Vanessa Cooper: The Science of Headaches

Transcript

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

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. Our guest today is Dr. Vanessa Cooper. But first, we’re going to check in on hot topics in health and healthcare. Harlan, sometimes you and I talk in advance and you tell me what you’re going to cover. Today it is open-ended.

Harlan Krumholz: I was debating. I have two quick things here today I wanted to talk to you about, one I wanted to reflect on. We’re recording this on the first day of the government shutdown. Howard, you know that this will come out tomorrow. Maybe if we’re lucky, it won’t continue, but people will be listening to this. It’ll be at least the second day.

Howard Forman: Yes.

Harlan Krumholz: You’re going to talk a little bit about some of the issues in the latter part of the show, but I wonder what you think about this. As I was reflecting on this brinksmanship that’s going on in this country, listening to Pete Hegseth talk to the generals yesterday, I just had this sense that we’ve entered this stage where it’s winners and losers. There’s not about negotiation or compromise. It’s really about a zero-sum game and one group winning. I mean, they may gesture at the idea that they want to negotiate, but in the end, this is where we are today. It’s very different worldviews and a sense that you need to win. You need to win. I think that’s what put us in this predicament. Both sides are going to need to appeal to voters and try to get more than what we’ve got, which is a standoff, and when we have a standoff, we just cannot progress as a country.

Howard Forman: I agree. We only have meaningful elections every two years, but we do have an election coming up this year that’s less significant parts of the country, but there are some states that are in play for governorships and there’s some special elections. It may give us some signal where the voters are as disenchanted as I think they are with our Congress and our elected leaders and try to force them to be a little bit more collegial, conciliatory, and collaborative.

Harlan Krumholz: Our friend Ruth Katz would tell us that when she was working as a staffer in Congress, now maybe 30 years ago, that there were a lot more conversations trying to broker deals and reach some level of... I don’t know whether that’s the fog of history that really—

Howard Forman: No, no. There’s no question that Orrin Hatch and Henry Waxman and Ted Kennedy—

Harlan Krumholz: They would broker deals.

Howard Forman: That’s right.

Harlan Krumholz: They would broker deals. I mean, that’s the whole idea of the Senate, this idea of the 60 votes was going to force them together, but we have to stop this, this brinksmanship. It’s just not good. We are a health podcast, but I’ll say that all this intersects with health, as you’re going to talk about—

Howard Forman: Sure does.

Harlan Krumholz: ... later in the show. The other thing I wanted to mention is an editorial that I wrote this week for JACC. I get the opportunity, I’m actually doing this weekly now, putting out editor’s pages on different topics.

Howard Forman: I don’t know how you do all the stuff you do.

Harlan Krumholz: Well. The title this week was “Tools, Not Ghosts: Artificial Intelligence, Writing, and Responsibility.” I took on this idea about , what should we be telling authors about their use of artificial intelligence? Here, I’m not talking about AI. Of course, there’s lots of nefarious ways that AI could be used in fabricating research or papers without human engagement. I’m not talking about that. I’m talking about when authors are saying, “I need to improve my writing, and so I want to use AI as a tool to help me express these ideas more clearly.”

What I had detected was that there had been a stigmatization of authors using artificial intelligence, even to the point where I heard one of my editors say, “Gosh, this is coming from X place and it’s written too well, they must have used AI,” as if that was a problem. A lot of the journals were in a position where they were saying, “Well, if you use AI, you need to disclose it’s used.” I wanted to come out, and the JACC Journals writ large are 10 of them, we’re all together on this, wanted to come out and say, “Hey, use it. I want you to use everything possible. You guys use spell checkers.”

Howard Forman: You guys are going to edit the manuscript in the end anyway, so there’s always...

Harlan Krumholz: I want it to be as well written as possible. It just it needs to be your work. The point was to encourage people to use whatever you can. I mean, whether that’s a human editor, whether it’s a AI editor, we need to be able to take advantage of these tools, but that doesn’t mean you can delegate the responsibility. If something’s wrong, if something’s plagiarized, if something is incorrect, you’re not going to be able to say, “Well, that was AI.” That’s you.

