Emily Oster on RFK Jr., New Food Pyramid and Why Medicaid Should Cover Ozempic

0:00RFK Jr. promised to make America healthy again. Is it working? A report card on the Maha movement one year in. This country was stone cold dead. Good day from Newsweek headquarters at the top of the World Trade Center here in New York City. This is The 1600, and I am Carlo Versano. Carlo Blood Eye Versano, if you want to use the name that my daughter now refers to me as. Since my pathetic weekend injury in which I sneezed and popped a blood vessel in my eye, I have been told by my colleagues here at Newsweek that I need to come up with a better story for how I got said injury. So, yeah, I guess let's just say I got into a fight and you should see the other guy.

0:38Today I have with me Emily Oster. She is a Brown University economist. She's a bestselling author. She's the founder and CEO of parentdata.org. She's been called the Dr. Spock for millennial parents, which I can personally attest to. She was hugely, hugely helpful. Her newsletter was hugely helpful to my wife and I when we had our baby Francesca. So, Emily, first of all, thank you so much for taking the time. I know you are a busy person. I am very excited to be here. I appreciate that. So let's just jump right into it. We are we're shooting this on what day today? Wednesday. It's a year more or less since Trump was was inaugurated for his second term.

1:18RFK Jr., the Health and Human Services Secretary now for a year. And this Maha movement, which, you know, make America healthy again, is the you know what it stands for. sort of has a weird mouthfeel when you say it. I don't know if I really like it, Maha, but I guess that's what we're going with. Are RFK and the Maha movement fixing America's health, public health, industrial complex, or are they making things worse? That's sort of my overarching question to you. I would say my overarching answer is, on the whole, they're making things worse. There may be some occasional pockets of positivity, which we can talk about.

1:57But I would say on the whole, disaster on the whole bad on the whole, I think really pretty negative. Yes, I would. I think I would agree with that. I think before we get into the specifics, I think it's worth sort of like looking at this coalition because it's very bizarre to me. Right. It's like you have these you know, you have these sort of crunchy hippies, people who are more or less my mom. Right. My my sort of like boomer mom who has been talking about, you know, the dangers of seed oils or certain, you know, fats and ultra processed foods for as long as I've been alive. And then you have them sort of in alignment with sort of like the more, you know, the MAGA moms out there, the, you know, the MAGA movement writ large.

2:43Then you've also got the vaccine skeptics who are aligned with these manosphere figures who, you know, talk about things like raw milk as though it's like this elixir of the gods that's going to keep you alive till you're 100. It's just very strange. Right. Right. But these people are, I believe, at least I don't want to give them too much credit, but I think that they're they're tied together by this belief that I certainly do share, which is that the public health status quo in this country has only made us sicker. Is that is that reductionist to me? Is that fair? No, I think that's very fair.

3:14I mean, I think they're I think they're sort of tied together for me by two things. So one is a belief that the public health infrastructure is not helping with public health. And that if you look at how sick Americans are at what kinds of chronic disease rates we have, that those things have gotten worse over time. And that's clearly true. And that is clearly a problem. The second thing I think that ties them together is a kind of commitment to individual decision-making and a distaste for anything that seems like mandates or requirements in the public health space. And I think that has always been undercurrent in some of the vaccine skepticism and some of these seed oil things.

4:07It got much more extreme during COVID. I think many people were kind of got this, were revolutionized a little bit by some of the experiences they had during COVID and kind of adopted this particular individualist stance. And I think that both of those are coming together. Yeah. Well, I think that's a very good point about COVID because it does feel to me that even though we're, first of all, I mean, you know, in some ways the pandemic feels like it was 100 years ago. in some ways it feels like it was yesterday. But I think it's fair to say that we're still sort of in the aftermath of what happened in those few years.

4:41And it's manifesting itself in all these different ways. But back to RFK. So you've called him, you've written that he is, quote, an unmitigated disaster, which I would agree with. But I do want to drill down on him because he, again, is an interesting character to me, right? He has some views on food and diet, again, that I recognize from from my mom, from from things that I was always told growing up. But then he's also got this crazy wackadoo vaccine stuff, which to me sort of renders whatever good that he could do on food and diet to be almost moot or inert, because, you know, the the vaccine skepticism that he's kind of heralding this this new era of vaccine skepticism.

