four of them are, just clearly have a bias. At least two or three of them have legitimate conflicts of interest for one or more vaccines. And it should be very concerning to everybody—‌

Harlan Krumholz: And are part of our lawsuits against vaccine makers, some of them, and at least one of them I know. And I don’t—‌

Howard Forman: I’m concerned to follow up on that point. I’m concerned specifically about what will happen when the ACIP, this committee, removes their recommendation for anything, because their recommendation means that the Vaccines for Children Program no longer will pay for the vaccine for poor individuals. And it also means that insurance companies no longer have to cover it without cost. So their recommendation, however much it may sound like just a recommendation, has enormous influence on whether people are getting vaccines that are typically costing in the hundreds of dollars if insurance isn’t paying for it.‌

Harlan Krumholz: And let me tell you what my concern is, is that right now the country is split. People don’t know who to believe or what to do. If you really wanted to do a service, you would try to bring together a group that people could feel confident... diverse voices, but the very best scientists and make this as transparent, as clear as possible so that we could try to get to a recommendation that everyone could understand and that was highly supported by evidence. And sometimes you have to make some recommendations under uncertainty, but being clear where that is.‌

We need a process that is not going to polarize further, but one that’s going to actually try to help people understand what their choices are and give people the most optionality, but also the most information to be putting forward. And I’m concerned that this kind of approach, firing one group, bringing in another group, now makes it a highly partisan effort that no matter how good a job these people do that they’re sort of tainted by a process that makes it feel that they were political appointees in order to fulfill a political agenda. And that puts them in a very difficult position to have real credibility across the spectrum of Americans.‌

Howard Forman: Absolutely. And now what do you do when you get a new president? And a new president now is going to feel almost compelled to replace the entire slate again because you’ve set a precedent that instead of having these rotating terms, where you maintain implicit knowledge within the committee by having people roll off at a varied point in time. Now it’s absolutely a political process and you hope that whoever is next will be balanced and not pick people from one area or the other, but people across the spectrum. But that may not be the case, you could have the opposite coming next.‌

Harlan Krumholz: And then it’ll play into, again, conspiracy theories about both sides having very different views on vaccine as opposed to a group that can dispassionately try to follow the science and make the best recommendations for the public. This is a problem. Let alone the fact, and our friend Jeremy Faust was writing about this week, that we still don’t have a head of the CDC and that’s also leading our major public health institution to be a bit rudderless. And also, it’s—‌

Howard Forman: It’s empowering RFK.‌

Harlan Krumholz: ... impede the ability to make recommendations that people are waiting for.‌

Howard Forman: It’s definitely concerning. I’m worried about this overall.‌

Harlan Krumholz: Yep. Okay, let me hop to another topic. I guess I’m more on business today than you are. So you may have been following this issue about ambient AI, right? We’ve talked about this on the program before.‌

Howard Forman: Yes.‌

Harlan Krumholz: So for people listening, what is an ambient scribe? These are... It’s simple. It’s a tool to record clinician-patient conversations and generate structured clinical notes in real time. The audio is typically captured through a mobile device. It syncs directly with the EHR [electronic health record]. What happened was, doctors were feeling burdened by the fact that they were having to do their notes after the patient’s left or if they’re doing it while the patient was there, patients saying, “no one’s even looking at me anymore.” They’re just looking at the screen. Doctors are talking about how they’re up till midnight just keeping up with the clerical part of their jobs.‌

And in walked this sort of new AI that was, they call it “ambient,” sort of exists within the room, is listening carefully and is taking notes and getting it into the record. Now, I wondered whether or not patients would feel as if they were being spied upon, because this is now recording all the very intimate nature of the conversations that traditionally people would have privately just with a doctor, but now it’s being taken up into the cloud and then processed into notes. And all of this is occurring within the context of these software systems. But here’s the thing. One of the programs, of course, is one that is Microsoft has, it’s called DAX, the Dragon Ambient eXperience. You may remember—‌

Howard Forman: We talked about this about a year and a half ago when it first came out—‌

