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 Jonathan Cohn of The Bulwark. But first, we like to check in on current or hot topics in health and healthcare. What do you have today, Harlan?
Harlan Krumholz: Yeah, thanks, Howie. Well, this week, Epic Systems and several large healthcare systems filed a lawsuit against Health Gorilla and a group of companies connected to it. The allegation’s pretty serious. It’s that patient medical records were accessed under the label of medical treatment and then monetized for other purposes. You know I’ve talked about this before.
Howard Forman: Way before anyone else ever was talking about it, way before our podcast. No, no, I’m serious.
Harlan Krumholz: Well, these are things that concern me. And how does a company like Health Gorilla get access to medical records in the first place? So let me try to explain this again and try to help people understand what’s going on. You have to understand how the modern healthcare data sharing works. So hospitals and clinics store medical records inside their own electronic health record systems. But patients move, of course. Emergencies happen. Care happens across institutions. So over the past decade, the health systems have built a national data sharing framework to allow records to move quickly when they’re needed. And you can imagine how important this is. You get landed in an emergency room somewhere else and you want to get records from where you were before, and it’s important for those to be able to travel. One of those frameworks is called the Trusted Exchange Framework in Common Agreement or TEFCA. It’s a federally backed system designed to let medical records move securely between healthcare organizations.
Health Gorilla—interesting they picked that name, Health Gorilla. They don’t own medical records, and it doesn’t store medical records, but it acts as a connector. It’s approved to operate as a network inside these national frameworks. So it helps connect organizations such as clinics, labs, digital health companies, essentially moves the records from one place to another. When one of these connected organizations requests a patient’s records, the request goes directly from a system to another system using the, for example, a company like Health Gorilla’s infrastructure. There’s no person in the hospital manually reviewing each request. The system’s automated by design, to make it easy. The most important part of that request is something called “permitted purpose.” So of course, they can’t just say “We want to see your records.” They have to see it under this framework for a reason that is authorized. And every request must declare why that data is being requested.
And one permitted purpose is treatment. When a request is labeled as treatment, systems are generally required to respond and large portions of the medical record may be released automatically. And this is intentional. Again, if you end up in emergency room and it’s important for doctors to see your records, you want this to be able to happen. But it’s built on trust. Trust that the organization requesting the data is real. Trust that it is actually treating a patient and trust that the data will only be used for care. But according to the lawsuit—and according to my own observations—in many different instances, not necessarily about Health Gorilla, but this trust can easily be abused. And Epic and these health systems are claiming that the Health Gorilla has done that.
They allege that some of the organizations connected through Health Gorilla claim they’re requesting records for treatment, but then use those records for other purposes, including marketing data to law firms involved in mass tort, litigation, and other reasons, but monetizing, for example, your and the listener’s records and getting them for reasons. And I can tell you, this dispute’s going to be held in court. I’ll give you an example where I saw this kind of abuse. Remember these sort of things that popped up to do COVID testing like in New York, every corner. And they would say to you, “We’ll do it for free.” And you might be thinking, “Well, someone else is paying for this, maybe insurance company or something.” That could be true. But also what they were doing was they were now putting themselves in a position where they could get full access to your medical record because they called themselves treating you because they did that test.
There were other examples I had observed where, for example, your specimen was sent to a lab for a special test, outside lab. That lab could all of a sudden be claimed to be treating you and now get access to all of your medical records. And now once with your records, those organizations can in turn monetize those medical records because they’re fluid, valuable, and increasingly portable. When people like that get your records, they can use them for a whole variety of purposes. So it’s going to be very interesting. I think what happened was not that Health Gorilla itself sought to deceive anyone, but if someone using the Health Gorilla service was claiming they were treating you and there are questions about whether that was really legitimate, then Health Gorilla has become the target of the litigation.
But this is going to, I think, put in bright relief what’s happening. It’s not a case about one company or one lawsuit. It’s about how we govern medical data at scale, how we balance the speed with accountability and how we show the systems are built to help patients don’t end up just undermining their trust and exploiting their information for profit when the patients themselves don’t even know it.
Howard Forman: I will say, if I were to decide that I want to know what’s going on with Harlan Krumholz right now, I can go to Epic, I can go in the health record system, look stuff up, and I will be fired within seven days probably. I mean, our system is so tightly structured to protect our privacy that I would get fired for that. If I do that for my daughter, I would be fired. In other words, it’s really tight control on that one-on-one level.