5:26I know it's always been there, but it's you know, it's obviously much more potent now. It's just much from a public health perspective, that is a much more relevant thing than these sort of things he's tinkering with in, you know, the dietary guidelines, etc. Is that fair? Yeah, I think that's fair. I mean, I think one way to see it is that, you know, there are really two axes on which the Maha movement has worked. One is on food and one is on vaccines. And they've made relatively little progress on food. And also, there isn't that much they can do other than change these dietary guidelines, which no one is listening to anyway.

6:01And we can talk about how they did that. But their actual impact there has been very small. And then they do have a fair amount of impact on vaccines and everything they have done on vaccines is terrible. And I think in some sense, this comes from really RFK's personal beliefs about this. I mean, I think he personally thinks that vaccines are bad, just like he personally thinks that, you know, 5G radiation is dangerous in some way. These are kind of crank conspiracy views. But nevertheless, I think he does genuinely hold these views. Unfortunately, they're not evidence based. So let's talk about the dietary guidelines.

6:39So this happened. They put these out within the last couple of weeks. Basically, they inverted the food pyramid, the one that we all grew up on, you know, the crazy. OK, if I I'm not a conspiracy theorist, Emily, but if there is one conspiracy that I agree with. It's that that the original food pyramid from back in the day was a total scam that was underwritten by, you know, big ag, big food. I mean, they were telling you back in the day to eat something like 11 servings of grains a day. Right. I mean, that was. I think it was. So I have a I also think it was ridiculous. But my view is it was just a very, very poor understanding of causality, which we still actually have a very poor understanding.

7:18But people, they looked out and they saw, you know, the people eating saturated fat are fatter. And so let's just have a lot of bread. Right. OK, well, that's OK. That's a less conspiracy tutorial take on it. And you're probably right about that. So basically, with these new these new dietary guidelines kind of invert the food pyramid, there's a much greater emphasis on, quote, eating real food, which, again, none of this is particularly new. Right. I mean, the food writer Michael Pollan has been saying this forever. Right. I think none of it is new. I mean, I think if you look at the, you know, they keep saying they inverted the food pyramid.

7:50It is true that they took the picture and they turned it upside. That's accurate. But if you look at what is said in the guidelines relative to what is in the last set of guidelines are really very similar. They don't actually line up that well with the pictures and the pyramid. I mean, I think a lot of the discussion has been like, look how large the steak is. It's like, yeah, but look how large the carrots are. I mean, this graphic is bizarre. But if you look at what's said in the in the guidelines, it's not hasn't changed very much at all since the last set of guidelines before this administration.

8:21Well, so one of the things I mean, I think there's more of an emphasis on and look, I think we can we can agree that it's hard to know how much stuff, how much this kind of thing really matters. Like, are people really looking at the USDA guidelines like when they're in the supermarket aisle? No, they're looking for foods they know, foods that are relatively affordable, that are quick to make. But, you know, if you if you believe that there is some sort of like downstream effect from what the federal government tells you, you can and can or should and should not eat. They're basically saying, like, focus on whole foods, introduce allergens earlier.

8:55And again, I think that that's probably I think that's new and probably true. And I but I think this is actually a really important point. So please see when they discuss. So one of the things that's in this dietary guidelines, dietary guidelines are now like 10 pages long. And when they talk about feeding kids, one of the things they say is, you know, parents should introduce allergens early so their kids don't get allergies. That is a strong evidence-based recommendation, which a lot of parents need to hear because it is a key to preventing allergies. That's in the old guidelines, but it's on page 58 of like a 250-page document.

9:30I see, yeah. And so no one saw it. And I think this is the one really, if I had to pick out something that I think is especially good about these guidelines, it is that making them shorter and more readable. I do think there's a lot of value in that in that communication, even though most people are not going to listen to them anyway, because that's this is unfortunately most people are not listening to any of these guidelines. Well, right. And I mean, it's much easier to, you know, getting people and you've written this in your work, but like getting people to change how they eat is that's like that's that's really difficult to do.