Howard Forman: Right. You own it.

Harlan Krumholz: You’ve got to take that responsibility. I only tell people, AI right now, it’s like an instrument you need to learn to play. You cannot yield to it. Automation bias, where you basically just truck it over, is something that really will get you in trouble. It is not so expert that you can’t know that it’s either... It may have plagiarized, it may have misrepresented. There’s lots of things it can do, but it can help as an editor, and I want to say as an editor of a journal, I think we’re one of the... we may be the first journal that’s come out and said, “Use the tools, absolutely, but just use them responsibly and take responsibility.” To suggest otherwise, you’re putting authors in a place where they’re going to be forced to mislead or...

Howard Forman: Yeah. I admire that you’re taking that leadership role, like you are somebody who has an enormous body of work that you’ve contributed to and you’re the editor of this large set of journals, and when you speak about these topics, it’ll have an impact. I think it’s really a positive leadership role for you.

Harlan Krumholz: Well, I think it’s about recognizing the inevitability of these tools. They’re ubiquitous now, and people, to be top authors now, then you need to be able to use these tools. Just like I say, if you want to be a top athlete today, you need to be using AI. You need to be using a whole range of tools that will help you make sure that you’re developing the skills you need. But ultimately, that athlete’s the one performing. That’s why the author is the one who’s performing, but they should be using whatever tools they can to help them.

Howard Forman: Well said.

Harlan Krumholz: Yeah, so we’ll see. So far it’s gotten a good reception. We’ll see how it plays. A lot of old-school folks—

Howard Forman: I bet.

Harlan Krumholz: ... who don’t want to see this happen, but like I said, I think they’re up against an arc of history. Hey, let’s get to our guest today. She’s going to be terrific.

Howard Forman: Dr. Vanessa Cooper is a neurologist and assistant professor of neurology at the Yale School of Medicine. She serves as a longitudinal coach for Yale medical students and is the Associate Director of Collaborative Excellence Education for the neurology department and the residency program. Dr. Cooper specializes in headache medicine and provides outpatient care for individuals with chronic headaches. Dr. Cooper received her bachelor’s degree in chemistry and sociology from Stony Brook University and then earned her medical degree from New York Medical College. Subsequent to that, she completed her internship, her neurology residency, and a headache fellowship at Yale New Haven Hospital.

We welcome you to the podcast. We do not spend enough time talking about some of the most common medical ailments that afflict each of us, and Harlan and I both have our own personal experiences with headaches. Quite frankly, when I see statistics that say 50% of people have a headache in the past year, I’m shocked because I would have thought it’s 100%! I think headaches are one of the most common things that I hear from people, and so I’m so glad to have you on. I wonder if you could just start off by telling us a little bit about what drew you to headaches in particular, given that you start off in a neurology orientation.

Vanessa Cooper: Yeah. Thank you so much for having me. One, headaches, migraines, in particular, very complex, and often, it’s an invisible illness. Because of that, there’s a lot of stigma. It primarily affects women, certain headache disorders, and because of that, like I said, a lot of stigma around it. I wanted to really get involved as far as advocacy for my patients, and within the last five to 10 years, there’s been a lot of research, a lot of new treatment options where we’re able to make a difference and decrease disability, so that’s what drew me towards headaches and migraines in particular.

Howard Forman: Just one quick follow-up for our listeners. To me, in the ER, I’m doing a lot of head CTs for headaches, and for the most part, they’re looking for I think what are called secondary causes of headaches, like structural problems in the brain, which are very uncommon but nonetheless are either treatable or at least something that requires a different type of treatment. Can you just quickly say just for our listeners, what should people be thinking about if they get a really bad headache? What should cause them to have concern?

