Vaccines, Cholesterol, and Other News

Transcript

Harlan Krumholz: Howie, welcome. It’s so good to see you this week. We’re in the studio. And let’s just say it to everyone, welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I am Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. We have a lot to cover today.

Harlan Krumholz: Oh, my God. And this podcast is a juggernaut, Howie. It is just taking off like crazy.

Howard Forman: It is fun. I got two emails this week from people that have no connection to us whatsoever telling us how much they love the podcast. I should have forwarded them to you.

Harlan Krumholz: I think they were my relatives.

Howard Forman: No, they were not. They were random places. I don’t know, but we appreciate them. We really do.

Harlan Krumholz: We do appreciate.... We’re continuing to grow, slow but sure.

Howard Forman: Yeah.

Harlan Krumholz: We think by 2050, we will hit a very large number.

Howard Forman: We’re aiming for a million, but—

Harlan Krumholz: We’re aiming for a million.

Howard Forman: ... maybe it’ll be... in 2050, I think that’ll be a good time for us.

Harlan Krumholz: Well, let me just say, whoever you are listening, thank you. We just appreciate each and every one. And actually we are growing, so it’s nice.

Howard Forman: No, it’s fun. And really, I do feel like we’ve hit our stride in terms of meeting our listeners where they are and trying to cover topics and interests.

Harlan Krumholz: We keep trying to innovate. So you want to kick us off today?

Howard Forman: Yeah. You know I like doing the updates on the infectious diseases, and so I thought we’d cover a bit of that today. The flu season is pretty much over now. It’s fading. Still cases of flu, COVID, RSV [respiratory syncytial virus] circulating, but they’re already at pretty low levels and mostly heading lower. We’re now in a position to look back and assess what the season was like. And if you remember, early in the season, it was gangbusters. It looked like it was going to be the worst season ever. And it’s true that we did have the highest—

Harlan Krumholz: Yeah, you were scaring the bejesus out of me.

Howard Forman: Oh, I was scaring myself. We were hitting peaks that early that we had not seen in the time that we’ve measured it, so it was pretty scary. But then it just came down. There was no meaningful second peak. Basically, we had a mildly better flu season this year than last year overall. And one way to measure that, not that it’s a single way to measure it, is pediatric deaths. At this time last year, 134 children had died from flu.

Harlan Krumholz: That’s tragic.

Howard Forman: This year, it’s 101, so that’s substantially lower. And every other number sort of tracks that overall better than last year. Remember, last year was a worse-than-average year nationally. And worth noting, 85% of the pediatric deaths have been in the unvaccinated, even though it’s a closer to 50/50 split among vaccinated and unvaccinated in the pediatric population. I’m going to come back to talk about that in just a second.

Harlan Krumholz: What’s the recommendation for kids around vaccination for flu?

Howard Forman: I believe we recommend flu vaccination at six months and over.

Harlan Krumholz: Okay, yeah.

Howard Forman: Current rates of flu-like illness in the nation—“flu-like illness,” not just flu—are lower now than at the comparable time last year and even the year before. Missouri is the last state to be registering, quote, “very high activity,” and even this week it’s probably lower. New York and Connecticut are already registering low—and heading lower—activity. To the point I was making about vaccinations before, about 47% of children and adults got their flu vaccine this year. Early indications are that it was low on the effectiveness scale: for adults, about 30% protection from hospitalization and for children, 41% protection against hospitalization. This should not be seen as a failure. It is a reality that we pick the vaccine now. Right now, we’re picking the vaccine for next year, the components of the vaccine. We knew early on in this past flu season that the circulating subclade K was antigenically drifted from the actual antigens that we used for the vaccine.

The data in the U.S. are mostly consistent with similar findings from around the world, but I just want to make sure our listeners know that saying the vaccine didn’t work is plain wrong. We would love higher effectiveness, but there were still evident protections.

Harlan Krumholz: And then this gets to this whole thing about the mRNA vaccines, right? Because we could select them closer to the season if we had a different way of administering the vaccine.

