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. Ordinarily, we have a guest, but at least once a month we like to do a deeper dive on health and healthcare. There’s a lot going on in the world right now, Harlan. So what do you have for us to start us off?
Harlan Krumholz: Well, hey, Howie. It’s good to see you. Usually we’re in the studio together. This time we’re on video. I miss seeing you in person, but this will be fun. A couple topics, a couple about the research infrastructure going on that I thought might be good to hit on. I’m kind of interested in your idea. So the NIH just floated a provocative idea. What if they put a limit on the number of grants that any one scientist could lead at a time? The argument said science might actually work better if funding were spread among more investigators rather than concentrated among a relatively small number of highly successful researchers. And so I thought this raised a really interesting question. There are a small number of investigators who are holding two, three, four, even more grants that they’re leading. And it’s this balance between thinking, should we be investing in those who are successful? If people are doing that and they’re producing great science, it’s this idea of a superstar scientist. Should that person be getting those kinds of resources, or should we be saying, “Gosh, I don’t care how good you are. This is team science. It should be spread. We shouldn’t allow it to be concentrated.”? And when we really look at someone holding a large number of grants, the question arises, can you truly invest your intellectual energy in that much research? In the sense of different types of research, different types of projects, or maybe they’re all tied together and there’s synergy there. But I don’t know, I was just wondering what you thought about this because it gets to this issue of teamwork and superstardom.
Howard Forman: So look, I think for our listeners and even for me, because I’ve never been funded by an NIH grant or if I have, it’s been as a marginal, tiny percent of my salary. But my understanding is that the people that have multiple grants are typically 25% funded as a PI on two or three grants and they may be funded a few percent more on somebody else’s grants as well. And that adds up to the 80% or 95% that they’re supposed to be funded as a principal investigator or PI. So what I’m asking you is, are they suggesting that a researcher gets to be a PI on one for let’s say 20%, but then a co-investigator or another investigator for the other 70%? Or are they suggesting that people have to figure out other ways of funding their career?
Harlan Krumholz: Yeah. Well, this is out for comment. You’re right. It’s this business model piece that I think has always been a little fragile. So for example, there are these grants available early in your career where you can get up to 80% funded on a single grant. It’s a grant meant to develop you. You have a mentor, your development plan is as important as the project itself. But then when you go off that, it’s like falling off a cliff. How you cover 80% of your salary with grants is quite challenging. Our usual approach is not to put 80% of ourselves on the grant. The convention is to put 20%, 15%, 20% if you’re the lead on this grant. And so then people have pressure to get multiple grants. Now, this is about leading and you can be a co-investigator on some, but people aspire to be leaders.
And I think it also raises another interesting point, which is in research, should we be funding projects or people? The Hughes, of course, investigators, that amount of money that came from Howard Hughes that is distributed among investigators is about finding an individual and funding that individual for a period of time so that they can explore different directions. The NIH model is individual projects.
Howard Forman: And for our listeners, because I know it’s good for them to think about this, Akiko Iwasaki is a good example of a Howard Hughes–funded researcher, right?
Harlan Krumholz: That’s right. That’s right. Yep. And so these are the stars. They present a portfolio, they present ideas about every, I think every five years or so, they’ve got to go back up in front of the committee to continue to be renewed. And not everyone is renewed, but I think a large percentage of them are. But it’s an investment in individuals. So these are the things I think that… And by the way, I’m not usually… And I’m going to connect this to something else going on, but we’re usually wondering what the direction of this and what does it mean for science. I think this is a legitimate debate about what’s the right number? Should there be a limitation?
Howard Forman: I agree. I could see both sides of it. I don’t personally know an answer because it’s just not something I think about a lot, but I can imagine there are people who have strong opinions.
Harlan Krumholz: And the reason it’s important and why listeners who even aren’t in research I think should pay attention is we depend on our research engine in this country. And in the biomedical sciences, NIH and the federal government’s an important funder of that research. And the question is how do we optimize that? A guy by the name of Stuart Buck has been spending a lot of time writing about whether we should be innovating in our research approach. Stuart visited Yale a couple of months ago, was talking to him.