Harlan Krumholz: In the health system, it’s tightly controlled, but then all this data leaks out of the health system.
Howard Forman: Exactly. So it’s just amazing to me that the magnitude of harm that could occur is not being controlled. And yet at the micro level, we’re doing everything to control it, and we need to do better because people have to be able to have trust.
Harlan Krumholz: That’s a really great point. Really good point. So we’ll keep posted, I’ll keep you posted on this trial, but I think it’d be very interesting—
Howard Forman: No, it’s really—
Harlan Krumholz: … if it comes up in the kind of discovery. Hey, let’s get to our guest, Jonathan Cohn. This is going to be a terrific interview.
Howard Forman: Jonathan Cohn is a senior national correspondent at The Bulwark, where he authors the newsletter, The Breakdown, on topics including health policy and economics. Before joining The Bulwark, Cohn held positions at The American Prospect, The New Republic, and HuffPost. He was also formerly a media fellow of Kaiser Family Foundation and a senior fellow with the think tank Demos. He is the author of the books The Ten Year War and Sick, covering the process of enacting the ACA and the decline of the American healthcare system. He’s a two-time winner of the Sydney Hillman Prize for journalism, among many, many other awards. He received his bachelor’s degree in political science and government from Harvard University and currently resides in Ann Arbor, Michigan. And I have to say, when you joined The Bulwark last year, I was so excited by that because I was an early on-boarder with The Bulwark.
Once Trump came into office, I became obsessed with The Weekly Standard and their successor organization, which was The Bulwark. And they have assembled some incredibly thoughtful writers, but with one unifying theme, which is, how do we maintain our liberal democracy and how do we move this country forward in a unified way, try to hold the center together? I’m curious to hear what drew you to The Bulwark and how this fits into the prior work that you’ve done covering healthcare?
Jonathan Cohn: Yeah. Well, first of all, thanks for the nice introduction. And I will say I feel incredibly lucky to be at The Bulwark because it really is a special place. I mean, I feel incredibly fortunate. This is a tough time for the journalism business. It’s tough, especially if you write things that don’t necessarily, always aren’t exactly clickbait, and health policy frequently is not clickbait, except for maybe the people on this who are listening to this. I mean, there were a number of things that drew me to it. One, I will say honestly is, if you look at my past and where I came from, I was from publications, The New Republic, The American Prospect, identified with left of center. And I think most people would say HuffPost, although it thinks of itself as a news publication and operates like one. Nevertheless, it’s got a kind of a progressive lens on things.
And if you know the backstory of The Bulwark, it is started by people who were associated with the Republican Party, but really kind of split over a number of things, but especially Donald Trump, and wanted to create a place that was dedicated, as you said, to democracy and the values of democracy. And the idea of being at such a place, first of all, just I care about democracy a lot. And I don’t care what your pet issue is, whether it’s healthcare or economics, environment, whatever. Right now, that’s got to be the sort of fate of our democracy to me is the most important issue on the menu right now, just when you see what is happening. But also the chance to be around some people who come from a different background. I think for me intellectually, that’s really important because I’m one of those people, I’m constantly trying my best to question my own priors and make sure, you know, ask tough questions.
And also, I love the fact that they sort of practice what they preach there—“here,” because I’m there now—of part of this commitment to democracy and civil debate is having debate and having people who might have different points of view from time to time and making arguments and talking about them. And it’s hard to do nowadays in this environment, but God, I want so badly to have a space and a place where we can have intelligent and well-informed debates where we have real differences of opinion and we argue about them, but we share a commitment to facts and we share a commitment to civility and maybe the overall goal is that we want to make this country and this world a better place. And we can disagree. Reasonable people, reasonable, well-informed people can have disagreements about that and we should and we should all have those debates. I feel like the space for that in today’s media environment is shrinking, is tiny. And the nice thing, one of the things I love about being at The Bulwark is I feel like it’s one place where that is taking place.
Howard Forman: How surprising is it to you though that Bill Kristol, Charlie Sykes, who I think has left The Bulwark but helped found it, Tim Miller, Sarah Longwell, these aren’t just Republicans. These were stalwarts of the Republican Party. And in the case of Charlie Sykes, he was practically a right-wing shock jock. How surprising is it that that group has moderated so much that you’re all cohabiting and really in sync about where the country needs to go?