Vanessa Cooper: If it’s the worst headache of your life, meaning you’ve never experienced headache pain like this before, that would be something I would seek immediate emergency attention for. Other red flags include if the onset of the head pain is very fast or sudden onset, so you’re having maximal intensity of pain within one minute, that can mean a secondary headache such as a brain bleed in particular. Other red flags, look out for if it’s a new headache but it also comes with significant fever or other neurological conditions with it, so a headache but you’re also having visual changes. You’re having weakness on one side of your body, you’re having difficulty speaking or understanding or any type of sensory changes on any side of your body. Those would be things that I would seek emergency care for.

Harlan Krumholz: First of all, it’s a delight to have you on the program. The issue of headache is so interesting to me. I’m a cardiologist, and it has certain parallels, because the truth is that there are a lot of people that have what you just described. They have rapid onset, it’s a severe headache, and it actually ends up being nothing, just like there’s a whole bunch of people who feel chest discomfort. Now, what we see as cardiologists is the people come in with a heart attack who waited too long. But if we start seeing every single person who has any sort of discomfort from the bottom of their jaw to the top of their stomach or, in any way, their shoulders or going down their arms, should be running to the emergency department, we’ll be overrun with people who don’t need to be evaluated, and that ends up being a hard problem.

Because if we overindex on the person we know who had the disaster in the case of headaches, the person who ended up having a bleed or a brain tumor, then we’ll end up having massive numbers of people come in for evaluation who don’t need to, and it becomes really hard to discriminate. On one hand, we don’t want to give false assurance to people like, “Don’t worry, stay home. It probably is nothing”—which, by the way, on average, it will probably be nothing—because we don’t want to miss the catastrophic stuff where early intervention will make a difference. As you’ve thought about this, because on the show, we can say those sort of high-level things, if it’s the worst headache of your life and so forth, but is the field working towards better tools that can help people to make that determination, like “This is something I really need to be seen for,” so we don’t miss anyone with important conditions?

Vanessa Cooper: Yeah. I think one of the most helpful things is, really, getting a patient that has a history of headaches established with a headache specialist and neurologist. Because that way, one, they develop a relationship with this person who knows their pattern. And a lot of headache patients, especially migraine patients, they are really in tune with their body, so they will know if it’s a regular headache attack that has an aura. So aura will have, you know, reversible neurological symptoms. They’ll have the vision changes sometimes, they’ll have the difficulties with speech. However, if it’s lingering on and it’s more than that one hour, which we usually say, if it’s an aura, it should last up to an hour, can last more, but if it’s more than you normally are used to, that’s when they should seek care.

As far as specific tools to determine who should go to the emergency department and who shouldn’t, I don’t think we’re there yet. I think a lot of it is... like you said, we don’t want to miss the catastrophic things, and I know it’s very cliché, but essentially, worst headache of your life, they should definitely seek emergency care as far as new neurological symptoms. It’s going to be hard-pressed to say, “Maybe it’s nothing,” especially if they’re having their first aura, they’re not familiar with it, so we actually still encourage patients to still go to emergency room, just because if it does happen to be a stroke, we can do interventions for those things.

Harlan Krumholz: Given the number of people, at least... what did we say, Howie? You said 50% of people, there’s this maybe greater number of people who’ve got headaches. Are there enough of you guys, enough of you headache specialists to be able to... well, how long does it take to see you now if I try to make an appointment?

Vanessa Cooper: Six months.

Harlan Krumholz: Wow. We got somebody here who I feel like we’re good we got on our calendar.

Howard Forman: I know. We should get on now.

Harlan Krumholz: How are we going to solve that?

Vanessa Cooper: Great question. There are not a lot of headache specialists. I think what has happened to neurology in the last decade is that a lot of neurologists are no longer general neurologists. General neurologists are very comfortable with seeing patients with headache. They kind of take care of all subspecialties within neurology, but now everyone has subspecialized, meaning we now have experts in epilepsy, movement disorders, multiple sclerosis, neuro-oncology, and now headache. Now everyone is branched off, and unfortunately, not that many neurologists, when they’re graduating from residency, are going into headache medicine. I would say on average, from our department, maybe one or two per year, so about 10% or less. Definitely not a lot of headache specialists, and there are actually two states I think in United States that have actually no headache providers. We cover that in our annual meetings, on how to bridge those gaps.