He’s very creatively thinking, what is it that makes the difference? And should we be experimenting? We’re scientists after all, so should we be experimenting? I’ve always had the idea, by the way, that we should change fundamentally the way that we do applications to these grants. We write these long grants and I’ve thought, just write the paper that you think you’re going to produce if you’re funded.
Show me what the product is going to look like. What do you think you’re going to come up with? And then let me determine whether or not the amount of money you’re asking for would be worth it. That would be all speculation, but you’re saying best-case scenario, where’s this going to land if it’s successful? I think we should be looking at different approaches. I do like the Hughes idea of funding individuals in the sense of letting people have a certain amount of freedom. The problem with the NIH model is, I come up with an idea, I’m not going to get that money for nine months, maybe 18 months if I have to go through two rounds. The way science is moving, it becomes stale. We’ve got to come up with a better idea of how to fund people so that there’s not that kind of delay and tying me to a project when the world may have changed and actually I should be looking a couple degrees to the left or right.
It’s not ideal. So that’s one thing. Let me just hook on to this other issue that came up around research, because I think it’s interesting. So OMB, the Office of Management and Budget, which has wide-ranging power within the federal government and they’re really overseeing the departments and agencies with regard to how money flows. They’ve made a proposal that scientific peer review in the federal grant-making process would remain advisory, but senior political appointees are the ones required to review grants before award decisions are finalized. And that grant decisions should advance presidential priorities and that peer review should not replace agency discretion. And this proposal, it’s out for comment, but it’s fully… now there’s always been politics in our science. Let’s just be honest. No matter the administration, there has been areas that people have favored and areas that people have not favored.
And there have been ways in which politics have influenced what’s been funded to some extent, but this is making it highly overt and saying that political appointees should be reviewing these to see whether they’re aligned with presidential priorities. And Howie, this is really a big deal. Lots of people are taking notice. I wonder if you’ve heard about this or if you have any thoughts about it.
Howard Forman: So it aligns with Article II statutory authority. It aligns with the constitutional authority that we vest in the executive branch. I don’t know what Congress has said previously about how grant-giving authorization of funds should be occurring. I think we’ve gotten used to a norm where scientists and advisory panels are taking that authority. But unlike the ACIP or the CDC and the FDA—
Harlan Krumholz: ACIP, you want to just…
Howard Forman: Yeah, the immunization practice committee from the CDC, which actually has legislative and statutory authority for making decisions and therefore even though it’s appointed by—
Harlan Krumholz: Those are policy, not federal grant-making, right?
Howard Forman: Correct. But the point is, where is the executive branch authority in each of these situations? And so what may be constitutionally appropriate may not be good policy. It may not be propriety, but it may be constitutionally. It’ll be very interesting because again, I don’t know the law around this at all. I only know executive [Article] II authority has been expanding over the last decade and absolutely more with President Trump where numerous times the Supreme Court has deferred to Article II. And it remains to be seen whether this aligns with that or if it’s not and it’s contestable.
Harlan Krumholz: Yeah. And I think the point for many people, including me, is, this may be legal, but to what extent can we insulate science from politics? Now I want to say it, let’s be honest, it never has been completely independent of politics, but that should be our aspiration is to see what the science—
Howard Forman: Yeah, absolutely. I’m just saying I can imagine from a legal point of view that this is actually okay. From a policy point of view, from a science point of view, it’s not okay. It really is absolutely not okay. I don’t even see the other side to it, but I do see the legal issue around it.
Harlan Krumholz: Yeah. And you can imagine, if you’re an administration that has certain views on vaccines and autism or climate change, you may be weighing in to say that further research in this area that is counter to that is not in the president’s agenda. And then all of a sudden you’re stifling certain kinds of inquiry. Again, I want to admit, it never has been completely clean of politics, but this is a concern. It’s a concern about how this would play out, I think. And we’ve seen examples of this. Of course, Russia in Stalinist times fabricated research in a way that supported state interests. And anyway, this is a thing that I think that is going to continue to be debated and may rise to higher levels of discussion. Anyway, okay, let’s go onto your topic.