Jonathan Cohn: Yeah. I mean, I joke sometimes, what would 1997 me think about the fact that I’m on the same publication with Bill Kristol, who I first met, I actually remember it, a New Republic/Weekly Standard softball game where he was pitching. And I still remember, I got a nice line drive double off him and felt very good about that. It was right on the mall where they have the softball fields. So the thing about Bill Kristol, incredibly thoughtful. I mean, people knew this before, I knew this before because I’d interviewed him. He’s very smart, thoughtful. And I think that’s an example of what I was talking about, was people can believe very passionately on issues that might not be or might be what I think, but sharing a much broader commitment to the fact that we should have these debates and that it’s important to create and protect a society where you can have those debates.
And actually, the two things that happen, I always find when you’re in conversations with people who maybe don’t come from your point of view or don’t always share your point of view, two things will happen. Number one, you’ll ask tough questions of your own view that will either strengthen your views or cause you to modify them in ways that sort of are closer in line with the evidence and what’s out there. And it’s really important to ask those questions. I mean, a couple weeks ago when this whole Minnesota thing was blowing up, I sort of took a deep dive into what was going on there, where these stories of fraud. Which for people who haven’t followed this, I mean, one of the ostensible premises for the crackdown in Minnesota is that there’s lots of welfare fraud there and a lot of it is centered in the Somali community.
And I think anybody following this story and seeing the rhetoric from Donald Trump, who was attacking Somalis long before this and in vile and racist ways, it doesn’t take a genius to see what’s really going on here and that this is being exploited and exaggerated. And yet, if you take a really hard look at what’s going on there, there was some really serious fraud in the past. I mean, real high-level and somebody was asleep with a switch and didn’t catch it. There may still be some going on and you need to be honest about that. And I think being around people with different points of views forces you to ask those tough questions of yourself and of your own, if you want to call it your team, to sort of pressure test your own views.
The other half is, you discover you actually have a lot in common with these people and that you share a lot and those things that you share are really important, whether it’s a commitment to rights and a commitment to things that we took for granted. I always took for granted in the context of American politics that like, we want to be the good guys in the world order. We want to be a sort of symbol of hope, that we want to stand for the idea that might doesn’t make right.
So it’s been great. And like I said, I mean, they’re an incredibly nice bunch of people to start with, but even putting that aside, it’s an incredibly rich and constructive and thoughtful conversation we’re all having there. And I’m certainly learning a ton from them and maybe they’re learning from me. I don’t know. And like I said, I think at the end of the day, we all discover, especially now, we have a lot more in common than I thought.
Harlan Krumholz: You know, you talk about this spectrum of individuals at Bulwark, and yet the truth is I think actually you have more in common than you have differences because you share an antipathy toward the current administration. But as you look to health policy and what’s being done, are there things that you can say, “Yeah, I’m firmly strongly against these things, but actually I can concede that there are some things being done by the administration that were never advanced under other administrations and were long overdue and I applaud.” I mean, can you get to that point? I mean, are there things that you can identify that are going on that you would embrace?
Jonathan Cohn: So I would say there are things… If the question is are there sort of health policy initiatives and priorities of the current administration that I could embrace and support and praise? Absolutely. There are things they’re doing well. I could give you a list. I mean, they’ve talked, for example, about cracking down somehow on direct-to-consumer advertising by the drug industry. Those are these ads that you see, right? Especially if you’re a sports fan, I watch football all the time, basketball, a gazillion of these ads, also on cable news, right? There’s only two countries in the entire planet who allow drug companies to advertise that way because it’s so prone to misleading information and there’s a whole literature on this and how damaging it is and why there should be a way to regulate it very tightly or a prohibitive that doesn’t step on free speech rights. There’s two countries in the world that allow it. We’re one of them. Trump has talked about getting rid of that. Secretary Kennedy has talked about getting rid of that.
I think that’s great. It’s hard to do. There is the First Amendment and it’s a legal issue here in a way that it isn’t in other countries. I think you can do it. They just did these dietary guidelines and we can talk in a minute about all, as a whole, but a lot of those recommendations make a lot of sense, trying to push against ultra-processed foods, that makes a lot of sense. So there’s definitely priorities of this administration. I think everybody or lots of people, even if they don’t agree with this administration, if they’re Liberal, Democrats, Progressives can support. And you hear that sometimes, right? You hear every now and then, Bernie Sanders will say, “Hey, Donald Trump wants to do something on drug prices.”