Harlan Krumholz: We talked about it.‌

Howard Forman: ... I was blown away by it. I loved it.‌

Harlan Krumholz: So Microsoft bought Nuance Communications. You may have remembered this product, it was called Dragon NaturallySpeaking, that people used it as a dictation program for a long time. But then this sort of evolved into this product, DAX, as an AI-powered ambient clinical documentation tool that listens to patients. You would expect that Microsoft would have an advantage. But there was another company that came out... actually several. There’s not just one. There’s a whole group that are attacking in this direction. But one of them started by cardiologists, Shiv Rao, is called Abridge. And Abridge started actually as a consumer tool, so that people could record conversations with their doctors and when they went home, they could read the text of that conversation organized and curated in a way that they could understand. So that if in the moment with the doctor they were sort of frozen and didn’t really remember stuff, they would have that thing.‌

Well, that turned out not to be a great market, but they positioned them to go into this ambient AI market and they just after... months ago, they closed a $250 million series D raise at a $2.75 billion valuation. And now they’re reportedly raising another $300 million, and wait for it, this time, add a $5.3 billion valuation led by A16z, basically a 2x step up in just a matter of months, a 45x multiple on contracted revenue for basically what’s a note-taking tool. Now the thing about it is that what people are thinking about is that the value here is not just in the note-taking, but that—‌

Howard Forman: The information.‌

Harlan Krumholz: ... that it’s going to be in the data and all of this, it’s going to be captured, and then they’re going to end up being able to be a tool that inserts itself in so many different ways within the larger ecosystem. But this is mind-blowing, Howie. And here’s the thing that... we’ve been talking about “AI in medicine” and where can it go and what can it deliver? And so far the ratio of hype to actual—‌

Howard Forman: Reality.‌

Harlan Krumholz: ... traction has been quite high. But the ambient AI was a brilliant strategy because this is a rare tech that doctors actually want. This is among the very few technologies in healthcare that is clinician-driven. You don’t have to force people, you don’t have to say there’s compliance, you don’t have to... because doctors don’t want to be taking notes. They want to be able to talk to patients. And yet when they’re done talking to patients, they can have their note ready.‌

So that basically physicians are demanding these products because they reduce documentation time and they let them focus on the patient. Burnout drops, satisfaction rises. And so this becomes something that they can ride that wave in terms of adoption. And then, like I said, the note is just the wedge, the real play here is data infrastructure. They’re not just replacing typing, they’re creating a structured, standardized, portable data that opens the door to revenue optimization, pre-charting and coding, decision support, longitudinal care summaries, research. And really they’re trying to move from scribe to clinical OS, clinical operating system.‌

But here’s the thing, something like Abridge is very tightly paired to Epic. And if they go too deep in this clinical OS, they’re going to start competing with the EHRs because that’s what the EHRs want to be. They want to be the operating system for medical. So this is going to be very interesting to see how this plays out because ultimately at this valuation and at this building, and if they become the clinical OS as a wedge, the note became only the wedge to get in. It’s going to be a real competition between legacy organizations like Epic and these newfangled groups like Abridge. And then you’ve got DAX within Microsoft. Who’s going to win this battle? It’s going to be very interesting.‌

Howard Forman: And in the interest of disclosure, I think we are adopting Abridge here at Yale University—‌

Harlan Krumholz: We have Abridge at Yale University, yup.‌

Howard Forman: Yeah. Yeah. Well it’s great, Harlan. It’s a lot we covered today.‌

Harlan Krumholz: We covered a lot. It’s always great talking with you and—‌

Howard Forman: Yep, we’ll do it again soon.‌

Harlan Krumholz: ... we’ll do it again soon.‌

So 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, including LinkedIn and Bluesky.‌

Harlan Krumholz: And we love your feedback. Send it to us, let us know. We read it. It helps people find us if you rate us on the... like, Apple Podcasts and—‌

Howard Forman: We appreciate it.‌

Harlan Krumholz: ... keep it coming.‌

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

Harlan Krumholz: Health & Veritas is sponsored by the Yale School of Management, the Yale School of Public Health. We are blessed with two superstar undergraduates, Gloria Beck and Tobias Liu, and an amazing producer, Miranda Shafer. And I’ve got the greatest partner of the world, Howie Forman.‌

Howard Forman: Right back at you. I appreciate you, Harlan.‌

Harlan Krumholz: Yeah. Talk to you soon, Howie.‌

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