Howard Forman: I got one really quick one I’m going to do now and then I have a few others that I want to cover, but I want to get this in because I think it aligns a little bit with the idea of where the authority is and the Supreme Court and so on. So we’ve been keeping an eye on the Supreme Court for the five years we’ve been doing this podcast and we’re now in June, which is when all the big Supreme Court rulings come out. And every year we’ve been doing the podcast, there’s been several major healthcare rulings that have come out. This year it’s pretty damn quiet. If you set aside the shadow docket emergency orders, there have only been a handful of cases with direct health implications, nothing on the scale of Braidwood or other cases we’ve heard last year or the year before. What’s striking is how uncontroversial the actually decided cases have been, the conversion therapy ruling, the healthcare immunity case, unanimous or near unanimous across a deeply divided court.
So that tells you something, to begin with. The one ruling worth watching or having been decided basically is Hikma v. Amarin, which was a 9–0 decision, so a unanimous decision, and it upheld something called “skinny labeling.” That’s the pathway that lets generic drug makers bring cheaper versions to market for unpatented uses of a drug even when there are still patented uses that are protected. A ruling the other way, if they would have ruled against skinny labeling, could have chilled generic competition and raised drug costs broadly. And look, there are people out there that would have liked that. But for now this pathway survives, and we have generic competition in these narrow areas with so-called skinny labeling.
Harlan Krumholz: I could see that this is another thing I thought was interesting going on these days. We just had the American Diabetes Association meeting. And of course there’s lots of new stuff coming out about these new anti-obesity drugs. But again, I’m still fixed on access issues. And there is this really interesting patent expiration that’s going on for Ozempic in many countries. Canada just went, you know, the patent came off there, it’s going to be generic. Brazil, China, India, not the United States. But I think what’s interesting is that that patent protection is for the use in diabetes.
Howard Forman: But, not obesity.
Harlan Krumholz: But because Ozempic is the same drug that’s being used for anti-obesity treatment.
Howard Forman: That’s exactly the issue.
Harlan Krumholz: Is that what it is?
Howard Forman: It is.
Harlan Krumholz: Is this diabetes drug repurposed by the physicians to—
Howard Forman: Right, exactly. That’s basically what the issue is. And I’m sure that’s the reason why people are worried about it.
Harlan Krumholz: Yeah. Or who’s worried?
Howard Forman: The manufacturers.
Harlan Krumholz: Yeah, exactly.
Howard Forman: Yeah, yeah, yeah.
Harlan Krumholz: The patients may be celebrating because…
Howard Forman: No, exactly.
Harlan Krumholz: By the way, it is a huge deal. These drugs, which you may have thought were going to be beyond reach because they’re so new still and transformative around obesity, in many countries are going to be extraordinarily inexpensive.
Howard Forman: $5. Yeah, maybe less.
Harlan Krumholz: Yeah. But imagine side-by-side Canada, United States, in Canada these will… first of all, they have, of course, universal healthcare, but I’m just saying it’s not going to break the bank and the healthcare system for them to be prescribing these medications. In this country, it’s going to continue to be a drag. And employers continue to cut benefits for these meds because of their costs. And then next door, our next-door neighbor is going to be able to prescribe them for anyone who needs them without worrying about that.
Howard Forman: It will come here too, though. We’re just a few years away from having both brand competition at scale and then generics being introduced.
Harlan Krumholz: I don’t know about $5.
Howard Forman: Well, but once it goes generic, we’ll get to that.
Harlan Krumholz: Yeah. And that’s going to be really interesting. Are we going to start treating obesity like we do hypertension?
Howard Forman: Yeah. What do you got next?