Great. I’m all for that. I will say it’s hard for me to think of something they’ve done that at least wasn’t a priority of the last couple of Democratic administrations. There may be cases where the Obama administration or Biden administration didn’t make it a priority, and now if Trump really goes after the direct-to-consumer advertising, I don’t think that was a priority of the past administrations. Mostly I think because they didn’t think they could get it done.
Harlan Krumholz: And I’m thinking less of priorities, of whether things they actually have gotten done. And I don’t know, I don’t have a list in my head either. And I’m not being critical. I’m just saying, I think it will give us, those of us who are criticizing many aspects of what is going on, more credibility to be able to say… Because what I’ve noticed about this administration that’s interesting, the same things that are maddening are liberating in the sense that they aren’t constrained by the kind of things that held people back from movement. So for example, when I’ve talked to the administration about instituting unique device identifiers, I’ve never been able to get any movement on that. These are the barcodes that are associated with every medical device. If we could get them into the medical record, we could really follow what happens to people, who gets into trouble, how things happen.
Right now, if something happens to someone, you can’t even tell often what device they had, let alone what factory it was produced at or what lot it was. And there are these numbers associated with them. When I talk to the administration about that, they’re going, “Well, why didn’t anyone do this?” I go, “I think because the American Hospital Association pushed back on it, they said it was just more work, an unfunded mandate for us.” They’re going like, “Well, if it’s the right thing to do, maybe we’ll just do it.” They haven’t done it yet, but I’m just saying sometimes I get a sense that in other administrations, everyone’s waiting for full consensus around doing things when sometimes they were just being moved forward. That both is a pro and a con. It’s a pro and a con. And anyway, I guess my point is sometimes we’ll have to stretch, but we have to not be reflexive but more thoughtful.
I’m talking about myself, probably. In terms of not just automatically saying “good” or “bad” but like saying, “Is there something here that could be beneficial or not?” Separating it out from the rhetoric about the last elections that needed to be overturned or the incongruency of looking at what’s going on in Minneapolis versus what happened on January 6th. I mean, there’s all these other things that can be true, too, that are problematic. But anyway, that’s sort of how I think about it.
Jonathan Cohn: Yeah. Yeah. Well, I would say I agree with that in the following sense, which is they are willing to push past resistance and they are less sensitive to heat, political heat than you have seen in past administrations. And there is a version of that I really support because I do think it is hard to get things done in Washington. I mean, I remember, talk to people in the Obama or Biden administrations or anybody, go back further to Clinton, any of them. We tried to do X and we got stymied by the career bureaucrats, the lawsuits, and then we got the lobbyists from the hospitals or the drug, whoever it was. And I think the willingness to push through that is great. And if that could be applied in ways for good, I’d love to see that.
What I worry about, frankly, is that, at least in what I see in this administration, I’m mostly seeing that being applied in ways that just run roughshod over—
Harlan Krumholz: Over norms that are actually doing service, right?
Jonathan Cohn: Yeah. I mean, look, that was the whole DOGE mentality. And I look at something like USAID, which I’m sure, was there waste in USAID? Of course, every agency has it. Did the administration have a right to realign the program with its priorities? Sure. But did you have to cut off all these programs with no notice and then just completely demolish U.S. foreign aid in a way that it’s going to lead to, already has led probably, to tens and then hundreds of thousands of deaths. And that was a case where I would not have thought that possible before, because I would have said, “Well, there’s procedures, there’s legal civil service protections, there’s a bureaucracy, there’s a sort of greater Washington establishment to push against that. There’s a Congress that’s not going to let it happen.” And they just pushed through it and it turned out, you can do that. Who knew? But now we’ve decimated globally. That’s the one that upsets me the most.
If you could capture a little bit of that spirit and do it in a careful way, I would love that. I don’t see that much from this administration, but maybe I’ll be surprised. I will say, I do tend to hear when people say, “What parts of the government are still functional in the Trump administration?” CMS is the one place I tend to hear about. Sounds like Center for Medicare and Medicaid Services still functioning pretty well. And maybe that’s a credit to Dr. Oz, I don’t know, but there you go.