Howard Forman: It’s ironic that at a time when one part of the population is even more excited about the utility of mRNA for both vaccines as well as cancer therapies and so on, there’s another group that is just pushing so hard against them, implying that there’s real harm from it, that we’re going to need to do a lot more work to build up the confidence of the public before we start using mRNA vaccines more widely.

Harlan Krumholz: I was so wondering whether there might be some countries that aren’t going to be as averse to them as we are, and they’ll represent experiments, natural experiments, to sort of see what happens when people pick the vaccine closer to the season.

Howard Forman: I think we need to do a lot more work. And look, maybe I’m just biased at this point because I believe a lot of the data we’ve accumulated from observational studies over the last few decades, but I do think we’re going to need to a lot more work of randomized trials over the next five to 10 years to build the confidence back up to where it should be, because rightly or wrongly, we have destroyed confidence in so many vaccines right now that we have to do something. We can’t just say, “Look at all this evidence. Look at measles. Look at varicella. Look at all these things” and say “Here’s great evidence,’” because if people aren’t believing it, we do need to invest the time and the money in doing more of these studies and real randomized trials so that they can be unimpeachable as opposed to the observational studies where people are always going to have the opportunity to pick them apart.

Harlan Krumholz: Yeah, I agree with that. I think that definitely would be a good thing to do in that trust bridge and that definitely needs to be crossed.

Howard Forman: So what do you got?

Harlan Krumholz: Well, I thought I would start with the cholesterol guidelines. I don’t know if you’ve noticed this, but—

Howard Forman: I saw that they’ve lowered the age or something.

Harlan Krumholz: Well, so just so people can get a sense of this, every couple of years, the American College of Cardiology, American Heart Association, and a variety of other specialty societies will come together and produce a document that lays out guidance for populations around certain topics. So we had recently, for example, the hypertension guidelines came out. These are the cholesterol guidelines. I think that the core headlines were earlier treatment, even as early as 30... the first time a guideline has come out and really said we should start treating really younger, we start assessing people who are as young as 30, focus on lifetime risk, not just 10-year risk. This is a very interesting idea, meaning that if I’m going to be helping you to make a decision about what you want to do, don’t just talk about what’s going to happen next year or even in the next decade, but I’m now projecting out 30 years, are you possibly going to get infected? But this means that we’re starting something now for an asymptomatic condition for the prospect that it’s going to help you over a lifetime.

There was also the introduction of recommendations around new testing, around Lp(a) testing, for example, at least once in your life. This is a blood test that is going to become more relevant as a treatment emerges. I think it’s unquestionable that there will likely be trials published that many of us believe will likely show benefit. We’ll see. But right now, there’s no treatment of it. It’s just about risk stratification, but these guidelines are leaning into that. And also apo B, which is another measure that people haven’t been getting, maybe have never have heard of, but is starting to recommend. Expanded use of coronary calcium is another recommendation here. I’m a big advocate for it because sort of as much radiation as a mammogram, it takes a few minutes, costs about 50 bucks. It’s really inexpensive and it can give you some insight as to risk.

And then a return to LDL targets. Many of us have, for a long time, argued that the trials that have been conducted have been drug trials. So they give somebody a drug and see whether it reduces risk. Those drugs do lower cholesterol, but not all drugs that lower cholesterol lower risk. And we’ve been, many of us, outcomes researchers in particular, have been pushing to say that we should be endorsing the medication, not necessarily the target, because how you get there may be important, but these guidelines return back to target. So let me just take quickly where some of the controversies are, because the social media sphere has been lit up around these guidelines. These are some of the things that people were saying: “Are we overtreating low risk people?” “By focusing on people who are 30 and talking about 30-year risk or lifetime risk, are these going to be important?” “We may be shifting from preventing disease to treating risk factors decades before disease occur, is that good or bad?” There are many people who are strongly in favor of that, other people questioning it.