Harlan Krumholz: Well, there’s another interesting thing I wanted to talk about that again, in your area, a policy thing that you may have paid some attention to, but you may not have because it’s coming out CMS and it really affects cardiologists to a big extent. So let me just back up here. So for a long time, we’ve talked about value-based care. This is the idea that rather than focusing on this fee-for-service system, where we’re going to pay everyone for every single thing they do and seeing that as an accelerant to more healthcare utilization, higher costs, putting the healthcare system—that’s just not doctors; doctors, health systems, everyone—in a position where they’re looking for how to do more things rather than fewer things. The value-based care is the idea that you’re responsible for individuals and the total cost. And so if you spend more money and don’t get any return, that’s going to be a problem.
And they’re being used as a way to incentivize doctors and health systems as a source to think in very responsible ways about the care of patients. And the notion is that this will help constrain some of the costs. In general, these have focused on hospitals or primary care or region, larger groupings of responsibility. But now Medicare is asking a different question. What if cardiologists themselves—an individual cardiologist—were accountable for the outcomes and costs for caring for patients with heart failure? So this is really interesting because the patient, you got to think about it holistically. The outcome depends on more than the cardiologist. You can have the world’s best cardiologist, but patients see primary care physicians, nephrologists, emergency departments, hospitals, home health. It’s a team effort. Not only that, the outcome is not just tied to the medical parts of this.
The social determinants are important. What other headwinds do people hit that make it hard for them to optimize their outcomes? And so how accountable can you hold one person for what really is a team sport? And is this going to work? And like I said, traditionally, specialists have largely paid for activity, and now they’re saying, “We don’t just care what you do. We care what happens to the patient.” That’s probably a good thing, that shift towards what are we achieving for the individuals. But this is going to be complicated because if you’re going to tie this to an individual and you’re asking questions about how does the patient feel and are they on the right medications? Are you improving their care? That’s going to make it a lot more complicated. I don’t know if you’ve thought about this or you have thoughts about it.
Howard Forman: You’ve taught me a lot about this with regards to the hospital readmission reduction program about how social determinants impact that. But in this case, the problem of adverse selection, or cherry-picking the opposite of that, is what would worry me the most. How confident are you that CMS can risk-adjust enough to prevent heart failure doctors from picking the patients where they know they can have the biggest impact and ignoring those where they fear they won’t have a big impact because those patients may be underresourced or may have other complicating factors? How confident are you that can be corrected for?
Harlan Krumholz: Well, I don’t know exactly how you select for those patients, but it could be a labeling issue where you start labeling people with heart failure who are borderline. It gets to the question of denominators. How many patients do you actually see? When you’re dealing with a hospital or a health system or region, you’ve got large numbers and these tend to settle out a little bit, even though there can be case mix differences.
There can be differences in the type of patients that different groups see. But when you’re talking about individual physicians, then you’re really getting down to smaller numbers. And just like you said, it could be that there are issues of selection. These measurement issues are very important. The general overall turn towards saying that we doctors should be responsible for more than, you know, how much do we do, but actually what happens as a result of what we do, is a good one.
The instinct is good. But the devil’s in the details about how you do this in a way that doesn’t create perverse incentives or actually finds ways for people to try to game these measures so that they can look good but not necessarily produce the best results for individual patients. And if a patient decides not to take medicines, for example, just like, and we’ve talked about, patient decides not to take vaccines…. There’s a whole bunch of things patients don’t do necessarily just because doctor recommends it. And it’s within their rights to decide for themselves what they want to do. So am I going to be held accountable for a patient who decides they don’t want to follow—
Howard Forman: But that’s my point.
Harlan Krumholz: … medical practice?
Howard Forman: Yeah, but that’s my point. Wouldn’t I want to start picking patients who are well educated, otherwise very proactive about their health over patients who are less educated and may push back against things I want to do or just ignore things I want to do for one reason or another? I could imagine cherry-picking here.