Harlan Krumholz: You know, Jonathan, I wanted to reflect a little bit on an amazing piece that you wrote that I highly recommend to people who are listening. It’s a piece about Japan, but maybe it really isn’t about Japan. It’s about what becomes visible when you take a step outside the American debate. I want to just tease out a core idea that came out of the piece, whether healthcare should be universal. And the notion that in Japan, it’s something that’s not contested at all. You talk about it as a place where even ultraconservatives don’t question universal coverage. And what happens in a political system when healthcare is no longer an existential question is what you raise. And it sort of gets me to say, how did we get to a place where like everywhere else in the world, many places with similar economic status, let alone less economic status, are willing to say, “This isn’t even debatable. People who need healthcare should be able to get healthcare without financial toxicity, without all these worries.”
I mean, how did you experience that as you were writing this piece? Where did it sort of leave you? How do we move this country so that the center can say that, “Yeah, this actually isn’t a controversial issue here. We may have to figure out the how, but this notion isn’t controversial.”
Jonathan Cohn: Yeah. I mean, it’s funny, I’ve been sort of doing this thing where I try to learn about other countries’ health systems when I get the chance for about 20 years now. Frequently, I have some excuse to go to some country and I’m like a medical tourist, I guess, a little. I’m like, “Oh, tell me about your healthcare system.” And that’s sort of what happened in this case, it was actually started as a family trip. I’m like, “Oh, I’m going to be in Japan. Who knows when I’ll get there again? Let me learn about their system.” It has been a constant in every single one of those countries. You talk to people and there’s vibrant debates about healthcare in all of them. And I’ve yet to find a country where people don’t complain about their healthcare system. This is wrong, that is wrong, that is wrong. Nobody in these countries, as best I can tell, no serious political actor questions the commitment to universal coverage.
I mean, it is just sort of assumed. Everybody has a right to healthcare. We’ll argue about how to do it or argue about how much to spend on it, but we don’t question that. That is a uniquely American debate. I have struggled with this because my first book, which was called Sick, was kind of a sort of set of stories designed to sort of explain how did our healthcare system evolve this way and where are all the gaps? And there’s a lot of gaps. As you know, you got people don’t have insurance, there’s people who are underinsured, their costs are so high, even with coverage, they can’t pay for their medical care, people can’t get care because of insurance bureaucracies, you just go down the list.
And sort of the meta theme of that book in a lot of ways was to… I picked out these stories to tell people, was to convince people, “You might think this isn’t you, you might think you are not the person who tomorrow is going to lose your health insurance or you’ll have a condition and your insurance won’t cover it, but guess what? It could be you. And if nothing else, that is a reason for you to support this idea that everyone should have healthcare.” And that book came out in 2007 and we went and it was right in the campaign, it led to the 2008 presidential campaign. Then we get the debate over the Affordable Care Act.
And I came out of that debate thinking maybe we’ve gotten to that point that maybe we’re now at this place where we do think everyone should have healthcare. And I can make an argument that we kind of are sort of getting there. I mean, the fact that nobody attempts to repeal the Affordable Care Act have failed and proved unpopular. And the thing about it that’s unpopular, if you look at the polls, nobody wants to take away the protections for people with preexisting conditions, which for me is a kind of implicit acknowledgment that you shouldn’t be locked out of healthcare just because you had cancer. You were unlucky.
Harlan Krumholz: But to be clear, getting everyone insured is not universal healthcare.
Jonathan Cohn: No, it’s not. And I will say, I mean, I don’t actually… now, recently, some of the debates we’ve seen, I don’t even think people are necessarily—I think there is still a lot of people who think we maybe shouldn’t give everybody healthcare. I think there’s a larger, or at least a louder contingent of that than I thought. But no, insurance is not the same as healthcare. You can insure everybody; if they can’t get healthcare, it’s not universal healthcare. And of course, there’s people who would say we have universal healthcare because if you walk into an emergency room, you’ll get taken care of even if you don’t have health insurance. But you all know, I know, that’s not true. You miss out on a lot, you still get stuck with medical debt. So we don’t have universal healthcare in any way, shape, or form right now.