There is a risk model, which, essentially you fill in numbers like your age and characteristics about yourself, called the PREVENT risk model, which replaces the old risk model, which is said to be better, but people are concerned that it’s overestimating risk or misclassifying risk, especially for certain populations. Finally, this lifetime risk thing, people feel is a specific issue, mentioned it around long-term, but it’s coming up again around asking people to take a pill today, prevent a risk they may have when they’re 60, 70. Does that make sense? And a shift away from simplicity. These guidelines are much more complex than the previous guidelines, and people are asking, “Is that really necessary? Is that helpful?”

My own view is we need to move towards more precision approaches for individuals. Averages, whether it’s average recommendations or whether it’s average risk models, don’t work as well as really understanding who you are. I think in an era of AI and much more what we call multimodal data, data coming in from your wearables, data coming in from your lifestyle behaviors, data coming in from your genes, meaning the very best family history, is understanding what your genetic risk scores are and so forth, all this is going to help us triangulate onto what’s best for you. And then we really need to hone our skills at working with you to understand your preferences, values, and goals so that we can make best decisions together.

Howard Forman: I have so many questions. I’ll ask just a couple of them, and I’m going to... use me as an example and feel free to say we shouldn’t talk about me, but that’s fine.

Harlan Krumholz: I always love talking about you, Howie.

Howard Forman: I am 60. I’ve been on statins, I think, for over 20 years now. My father had a heart attack at 49 and is thankfully alive at 93 and doing well. My cholesterol was high before I went on simvastatin. My cholesterol is now well within the normal range. My apolipoprotein B is in the normal range, but because of the statins, presumably, I have one tiny calcification in my coronary arteries by CT. The problem for me, if you look at all that, you’d say, “Why do you need to be on statins?” then everything looks really good. But the thing is, I think everything looks good because I’ve been on statins. I’m very much afraid of going off statins. I don’t have a compelling reason to go off statins, and so I just stay on it. But I’ve never seen anybody addressing that issue, maybe because it’s too narrow for them. What do you do about the person who’s been on statins for a couple of decades already who was appropriately put on them and probably is doing better than he or she otherwise would have done if not for the statins?

Harlan Krumholz: Yeah, I think it’s a complex issue, because to me it matters a lot about you. How do you feel about this? I can tell you, if you take a statin, you will lower your risk. Anyone takes a statin, they will lower their risk.

Howard Forman: Right.

Harlan Krumholz: Risk of heart disease, risk of stroke—this will lower your risk. And a lot of what times what we’re arguing about is, is your risk so low that the amount of benefit is de minimis? It’s not meaningful to you. But look, I think it depends how you feel about taking pills and how well you tolerate the medication, what the medication costs you. And to society, these statins now are generic. They’re very cheap.

Howard Forman: Very cheap.

Harlan Krumholz: Very cheap drugs.

Howard Forman: And because of Obamacare, it’s free for the consumer.

Harlan Krumholz: For consumer, but somebody’s paying for it. But I’m just saying it’s not incurring a lot of costs. You seem to be tolerating... well, it doesn’t seem to be bothering you and you don’t seem to mind taking a pill. It is interesting, there are a lot of people for whom taking a pill a day is a burden, just a cognitive burden to have to think about. But there are other people who don’t care. There are people who are doing things like taking peptides and doing all sorts of other stuff that has no evidence, even multivitamins, very little evidence for the average person of benefit. So, I say when I’ve got someone like you, you should keep taking them.

I had a situation, my 89-year-old mom has been on statins for a long time. Her mother, my grandmother, died at age 60 of a heart attack, but my mother’s 89, has never had any heart problems. She’s on atorvastatin and her doc is saying, “Should we deescalate, take you off the atorvastatin?” I’m going like, “I don’t know. It’s not bothering her. And honestly, if she’s on it, I believe it still lowers her risk. Just leave it alone.”

Howard Forman: That’s what I’m thinking of. And I just like the way the clarity of your thought about how to think about it, because it bothers me when people say, “All your parameters are so good, do you really need to be on it?” And I’m like, “I think my parameters are good because I have been on it.”