10:02Right. Especially at scale. People really like the foods that they grew up with. They like the foods that they like. They like salt. They like sugar. They like fat. This is like these are foods that we enjoy and changing our habits around food is really, really challenging. Right. The other thing about these is I know that this point has been made over and over again. It's kind of like hack to even point out, but it is important. Michelle Obama basically was doing what they're doing here and she was crucified for it. Right. She planted a vegetable garden in the White House and, you know, they almost tried to like impeach her over it.

10:37Totally. No, it is this whole thing has been in light of Michelle Obama's Let's Move campaign. There are definitely some moments where you're like, yeah, yeah. Remember when Michelle Obama tried to do that and you were like, oh, let's not do that. So, yes, Michelle Obama tried to do many of these things before. Right. So there is certainly a fair amount of hypocriticism happening here. Is that even a word? I don't know. Hypocrisy. There's also some some cookies. Hypocrisy. Oh, my God. That's embarrassing. Maybe we have to cut that, Mickey. There's some kooky stuff in here, too. No added sugar until you're 10 is the guideline.

11:16I mean, do these people have children? You're going to tell your five year old they can have cookies. Do these people have? No. So that guideline is both ridiculous because have you have you met children? But also it is a good illustration of how you can write a guideline like this. And it would be impossible, basically, for people to follow. you know i was talking about this with someone and i i thought about bringing on i should have got it on here like the whole foods multi-grain seeded whole wheat bread that i have in my fridge which i think like anyone would look and be like if i saw that in the grocery store i'd be like that's a healthy food to feed my kids it's got seeds and grains and fiber and it says on it organic and it's from whole foods the third ingredient is sugar i didn't have a lot of sugar but it has added sugar because sugar is in everything.

12:02And you could say it would be better if whole wheat bread did not have added sugar. And I don't disagree with that. But the reality is, if that's true of your food system, telling people don't give your kids added sugar until they're 10 is like a ridiculous thing to say. Right. And the other thing is this weird obsession that RFK has with beef tallow. I don't even really know what beef tallow is or where I would find it. What is this all about? I do have one friend who emailed me to tell me that he has beef tallow in his fridge, along with duck fat, because they're good for different kinds of cooking.

12:36But so he is the one person in America who is going to be following these guidelines. Right. But it's not that's just beef tallow is just not something that I mean, I saw that, you know, Whole Foods is planning to stock it. But most Americans aren't shopping at Whole Foods, right? They're shopping at their their local grocery store, Kroger. And this is just not something that exists there. Also, it's actually fair. I don't I don't know that many people it's not like you just use it instead of olive oil like these kind of cooking fats are used in different ratios. People are not going to start using beef tallow.

13:04Right. One of the other things that that this wasn't in the in the dietary guidelines, but one of RFK's sort of like broader points is making this point that, you know, smartphones and, you know, are sort of like screen addictions are a driver of chronic illness. This is one of those things that seems like it's right, but I have no data to support it. You, of course, are a data person. Is there is there a causality here? Between smartphones and and ill health? No, I mean, not that I'm not that I am aware of. I'm sure there are correlations in part because people are on their smartphones instead of exercising or something.

13:44But I think that's the point they're making. Right. Yeah. I mean, I think there is this general feeling of like, you know, people aren't exercising enough. and they're doing too many sedentary activities. You know, that's been true for a long time. Exercise hasn't really varied very much. You know, like television makes you not want to exercise either. Sure, right. At least you can take your phone with you. You watch your phone on the bike. No, I know. I'm just thinking back to my parents. You know, TV would rot your brain. But, you know, I watch TV and I'm okay, as I'm sure you did too. Many of us are.

14:19But I do think that if, you know, if we're talking about sort of like the, you know, the things that RFK and HHS are doing that are, if not, you know, good, at least not probably, you know, overly bad. I think that sort of like reframing the conversation around public health and chronic illness is probably useful. Again, who knows how much this stuff actually does. But I think, you know, focusing on ultra processed foods, this idea that I think Mark Hyman wrote about that, you know, real health starts in the kitchen rather than the pharmacy. It seems like that's he's on the right track, right?

14:53Absolutely. And I think that, you know, focusing the conversation there is good. I think the other thing that they have done, which I don't know how much is out of just the basic Trump administration as opposed to RFK, but is the negotiations are having with GLP-1 manufacturers around drug pricing. You know, I am I understand people have different feelings about this. My view is that in general, GLP-1s are going to be very important for a lot of people in terms of giving them both the direct weight loss effects, but then just giving them the kind of ability to change their diet in positive ways.