It’s a hard question. And I think in some ways saying you believe in universal healthcare, that’s a really important threshold to cross, but then figuring out how to get there is a whole other story. And something I struggle with because it’s actually, I look at countries like Japan or pick your country, and a lot of them have systems that I think if you could just plot that system on the United States and give it to Americans, Americans would be pretty happy with it, much happier than they are today. And I think that’s true of the Japanese system, I think it’s true the French system or the German system, but you can’t do that because we’ve got this mess of a system now and the transition problem is huge and that’s its own challenge and it complicates things like Bernie Sanders saying, “Medicare for all would be great.”
I actually think most Americans would probably like a Medicare for All system, and you can make a really strong case that it would be more efficient and better outcomes and more convenient too, but how do you get there? Well, that’s tough because that would require reorganizing basically a fifth of our economy.
Harlan Krumholz: One other quick thing that you said in this was about that quote, “Americans are often told universal health systems mean long waits and denied care.” And you saw the opposite in Japan. I just wonder if you want to take a minute just to expand on that thought too, about people’s concern about, “Well, we don’t want to do this system because it’ll take three years to get my hip,” and all those kind of things.
Jonathan Cohn: Yeah, no, it’s the biggest myth out there is that when you go to universal healthcare system, you’re going to have to wait longer for your care. And usually when people say that, it’s because they know about two countries where you do frequently wait for specialty care, which is Canada and United Kingdom, England, et cetera, but that’s not true of all universal coverage systems. And there are many where you can get care very quickly. The Japanese actually pride themselves on that, that the access is quick. Now, that doesn’t mean you always can get care right away. If you want to see the best X surgeon in Tokyo, you might have to get on a list because everybody wants to see the best X surgeon in Tokyo. But you can get care, including specialty procedures, including tests, pretty quickly.
And the second part of that is to remind people that if you’re here in the United States, you are not getting care quickly a lot of the time. That’s certainly true if you don’t have health insurance or whatever, but it’s also true even if you have good health insurance. I mean, I live in Ann Arbor, I—
Howard Forman: We talk about it all the time.
Jonathan Cohn: Yeah. I mean, you’re there at Yale.
Howard Forman: We’re doctors at Yale, and we have trouble.
Jonathan Cohn: Yeah. I mean, and look, this is the top of the food chain, right? Yale, Michigan Medicine, this is the best of the best in the United States and you’ll wait weeks, months to get specialty care or find a primary care doctor.
Harlan Krumholz: Somebody told me yesterday, they were making an appointment in Yale Endocrinology, Howie, in the bone clinic. June, July.
Howard Forman: Oh, it doesn’t surprise me at all. No, I mean, always—
Harlan Krumholz: We talk about rationing and wait times.
Howard Forman: No, no. Harlan and I have both had individual personal experiences. These are our colleagues, and they’re doing favors for us, and we’re waiting four months, five months. So it’s very hard. Before we wrap up, I just want to make sure we get a little bit more in on the Make America Healthy Again movement because number one; I just want to say briefly, your column The Breakdown for The Bulwark, it’s fantastic. It’s meticulously referenced, and it is such a great deep dive. And I really do think the piece about the fraud in Minnesota is a great example of your work because it shows that balance and it shows the truth coming through.
The MAHA movement is so frustrating to me because the vaccine stuff has been crazy. It is not illuminating. It is mostly demoralizing and destructive, but a lot of the food issues that they’re highlighting and raising are big issues, issues that Harlan and I have talked about for a while. And so your last piece, which I thought had the funny line about the beef tallow is really great because you talk about the fact that Michelle Obama 13 years ago was moving in the same direction, and at that time was being vilified for proposing that government should be a little more involved in our healthy eating. Can you just say a few words about that and what the crux of that piece gets to?
Jonathan Cohn: Yeah. Yeah. So I mean, it’s kind of wild. People remember when Michelle Obama became the sort of spokesperson, public face of efforts by the Obama administration to promote healthy eating and was attacked viciously. “Nannies,” I mean, on Fox News, I mean, people were all over. Now we come along and Robert F. Kennedy is saying we need to eat healthier. And it now is policy of the Trump administration, which by the way, when they got into office last time, tried to undo a lot of the Michelle Obama rules and regulations around school lunches.
Harlan Krumholz: Healthier eating. Yeah.