Harlan Krumholz: Yeah, and like I said, anyone who takes it will have lower risk on it than without it. And if it doesn’t bother you and you’re one person who’s avid for ways to lower your risk, then there’s nothing wrong with it.

Howard Forman: All right. I’m going to do a quick update on measles because I think that’s going to continue to be in the news. And there is seasonality to measles and we are coming to the end of the typical peak season for cases. So it should not surprise people, nor should it embolden them that we’re doing great with measles right now as cases go down. We’re still seeing about 90 cases per week, which is very high, but that should continue to fall off, unless there’s another large unvaccinated community that gets affected.

Harlan Krumholz: Just remind me, in a typical year before we had all this issue with the vaccines, were we getting close to zero?

Howard Forman: Yeah, we’d have 10 or 20 cases and they were almost always imported and rare outbreaks. And remember, there’s a difference between having a couple of cases that occur because somebody comes in and two people get infected in a household, and an outbreak where it perpetuates and you have increased numbers of cases over a period of time. This is grossly above what we’ve been experiencing for three decades now. We had one bad year, I think in 2019 in New York, but most years—

Harlan Krumholz: Well, that was in the Hasidic community, right?

Howard Forman: Exactly. It’s almost always in these religious exclusion communities. We’re still on target to far exceed last year’s 33-year high of 1,362 cases. We could even get there by summer or shortly during summer. And just to point out, the South Carolina outbreak, which has been the dominant outbreak of this last six months, is nearing an end with just one new case since Friday. On the other hand, Utah, which has had multiple outbreaks, is getting worse right now, with 30 cases in the last week, and there’s a high potential for more cases coming from there. So we’re not out of the woods. I would expect cases will continue to drift lower, and then come October, they’ll start to drift higher again. We could get massive outbreaks at any time because there are some still many very under-vaccinated communities. I’ll come back to that in another segment.

Harlan Krumholz: What’s the official federal policy on it right now?

Howard Forman: I think we recommend MMR vaccination on a specific schedule.

Harlan Krumholz: So we haven’t steered off that, for all the controversy about vaccines?

Howard Forman: We have not, but we’ve made it a little bit harder to do, I think, the first shot. And we’ve also removed one vendor of... I mean, certain combinations. There are things that are changing that are confusing people. I think the worst part is that people, and I see this in narrative all the time, people are going into the office and saying, “Doc, tell me why I should be doing this?” as opposed to coming in and saying, “We’re here for our vaccinations.”

Harlan Krumholz: Yeah, and putting children at risk.

Howard Forman: Right. Absolutely.

Harlan Krumholz: Great. So let me jump to my next thing. I want to talk a little bit about the NIH. So the NIH director was testifying in Congress this week. It was really striking because at the same time that there’s a lot of concern about funding delays, workforce attrition, uncertainty across the research community, by all claims he performed very well. Gave people some more confidence that NIH is actually on the right track, that they’re going to be able to spend the full $48 billion budget this year, and he urged scientists not to pay attention to the hype. He promised an acceleration of grants later in the fiscal year and that new institute directors will be named soon. I think that the general sense was that he had a calming effect.

I was just at the CMS Quality Conference in Baltimore, and there was a panel of Mehmet Oz, Jay Bhattacharya, and Marty Makary. These guys are like the Three Amigos. They’re very good friends. It’s not that common to get heads of the agencies come down, sit on a panel together. I could see that maybe they’re all feeling a little more comfortable in their roles and they certainly are working well together, which is good. But I was happy to see that Jay was able to sit and the things that he said, that we’re going to get these grants out, we’re going to meet our budget. It’s, in essence, what we promised to get out in grants and that we’re going to try to get the leadership thing squared away.

Howard Forman: I was so pleased when I was reading the follow-up from that hearing. I’ve not had love for him in the past. There have been things he’s done that have irritated me and I thought were frankly wrong. When he’s doing the right stuff, I couldn’t be happier. And everything that he said at that hearing, as far as was reported, at least—I didn’t read the whole transcript—was completely aligned with evidence-based medicine and science and good practice. He seems to be steering both the CDC as well as the NIH in the right direction at the moment.