Harlan Krumholz: With regard to lifestyle, are there recommendations that you can make to people that are known to help reduce the frequency and intensity of different types of headaches? I mean, is there a lifestyle component here, and can people be encouraged in that way?

Vanessa Cooper: One hundred percent. I think a big thing is consistency. The migraine brain or the headache brain in general really likes consistency, so consistent sleep schedule, making sure that you’re going to bed at a consistent time every night, waking up at a consistent time in the morning, and really aiming for eight to nine hours of sleep a night is a huge one.

Harlan Krumholz: How many hours of sleep a night?

Vanessa Cooper: Eight to nine.

Harlan Krumholz: I mean, Howie’s the only person I know who gets eight to nine hours a night.

Howard Forman: I rarely get eight to nine, but I do aim for eight to nine.

Vanessa Cooper: Hydration is a huge one as well. Dehydration is a known trigger in some patients, so really want to aim for more than 64 fluid ounces of water a day, not overly caffeinating. Some patients will say caffeine helps their headaches, helps during a migraine attack, which is true, caffeine does have an analgesic effect. However, too much caffeine can be a trigger, so definitely want to limit to less than 200 milligrams of caffeine a day, and then exercise is a big one. Being physically active helps to minimize frequency of headache attacks, so that’s one that we really try to tell our patients. Sleep, hydration, caffeine, exercise, and then not skipping meals, so being on a consistent eating schedule. Sometimes skipping meals can definitely be a trigger or increased risk of having a headache on a certain day.

Harlan Krumholz: Yeah. These disruptions in circadian rhythm really are associated with headaches too. It’s like just what you’re saying, consistency is so important.

Vanessa Cooper: Yep, very important.

Howard Forman: What is the typical makeup of your patients? Is it mostly people that have ongoing migraines or is it mostly people that have post-concussive? What is the mix that you see?

Vanessa Cooper: Yeah, I would say the mix. Majority of my patients have chronic migraine, meaning they average about 15 days or more per month of headache in general.

Howard Forman: Wow.

Vanessa Cooper: I would say majority is chronic migraine. The second-commonest, I think, would be episodic migraine, meaning anywhere between one to eight, 10 migraines per month. After that, I would say post-concussive is pretty common. A lot of patients, they have car accidents, some type of head trauma, fall, and then there are more rare types of headaches. We see cluster headaches, trigeminal neuralgia, which is this very specific type of facial pain disorder.

Harlan Krumholz: I have this... since we’ve got you here and it would take me six months to see you, I might as take advantage of the consult. From time to time, I get just the aura, no headache, and it will last for 20 minutes or so. What’s happening, physiologically? Just for people who are listening who are fortunate enough not to have this, my vision is obscured, so mostly on the periphery, and it’s sort of scintillating aura at the periphery, but sometimes it can go more towards the center and it’s just bothersome. I mean, it’s hard to see. I can see, but it’s bothersome. I don’t have a big headache, but I’m just wondering, what’s causing that?

Vanessa Cooper: Yeah. The pathophysiology... just to back up, so about 20% to 25% of people that do have migraine will have an aura, and the most common type of aura is like you described, the visual aura, and the second most common is a sensory aura, and it’s not uncommon that patients may actually have two different types of aura at the same time.

Harlan Krumholz: What’s the sensory aura? How would that manifest?

Vanessa Cooper: Yeah. That manifests usually as a loss or a tingling. They mostly will describe one heavy half of their face becomes numb and tingling, and then sometimes it’ll spread down to their arm and then also can spread down to their leg. Patients that have had the sensory aura, they typically will say they have the visual aura first and then, all of a sudden, they notice that their face kind of feels weird and then they notice a spreading down of that sensation, spreading down to their arms or their legs.