15:28We know it's very, very challenging for people to change diet. So around those conversations, sort of thinking about metabolic health and food as a core part of people's health investment. Yeah, I think that's good. Again, I'm not it's not not the first person to mention this, but to the extent they make any progress on it, I think that will that that would be good for America's health. Well, so let's stay on GLP-1s because I wanted to ask you about you wrote a great piece in The Atlantic a couple of months ago. And I think it was a very persuasive argument in which you talked about, you know, if if Trump and RFK, if they if they really wanted to do something to, you know, sort of make real inroads with, you know, American public health, with our metabolic health, they would allow or push for these GLP-1s, Ozempic, Monjaro, Wagovi, the fat drug, as Trump calls them.

16:16The fat drug. Covered by Medicare and Medicaid. And that would that would actually do something at scale. Can you sort of walk me through that argument for those who haven't read it? Yeah. So the argument there was about how we think about costs. So generally, Medicare and Medicaid, and the argument was largely about Medicaid, Medicaid, which covers a large number of poor Americans, many of whom are suffering with obesity, generally is required to cover any drugs that are approved by the FDA. but there are exceptions for the GLP-1s because they're very expensive. The point I was making in the article was that given the potential cost savings associated with improvements in health from these medications, that in fact, at some price, they will pay for themselves and that that price isn't as far from where we are pricing-wise as people might think.

17:13And in fact, after I wrote that piece, like two weeks later, although I don't think that there was any, I'm not inferring causality, But a couple of weeks later, the administration announced that they have made some deals, both sort of ongoing with the various manufacturers around drug pricing. And now that there's an oral, there's an oral GLP-1 that's generally going to be cheaper. So I think we're moving in a direction in which these drugs are going to get much less expensive and that to the extent they are then going to be covered by the insurance that many people have. There is potential for the people who need the most to get this.

17:53I mean, I worry a little bit looking out the landscape of GLP-1s that the only people getting access to them are people who don't actually really need them that much. Right. Right. Yeah. No, no, I feel the same way as a non-expert. I mean, you really start to notice it now in New York City. You know, when you watch some of these award shows, I mean, you can just sort of like clock some of these celebrities and politicians even that are taking these things. And like, that's great, like more power to them. But it certainly seems like the people who need them just do not have access. And I think that your argument is really, I thought, provocative and good because it makes the point that, you know, these people have, especially if you're on Medicaid, you know, they have they cost a lot of money.

18:36You know, obesity obviously is a, you know, is a condition that makes you as a sort of like unit of the health system much more expensive. So what you're sort of saying, I don't want to put words in your mouth, but is, you know, if you give these people access to these drugs earlier, you can actually save potentially save money down the line. Right. You pay now or you pay later. And if we pay now, people will have better quality of life than if we pay later. Exactly. And it also just it seems, you know, Trump likes to make deals. Right. He's the he's the dealmaker. That's that's his whole thing.

19:06So it seems like this would be something right up his alley, right? Like negotiate with Lilly, negotiate with Novo and the rest of these companies, basically strong on arm them into lowering the prices for these drugs for for Medicaid. You know, Medicaid already gets, you know, they get lower prices on these drugs than private insurance. So it strikes me as a little bit weird that we haven't sort of seen him take this on more because it just does kind of seem like something right into his wheelhouse. I think he's been pushing in this direction. My guess is that these drugs will get more that, you know, by both a little bit of negotiation there, but also just the general, you know, time path of of these drug prices that in a year this will be widely accessible.

19:50Yeah. OK, back to the last thing that I wanted to ask you on sort of like the good slash not terrible provisions of our new health imperium under RFK is you've written about this. And again, it's a little bit controversial, but I think it's a it's an important point that I want to sort of dig into a little bit, which is, you know, what they're doing is they're letting the USDA allow some states to issue waivers so that you can't buy soda or I believe candy with EBT. Right. With your SNAP benefits. Again, this is controversial among liberals because, you know, there's a lot of people who are like, you know, these people, we should the last thing we should be doing is telling people, you know, the government should be telling people what they can and can't eat, even though, you know, this is food that they are buying with tax money.