Harlan Krumholz: Yeah. And I think it gets to this idea that in this data-driven age, this area where all the data are digital and we’ve got AI and a lot of other tools, how do we begin to develop more holistic assessments of what represents high-quality care, which incorporates the preferences, values, and goals of the patient? It doesn’t just reflexively say you should be prescribing this medication, they should be taking that medication and understands root causes of failure. Where do they reside and why do they reside? Someone decides not to get vaccinated and they have a bad outcome, who owns that outcome if you’re in a system where you’re going to start measuring outcomes and how do you take it into account? I do not want to get into a position where doctors are strong-arming patients just so that their metrics look good.
It really needs to be about, how do we meet patients where they are and help them to get the kind of care that they want? So anyway, I think this is an interesting thing is unfolding. Again, I like the instinct of trying to think about outcomes. Of course, I’m an outcomes guy. But it’s all going to be a question of how it’s done, how it’s done.
Howard Forman: We’ll follow on it. Yep.
Harlan Krumholz: What’s next for you?
Howard Forman: So you may have seen the headlines this week about something called the New World screwworm turning up in Texas cattle for the first time in 60 years.
Harlan Krumholz: Howie, this is a family show. I don’t know.
Howard Forman: I know. The name alone is enough to make you shudder. And honestly, the biology justifies it. This is a parasitic fly whose larvae literally burrow, corkscrew-style, into the living flesh of warm-blooded animals, feeding as they go deeper. Left untreated, an infestation can kill a full-grown cow in days. Right now, there are a small number of confirmed cases in south Texas. But if you look at the geographic trajectory, that number is almost certainly going to grow. The screwworm has been moving steadily northward through Central America and deep into Mexico since 2023. Its arrival in Texas wasn’t a surprise to anyone watching the data. It was just a matter of when, not if.
Now, this matters. Let me be clear about what this is and what it isn’t. This is overwhelmingly a veterinary and agricultural crisis, not a public health one. Human infections are genuinely rare, documented in only a handful of travel-associated cases. And critically, unlike virtually every other pathogen we discuss on this show, there is zero risk of human-to-human transmission, even in the rare person who does get infected.
This is not COVID. It does not spread person-to-person. Full stop. The threat is to cattle, wildlife, and farms, and that threat is enormous. A full outbreak, by the USDA’s own estimates, would cost over $10 billion in economic losses nationally. So how do we stop it? Here’s the good news. We’ve actually done this before and we won. In the 1950s and ’60s, American scientists developed the sterile insect technique. They mass-produce male screwworm flies, sterilize them with gamma radiation, and release them by the millions because female screwworms mate only once in their lives, one encounter with a sterile male means no viable offspring. Ever. It worked. The screwworm was eradicated from the U.S. by 1966. And we repeated the trick in the Florida Keys as recently as 2017. The USDA is already releasing four million sterile flies per week in the affected Texas region with plans to scale that to 300 million per week from a new facility in Edinburg [Texas]. This is a known enemy with a proven weapon and a track record of success. If the response stays coordinated and funded, I’d put my money on the humans.
Harlan Krumholz: This is interesting. Has this been tried in other diseases like malaria and others, Howie? It’s an interesting approach.
Howard Forman: I don’t remember. I meant to look this up. It has been tried for some other diseases. I don’t remember which ones they’ve been tried. And it really has to do with the fact that, in this case, these parasitic flies mate once. So you have that going for you. It’s not a matter of randomness. And if they meet a sterile fly but then meet another fly that’s not sterile, they could still get infected. It doesn’t happen, because they only mate once.
Harlan Krumholz: And what the heck’s going on with infectious disease, Howie? It seems like every week there’s antivirus, there’s Ebola. Now you’re talking about screwworm. Do you think that we’re in a different time now where these things are occurring more commonly? Or it’s just that with social media and news and so forth, we’re more aware of this stuff than we’ve ever been before?
Howard Forman: I think it’s mostly awareness. The Ebola thing happens every few years. It’s an issue that has come up. This particular Ebola outbreak has other issues, as we’ve discussed.