I forgot your question already.

Harlan Krumholz: What’s happening at the level of the biology that’s causing that?

Vanessa Cooper: Yeah. There’s a depolarization, a wave essentially, that is going across the cortex. That’s kind of what we know to cause aura, a little similar to seizures, so in particular in patients that only have aura, seizure medications actually have shown to be effective because of that depolarization wave that goes along the cortex. Anticonvulsive medications can kind of shut down that pathway and minimize auras in some patients.

Howard Forman: When I was younger and I had more classical migraines, I don’t remember if they’re called classic migraines, but the aura followed by the headache, I would have hemineglect of a type, of a visual neglect that would occur for the rest of the day—

Harlan Krumholz: Really?

Howard Forman: ... where I would react slower to things on one side of my body. If someone threw me something on one side, I would almost ignore it, whereas if you threw it on the other side, I would notice it. I’m fascinated by the same thing Harlan’s saying, is like how utterly complicated it is. I’m more impressed by the fact that we’ve made so much progress now. There are really medications available to be able to proactively, preventatively treat in so many people. How successful are those, and can you give us some sense of the categories that they’re in?

Vanessa Cooper: Yeah. The hot thing right now are the CGRP, so calcitonin gene-receptor peptide, monoclonal antibodies which are used for prevention, and then we also have the antagonist for acute therapy or as-needed therapy. What we do know is that when a patient is having a headache or migraine attack, the CGRP molecule increases in the bloodstream. What the preventative medications or the monoclonal antibodies do is that they target the actual molecule or the receptor of CGRP and prevents it essentially from binding, so that will minimize headache frequency as well as severity in patients. The same thing goes for as-needed therapy, prevents the molecule from binding, and that has been all the rage right now within the headache field. We’ve had several medications that have come out within this newer class, and it’s actually the first class within the last 10 years. Well, ever. Ever in history. The first class, which is migraine-specific. Historically before these medications, all medications used for migraine prevention were of different categories, so blood pressure medications, anticonvulsants, etcetera.

Howard Forman: Just to speak one more thing about biomarkers, because I didn’t even realize that you have a specific biomarker that can be measured. Are we testing people for that when they’re having a migraine? Is that a diagnostic test or is that just used in terms of developing the drug?

Vanessa Cooper: Yeah. From what I understand, we only use this for research as far as a diagnosis of migraine is strictly clinical, and any headache disorder is strictly a clinical diagnosis.

Harlan Krumholz: These advances are terrific. One thing I have to ask you, though, is how much does it cost and are people able to get them? There’s so many people suffering. I worry that sometimes we have these great new things to be used and help, but is there any issue here with people getting access to them?

Vanessa Cooper: It’s a huge issue. These medications are very expensive. The preventative medications, the monoclonal antibodies, you get one injection per month, that will run you about $1,000 to $2,000 per month just for that one injection. They’re using it chronically, so this is probably going to be on it for a lifetime or plenty of years. A lot of insurances will require that a patient try nonspecific headache medications before they will even approve it, so there’s another step we have to do prior authorization for all of these medications, which makes it extremely difficult for patients to get, and then once they do get it approved, the co-pay is astronomical. Thankfully, a lot of the companies do have patient assistant programs and co-pay savings cards that do bring the cost down for the patients, so we’ve been able to utilize that. Unfortunately, for patients on Medicare, which I’ve seen the biggest issue, they cannot use any of the co-pay savings cards, so essentially, we have a subset of population of patients that are unable to really get access to these medicines.

Howard Forman: That’s a real big problem, in at least short run. Hopefully, in the long run, you can have broader availability for individuals. How effective are they?

Vanessa Cooper: Very effective. As far as numbers go, majority of the monoclonal antibody... I’m just going to ballpark, so a patient will have close to a 50% chance of minimizing or decreasing their headache days by 50%. If they’re having 30 days per month of headache, they have about a 50% chance of reducing it to 15 days or less per month, which, in the research world compared to other headache medications, is really great.