Harlan Krumholz: Yeah, just to say, STAT News did report that there have been, let me just be clear, 74% fewer new grants this year than prior years at this point.

Howard Forman: That’s right.

Harlan Krumholz: That’s not a small fluctuation.

Howard Forman: No, that’s where my criticism was.

Harlan Krumholz: Well, that’s a big deal. And early career funding rates are dropping sharply. Scientists are leaving the NIH. There’s not a good buzz on the street or morale.

Howard Forman: But he was clear. He went through line by line about how they’re going to catch up, how there are great grants coming through. If you take him at his word, people do make mistakes. People do things for political reasons. I’m not going to defend that. But if he can self-correct, I’m all in favor of it.

Harlan Krumholz: No. Look, we’re rooting for him. We want him to do well. It probably takes a while to get... I don’t know if I shared with you the suggestion I gave him. One of the problems is, you put in these grants, we put in a grant last June, you don’t hear until February what the score is. Even with that score, it’s pending. It’s still months after that to know whether about funding, and then you’ve got to put in another grant. In general, our science is hampered, not only because grants aren’t going out the door, but because it takes so darn long to learn it. You’ve got an idea, science is moving quickly, maybe a year before you’re funded—and the world has changed. That’s a problem. I said we should change the way the whole grant structure is set up, make it go faster, easier, to ask people to submit a sample. That’s all. This is the whole grant.

A sample of a mock paper that would represent your work if you’re successful with this grant. What’s the most important paper you’ll publish? What does it look like? And make up the results, do it as a mock paper and just say, “If this grant’s successful, here’s what a product will be in the academic literature,” then let the committee just read the paper and then see what the price is. Oh, wow, this is the product and it’s going to cost a million bucks and say, “Is this paper worth a million bucks or not?” I had made this suggestion when I was editor of Circ Outcomes [Circulation: Population Health and Outcomes] and no one’s moved on, because I was trying to get PCORI [Patient-Centered Outcomes Research Institute] to do this. I’m going, “Simplify the process. Show me what you think your best product would look like. What’s your best discovery? And then we’ll decide whether or not your budget’s worth it.”

But meanwhile, what we do is big, thick grants. By the time you get all the appendices together, they fund them. And then at the end, you’re not even sure what they produced and you’ve spent a lot of money. I said, “Turn this on its head.” And I’ll tell you, to his respect, he got back to me and said he’ll think about it.

Howard Forman: That’s good. And look, like I said, I’m optimistic at the moment for NIH and CDC, and we’ll talk more about that.

Harlan Krumholz: CDC?

Howard Forman: At the moment. He said some really nice things about the CDC, and they’re going to be forced to name a new director soon, I’m hoping.

Harlan Krumholz: There’s still a lot of good people at the CDC.

Howard Forman: Absolutely. Most of them, right? A nice report out of the CDC, what we call Morbidity and Mortality Weekly Report, we’ve talked about that many times, from New Mexico showed how successful New Mexico Department of Public Health and the public health authorities there were in vaccinating individuals in the wake of their part of the West Texas measles outbreak. So that was a really nice short study. It showed a 55% increase in MMR vaccinations during January through September of 2025 compared with that same period in 2024. New Mexico used their best tactics to squash their outbreak, and they did. That requires vaccination programs that are geared toward achieving herd levels. Unfortunately, if you look at the rest of the country, we are headed in the opposite direction. It’s worth pointing out to our listeners that we are substantially losing herd immunity in the majority of counties in this country.

Now, most of those counties are rural, so the population is still well covered, but the majority of counties in this country do not have herd levels of immunity right now. If a measles case moves in, there’s going to be an outbreak. We’re also undercounting our measles cases. We talked about what the numbers are right now. You have to understand that whatever we’re measuring, there’s another layer that we’re just not measuring because people have no great incentives to report benign-appearing measles cases. And so I think it’s important for us to think about—it goes back to our earlier segment—what are we going to do to encourage the public to have faith and trust in vaccinations? And how do we get the states to reverse their pattern of having more and more exclusions so that you can have more and more people vaccinated and achieve herd immunity?