Jonathan Cohn: Yeah. Now, it’s a bit of a mixed bag and I’m not a nutrition specialist, so I’m really leaning heavily here on the people who I talked to about this. In general, when you look at the guidelines, they’ve now updated the dietary guidelines, the official U.S. dietary guidelines, and they’ve changed some of the policies around school lunches, the thrust of it is still whole grains, nuts, try to avoid too much saturated fat, which is all good. And in fact, we were talking before about things that this administration is really pushing for maybe more than last week. If they can really push through on the processed foods, that would be great. That’s a tough one because food lobbies are very powerful. I think people who were part of this effort, the Obama administration said they would have wished they had done more and could have done more. So maybe they’ll have some success there.
Not everything in… Kennedy himself has this real… He’s very into, he’s like, “Meat is not bad. Beef tallow is not bad.” They gave him a steak for his birthday instead of a cake. It was a birthday steak. And I think most of the wine—
Howard Forman: I missed that. They brought him a steak?
Jonathan Cohn: They brought him a steak with a candle in it. I mean, he sort of declared, “We’re ending the war on saturated fat.” That was one of the things he said when they brought out these new dietary guidelines. The funny thing was, if you looked at the guidelines, actually the saturated fat recommendation stayed at 10%. But on top of that, you could see there was this sort of, on the one hand, pushing for mostly good dietary advice, but then kind of lacquered over that was this, but we need to do what we do in the Trump administration, which is to own the libs and kind of sort of trash what was done before us. So in addition to sort of hyping this, and there’s a big thing about, “Oh, we’re bringing back whole milk.”
Howard Forman: Whole milk, yes.
Jonathan Cohn: Yeah, with the milk mustaches and all that. They insist on redesigning the food diagram and the food pyramid. And the irony is, we used to have a food pyramid, pointy top. And for years everyone said, “I don’t understand what it says. Are you supposed to do more at the bottom or the top?” It had weird lines on it. So the Obama administration said, “Okay, let’s do something else.” They brought design people together and they came up with the idea of a plate. They said, “Do like a circular plate and divide it.” And then you could actually see, you can get a nice sense of—
Howard Forman: The portions.
Jonathan Cohn: Oh, yeah, this much in the fruit and this much of the dairy. And I mean, if you go look at it, pretty simple, but that’s kind of the point. They junked that and they said, “We’re going to restore the pyramid.” So now we have a pyramid again, which as people said before wasn’t a good idea. Only they’ve sort of turned it around. It’s now a downward pointing and like nuts and whole grains are at the bottom and beef and butter is up there kind of higher up.
And it doesn’t really line up with the guidelines that they issued. It looks more like this is like, I think what Kennedy imagines it should look like, which isn’t great advice. And it’s just like, you look at anything like, couldn’t we just do the guidelines and push the getting rid of processed food and pushing all the good stuff. And just not only A, does this seem like bad advice, but two, why does it have to be so political? I mean, this could be, should be, and once upon a time was something that we didn’t treat like bipartisan politics. I mean, food policy, that should be wholesome.
Howard Forman: What a pleasure to have you on today. And I hadn’t had a chance to talk to you before. And first of all, I’ve enjoyed your pieces and I understand your popularity now with just hearing your voice. I mean, reading your stuff is good. Hearing you directly is even just as good. And we really appreciate you coming on the program and sharing your perspectives.
Harlan Krumholz: Yeah. And just a reminder, listeners, the Substack at The Bulwark is The Breakdown. It comes out about twice a week, sometimes more, I think. And we really appreciate everything you’ve done. You’re going to come to Yale again this September for, I think your second time as a Poynter Fellow in Journalism. So we appreciate you doing that as well, but thank you.
Jonathan Cohn: Well, I’m really excited. Thank you for that invitation. I’m excited. Thanks for having me on the show. It’s an honor. And this was a great conversation, and I’ll be tuning in again.
Howard Forman: Wow. Yeah.
Harlan Krumholz: Hey, Howie, that was great. As advertised, Jonathan was amazing. That was just a super interview. Super. Now I want to get to the part of the podcast that’s another favorite of mine, which is hearing what you’re thinking this week. What’s on your mind?
Howard Forman: Thanks, Harlan. Last week, the CDC released updated data on opioid overdose deaths, and the news was good for a change. We have witnessed a decline from an annualized rate of 111,000 deaths at peak in 2023 to 73,000 annualized deaths as of this past August, which is the most recent data released. That decline of 34% over two years is incredibly compelling. It’s also surprising. And to put it in perspective for our listeners, that level of deaths would be the second most common cause of cancer deaths, if it were a cancer. And it is three times the number of current annual deaths from COVID.
