Meidas Health, Episode 10: The Calming Voices of Expertise

0:00Hello, Midas Mighty. Welcome to episode 10 of Midas Health. It's great to be with you. There's a lot of healthcare headlines happening as we speak. And again, the reason we're doing this 10 episodes and now, or this is the 10th episode, is very clear. The nation's best are not at the highest levels of government. So it is our commitment to bring the nation's best, whether they're researchers, government officials, former government officials, current ones, thinkers in the healthcare space, directly to you here at Midas Health. And so I'm so delighted to continue that trend. We've had Dr. Rob Califf, recent FDA commissioner on for episode two, senior leaders at the WHO for episode four, incumbent secretaries of health like Dr.

0:45Seishamani in Maryland for episode six. please go back if you haven't had a chance to listen to those on your morning commute. We are trying to provide a public service and bring you the nation's best to this massive platform. So without further ado, I want to bring two of our nation's leaders, some of our best thinkers, especially when it comes to vaccine policy, Dr. Fiona Havers, former medical epidemiologist at the U.S. Centers for Disease Control and an infectious disease physician. Dr. Kenneth Michelson, one of the nation's leaders in all things pediatric emergency medicine. Fabulous and really fascinating body of work when we're thinking about delayed diagnoses and our pediatric capacity across the country.

1:30I think very sort of related and complementary sets of expertise. So thank you to the both of you, Fiona and Ken, for being here. Yeah, good to be here. Yeah, thanks for having me. Fiona, I want to start with you. You know, there's a lot in the headlines today. The Dig Beautiful bill, which I think was just renamed by Senator Schumer as to not be that. I think they're still trying to figure out what the name is now. But it was just passed by the Senate. So we go back to the House and we're going to, you know, see kind of what ends up happening when it comes to the impacts of this bill on, say, Medicaid and some of our other entitlement programs.

2:08But there's a lot out there that I think our listeners and the general public are being peppered with every single day when it comes to healthcare news. I've seen that, you know, you've been quite vocal in the last few weeks with all things ACIP, this advisory committee on immunization practices that you were a part of up until recently that sets key vaccine recommendations for the country. I'm wondering, just as you're mulling and seeing what's happening, where do you think we're headed as we approach the fall? And, you know, what are you optimistic about? What are you worried about? Well, I am pretty worried.

2:46I think what we've seen, particularly in the vaccine policy space over the last month or two, and particularly in the last like two to three weeks, I'm very concerned that we're headed in a very bad direction as RFK Jr. has basically taken over the apparatus of vaccine policy for the United States by firing this committee and replacing them with a number of people that have kind of are well-known vaccine skeptics. And then the meeting that we saw this week, which was the first public meeting of this advisory committee on immunization practices with the new members, there was a lot in that meeting that was like very, very concerning.

3:20And I'm worried that we're going to have restricted vaccine access in the U.S. You know, Penn, you and I have had this conversation a few times. And when I hear Dr. Habers and I have had a chance to do some content together, talking about some of these implications, I look at your work. And I'm just wondering if you could detail to the audience the significance of your work when looking at things like pediatric bed capacity across the country, delayed diagnoses of pediatric conditions. Just wondering if you can help us understand where we are as a country when it comes to pediatric bed capacity and why it matters.

3:59Yeah, yeah, of course. I mean, I guess I would start related to what we were just talking about by saying that I think vaccines work. I think vaccines are very safe. I was a medical student in 2007. And even then, the pneumococcal vaccine was very new and was just sort of entering use in pediatricians' offices. And we were just starting to see kids age who were now like five, six, seven years old when I was a med student at that time. And it changed practice. I mean, we went from being in the emergency room if you saw a child with a high fever under 36 months. you had to do a lot to figure out whether or not they might have invasive pneumococcal disease, which is a really serious disease.

4:44And so that completely went away. Like for most kids under 36 months old who have a fever, we stopped having to do that because the vaccine was so successful. And as part of that, it meant that a lot of these kids with serious disease, we stopped seeing them in the hospital. And so in some ways, like we were really successful at reducing demand for inpatient services. Inpatient services are, if you're a child who goes to the emergency room with a serious illness and it's serious enough that you can't go home, then you get admitted, which means you go to a hospital bed. That's called an inpatient bed.