Harlan Krumholz: Yeah, this is a big one. This is a big one.
Howard Forman: The Hantavirus was a very random thing that happened on a cruise ship. If not for the cruise ship, we wouldn’t have seen it. Maybe we should start to reduce our ecotourism. Maybe that’s the lesson we should learn there. And I think in this case, this is something that would ordinarily be happening, and it just arrived in Texas at this moment in time. I do think we’ll eradicate this pretty quickly. I know there are people that want to politicize this and say that it’s due to the current administration’s reduced funding, that this got as far as it got, and that may be true.
But it’s also possible that this would have happened under any circumstances. But there’s no question that we have reduced resources in this case. The other two cases, there’s a lot more questions abounding. But in this case, the reduced resources probably did have an impact in letting it get this far. We should have stopped it in Mexico.
Harlan Krumholz: It’s astounding how quickly it can kill a cow.
Howard Forman: I know. And it’s disgusting to think about how this actually happens. The one thing I didn’t say clearly is most maggots infect dead flesh. That’s what larvae are, maggots. They infect dead flesh. A dead cow gets infested by maggots. For whatever reason, this particular parasitic fly only infects living flesh. Infected and open flesh, a wound, a mucus membrane, but it has to be alive. And that’s what makes this particularly unusual.
Harlan Krumholz: Yeah. Wow. Hey, thanks for bringing that one forward.
Howard Forman: Sure.
Harlan Krumholz: Hey, I want to get back to the ADA because there was something really interesting about this ADA meeting, this American Diabetes Association meeting. It was in New Orleans. Big meeting. They’re ground zero for talking about the anti-obesity drug. So recent years, these have been blockbuster meetings, lots of excitement. This year they invited NIH director Jay Bhattacharya to give a talk. And well, actually due to scheduling issues, he had to send somebody else, but it became a really big story and a controversy about academic freedom and the role of scientific societies. And let me tell you what happened. So many researchers objected to the invitation to the NIH director because they view the NIH and HHS policies as damaging to biomedical research. And so okay, that’s fine. There was differences of opinion, but what happened next caught everyone’s attention.
Several highly respected diabetes researchers, now these aren’t fringe people, these are mainstream leaders. Former president of the ADA. The editor-in-chief of the main journal of the ADA, Diabetes Care. These people had gotten together and had written an editorial and I think, led by Steven Khan, who’s the editor-in-chief of Diabetes Care. And so the editorial argued—they published it in the journal—the editorial argued that recent federal actions are harming U.S. biomedical research. Like I said, there are people who have this idea, want to be able to talk about it, raise the questions.
And it pointed to concerns about NIH staffing reductions, delays, and so forth. Changes in advisory structure, things like I’m talking about with OMB that people have concerns about the politicization of science in this country. All this is fair game. So what happened was, at the meeting, they printed up a bunch of these editorials and outside the hall where the NIH official was going to give the talk, they were handing out the editorial.
They’re handing out an editorial that was published in the flagship journal of the ADA. Now, this is what happened next, was the ADA got the security people to bring them together and kick them out of the meeting. They said, “You can’t hand out these editorials. You’re causing trouble.” By the way, there are a lot of videos of them. These are people that don’t look like they’re rabble-rousers. I’ll just tell you that. They’re more like hippies.
Howard Forman: You’re saying they’re our age. Yes.
Harlan Krumholz: Okay. They’re our age and they look pretty benign, but they’re handing out these editorials. Next thing you know, they’re on the street outside of the convention center and they’re told you can’t come back in and you can’t present to the meeting. And so it caused a lot of consternation about what was the ADA doing? There’s a lot of people saying, members saying, “I’m going to withdraw from the ADA. I’m not going to be part of this.”
Maybe some of them are sympathetic to the message. Others are just saying, “What in the heck were they doing? They were just handing out material from the flagship journal. They weren’t handing out something from somewhere else.” So this is raising questions about, what are scientific societies for? I’ll just say quickly here at the end, ADA’s saying, “We are completely nonpartisan.” Remember, we’ve heard this discussion in universities. Should you be taking sides? Are there pros and cons?