Harlan Krumholz: Yeah. One thing I wanted to pivot to, which I think is kind of an exciting area, is these neuromodulation devices, so remote electrical neuromodulation, transcranial magnetic stimulation, these vagus nerve stimulation, I mean, this sounds like science fiction, that you can actually be using electricity. Can you just explain to people listening, where’s this field moving? How does it work? Are you using this?

Vanessa Cooper: Oh, yes. I think neuromodulation is great, especially in this day and age, a lot of patients will say they don’t want to take medication. They’re really wary about pills and side effects, so neuromodulation devices are a great avenue for them to explore. We do have several neuromodulation devices, some that target specifically the trigeminal nerve, we have remote electrical neurostimulation, which is an armband, and then we have occipital nerve stimulators, etcetera, and then, like you said, vagus nerve stimulators. We have several devices that help minimize migraine frequency and help during attacks with migraines. The biggest thing is cost. Insurance does not cover neuromodulation devices.

Harlan Krumholz: Give us a sense of how this works. You come in the office... I mean, is it in the office? Can you do it at home or this—

Vanessa Cooper: Yeah. They do it at home. A lot of these medications, they can just order it online. They just Google it, they can order it online, they’ll ship it to the patient, and they use it at home.

Harlan Krumholz: How can you be sure it’s a credible device versus someone trying to scam you?

Vanessa Cooper: There’s very specific neuromodulation devices that we know are FDA-cleared. Cefaly is one of them. This is external trigeminal nerve stimulator. They can go to the Cefaly website and order that directly from their website. That one will run patients around $500 for the device. Again, not covered by insurance. Another popular one is gammaCore or Truvaga. Truvaga is the vagus nerve stimulator, where patients, they put a device to the vagus nerve, and all of the websites...

Harlan Krumholz: What does it feel like when you put it on?

Vanessa Cooper: The vagus nerve stimulator kind of feels like a slight vibration, and then patients will have a pulling of the...

Harlan Krumholz: It’s giving electrical pulses. I mean, what is it doing?

Vanessa Cooper: Correct. The Cefaly device is a external trigeminal nerve stimulator, so patients put it on their forehead to stimulate very specific branches of the trigeminal nerve, and that stimulation helps to minimize trigeminal nerve pain. The same thing with the vagus nerve stimulator. I think it’s really cool, the remote electrical nerve stimulator, it kind of works like a TENS unit. Patients will put this armband on their arm, and it works in some way to minimize head pain. A lot of it also is biofeedback. With the Nerivio device, which is the remote electrical nerve stimulator on the arm, they run a program on their phone, and while they’re running their program on the phone, it’s taking them through biofeedback exercises. I think a lot of that, if you believe it’s going to work, it may work for you.

Howard Forman: But are there randomized trials that are seemingly well structured that show that it does work in some people?

Vanessa Cooper: They are trials that shows that it works, but I’m unsure if it’s that much better than placebo.

Howard Forman: Okay, so you’re not fully convinced about this. Since you told us that it’ll take six months to see a headache specialist in our area here, as a final question, at least from me, what can we do to expand the primary care workforce’s capability in the headache space so that primary care doctors or whatever, whoever else is out there, could help patients get treatment earlier?

Vanessa Cooper: The American Headache Association or Society, the AHS, American Headache Society, they actually have a great primary care program specifically to teach pearls and tools or a workflow on how to manage a patient with headache disorders, specifically migraine. They have really short bits on their website as far as workup, tools, medications to start patients on while they wait for headache providers, and even how to prescribe the new novel medical migraine medications that are available. I do think educating our primary care providers to get the ball rolling with the headache treatment will go a long way, because at least if they start some treatment before they get to us, it makes the job easier to prescribe the newer medications to the patient.

Howard Forman: That’s great. I can’t thank you enough for joining us and talking to us about this. This is one of these topics that I continue to come back to for myself and for others all the time, and it’s great to know that we have a headache center here at Yale and that you are working in it. It’s great to have you as a colleague, so thank you.