5:21And so we were sort of anecdotally noticing that there was an increase in transfers to our hospital for really common basic pediatric conditions. And so we did this study where we said, okay, let's look at three really basic bread and butter conditions that we see all the time. Asthma, gastroenteritis, which is like a stomach flu, and croup, which is a certain type of upper respiratory infections. And we said, okay, if you can't go home from the ER to have hospitals, you know, do they admit you or do they transfer you? And how's that changed over time? And we found out that over the course of a decade, hospitals went from mostly admitting to mostly transferring, meaning that hospitals stopped being willing to put those kids in their own hospital, they started sending them elsewhere.

6:06And so we were asking the question of why that was, and we thought there were a few reasons, but our leading theory was that hospitals were really getting out of the business of hospitalizing kids. And it turns out that's true. So we did a follow-up study where we showed that in 2008, there were about a little more than 1 ,700 pediatric inpatient units in the country. And I should say there's about 5 ,000 hospitals. So most hospitals don't do inpatient pediatrics, went from 1 ,700 to about 1 ,200 over the course of 14 years. So 30 % loss in inpatient units, whereas the same time adult units had only gone down by about 4%.

6:45You know, Fiona, when I hear Ken talk about this, I've had a chance to look at Ken's research and read about it. It's been cited in the New York Times. You know, recently, Ken, And you published in JAMA, disparities in diagnostic timeliness and outcomes of pediatric appendicitis. For those that want to Google that, easily readable. But Fiona, when I hear about this, I draw my own conclusions, which is to say it feels like it's a perfect convergence, perfect storm of hospitals recognizing that maybe it's not as profitable to be investing in pediatric beds for reasons that we could talk about. that adults are, it's probably better business to care for sick adults than for sick kids, just from a cost standpoint.

7:32So we're seeing these inpatient units decline since 2008, to cite Ken's research, pretty significantly. And then I think about what you are, your leadership in adult infectious diseases and on the ACID committee. And I'm wondering if you ever, if you draw a correlation between the research and these trends at the hospital level and what you're seeing now with our national health policy? Do you draw a correlation? How do you think about all these sort of seemingly disconnected data points? I mean, I think one of the main thing that's really important is all of these decisions, whether it's about bed capacity or about vaccine policy and should be data-driven and science-driven.

8:12And I think the main thing that I'm finding really concerning is that this administration seems to be moving away from using data and science-based policy to make decisions about healthcare. I mean, I do think that from a pediatric standpoint, we're gonna see an increase in vaccine preventable diseases, including hospitalizations and severe illnesses for things like measles that we haven't seen widespread, but also even things like influenza. And there was a record number of influenza pediatric deaths this last year, over 250 kids in America died of flu. Most of those children that died were not vaccinated.

8:46And I think we'll see increases in pediatric hospitalizations balanced, on the other hand, by the decrease in RSV hospitalizations, because we have these amazing new products for RSV that have come out. But I think the concern is with this administration, sort of the infrastructure that takes into account science, it takes into account evidence to be making policy decisions has completely been thrown out the window. And I think that that's generally very concerning. When you talk to your, I guess, any of your colleagues that are still at CDC, is there a roadmap here? Or is the next three years, how do we navigate past this?

9:28Because then I say this as somebody that, you know, across sort of omni-channel media, we're trying to put good information out there. We're lucky to have both you and Ken here. But what is the solve? Or are we on a sort of holding pattern here for the next three years? I mean, I think one thing that I would say is that the data coming out of CDC still is solid as of right now. They haven't really started messing with that. And for example, like my main job at CDC for the last four and a half years is running a large hospitalization tracking system. COVID-net and RSV-net that track hospitalizations in all ages for those two pathogens.

10:02And like my team is the best team. They're still there. They're still collecting these data. They work with health departments. So like that data is still solid and hopefully that will continue. but the reason why I left my job is because I really didn't feel like this committee was going to like look at that data. I spent the last four and a half years prepping for so many ACIP meetings so that people would have good data to base policy decision on. But that's like completely getting far out the window. And I think my colleagues who are at CDC now are kind of like, why are we even here? Like what they did at that latest ACIP meeting where they just shoved through this like thimerosal, there was a vote on thimerosal containing flu vaccines that they just completely skipped over the entire policy process that was in place.