Harlan Krumholz: What was the secret sauce? Do you know what they did?

Howard Forman: First of all, it was occurring in a smaller region of the state, and the outbreak in Texas was receiving a lot of attention. They went in, and they went into local communities, and made vaccination very accessible. They did a lot through public health communications. I think that those communities in New Mexico had great faith in public health authorities at that time. There was no explosion in skepticism.

Harlan Krumholz: That’s great. Well, that’s terrific news and glad to hear it. When you see something like that, those are positive deviators. We should get people to copy it.

Howard Forman: That’s right.

Harlan Krumholz: All right. Let me return to a subject that you and I have talked about several times but has now had some new studies to sort of support it. That’s about football and brain health.

Howard Forman: Yes.

Harlan Krumholz: We talked about it. I grew up in Ohio. I’m a football fan, and it’s such a guilty pleasure because I worry that here I am watching these gladiators and then they’re really just hurting themselves. Well, there are two studies that came out. They’re important not just because they’re the first to suggest risk, of course—we’ve seen this before—but because they pushed the field in different and complementary ways. Study one is a large epidemiologic study that was in JAMA Network Open that had about 4,000 players. It included a range of exposure levels, youth to professional, and a matched control group. They really showed this dose-response relationship. The more years and the higher the level of play, the worse outcomes. They had measured very carefully a lot of these neurologic outcomes. I think the important thing is not that it just confirmed prior observational work, but it generalized beyond the elite players. It said for these youth football leagues, the kids are getting these repetitive injuries. This is an issue.

I think what gave more confidence about this study was this graded relationship between exposure and intensity and the outcome. That was an important contribution. But there’s another one that I thought was even more important, was in the journal Neurology that was talking about mechanism. What they did was, they were able to take a group of people and do what we call deep characterization of these individuals with plasma and CSF biomarkers. They’re getting fluid from the central nervous system...

Howard Forman: How many people did they study? Do you know?

Harlan Krumholz: I have to go back, but it’s not insignificant.

Howard Forman: Really?

Harlan Krumholz: And they got advanced imaging, cognitive testing, and they were able to connect inflammation, white matter changes, and memory impairment across these exposures to these repetitive injuries. Previously we’ve been very strong on autopsy studies, but we’ve been weak on in vivo markers, people who are alive, what kind of markers can we use for people who haven’t died but we’re concerned about? And this is really showing us that it’s detectable, modifiable pathways that are being impacted here. And so I think it’s really a concern. Of course, both of these studies are cross-sectional. They can’t really prove causation, but I think that we’re on the road here to start to understand how these work mechanistically. And again, the idea is even small repetitive injuries, and that’s really what they were able to uncover, can, in aggregate, cumulatively cause these problems.

Howard Forman: Yeah, I worry so much about this, because we do a lot of things because it comforts us. If you have a concussion, you can’t play for a certain amount of time and if you have another concussion... and those are “evidence-based” in the sense that more concussions are worse for you, but we’re still allowing people to have brain damage. There is not a single study out there that has convinced me that even one season of football play doesn’t result in harm.

Harlan Krumholz: That’s right. And putting people on the sideline, have them sit out a few games, that may address some of their symptoms, but it’s not clearing the long-term risk.

Howard Forman: So here’s another piece of a little bit of good public health news, I think. The U.S. District Court for the District of Massachusetts issued a preliminary injunction to stay Secretary Kennedy’s appointments to the Advisory Committee on Immunization Practices, or ACIP, which is within the Centers for Disease Control.

Harlan Krumholz: Now, good news—depending on your political standing.

Howard Forman: That’s what I said. I think to me it’s good news. The judge made the ruling that the appointments were likely made in violation of Federal Advisory Committee Act and he also—

Harlan Krumholz: That’s a Congressional law.

Howard Forman: That’s law. And the judge also stayed all the votes taken by the now-state ACIP.

Harlan Krumholz: Oh, wow.