So this is a big number. We should care about all these people, and they’re by and large younger people who are dying of opioid overdoses. Why did they decline so much after the seemingly inexorable rise? Well, many gave credit to Trump’s border efforts, which was clearly not the major component, considering that he’s only been president since last January. Others said it must be Biden’s border enforcement changes that did it, but those only began in the middle of 2024, well after the decline had begun and accelerated. Others wanted to say that it was due to better access to Naloxone or other interventions. And by the way, today’s guest mentioned just that with regard to this topic, but that would not explain the timing nor the variation by states that we’ve observed. So it may be a small component, but not a big one.
So our friend and colleague, Professor Harold Pollack of the University of Chicago, along with colleagues from across the country, published a piece in Science this month suggesting a different explanation. They analyzed several streams of data and made important observations. Purity of available fentanyl turned down around the same time that the overdose deaths also turned down, which is a logical connection and long proved to hold across other opioids, apparently.
They also discovered that drug seizures went down at around the same time. There’s no reason to suspect that efforts that contain illegal movement of drugs went down. Suggesting this has more to do with supply than anything else. This also aligns with the lower purity of fentanyl since drug dealers will dilute their product when they’re faced with shortages, but they didn’t stop there. They then went on Reddit, the social media platform, and they went on Reddit forums dedicated to fentanyl—who knew?—to gain insights. And what they found is that there was this accelerated mention of so-called fentanyl droughts that aligned with the other findings they already made, meaning that people were having difficulty accessing fentanyl. These are drug users. And their analysis even goes further than that, but I think I’ve covered as much as at least I can understand easily. They ultimately hypothesize that precursor chemicals imported from China were disrupted around this time in 2023, leading to the shortages that resulted in the findings that I’ve described.
Nobody’s quite clear why or how the supply chain disruption happened, but it does appear plausible, if not likely. So why should our listeners care about this explanation if it leads to good news? Because the good news might end just as suddenly as it began. Drug traffickers can and will figure out ways to get around the supply disruption, but it also suggests that diplomatic efforts to curtail supply might in fact bear fruit. Both things can be true at once. We should be very wary about this success and not rest on our laurels, and we should try to further elucidate how this happened so that we can sustain or improve on the outcomes we’re actually seeing.
Harlan Krumholz: Well, that’s a terrific report, Howie. And actually, I do think it’s important. First of all, I want to say, I want to flag, this is a health issue. This a health podcast and you’re talking about fentanyl supply chains, but why shouldn’t that be just as important as anything else? It’s an exposure, it’s a risk. It’s trying to understand what it is that’s causing health problems. And I’m really so glad that you’re highlighting that and not considering that something sort of extraneous to a health and healthcare podcast. It is important. And it’s also important as we think about targets of intervention. Just like everything else, we’re trying to prove what works.
Howard Forman: What works.
Harlan Krumholz: Yeah. So thanks. That was a terrific report. 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 social media, particularly our Instagram account.
Harlan Krumholz: Yeah, we love your feedback. We respond, we listen, we try to improve, and it’s only through your comments that we can really understand how we’re doing.
Howard Forman: Health & Veritas is produced with the Yale School of Management, the Yale School of Public Health. To learn more about Yale SOM’s MBA for Executives program, visit som.yale.edu/emba, and to learn about the School of Public Health’s Executive Master of Public Health program, visit sph.yale.edu/emph.
Harlan Krumholz: And we’ve got a whole team here. That’s what makes us great.
Howard Forman: We do.
Harlan Krumholz: And I want to just salute our superstar undergraduates Tobias Liu and Gloria Beck. Gloria’s with us today. She gave us a background for Jonathan. She does a terrific job every week. We’re so happy to have her on. Just as Tobias, we have a super producer, Miranda Shafer.
Howard Forman: And is graduating.
Harlan Krumholz: I get to work with the best in the business, Howie Forman.
Howard Forman: Thanks very much, Harlan. It’s been a great episode.
Harlan Krumholz: Talk to you soon, Howie.
Howard Forman: Thanks, Harlan. Talk to you soon.
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