10:45Usually if there's a policy vote, there's like months of preparation. They just skipped all of that, had one speaker, then shoved through a vote. And all of my CDC colleagues who had spent months preparing and all the other experts that had spent months preparing for these other policy votes were kind of like, what is even, why are we here? Like they are clearly not going to listen to us. And that's really disturbing. Fiona, I just want to stay with you for one more follow-up here. And I should say for all our listeners, if you're wanting to read more about Dr. Havers' tenure at the CDC, there's a lot out there.

11:23Thank you for your service to our country, Dr. Havers. You've done a lot over a very distinguished career. But you were profiled by Apoorva Mandavilli at the New York Times on June 18th, with the headline, why vaccine expert left the CDC, quote, Americans are going to die, unquote, was one of the big sort of quotations they brought out from that interview with you. And that's something that that's a message you've been highlighting, even on the media that we did together. I noticed that medical societies and the AMA, the American Medical Association, others have been trying to step in and fill the void.

12:02American Academy of Pediatrics has been partnering with the AMA. Do you think that that is a roadmap for the future that we're going to be relying less on the government and more on medical societies? Medical societies are going to be relying more on their local chapters and leading providers within those chapters to create an echo chamber. Just wondering if we've seen a fundamental shift away from government institutions leading on health messaging. Well, forget health messaging. I'm concerned about coverage. I do think that if this committee goes in the really concerning direction, it looks like it, that the policy recommendations coming out of ACIP and CDC may not be reliable in the future.

12:43I'm very concerned about that. That's going to cause mass confusion for all clinicians who historically have turned to the CDC immunization schedule for the go-to place to vaccinate their patients. One very important part of the ACIP process is that they have a work group for each vaccine. In these discussions before a vote happens, there are 30 liaisons from American College of Physicians, American Academy of Pediatrics, American College of Nurse Midwives, who all weigh in. And then before there's a proposal and a policy change, they vote and weigh in and then endorse the CDC schedule. That's historically what's happened.

13:19But all of those organizations were completely cut out after RFK Jr. took over the vaccine schedule. So we may end up being where, if the American Academy of Pediatrics has more science-based recommendations, there may be like an alternate set. The problem is only ACIP and CDC recommendations are legally required to be covered by insurance. and also ACIP votes on what is included in the vaccine for children's program. And that is a very important program that provides free vaccines to more than half of the children in the U.S. So there may be other better recommendations coming that are reliable and science-based, but I personally am uncomfortable, you know, sort of trusting my child's access to vaccines, to the goodwill of the insurance companies to voluntarily cover things that ACIP or CDC don't recommend going forward.

14:13So like, this is not just a like, there's gonna be confusion because there's gonna be different recommendations coming out. It's a real access problem. Like parents, if they take vaccines off the schedule, like next year, you could show up at your pediatrician's office for your kids to your checkup and find that the vaccines that they recommend are no longer covered by the Vaccines for Children program. And then you have to make a decision if you can get the vaccines at all of paying potentially several, like hundreds of dollars out of pocket or leaving your child exposed to a vaccine, you know, to a potentially fatal disease.

14:44And so I think, you know, it's a problem that we're moving away from. If ACIP recommendations and CDC cannot be, like those recommendations can no longer be trusted because RFK Jr. like hijacked the process, there's going to be like real access issues, not just confusion. You know, Ken, I'm looking at some of your, Thank you, Fiona. Ken, in 2024, you published in JAMA Pediatrics, Emergency Department Volume and Delayed Diagnosis of Serious Pediatric Conditions. For all our listeners out there, there's a quick abstract if you want to get the high points here. But Ken, I look at this work, I look at some of your other work, how it dovetails with all of Fiona's leadership on the ACEIP side the house.

15:34And I can imagine that everything that we're talking about must at minimum be frustrating for you. And just wondering your thoughts on your research and as it pertains to the current set of news headlines and kind of how you're reconciling everything. Yeah. I mean, I think I agree strongly with Fiona that the main and most direct concern from all the ACIP changes is that a decrease in vaccine recommendations is going to reduce coverage. And that when you reduce coverage, especially for people who have a hard time affording healthcare as it is, they're more likely to forego important treatments.

16:14And, you know, as an emergency medicine doctor, looking at primary care, I think like the average primary care doctor saves more lives vaccinating kids every day than I will in 50 shifts. I think vaccines are probably the single most important intervention in pediatrics today because of the sheer number. We don't even see the lives saved. I mean, it's so routine, but you can't even imagine just the number of kids that vaccines benefit, which is not to say that vaccines are risk-free. It's just that their risks are much lower than the diseases that they prevent. And so I think the coverage piece is really, really, really important.