Howard Forman: So, in other words—now, remember, what this is doing is it’s doing a couple of things in sequence. One is, it’s just saying that the plaintiffs are likely to be correct or at least have enough likely to be correct that we should stop everything that we can stop. And so they’re reversing the ACIP appointments and reversing what those reversals—

Harlan Krumholz: The recommendations.

Howard Forman: Exactly. All those things, the people and the recommendations. He’s not ruling on the merits yet. He’s just saying, “There’s enough of a likelihood that I’m going to stop it in its tracks right now.” The injunction further stays the heavily revised vaccine schedule that was issued by the U.S. Department of Health and Human Services on January 5th. It overturns the May 2025 secretarial directive on COVID-19 vaccine recommendations and reverses the downgraded hepatitis B vaccination recommendations made at the December 2025 ACIP meeting, all things that we have talked about on this podcast. Those were all on hold. It doesn’t reverse them permanently. It just basically says, “Until we rule on the merits, we’re stopping them.” Now, it’s worth noting this will get appealed. His ruling on the injunction will get appealed, and we should be watching for both the status of the injunction as well as the status of the actual case, which has yet to be ruled on.

It is possible that this will move very quickly now to the appellate court and then even to the Supreme Court. And the Supreme Court could be called on to weigh in on both the injunction and the merits of the case. It could rule on the injunction as early as this term. If it rules on the merits of the case, it’ll likely be in the next term. For now, though, the current meeting of the ACIP that was scheduled for this week has been canceled. In my opinion, this is a win for public health generally, and specifically for the many organizations and individuals who joined in bringing this case. I just want to call them out because I think it’s important: American Academy of Pediatrics, American Public Health Association, American College of Physicians, the Infectious Diseases Society of America, the Society for Maternal Fetal Medicine, the Massachusetts Chapter of the American Academy of Pediatrics, and the Massachusetts Public Health Alliance, along with three anonymous individuals, were the plaintiffs in this case.

Harlan Krumholz: Yeah, it’s interesting. The only net result here is that people are just confused.

Howard Forman: Absolutely.

Harlan Krumholz: It’s going to cause chaos, and now no one knows what to trust. This is going to be caught up in the courts, no one’s going to know what recommendations.... I think it’s going to push it back to the states. The states are going to need to provide some clarity here for...

Howard Forman: But sadly, a lot of the states are moving in two different directions. Some states are trying to codify our current vaccination programs. There are a lot of states that are trying to loosen up on vaccinations and allow for more religious exemptions.

Harlan Krumholz: Yeah, one of the shames was... I get it about the committee, but they were going to talk about long COVID this week.

Howard Forman: I know.

Harlan Krumholz: I think that still deserves a lot of attention. We published a recent paper about what’s going on long COVID up to 2024, and it still has a very substantial prevalence in society. And so yeah, it’s a shame they couldn’t get a chance to talk about that.

Howard Forman: It is a shame. Absolutely.

Harlan Krumholz: All right. I know we’re getting close to the end here, but this is something I really want your view on. This would normally be kind of your topic, which is the MedPAC report.

Howard Forman: For March, yeah.

Harlan Krumholz: MedPAC is the organization that advises Congress, independent organization that is nonpartisan and is meant to help guide with regard to Medicare and Medicaid. This report is always dense, but it’s one of the most important reality checks each year that comes out. So one thing I think that was really important was that it came out with an estimate for the amount of overpayment that Medicare Advantage is conferring on the... let me just put this stat here. I’m sure you saw, Howie—I’m just saying for the listeners. They say that there’s about a 14% higher payment to Medicare Advantage plans than it would be if they were in fee-for-service. We developed Medicare Advantage because it’s a value-based plan. You’re responsible for a certain number of patients, you’re going to get a certain amount of money. The idea was you could manage these patients better, get better outcomes, and reduce wasteful spending. That’s why it’s Medicare Advantage, and it’s managed care approach, value-based approach.