20:34Right. It does seem like this is the kind of thing that actually could have real public health benefits, just given how unhealthy soda and candy are. Yeah, it's actually there's a lot of interesting a lot of interesting economics here because most people who are purchasing food with SNAP benefits are also using other money. So SNAP does not typically cover people's entire food baskets. Right. And as a result, kind of basic economic theory would tell you that it doesn't really matter what you tell them they can spend it on because the money all can kind of be moved around. As it turns out in the data, people don't act like that.

21:12So actually, if you change what they can spend their SNAP benefits on, you should expect to change what they consume. And so putting this additional restriction on SNAP, I think, is likely to lower people's consumption of these sugar-laden beverages and candy. and you know I see the I see the counter arguments I will say we already have quite a lot of restrictions on what people can spend their SNAP benefits on it's not just sugar it's also like can't buy prepared foods you can't buy hot sandwiches there's like a lot of restrictions already on this and so this adding this particular restriction I'm interested to see in the data what happens.

21:56And I can easily believe this would turn out to be a positive change from a health standpoint. I can see how someone in your line of work would be itching to get some of the data out. You know, it would obviously take a little while, but I believe Utah was one of the states. West Virginia. There's a handful of them. West Virginia that just implemented these waivers at the beginning of this year. So hopefully we'll start to actually see some data on this, which will be interesting. But also you just bring up something that I thought about going back to our conversation about hypocrisy or hypocriticalism or whatever non-word I used.

22:30I just remember as a New Yorker when Mike Bloomberg made a big thing about trying to ban large sugary drinks. And the Republican outcry was, this is nanny state behavior. How dare you tell us what crap we can and cannot put into our bodies? So it's just so interesting to me how these things sort of change with the times, right? Mike Bloomberg tried to do this in, tried to do this in New York City with people's SNAP benefits. He tried to limit that you could, people spending on their SNAP benefits on soda. And it fell apart because, speaking of hypocrisy, it fell apart, I think, because a reporter came to his office to interview him about this.

23:11And it was clear that in the office fridges, there was a lot of soda, right? And then it was sort of like, well, what are you saying? Like it's fine for Mike Bloomberg's people, but it's not fine for people on Snap. And like that was the end of that. That discussion died on the Hill right there. Yeah. No, that was that was a classic like New York Post story. Right. Like, you know. Yeah. OK, so we got it. That was the good, I think, or at least again, the not terrible. Let's get into some of the bad because there has been a fair amount of it. And I want to start with what the president and RFK announced, I think was probably back in September now, about where they basically they did a press conference and they came out and said, you know, just straight up that autism is caused by Tylenol use in pregnant women.

23:54I know the answer to this, but tell tell our viewers and our listeners, since you have more, you know, you know this better than I do. Is there any empirical evidence that supports this? There is no good causal evidence to support this and a fair amount of good evidence to refute it there. This is, you know, like many pieces of data, you've got to really understand what you're looking at. And you definitely can find there are many studies which show a correlation between consuming high levels of Tylenol during pregnancy and neurodivergence in kids. But it is very clear that those results are driven by other differences, either the reason that you took all of the Tylenol or other demographic differences across families or differences in medical treatment or diagnosis, etc.

24:41the best studies of which, of which there are several, are ones that compare siblings. So two siblings, same mom, Tylenol during one's pregnancy and no Tylenol during the other. And where those, we just don't see any evidence of a link. And so this is an example of a time when if you kind of said, okay, well, there's like 50 studies over here that show a link and here are these two studies that don't. And you're like, yeah, but the two studies are good and the 50 studies are garbage. And when they sort of pulled this out, it was with a reliance on some of this very flawed evidence. And I will say, even if you thought that the links in those correlational studies were real, even if you said these links are causal, the size of the effect is teeny tiny.

25:28And the trend in autism over time is very, very large. And so this idea that was claimed at that press conference was sort of like, we found the cause of autism, like literally no chance that this really has anything to do with it, even if you believe this flawed data, which is also flawed. I mean, it's so hard to to to rank these sorts of things. But I think you could make an argument that that was the most irresponsible thing that Donald Trump or an American president has ever done. I don't know. That just struck me when it happened. I was just like, this is this is going to hurt people like this is crazy.