16:56I think on the messaging end, I think people want vaccines. I mean, more than 90, 93 % of kids are getting vaccines today and they want trusted information about vaccines. And I think the erosion and trust of government messaging has been proceeding over the last couple of decades, such that I think where most families get information about vaccines really from their pediatrician. Pediatricians remain a really trusted source of information. And so I think when it comes to messaging, the pediatricians that were seeing kids yesterday are the same as the pediatricians that will be seeing kids tomorrow.

17:39And so I'm less worried about messaging to the average family than I am about whether or not they'll be able to afford it. And that's, I think, a real concern. Um, you referenced my, uh, research about delays in diagnosis. And, you know, one of the things we showed is that when it comes to diagnosing these really rare, serious diseases is that experience matters a lot. So, um, I think that's the takeaway is that, uh, if you go to a hospital that has less experience with your condition, it's more likely to be missed. And I think today, vaccine-preventable illnesses are super rare. And I really hope that they stay that way.

18:22So I think there may be some convergence there. I don't know if that gets to your question. Do you feel like people, you know, I look at your research and some of the just, when I just look at the title, frankly, without even delving into the abstract, much less the actual manuscript, just the title in a delayed diagnosis. um you you chronicle since 2008 there's been a 30 percent decrease in pediatric and patient bed capacity for a variety of reasons i find that all to be very alarming and i say this as a clinician myself and somebody that lives in previous health care all the time if i it strikes me that the general public probably doesn't think about that but if they did just like fiona if they thought about all the things that you're seeing on the insiders saw on the inside with asap and how it's all playing out, it would be incredibly alarming that they would hold their elected officials accountable as to this problem and that we would need governmental solves.

19:19But I'm wondering, do you agree with that? Do you feel like there's lay awareness as to what's happening? No, I absolutely don't. I mean, I think the average person, and I think this is fair, I think the average person thinks all hospitals are created equal, that all hospitals can have the same capabilities and that if you are really, really sick and you go to an emergency room, that things are going to look the same at every, like you're going to get perfect care no matter what emergency room you go to. And I think we know that that's definitely not true. And that when it comes to pediatrics, that most hospitals, most emergency rooms don't see that many kids.

19:54It goes well in almost all cases, but it goes well more often at places that see more kids. And so when you think about inpatient closures, that affects kids who need to be hospitalized. So now a hospital that the community hospital nearest you that used to be able to admit you now is not admitting you. And what does that mean for you? Well, it means a couple of things. One is that you're probably gonna have to travel really far if your child needs to be hospitalized. Or if you go to the emergency room of your close hospital, doesn't have inpatient care anymore, all the pediatric resources are gone.

20:35So there's nobody in the building who practices pediatrics anymore, except perhaps in the nursery or maybe in a NICU. But in terms of seeing anybody out of the newborn age period, there's not somebody in the building who has more than a few months training in pediatrics. And so I think that's a big deal for what the likelihood of getting a correct diagnosis and things like that. I want to say, we're having this conversation today. It's Tuesday, July 1st. Dr. Kenneth Michelson, Associate Professor of Pediatrics and Envision of Emergency Medicine at Northwestern Lurie Children's. Dr. Fiona Habers, recently member of ACIP, Advisory Committee on Immunization Practices, that advises the CDC and our government institutions on vaccine recommendations, infectious disease doc, medical epidemiologists.

21:24We're having this conversation. No, I don't want to cut off. I wasn't actually a member of ACIP. I was a CDC official that provided data for ACIP meetings. So sorry, I didn't. No, no, no, I appreciate the clarification. All right, thank you, thank you. We want to make sure that we're very clear here. Thank you, Fiona. We're having this conversation on July 1st, 20 minutes after the Senate just passed, the most recent reconciliation bill, where it's estimated that the cuts to Medicaid over the next 10 years will likely result in hospital closures. Some estimates, Families USA estimates over 300 hospitals, primarily rural, will potentially close.

22:07Ken and then Fiona, I'd like to get your thoughts on this as well. How does that number, what do you think that means in the context of your research? Well, I think that's bad. I mean, I think Medicaid, as a pediatrician, there's, Medicaid is our biggest payer. Medicaid covers more children than any other insurance by a long shot. I use Medicaid data a lot of my work and we're looking at Medicaid data from a couple of years ago, 2022. And more than half of kids in America were insured by Medicaid in 2022, or CHIP, which is the children's health insurance program. So between those two programs, that's more than half of children in America are insured by those programs.