But is it really taking a side when you are telling people they can’t hand out editorials? Where does that fit in this spectrum? So I don’t know if you’ve heard about this or do you have any thoughts about this?
Howard Forman: So a couple of thoughts. One is that apparently they were told in advance not to do this, which is the right of a conference organizer. If you go to the conference organizer and say, “I want to give out these letters,” and they say to you, “We are not going to allow that. We see that as politicizing,” or whatever they wanted to say, it is within their right for the ADA to do that. The issue then becomes why did the ADA take that position? And it is likely, I think, that the ADA takes that position because there is a high-level government official supposedly coming and they do not want to offend the sitting administration because they fear, what we talked about earlier, Article II authority, and the fact that the government could cut off funding to the ADA itself or some of its individuals that are receiving funding from the federal government.
There are all sorts of things they could fear, which gets to, I think, the bigger issue, which is that while this is not a violation of First Amendment right to free speech, since that only applies to the government suppressing speech directly, this is an example where the fear that has been instilled on institutions by our current government for individuals that have spoken out and we see this across the spectrum, whether it’s journalism, whether it’s journal editors as you’ve seen, or whether it’s institutions as you already mentioned, if you create enough fear in them to not offend, they will suppress their own speech.
And that is what I think the ADA did is I think the ADA suppressed speech that it otherwise probably would have encouraged for fear of offending the current administration. And I do find this very, very troubling because it’s not a clear-cut case that you can go to the courts on. It’s clearly defensible on the part of the ADA. The only pushback is, as you say, people voting with their membership, people voting with their feet, and hopefully the ADA learning a lesson from this.
Harlan Krumholz: Yeah. It was interesting because you and I have talked about this. Somebody gets invited to Yale with views that are unpopular to some people. We’ve said you shouldn’t be outside chanting, shouting them down, preventing them from presenting their views. That we should be able to be a place where people can express their views, even if we strongly disagree with them. In this case, these people were, as people were entering the auditorium, handing out an editorial.
Howard Forman: A hundred percent right.
Harlan Krumholz: Weren’t chanting, weren’t saying that the government official shouldn’t speak.
Howard Forman: It’s the right way to go.
Harlan Krumholz: This is where to me they made it a bigger story than it had to be. They made it worse, the ADA.
Howard Forman: A hundred percent.
Harlan Krumholz: If they wanted to quiet the controversy, all they did was inflame it. And I think what’s also interesting is, and yet the flagship journal was allowed to carry this editorial. But also interestingly, twice in the editorial, it’s redundant, they have the exact same sentence. “This is not the view of the ADA.” If you look at this editorial, it says it in two places. It’s only 1000 words.
Howard Forman: Because the editor is involved, so I can understand that. If you were writing an opinion piece for JACC—
Harlan Krumholz: Yeah, but it says it twice.
Howard Forman: I know. I’m with you. Look, I think we’re 100% aligned on this. My only point is I’ve seen people say this is First Amendment. It’s not First Amendment. But it is a way in which the pernicious effects of an administration that is actively pressing down on speech it doesn’t like can perpetuate itself in a private setting.
Harlan Krumholz: Yeah. And it may have been that Jay Bhattacharya actually got some wind of this and that’s why he ended up not coming out. In a perfect world, you would have allowed these people to be on stage with the NIH director and have a discussion. A respectful discussion, but a discussion where people disagreed and raised issues.
Howard Forman: Totally.
Harlan Krumholz: I guess we’re just not there. All right. Hey, take us home. What else have you got?
Howard Forman: I’ll give you one last quick thing, which I think is on the category of good news. A federal judge handed down an important ruling this week that most Americans might have even missed. But if you depend on a doctor and especially if you live in a rural or underserved community, you should be paying attention. Back in September 2025, President Trump issued a proclamation imposing a $100,000 fee on new H-1B visa applications.