Harlan Krumholz: You deserve a six-month waitlist. You deserve a one-year waitlist, and I’m glad I was able to jump the queue today…

Howard Forman: That’s right.

Harlan Krumholz: ... on the podcast.

Howard Forman: That’s right.

Vanessa Cooper: Anytime. Thank you so much for having me.

Harlan Krumholz: Thank you.

Howard Forman: Thank you.

Harlan Krumholz: Well, that was a terrific interview. Thank you for bringing Vanessa Cooper on. Yeah, she’s really smart, great, articulate. But look, you are going to get into some of these nuances about what’s going on with the government shutdown and help explain it to the listeners. What is this issue about these credits and so forth?

Howard Forman: Right. It’s not the first time that we’re even talking about this. We just did it a few weeks ago. As you said at the beginning, the government is in some phase of shutdown right now. It doesn’t happen all at once, and if this lasts longer, people will start to feel it, but in the first few days, it’s a minor nuisance at best. But it’s all about Congress not agreeing on appropriations for all of the executive branch parts. One of the key sticking points that Democrats have made an issue is whether our government continues to provide extra subsidies on the Obamacare or ACA exchange. I want to better explain that, because I think this sounds too wonkish for people. As our listeners know, nearly 70 million people are on Medicare, nearly 80 million are on Medicaid, some of these are double-counted because people are on both, and about 150 million people get their healthcare insurance through their employer or a family member’s employer.

Those who aren’t poor, disabled, elderly, or work for a large employer are often at the whims of a market that has not been really accommodating, so there are roughly 24 million people who get insurance through the so-called Obamacare exchanges. Now, initially, policymakers hoped that the so-called mandate tax or the mandate that Obamacare had written in in 2010 would force people to get this insurance, but that was completely undone in 2017, and the main thing that makes this market work at all are large financial incentives for lower-income individuals. What do I mean by “work”? What I mean is that if you were to allow people to choose whether to be insured or not, those who are the healthiest among us might logically choose not to buy health insurance because they might perceive that it’s not worth it for them, and the remaining people would be forced to share ever higher costs.

We’ve proven this time and time again, and health insurance becomes unaffordable if healthy people don’t buy health insurance. If you force everybody into the pool, which is not easy, then you have perfect spreading of risk and it absolutely is more affordable for everybody and particularly the higher-cost individuals. As I said, the mandate tax was not a strong incentive, but it did help, but it’s gone. Income tax credits or financial incentives do help a lot. The lowest-income individuals have been able to buy policies on the exchanges oftentimes with zero of their own dollars, so they contribute nothing even though those policies might have high deductibles, and those individuals would then have a health insurance policy. Now, those people are not poor enough to qualify for Medicaid but they are poor, but the credits themselves phase out at 400% of the federal poverty level.

Just for our listeners, that equates to about $62,000 for an individual, so what most people would equate with lower-middle-class right now, and thus many middle-income and higher-income individuals would not qualify for those incentives. Enter these so-called enhanced premium tax credit subsidies. These were brought about with COVID in the American Rescue Plan of 2021, and then they were renewed with the Inflation Reduction Act, and they expire December 31st of this year. They have been wildly successful. Enrollment on the exchanges has doubled. It was 12 million before, it’s over 24 million now. These credits help even many higher-income individuals. You might say, and logically, I don’t think it’s wrong to ask, why should the taxpayer be subsidizing the health insurance of higher-income individuals? It’s a good question, but the answer is an easy one. We already subsidize health insurance purchased by everyone else. We substantially subsidize employer-sponsored health insurance, we obviously subsidize Medicaid and Medicare, and we also subsidize military and veterans benefits.