What they’re saying is in Medicare Advantage, for any given person, you’re spending 14% more money. There’s never been any evidence we’re getting better outcomes. And they’re saying these higher payments are driven by favorable selection, healthier patients enrolling, but they’re getting credit for sicker patients, and this coding intensity that’s going on, which is that they’re spending a lot of their money, much with AI systems, figuring out how we can make sure that people are coded up. That is, each person has as many diagnoses associated with them as possible because they get paid more for sicker populations. This is an issue.

The other thing that they bring up, just to hit some points, coding intensity is persistent and structural, that Medicare Advantage consistently document more conditions per patient than fee-for-service, and even after the adjustments, MedPAC is seeing excess payments, so there’s even more than that going on. It’s a business model feature that we’re paying more for right now. The margins for these companies remain very strong and that they have strong financial performance because we’re probably overpaying them. The extra payments are funding extra benefits like dental, vision, gym memberships, and so forth, but they’re also funding big profits for what’s going on with these companies. The risk adjustment is the core battlefield about this coding. The tone of the report is very direct, more direct about overpayment concerns and the need for policy corrections than I’ve almost ever seen before. I don’t know what you’re thinking about this.

Howard Forman: Look, first of all, I’ve always been an admirer of MedPAC. They come out with two hefty reports every March and June.

Harlan Krumholz: You’re just the kind of wonk that loves them.

Howard Forman: I used to get them in a paper copy that would come, right up until probably two or three years ago... now, it’s only digital. But I used to love getting that, for 20 or 30 years. This is a constant problem. The only thing that you say differently is that there are people that will argue that Medicare Advantage is delivering better care. I do not believe that. I think that the way that the evidence goes the other way, that it’s mostly the selection bias and the coding that makes these things appear that way. MedPAC does point out that we’ve done better on the coding side, but the selection issue persists. And these are not small numbers. These are tens of billions of dollars of extra spending.

Harlan Krumholz: Why don’t we run a trial, randomize people or create something that...

Howard Forman: I think it’s hard to do.

Harlan Krumholz: Of course, Medicare Advantage isn’t a single thing either, because there’s so many different companies with different plans, so it isn’t A versus B. It’s A to Z versus something—

Howard Forman: I think on one of our prior podcasts, I made a point that I still believe could be true, and that is even if we’re overspending by $50 billion a year for 10 years, if you told me that at the end of the 10 years, we would have learned so much about delivering better care that we would then be delivering higher quality, then it might be worth it. But I’m not even seeing evidence of that right now. CMMI is specifically targeted at that type of work. That’s not what Medicare Advantage is around for.

Harlan Krumholz: So you mean if we pay more for the cost of gas today, it’ll be cheaper in the future?

Howard Forman: Right. If we were innovating in some way. Yeah, exactly. No, I know. I hear what you’re saying.

Harlan Krumholz: It’s a promissory note.

Howard Forman: Yes.

Harlan Krumholz: All right. Well, this is a great session, Howie. And gosh, I really love getting to see you in person. Of course, we often see each other otherwise, but in the studio, it’s fun. Thank you all for listening. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: How did we do? Give us your feedback or to keep the conversation going, email us at health.veritas@yale.edu or follow us on LinkedIn, Threads, Twitter, Instagram, wherever you want to find us.

Harlan Krumholz: Yeah, and give us feedback. Let us know how we’re doing. Rate us, put in some comments, do whatever you can to help us build the listenership, but also to get better. We’re always eager to hear that—

Howard Forman: And if there are topics that we’re not covering and you want us to cover, let us know. We’ll think about them. Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. To learn more about the Yale SOMs MBA for Executives program, visit som.yale.edu/emba. And to learn more about the School of Public Health’s Executive Master of Public Health program, visit sph.yale.edu/emph.

Harlan Krumholz: And I always want to give a hat tip to our superstar undergraduates. Today, we’ve got Gloria Beck with us, who’s done a wonderful job. We have Donovan Brown and Tobias Liu, our great producer, Miranda Shafer, and I get to work with the best in the business, Howie Forman.

Howard Forman: It’s so much fun to be here with you, Harlan, and I am so grateful that we got to do this together.

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

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