It’s the primary visa pathway that allows foreign-born, highly skilled workers to practice in the United States. It’s a pathway to citizenship. The stated rationale was protecting American workers from being displaced, but the medical community immediately recognized a serious problem. This wasn’t just about tech workers in Silicon Valley. This was doctors. And this week, U.S. District Judge Leo Sorokin struck down that fee, ruling that it amounted to an unauthorized tax, one that only Congress, not the president, in other words, Article I, not Article II, has the authority to impose.
That’s a significant constitutional finding, and the administration will almost certainly appeal, but here’s why the stakes were so high. According to a JAMA research letter published in October, roughly 11,000 physicians are newly sponsored for H-1B visas every year, out of a million practicing physicians nationwide. That sounds like a small fraction, just under 1%, until you look at where these doctors work. They are nearly twice as likely to practice in rural counties as their urban counterparts and four times more concentrated in the highest-poverty communities than the lowest. These are safety net hospitals, underserved clinics, the places where the physician shortage is already most acute. One year of this policy might not crater the workforce overnight, but H-1B visas run for up to six years and are routinely extended, meaning the physicians practicing under them today represent years of accumulated sponsorships, not just one cycle.
Choke off that pipeline long enough and the accumulative loss becomes very real. We’re already projecting a shortage of up to 86,000 physicians by 2036. A sustained $100,000 barrier to entry would make a bad problem immeasurably worse in exactly the communities that can at least afford it. Today’s ruling bought some time, but with an appeal virtually certain, the uncertainty isn’t over.
Harlan Krumholz: That’s a really good point, Howie. Does this also affect trainees, by the way?
Howard Forman: So most of our trainees come here on J-1s, but some come on H-1Bs as well. So it can affect them, but the J-1s typically move on to H-1Bs. So our trainees that want to stay go on to get an H-1B, that can affect them as well.
Harlan Krumholz: Yeah. And I’ve also heard for some people, this green card issue is also… they’re trying to say people should go back to their countries for two years and apply for the green card. So if there are doctors in the midst of trying to get green cards, this is also an issue, right?
Howard Forman: Yeah, no. The immigration system right now is so uncertain for people that it’s not surprising that in the next cycle or so, we may actually see fewer qualified applicants applying to our country to be able to practice here.
Harlan Krumholz: I think one of the things that will be interesting to watch, I’ve always felt that one of our great strengths is that we attract so many people from around the world who want to come to the United States, who have great talent and there’s no question that this is changing the equation. And we have depended in the healthcare system on these people just precisely for what you’ve said. In the areas that are in most need of physicians, you say that was a small percentage, but to get an extra physician or two in an area that is a great shortage area makes a huge difference.
Howard Forman: Totally agree. That’s what concerns me. And again, they will appeal this ruling. It does seem like a pretty solid ruling. So hopefully at no point will they stay the ruling and at least allow the process to play out.
Harlan Krumholz: Because we’ve never seen this type of court side with the president in areas that are controversial. I don’t know. We’ll have to see. Stay tuned to this. Thanks for bringing it up. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.
Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, email us at health.veritas@yale.edu or follow us on any of social media, including our own Instagram account and our now YouTube videos.
Harlan Krumholz: And give us feedback. Hey, we’re noticing more and more followers every week, so we want to hear from you. Tell us what we can do better.
Howard Forman: We really appreciate it. Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. To learn about Yale SOM’s MBA for Executives program, visit som.yale.edu/emba. And to learn about the Yale School of Public Health’s Executive Master of Public Health program, visit sph.yale.edu/emph.
Harlan Krumholz: And hat tip to our superstar undergrads, Donovan Brown, who’s with us today, Gloria Beck, to our great producer, Miranda Shafer, and Howie, I get to work with the best in the business every week. Thanks to you.
Howard Forman: Thanks very much, Harlan. Talk to you soon.
Harlan Krumholz: Talk to you soon, Howie.
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