The only group we have not explicitly subsidized are these individually-purchased health insurance products until the passage of the ACA, and now with these credits, we extend that subsidy up a little bit higher, and they’re also bigger subsidies. It’s a long way of saying that these enhanced premium tax credits that Democrats are fighting for right now are working as intended, and we can ill afford to watch them expire, this year or next. It’s going to cost about $35 billion a year, so it’s not a small amount, but it’s certainly not in the range of the trillions of dollars involved in the recent tax cut bill that was passed in early July. I’m eagerly watching to see this resolved not just for the coming year but for the foreseeable future, and I think all of us should look out and try to better understand why Democrats feel this is a hill to die for and why Republicans, I think some in good faith, say, “Let’s discuss this, but we don’t have to do it right this minute when the entire government is at risk.”

Harlan Krumholz: I want to try something here with you. If you are a Republican spokesperson right now and you are making the case for why you’re not extending those right now, why you’re saying, like, “Hey, let’s do a continuing resolution, it’s a clean continuation bill, and let’s now negotiate this separately or deal with it,” and you’re a Republican spokesperson right now, what’s your case for this? Isn’t there another case that can be made?

Howard Forman: I think that if I were speaking on behalf of a member, I would say exactly what you said, but I think a lot of people know that even if you get members to speak out right now that they want to make this happen, when push comes to shove, it may not happen, and very importantly, the rates on the exchanges for January are set now. The exchanges will open up in a few weeks for people to buy policies for next January, and if they see their rates going up by 75%, which is the average rate increase that we expect, we expect about 4 million fewer people to buy policies. Now is the time you have to act.

Harlan Krumholz: What’s the case for, this isn’t what we should be doing? Because as I think about this, and the part that I don’t quite understand, is I think this will disproportionately hurt people in red states.

Howard Forman: I think that’s right.

Harlan Krumholz: I mean, it’ll hurt people across the country, but in terms of people who are vulnerable—

Howard Forman: Yes, you’re correct.

Harlan Krumholz: ... just given the socioeconomic standing across the country and so forth.

Howard Forman: The types of people that are on the exchanges, they tend to be small business owners, they tend to be working for small businesses.

Harlan Krumholz: What’s the case for saying that we should either let this lapse or we need to change this because it’s not working? It just seems to me like it’s what they might, in other situations, be fighting for.

Howard Forman: Yeah. If I were trying to navigate this and just do what’s right for the country and not necessarily political considerations, there are things you could do better. There are some people out there who believe that some of the policies that are being encouraged, $0 policies, are basically making insurance companies money.

Harlan Krumholz: I see.

Howard Forman: We should be minimizing that. We should be tweaking it. We should always be tweaking things. We should be making them better. That’s not what’s seemingly in play right now. By the way, if you wanted a good-faith effort, I personally, if I were the Democrats, I would accept a one-year extension now. I realize politically that might not be smart, but a one-year extension of this would be a really good-faith effort to say, “We can make this better. We’re going to start working on it tomorrow, but for now, we’re going to make sure next year is going to work.”

Harlan Krumholz: I see. I do think that maybe part of this is, it gets tied to this tag “Obamacare,” and there still are people who just—

Howard Forman: Of course.

Harlan Krumholz: ... really want to overturn Obamacare. Well, that was a really good explanation. Thank you, Howie.

Howard Forman: Thanks, Harlan.

Harlan Krumholz: 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, email us at health.veritas@yale.edu or follow us on any social media.

Harlan Krumholz: And give us feedback. We got some feedback this week from some folks, some that we had mentioned on previous podcasts, so we really enjoyed that. But yeah, give us feedback, rate us. It’s all good.

Howard Forman: By the way, we talked about headaches today. If there’s a favorite, maybe “favorite” is not the right word, but if there’s a condition you want to hear us talk about, email us or post it on social media. We will find somebody to talk about it. We really want to meet your needs. 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’re fortunate to have some superstar undergraduates working with us, Gloria Beck and Tobias Liu. We have a remarkable producer, Miranda Shafer, and I have the best cohost in the world, Howie Forman.

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

Harlan Krumholz: Talk to you soon, Howie. It’s great to see you.