22:49So if you cut Medicaid by more than a trillion dollars, it's going to impact pediatrics. And I think it's doubly concerning because Medicaid is the best value for the healthcare dollar. I mean, they pay 30 cents less on the dollar than Medicare for the same care. So Medicaid is already at a deep discount. And so hospitals will look at a patient on Medicaid and say, I don't know if I can take you as a patient now. I already was losing 30 cents on the dollar compared to a patient on Medicare. And I just think that's really bad for all Americans and in particular for children, which is the population I serve.

23:35Diona, curious your reaction just to today's events in context of everything. No, I mean, I live in Georgia, a state that decided not to expand Medicaid. I also am a practicing physician. I see patients at the Atlanta VA. And while those patients have coverage at the VA, I definitely see the role that health disparities and access to care make outcomes for adults a lot worse as well. And, you know, throughout the pandemic, also the hospitalizations tracking system that I worked on did a lot of work on racial and ethnic disparities in outcomes for COVID, for example. And we really saw that, you know, kind of systemic issues with our health care system really played into certain groups, particularly, you know, among black or Hispanic groups that have less access to health care, rely more on things like Medicaid, had worse outcomes throughout the pandemic.

24:25And there are many systemic problems that this vote, if they cut off access even more, is just going to worsen health outcomes for a lot of vulnerable groups across the country. Children, certainly, but also like vulnerable adult populations as well. I think Medicaid is like seen as a safety net, but for kids, it's really the default. It's the dominant player in pediatrics. i i push the two of you to say i don't i i suspect and there's some polling out there today from priorities uh usa that was released that suggests eight percent of americans are tracking these changes to medicaid and 92 percent are not tracking or following the headlines whatsoever and i my push the two of you is do you what are we not getting right the other is starting with you why is this message not resonating?

25:17And I'll say from my perspective, it feels like outside the beltway, outside of DC, it feels like if somebody's talking about these cuts to Medicaid, and I've gotten a lot of this feedback on social, it's, oh, well, what's wrong with cutting Medicaid for those who don't deserve it, quote unquote, or those who are, quote unquote, undocumented, that this top line has really stuck, which is to say work requirements and let's remove people that aren't in the country with the proper documentation or are not working, that that's the top line and it's stuck and a lot of people agree with it. Versus, I don't think most people recognize, Ken and Fiona, you both made this point, that most of CHIP and the ways in which children get cared for in the United States is funded by Medicaid.

26:03I would venture a guess that most people do not know that. simple fact that you guys are just delineated. So what are we not getting right? Fiona, you've been, you've seen how the sausage gets made. You've been, you know, advisor to these influential committees, working at the CDC, just wondering what is it about how sort of persuasion, public persuasion that we're not cracking and not getting right? I mean, it's really challenging. Like even just me trying to explain what this, what ACAP does is like complicated, boring as government processes and i think people tend to tune it out in terms of like the role of medicaid and how important it is like i i think people don't really want to hear that and i think but public messaging is really really hard i mean i was at cdc throughout the pandemic and we got slammed for how we were messaging and i i think it is challenging to really connect human stories to government policy and speak more broadly to the impact of these huge decisions and how they impact millions of people.

27:02If you talk about millions of people, people will tune it out. Yeah, it's extremely challenging. And I think, I'm guessing the 8 % that are tracking it are not necessarily the ones that are going to be most impacted by it. And I think access to information is hard. There's a lot of misinformation out there in general about who's taking advantage of Medicaid and who it really benefits and people sitting around expecting government handouts when really a lot of them are like working for like have full-time jobs, maybe two full-time jobs, but their jobs don't give them health insurance. They don't have, it's challenging to earn a living wage in a lot of places.

27:40So I think, I mean, there's just so many factors in the way our healthcare system is set up that communicating about the real impact of these big policy decisions on people's lives is hard. And there's a, I think there's a certain contingent out there that makes it even harder by deliberately spreading this information about who's actually benefiting from Medicaid. Yeah, I think, I think, you know, healthcare payment policy is simultaneously incredibly complicated and incredibly boring, and that's a bad combination. And so I think for your average person, like they don't necessarily want to be in the weeds.